Introduction
Since the beginning of humanity the female breast has been synonymous with the idea of femininity. 
The “ideal” size, however, always depended on whatever was in vogue at the time, and any appropriate changes were made on illustrations. 
The ?rst references to surgical interventions to increase the size of the female breast date back to the end of the nineteenth century. 
There are reports of treatments ranging from fat transplants to paraf?n injections, from creams and various synthetic materials to silicone injections, and, as one can imagine, these had disastrous consequences. 
It was not until the 1960s that it became possible to develop usable silicone gel implants. 
The further development of these has continued until the present day and has given rise to a safe method of breast augmentation. 
This is due above all to the viscosity of silicone gel, which enables the implant to be as natural as possible. 
There are also saline-?lled implants on the market, but these have inherent disadvantages. 
The saline can diffuse more easily through the outer silicone layer, which ?rstly may produce a loss and unevenness in size, and secondly may give rise to noises.
The advantages of titanium-coated hydrogel breast implants and others need to be demonstrated in long-term studies. 
For decades we have been using roughened implants with silicone gel (INAMED Aesthetics, Santa Barbara, CA; D?sseldorf, Germany [formerly McGhan Medical]) without complications and with a low capsular ?brosis rate.
Breast enlargement is a very frequently desired operation.
This book presents the most simple,clear technique in order to ensure that the novice has a basic idea of how to introduce breast implants and to avoid risks.
The simplest,safest access is by means of a 3- to 4-cm-long incision in the inframammary fold which,if it is made precisely,if an atraumatic suture technique is used and if there is good postoperative treatment,is hardly visible after 3months.
The access described in the manual is very clear and easily understandable and also produces good aesthetic results.
Of course,a breast implant may also be introduced via the nipple and via the axilla.
This requires the person carrying out the operation to have appropriate experience. 
In some cases it will be indicated.
Any breast implant,however,may be introduced without any problems by means of the access described in the manual.
It is then up to the young aesthetic surgeon to build on this knowledge.
Once the question of access has been resolved,the second-most-important decision is whether the implant is going to be placed above the pectoralis major or underneath it.
Here,too,the manual gives clear and easily understood instructions,namely,that generally,if there is good skin and gland coverage,the implant is positioned above the muscle,between muscle and gland.
The operation is carried out macroscopically and the dissected pocket is monitored by means of an endoscope so that any bleeding is seen,all strands of connective tissue are cleanly cut through, and the implant pocket is prepared in an anatomically clean manner.
In a clinical study of 500 patients followed up at the Bodenseeklinik,the ?brosis rate was not signi?cantly lower with submuscular access than with supramuscular access (<4%).
Submuscular access is and must be carried out if,following pregnancy or dramatic weight loss,only a very thin ?ap of ptotic skin is present, meaning that the covering is very weak.
Otherwise an impression of the implant and a rippling phenomenon is unavoidable.
In this case the implant must be placed under the muscle.
This intervention is more laborious and causes more bleeding.
The pectoralis major must be separated while in view,including by endoscope,at its lower margin up to the midline using an electric scalpel,cutting through its points of attachment on the relevant costal arches,directly from the rib.
Subsequently, the muscular pocket can generally be dissected bluntly.
A disadvantage of this method may be that the implant slips and that the muscle contracts and changes,which means that when the implant is in the submuscular position,there may be later cosmetic problems and changes if the submuscular pocket is not dissected completely cleanly.
Consequently,a novice in the area of aesthetic breast surgery should send patients who have dif?cult skin and ptotic breasts to an experienced breast surgeon.
As a novice,one does not do oneself any favors by carrying out complicated breast operations.
In this book,therefore, we have only selected subglandular breast implants with access via the inframammary fold since this intervention can be easily learned, is standardized,and is associated with low risk.
When implants are used,these should only be implants that have been licensed by the health authorities.
Similarly,to start with one should not use implants that are too large (not over 350g) since these are associated with signi?cantly more postoperative complications and a signi?cantly greater desire for subsequent operations than is the case ofsmaller implants.
Breast Implants 
Every day,women in Germany ful?ll their dreams of having well-formed breasts.
While the round shapes – which are obviously implants – are still preferred in the USA,German women want their surgically enlarged breasts to have a natural appearance:the ‘tear shape’.
Yet,it is not only important to have a natural appearance;the implanted material should also feel as natural as possible.
Tear-shaped implants are made entirely of silicone – with good reason.
Other materials used for breast implants have proved to be extremely disadvantageous for patients.Sodium chloride is certainly safe as regards patients’health but it has drawbacks: the implants gurgle and the material has nothing in common with the surrounding breast tissue.
For this reason,only McGhan silicone gel breast implants from Inamed Aesthetics* are used at Professor Mang’s Bodenseeklinik.
As the sole manufacturer,Inamed Aesthetics has experience with these implants stretching back more than 25 years. 
This is an important point as the quality and safety of the implant play an important role in the result of the breast operation.
Publications throughout the world con?rm the fact that these implants have the lowest complication rate,which is in line with the high quality and safety requirements at the Bodenseeklinik.
A standardized quality mark for breast implants has been in existence throughout the entire European Union for three years.
This guarantees that the implants will not harm patients’health.
The silicone implants used today are ?lled with cross-linked (cohesive) silicone and therefore cannot leak.
If such an implant is cut open,the contents appear as ?rm as a wine gum.
The surface has also been made rough which ensures that the implant meets completely naturally with the tissue.
Inamed Aesthetics guarantees the safety of the implants with the INAMEDPlus guarantee program.
This program covers every McGhan silicone gel breast implant which has been explanted due to unexplained damage to the implant shell and the resultant rupture of the shell.
The decisive factor is that it was implanted after March 31 2004. 
Even in such highly unusual cases, only a cosmetic correction is required – the patient’s health has not been put at risk because of this at any time.
If the explanted product is no longer being produced,it will be replaced by a current and equivalent breast implant.
And what is more,patients affected by this will receive a ?nancial contribution of up to 1,000 Euro for explantation required as a result of damage to the implant shell,as long as this is carried out within 10 years after implantation.
More detailed information on this exclusive guarantee program can be obtained directly from the Bodenseeklinik on request.
Duplicate Patient Information 
The patient is ?rst given comprehensive information about the objectives and risks of the procedure on the day of the ?rst consultation. 
A written record is kept of this.
One day before the surgical procedure,the patient is again given comprehensive information on two separate occasions:once by the surgeon and once by the surgical resident.
All the risks are set down in writing at this time.
In addition to general operative risks such as wound infection,impairment to wound healing,injuries to blood vessels and nerves,scar formation,subsequent bleeding,thrombosis and embolism,in the case of breast enlargement it is also necessary to give information to the patient about circulatory disturbances and sensitivity disturbances relating to the nipple,impairment of ability to breast-feed,necrosis of the skin, glands,and adipose tissue,asymmetry (especially if this exists already before the operation) and speci?cally about capsular ?brosis,prosthetic defects,and possible displacement of the prosthesis.
Surgical Planning
The operation is performed under general anesthesia achieved with endotracheal intubation or laryngeal mask ventilation.
The day before the operation the doctor carrying out the operation discusses with the patient in detail what changes the latter desires and how these can be achieved by the surgeon.
The patient must be warned about having unrealistic expectations,and the patient must be informed in detail about postoperative behavior.
There should be intra-operative singleshot infection prophylaxis with 2g cefaclor.
The surgical planning must incorporate information about the skin condition,muscle thickness,a mammogram,or ultrasound of the breast. 
It must also cover the shape of the chest,the current size of the breast, circumference of the thorax,and the weight and stature of the patient.
A novice in breast augmentation surgery should start with implants that are not too large (no larger than 320g) and begin by using the safest access.
This is access in the inframammary fold (3).
This access (approximately 3–4cm) is free from problems,can be clearly seen,and is easy to learn.
It ensures safe dissection in view and low-risk introduction of the implants.
Wound closure without tension using a 4.0 poliglecaprone 25 (Monocryl) intracutaneous suture ensures that the scar is as good as invisible if there is normal wound healing and good care is taken of the scar.
Often this scar is less unsightly than the scar that is produced with axillary axis (1). 
With regard to the latter,patients often complain that they have an unsightly scar when naked.
Periareolar access (2) is very rarely indicated. 
This may lead,in addition to visible scar formation,to sensitivity disturbances in the nipple area.
Both forms of access (1 and 2) should be in the repertoire of a well-trained aesthetic breast surgeon.
Since this manual is primarily intended to convey basic knowledge,the video and text will give detailed information about submammary,i.e.,supramuscular, access.
As an appendix to this chapter,reference is made to submuscular access,which is indicated if the skin is poor,in order to ensure better coverage of the implant and to avoid the phenomenon of rippling.
Submuscular access is more invasive since the pectoralis major has to be completely separated at its caudal and medial point of attachment. 
Detachment of the muscle makes the breast more susceptible to subsequent deformation.
The nipple is not lifted upwards to such a large extent,and on the basis of our studies (comparison of 100 patients) the ?brosis rate does not differ signi?cantly between the submuscular and supramuscular position (<4%).
In most cases the implant may be placed above the muscle (in over two-thirds of our patient group).
Incision Line in the Case of Submammary Access 
■ The incision lines are marked on the evening before surgery or on the morning of the operation with the patient standing upright.
First the jugulum is marked,then the midline down to the xiphoid and the navel. 
Next the cranial boundaries of the mammary glands are marked by pushing the breast upwards with the palm of the hand.
Depending on the intended degree of augmentation,the incision line is made either at the level of the inframammary fold or a corresponding 1–3cm lower.
The medial incision boundary should not extend beyond the medial boundary of the nipple.
The incision line is normally 3–4cm and runs,swinging slightly,precisely in the line that will subsequently be the inframammary fold.
It may be positioned slightly higher,but should never be too low,i.e.,underneath the inframammary fold,since the incision could be seen when wearing a bikini. 
■ From the medial margin of the nipple,a line is drawn in a caudal direction.
This vertical marking line may not be exceeded by the incision in a medial direction,since this scar region may be visible.
De?nition of the Subsequent Breast or Implant Size by Establishing the Distance Between the Lower Margin of the Nipple and the Subsequent Inframammary Fold 
■ The distance from the nipple to the inframammary fold is measured. 
By pushing the breast upwards with the palm of the hand in a medial, cranial,and lateral direction,the existing boundaries of the mammary glands are marked.
Depending on the ?ndings and on the patient’s wishes,the surgeon carrying out the operation draws the extension of the breast boundary in a medial direction (shrinking the intermammary distance),or in a lateral and caudal direction,according to the desired enlargement and change in the form of the breast. 
■ It is particularly important to be aware of the inframammary fold,which with appropriate enlargement of the breast must be moved in a caudal direction so that it does not,after the operation,come to rest on the lower breast pole but in the new inframammary fold that is in a lower position. 
■ The submammary incision is drawn in the submammary fold,or parallel to this but lower,beginning medially from the vertical extension of the medial areolar boundary to the intended submammary fold.
The length in the lateral direction is usually approximately 4cm and therefore enables the usual types of implants to be introduced easily.
The distance from the lower pole of the nipple to the incision in the subsequent fold enveloping the breast is dependent on the desired breast size (B,C,D) and therefore on the size of the implant.
The larger the implant,the greater the distance.A rule of thumb is that:
Size B:approximately 4.5–5.5cm
Size C:approximately 5.5–6.5cm
Size D:approximately 6.5–7.5cm
Positioning of the Patient,Disinfection of the Operating Area [0.9% NaCl 500ml,1% prilocaine 250mg (equivalent to 25ml), epinephrine 0.5mg,8.4% NaHCO3 5mEq] 
■ Following intubation (if the patient wishes,the operation may also be carried out under general anesthesia with laryngeal mask ventilation or by means of tumescent local anesthesia),the patient should be positioned on her back with a slightly raised upper body (30%–40%).
The arms are approximately 75% abducted.Attention must be paid here to any tension or pressure.
We recommend using soft silicone cushions under the entire arm so that there is no nerve damage to the brachial plexus.
Similarly,when operating it must be ensured that neither the operating surgeon nor the assistant leans on the arms. 
■ Disinfection is carried out carefully using the colored disinfectant solution Cutasept.
The sterile draping is applied in such a way that the operating area is protected from the head/neck or anesthesia area.
Tumescence The advantages of prior tumescence (manually or mechanically using a pump) are impressive.
There is less bleeding.The gland is lifted from the fascia of pectoralis major.
As a result,dissection is simple because the correct layer is easily located and time is saved.
Wound healing is faster.
Initially,the incision area is in?ltrated to deep into the muscle fascia. 
Then by pulling up the mammary gland with the left hand,tumescence is continued in the prefascial,parasternal,and lateral regions in the whole of the dissection area.
As an operating surgeon,one detects how the gland becomes detached from the muscle fascia and can predissect the subsequent dissection boundaries and layers with the tumescence needle.
As a result,much time is saved in the dissection process since this dissection can generally be carried out using the ?nger as a blunt instrument,in the correct layer and completely without bleeding.
For this reason it is important that the surgeon performing the operation carries out the tumescence him/herself and does not leave it to his assistant.
■ Approximately 100ml of tumescence solution is in?ltrated on each side, depending on the size of the breast.
In the process,the complete mammary gland is lifted up from the pectoral muscle. 
On the basis of a clinical trial,which involved the introduction of breast implants with and without tumescence (n=100),we have shown that postoperative swelling and pain are reduced and that the healing process is accelerated.
Note: Liberal preoperative tumescence of the operation site may be confusing for inexperienced surgeons since it results in an increase in the breast volume.
Submammary Incision 
■ The breast is lifted up by the assistant using his/her right hand,and the operating surgeon makes an incision precisely at the position previously marked.
It should be ensured here that the incision from the medial to the lateral level is performed in a slight arch shape that matches the intended inframammary fold,since this makes the subsequent scar as inconspicuous as possible.
The incision is made fully into the subcutaneous adipose tissue.
Preparation,Step 1 
■ Using his/her right hand,the assistant holds the sharp four-pronged retractor under traction on the upper incision margin in such a way that the operating surgeon can carry out the dissection along the mammary gland in the direction of the pectoralis major fascia cleanly and without bleeding using surgical tweezers and Metzenbaum dissecting scissors. 
Owing to the tumescence this is largely free from bleeding.
The excess tumescence solution ?ows back out again.
If there are small amounts of bleeding,the sites can be coagulated using bipolar tweezers.
Preparation,Step 2:Precise Demonstration of the Caudal, Medial and Lateral Borders of Pectoralis Major 
The use of an illuminated retractor or a forehead lamp enables one to get an overview of the operation site.
Strong strands of connective tissue are dealt with by sharp dissection in the lateral and medial directions.
In view,the entire lower part of the breast muscle can be demonstrated very well.
Tearing of the fascia or muscle should be avoided.
Strong strands of connective tissue generally lie medially in the direction of the sternum. 
These must be dissected cleanly and sharply,in view.
Bleeding from the vessels that perforate the fascia should be stopped carefully using bipolar tweezers since this is often the cause of postoperative bleeding. 
■ In this dissection step,the sharp four-pronged retractor is exchanged for a Roux retractor.
The assistant holds this up under traction so that despite the small cut,there is a good clear view of the operation site.
One must leave oneself time for this dissection step.
When the correct layer has been found,i.e.,when one is exactly on the fascia,further dissection of the whole implant pocket can generally be carried out using just the right middle or index ?nger as a blunt instrument.
Deep,Blunt Dissection 
■ When forming the pocket for the subsequent implant,it is important to dissect suf?ciently in the cranial and medial directions,in order to obtain a soft,inconspicuous transition of the implant margin.
In the medial direction,one should ensure that there is no connection between the sites of the left and right implants.
There should be a safety margin of at least 3cm,since otherwise there will not be a good aesthetic result. 
■ In addition,when carrying out blunt dissection,one should ensure that the pocket is not taken too far in the lateral direction,since this could cause the bed of the implant to be too big laterally,producing separation of the breasts,i.e.,they slide to the side and the result is not good.
It is important that the breast “stands”and that in the lower neckline,the medial,cranial margin is well positioned,without the implant or the margin of the implant being discernible.
The art of implant surgery is to create an implant site that constitutes an optimum precondition for the implant.
As a result of the prior tumescence,detachment of the gland from the fascia is trouble-free.
The boundaries must be smooth in all directions and they must be suf?ciently extensive so as not to cause later creasing of the implant.
If the dissection using the middle or index ?nger as a blunt instrument in the medial and cranial part is not completely successful,this dissection may be completed using Metzenbaum dissecting scissors with the illuminated retractor.
Pushing to the side can easily be performed bluntly. 
■ The implant compartments must be identical to the marking lines that were drawn before the operation.
It should be ensured that the two implant pockets are symmetrical and the same size.
Consequently,before incorporating implants,both the implant sites should be examined very precisely and hemostasis should be carried out twice using the bipolar tweezers.
Wound Revision and Hemostasis Using the Illuminated Retractor and Bipolar Tweezers 
■ Hemostasis is carried out by means of electrocoagulation and with the assistance of an endoscope or an illuminated retractor.
This hemostasis is carried out twice.
One always begins with the right breast.
After dissection and hemostasis have been completed,a damp compress is applied. 
When the left side has been dissected,a second hemostasis is carried out before incorporation of the implant.
Until now,we have not seen any postoperative bleeding in patients where this second hemostasis has been carried out.c
The patient,however,must not get up for 24h after the operation,during which time her blood pressure is monitored,and the patient is supine with the upper body raised and with a light compression bandage.
Determining the Size and Shape of the Implant 
The shape and size of the implant depend on the individual.
The operating surgeon must have a stock of implants that comprises all common sizes and shapes (anatomical,round,etc.).
The size is dictated by the skin and muscle conditions.
If,as an operating surgeon,one is faced with the decision of using a larger or smaller implant,then as a novice one should choose the smaller implant.
At the beginning the selection of the shape of the implant is not so crucial.
This is also something one can talk about with the patient before the operation using implant samples.
It is de?nitely not wrong to begin with round low-pro?le implants*.Later one can then incorporate other shapes into one’s repertoire.
The sizers produced by implant manufacturers are helpful when it comes to determining the implant to be used.
Implants of any size can be simulated.
The incorporation of the sizer is trouble-free and involves the assistant holding open the operative access using a Langenbeck retractor.
The sizer is ?lled up until the agreed breast size is obtained.
The same procedure is repeated on the opposite side.
The sizer also enables one to balance out differences in the size of the breasts very well.
Together with INAMED we are also developing sizers of different shapes, which means that it is possible,intraoperatively,not only to determine the size,but also the selection of the shape.
As a result one can determine more easily what shape of implant is best for each type of breast.
Fitting the Final Implant 
■ After removal of the sizer and after hemostasis has been carried out again,the implant,which has been immersed in betadine (Betaisadona), can be ?tted.
To do this the assistant holds the skin and gland tissue using a medium-sized Langenbeck retractor demonstrating the apex with strong traction in a cranial direction.
The operating surgeon ?xes the implant at the opening with his or her index ?nger and uses the other hand to prevent the implant from sliding out.
Through alternating movements of both index ?ngers,the implant is introduced through the small opening.
In doing this the correct position of the prosthesis must be checked,and it must not be allowed to unfold.
The incorporated prosthesis is then smoothed out both above and below the implant using the ?nger. 
■ In the center of the base,i.e.,on the underside of the implant,there is a small nipple.
After incorporation of the implant,this should be positioned approximately at the height of the actual nipple.
The implant must be free over its whole base and without folds and ideally ?ll out the entire dissection boundaries,without causing impressions,particularly in the cranial and medial part (bulging);if this is the case,the dissection of the implant site has not been suf?cient.
In these circumstances a smaller implant must be used or the implant pocket must be enlarged. 
This cannot happen if the shape and size of the implant have previously been correctly determined using the sizer.
Exact Positioning of the Implant 
■ If the desired implant is in the correct position and has an optimum ?t,it is immersed once more in betadine solution and is implanted in the way described.
In the process it must be possible to feel the small marking in the central region of the base of the implant using one’s middle ?nger to ensure that the positioning of the latter is correct.
The implant is smoothed above and below using the middle and index ?nger.
A check is carried out to ensure the implant ?ts the implant pocket exactly.
Insertion of the Redon Drain (size 10) 
■ A size 10 Redon drain is used for wound drainage.
It empties laterally and is ?xed using one suture.
One should ensure that the implant is not damaged and that the drain is positioned in such a way that between the implant and muscle fascia it extends from the edge of the incision to the medial dissection margin.
Deep Wound Closure 
■ Three concealed 2.0 Monocryl interrupted sutures are used as deep ?xation sutures,which connect the lower dermis with the fascia.
This suturing is important to achieve a stable,lower boundary to the inframammary fold and to avoid a later sinking or slipping of the implant in a caudal direction.
Consequently,the sutures must be deep and complete, protecting the implant,so that no dehiscence can occur.
The Redon drain should not lie under the suturing but rather should,prior to this,be pushed under the implant in the direction of the sternum.
For suturing the assistant should hold the implant away in the cranial direction using a Langenbeck retractor to ensure that there is no accidental puncturing of the prosthesis by the sutures.
Two-Layer,Atraumatic Wound Closure Using 4.0 Monocryl 
■ Following subcutaneous closure with 2.0 Monocryl interrupted sutures there is already good,tension-free wound closure of the skin.
Subsequently,the skin is closed continuously,intracutaneously using 4.0 Monocryl.
One concealed knot is made at the beginning and the end of the suture so that this thread does not have to be pulled out later.
Since we have been using only Monocryl sutures in breast surgery,we have not observed any problems with healing,thread granulomas or poor scar healing.
If good care is taken of the scar,the incision generally heals without any problems and is virtually invisible.
Dressing 
■ After wound closure,the incisions are closed using Steri-Strips that the patient may remove herself after 8days.
In addition to the dressing, small pieces of gauze and 10?15cm Cutiplast plasters are applied to the nipples,and a 10?10cm folded pressure dressing and 10?15 cm Cutiplast plaster are applied to the submammary incision.
Subsequently,a bandage is used for postoperative compression.
After 2days this is changed to a sports bra of the appropriate size.
Aftercare 
■ After the operation the patient is monitored for 24h.
The blood pressure is monitored and it ought not to be above 120mg systolic.
During this time the patient must stay in bed on her back with the upper body raised by 30°.
The ?rst day after the operation the Redon drain is removed and the bandage is changed.
If the course of the recovery is without problems,the patient is given a well-?tting sports bra.
This is adjusted in the clinic and the patient must wear it at home for 4weeks.
Where the implant is beneath the muscle,we recommend that the patients wear a ‘Stuttgart belt’.
This reduces muscle swelling,produces a supple connective tissue site (long-term study from the USA) and accelerates the contouring process. 
For the ?rst 8 days after the operation,the patient receives an antibiotic (cefaclor) and triamcinolone acetonide tablets,8mg per day.
After 8 days,the patient can remove the Steri-Strips herself.
The incisions must be taken care of for 2 weeks using dexpanthenol ointment,and after 4weeks silicone gel must be used or a plaster applied for 2 months.
Four weeks after the operation it is possible to do heavy physical work and sport.
Social activities and work do not pose a problem after 8days. 
Patients are requested to go to the breast clinic immediately if there are any problems.
After 12months there will be a ?nal check with precise photo documentation.
Appendix:Breast Augmentation Submuscular Access 
Submuscular access is more dif?cult,involves more bleeding and is more time-consuming.
This operation technique is indicated when the skin and glandular tissue are unfavorable and too thin:if the implants were incorporated above the muscle,the skin covering would be too thin and rippling and the impression of an implant would be inevitable.
In this case the implant must go underneath the muscle.
It cannot be said that one method is better than the other;the operating surgeon should,based on his or her experience,decide in each individual case whether the implant should be placed above or below the muscle.
A submuscular implant is appropriate if the following conditions exist: 
? Glandular hypoplasia,with thin covering of soft tissue 
? Postpartum involution atrophy with moderate surplus of thin soft tissue 
? Glandular aplasia 
? Previous subcutaneous mastectomy 
? Recurrent capsular ?brosis 
? Pressure atrophy of the breast where an implant is already in place 
In over two-thirds of the cases it will be ?ne to position the implant above the muscle.
This is why there is more detail about this method in the manual. 
■ If the implant is positioned underneath the muscle,then the points of attachment of pectoralis major are detached along the rib from the intermediate area medially in the direction of the sternum,where one should always ensure that there is a distance of 3cm or two ?ngers from the right to the left breast between the two implant pockets.
The implant pockets must not communicate.
■ The dissection may be carried out using a scalpel or Metzenbaum scissors.
It is recommended,however,that the electric scalpel be used since this produces less bleeding.
One should always use the rib for orientation.
When carrying out the dissection,one should ensure that no perforations are produced in the intercostal spaces.
A good light source is required for submuscular dissection,so that one can also stop bleeding in the deeper regions without dif?culty.
■ Like the supramuscular access,the beginning of the dissection is very important,as this is when the correct layer is demonstrated.
Then, even when carrying out dissection under the muscle,much of the detachment can be carried out using the middle or index ?nger as a blunt instrument.
In the medial and caudal part it may be necessary to cut through the connective tissue and strong muscle ?bers using a sharp instrument,either with Metzenbaum scissors or the electric scalpel.
If the electric scalpel is used,care must be taken to avoid perforations.
This diagram illustrates how the pectoralis major is inserted on the sternum caudally.
This part of the insertion,depicted with the dotted line,is detached up to the height of the nipple using scissors or the electric scalpel.
The process of completely cutting through it can be monitored using the adipose tissue behind as a guide,as this will become visible because the muscle retracts.
Meticulous hemostasis must be carried out twice in order to avoid postoperative bleeding,which always occurs during the ?rst 24h.
These two ?gures show the position of the implant underneath the muscle and above the muscle,respectively.
One can see that as a result of the traction and ?tting of the implant,the muscle retracts after being detached and this ensures good coverage over two-thirds of the implant.
The three-layer wound closure is the same for both access methods. 
The concealed ?xation suture of the muscle fascia with 2.0 Monocryl is important since this ensures that the inframammary fold is de?ned and a stable counter-position to the implant is created.
Results 
Patient I: This is a 24-year-old patient whose breasts did not make her feel like a woman.She wanted her breasts enlarged to a size 75 B. 
For this patient,access via the inframammary fold was used to insert a 230-g round,low-pro?le implant produced by Inamed.
The implant was placed above the muscle.
Patient I: Twelve Months After the Implant Normal wound healing, no scar formation, no ?brosis. 
The breast has an anatomical shape with a round implant.
Patient II: This is a 45-year-old patient who had given birth twice.
She expressed a desire to have breasts like she had before the births,now that she had ?nished having children.
A supramuscular implantation with a 260-g round,low-pro?le implant was carried out using the supramuscular access on this patient.
Twelve months after the operation:The breast shows no scar formation and has a natural shape.
An outsider would not notice that breast augmentation had taken place.
Patient III:32-year old patient with breast hypoplasia and thin skin covering with prominent sternum.
Implant 290,submuscular.
It is up to the experienced surgeon to decide whether a submuscular implant is appropriate.
If there is any doubt,then the submuscular implant is the safe option.
There has been no de?nitive scienti?c clari?cation relating to the incidence of capsular ?brosis.
Introduction 
Many patients who wish to improve the shape of their upper arms have a considerable surplus of skin.
The cause can be,for example,massive weight loss,but the process of skin aging can also leave such signs.
In this case only excision can produce the desired improvement in the contour.
Even the most careful upper-arm tightening,however,will result in a scar on the medial side of the arm,starting in the armpit and stretching as far as the elbow.
The patient must therefore be informed accordingly because most patients want this procedure in order to be able to show their arms in public again.
Upper-Arm Tightening 
Upper-arm tightening is requested increasingly by women over the age of 60.
It is often surprising that women of this age do not have a facelift; instead they are more bothered by their ?abby upper arms when they want to wear a bathing suit or sleeveless clothes.
The only way of eliminating the surplus skin and the wrinkles in the long term is cutaneous excision.
The art of the surgeon in doing this is to position the incision in such a way that it is on the medial side of the upper arm and to ensure that the resection of the skin is carried out so generously that the entire upper-arm region is tightened.
Upper-arm tightening is not technically dif?cult.
The thick skin/fat ?aps are dissected off the fascia,protecting the nerves and vessels,following exact marking of the incision line.
The same basic principle applies to all operations to tighten the skin,namely,that the ?ap is mobilized and, following appropriate measurement,is then ?xed in place in stages with key sutures so that neither too much nor too little skin is removed. 
Mang’s principle always applies:I can measure ten times but only cut once.
This should always be kept in mind so that each resection border is measured precisely.
The resection border will then be sutured without tension and no surplus.
As cutting too far towards the olecranon process during upper-arm tightening often causes problems in patients with poor healing,we developed the “?sh-mouth”incision in our department.
This means that an incision in the shape of a ?sh mouth is made in the axilla,stretching to the middle of the medial side of the upper arm.
This leads to a scar in the axilla and in about the upper third of the medial side of the upper arm,which is not so obvious.
Furthermore,the ?sh-mouth incision also achieves tangential tightening in the axilla and vertical tightening in the upper-arm area,so the troublesome surplus skin and the folds of skin in the axilla and upper third of the upper arm when wearing sleeveless clothes are eliminated.
Every patient must be informed of the possibility of scarring as a result of this operation.
Aftercare is also very important.
Subsequently,the scars are treated with ointment and silicone dressing.
Duplicate Patient Information
The patient is ?rst given comprehensive information about the objectives and risks of the procedure on the day of the ?rst consultation. 
A written record is kept of this.
One day before the surgical procedure,the patient is again given comprehensive information on two separate occasions:once by the surgeon and once by the surgical resident.
All the risks are set down in writing at this time.
Preliminary Examinations
Current preoperative routine laboratory examinations,ECG,chest X-ray, clinical examination.
Photographic Documentation 
■ Frontal view of the arms with the patient standing. 
■ Arms abducted by 30°–45°at the shoulder joint.
Surgical Planning 
The procedure is carried out under tumescent local anesthesia or under general anesthesia with endotracheal intubation.
On the day before the operation the surgeon discusses in detail with the patient which changes he or she wants and how the surgeon can achieve this.
The patient must be warned about unrealistic expectations and must be fully informed about postoperative behavior,in particular about how to care for the scar.
Intraoperative single-shot injection prophylaxis with cefaclor 2g. 
Compression dressing,patient is monitored for 24h.
Preliminary Marking of Incision Lines 
■ Before the operation,the areas of surplus skin are marked with the patient standing with his/her arms slightly abducted and bent at the elbow joint to 70°.
Optimum preoperative marking is extremely important for brachioplasty.
The surgeon must take his/her time and position the incision in such a way that it cannot be seen either from the front or the back when the patient’s upper arm is hanging down.
In order to do this the surgeon holds the surplus skin together between the thumb and index ?nger of his/her left hand and marks the outer resection border with a pen.
In general,markings are made for the upper longitudinal incision about two ?nger widths above the sulcus bicipitalis medialis. 
The exact course of the lower incision is only de?ned during the operation.
To achieve a symmetrical result,however,the incision is marked approximately before the operation.
If appropriate,the spindlelike resection in the axilla can be extended in an axillary direction by Z-plasty or a vertical ellipse.
In all aesthetic resections of cutaneous/fatty ?aps in the head,neck,or body the ?nal resection is carried out in stages in order to ensure that neither too much nor too little is removed,as in both these cases the result would be unsatisfactory.
The skill of the aesthetic surgeon is to have a feeling for the tissue,to be able to think in three dimensions,and to be able to ful?ll the patient’s wishes with a rigorous explanation of the procedure.
An aesthetic surgeon can only be successful in the long term if he or she does this.
Mang’s Fish-Mouth Technique 
In appropriate cases,i.e.,when the folds of skin do not extend a long way into the elbow region,a variation of the incision,without extension beyond the cranial third of the upper arm,can be successful.
With this incision not only vertical tightening in the upper arm area is achieved, but also tangential tightening in the axilla.
The advantage of this incision is that the scar is barely visible,and skin folds in the axilla and upper third of the upper arm can be eliminated very effectively.
The scar can hardly be seen at all when sleeveless clothes are worn.
Positioning,Disinfection 
■ The patient’s arms are abducted by 90°before the operation.
Care should be taken to position them correctly so that there is no pressure or traction in order avoid damaging the brachial plexus.
Disinfection with Cutasept is carried out to the edges and to the breast region.
Tumescence 
■ Tumescence is then performed without blurring the marked borders. 
Approximately 200ml of tumescence solution without the addition of triamcinolone acetonide is injected manually per side (0.9% NaCl, 500ml,1% prilocaine 250mg=25ml,epinephrine 0.5mg, 8.4% NaHCO3 5mEq). 
■ Tumescence is carried out in the layer where dissection will later be done, i.e.,on the fascia of the upper arm,so that the skin/fat ?ap is separated from the fascia by the injection itself.
During tumescence the surgeon can feel the thickness of the ?ap and can therefore carry out dissection quickly and with almost no bleeding.
The tumescence also predetermines the level of dissection,so that no deeper vessels or nerves are damaged.
Incision 
■ The incision starts at the marked line above the sulcus bicipitalis medialis.
The incision made with a size 15 scalpel should be wedge-shaped (30°),so that when the wound is closed later (equilateral triangle with the deepest point on the upper arm fascia),an inverted scar is not produced.
Super?cial Preparation 
■ After the upper,tangential (30°) incision has been made,the assistant inserts a sharp retractor and pulls it forward gently so that dissection can be done more easily with a scalpel.
It should be ensured that the medial brachial cutaneous nerve is not damaged.
Deep Preparation,Hemostasis 
■ The skin ?ap is best dissected by pulling it upward with two fourpronged retractors.
During this procedure the assistant should ensure that the retractors are pulled forward gently.
At the same time the assistant can carry out hemostasis with bipolar tweezers.
As a result of the tumescence in?ltration,the surgical area is clearly visible and not covered with blood.
This enables dissection from the fascia of the upper arm to be carried out quickly.
The surgeon can do this with either scissors or a scalpel.
Incision of the Dissected Dermofat Flap in Stages 
■ Once the skin/fat ?ap along the fascia of the upper arm has been dissected to deep within the marked resection border,Backhaus clamps are attached to both ends and rotated gently in a cranial direction.
Resection of surplus fatty tissue,in particular at the cranial and caudal incision borders,is carried out appropriately.
Incision of the dermofat ?ap at marked sites is then done while monitoring the tension.
When doing this it is important that the incisions are made under slight tension stage by stage in line with the cranial incision line to prevent too little skin from being excised,resulting in an unsatisfactory result,or too much skin being excised,resulting in the scar being placed under too much tension (risk of hypotrophic scarring).
Fixing of the Skin Flap with 3.0 Monocryl Key Sutures 
■ 3.0 Monocryl key sutures are placed at the incisions of the marked points.
In doing this the correctness of the extent of the incision and later resection can be checked once again.
After ?xing the skin ?ap,the surplus sections of skin and possibly of fatty tissue can be seen;these must be removed before skin resection.
Resection in Stages 
■ Resection is carried out in stages while keeping an eye on the resulting skin tension.
Following resection,subcutaneous tissue remains on the fascia without undermining.
As a result,no wound cavity is created, which would promote seroma formation.
Redon drains are not required here. 
■ Resection is carried out in stages with a size 15 scalpel,and the assistant holds the sections of the ?ap to be resected upwards under tension with two Backhaus clamps in order to achieve a clean resection border.
Two-Layer Skin Closure 
■ The skin edges are closed with concealed subcutaneous interrupted 3.0 Monocryl sutures.
Each successive suture bisects the wound length;this prevents “dog ears”at the end of the sutures.
It is best if the sutures are started at the distal end and progress to the middle.
Suturing can then be started at the proximal end (axilla) and continued to the middle. 
■ Complete wound closure is then carried out with two-layer 4.0 Monocryl interrupted sutures.
The wound is closed,therefore,with so little tension that the cutaneous suturing (running or intracutaneous) then only plays a minor role.
Cutaneous Sutures:Running or Intracutaneous 4.0 Monocryl 
■ In general,we carry out all cutaneous suturing intracutaneously with 4.0 Monocryl.
This suturing method has proved to be the best,as it does not need to be removed and does not cause granulomas.
It produces optimum healing of the suture line. 
Running sutures should also be mentioned in this manual.
A study (n=25) comparing running sutures with intracutaneous sutures showed that results were similar.
Running sutures are removed after 8days.
Dressing 
■ Steri-Strips are ?rst applied as a dressing to relieve the tension on the cutaneous sutures.
Afterwards,sterile cotton is wound around the Cutiplast wound dressing.
In addition,the arm is then loosely wrapped with elastic bandages from the wrist to the shoulder.
Aftercare 
The operation can be carried out either on an inpatient or outpatient basis. 
■ The dressing is removed on the ?rst postoperative day.
The Steri-Strips are left in place for 8days and can be removed by the patient.
During this time there should be antibiotic prophylaxis and the arm should be elevated.
The patient should avoid physical exertion for a period of 2–3weeks in order to permit undisturbed wound healing.
To prevent congestion of the lymphatics,lymph drainage can be carried out from the 8th postoperative day.
After removing the Steri-Strips,the patient should treat the scar with dexapanthenol ointment for 2weeks and then with silicone ointment for a further 2months.
If after 2months it can be seen that scarring is disturbed,it can be treated,as with all scars,with intralesional injections of triamcinolone crystal suspension 40mg.
With any scar this treatment should be carried out as soon as possible,as these injections improve erythema and bulging scars considerably in the ?rst few months. 
In extreme cases hypertrophic scars must be excised after a period of 12 months and treated with stimulating radiation in divided doses for several days immediately after excision.
Cooperation with an experienced radiologist is necessary for this.
Note: It is possible to insert a Redon drain to drain off wound secretions. 
In most cases,this may be removed as early as the ?rst day after the operation.
Results 
Patient I:This is a 64-year-old patient with skin folds owing to her age in the entire axilla and upper arm region,extending to the elbow.
In this case a longitudinal,spindlelike excision was carried out.
Patient I:Twelve Months After the Operation Twelve months after the operation there is no noticeable scarring, and the skin folds have been eliminated as far as the elbow area.
Patient II:This is a 59-year-old patient with folds of skin in the upper third of the upper arm,extending to the axilla. 
The “?sh-mouth technique”was used for this patient,i.e.,the incision was only in the axilla and the upper third of the upper arm.
This results in a shorter operation time and less scarring.
Patient II:Twelve Months After the Operation 
After eliminating the folds,the volume was also reduced.
The incision in the axilla and the upper medial part of the upper arm is not visible.
Introduction
If the result of liposuction in the abdominal area is inadequate or there is an excessive overhang of abdominal skin and subcutaneous adipose tissue,it may be bene?cial to perform an abdominoplasty to improve the functional and aesthetic result.
In the abdominoplasty,the surplus section of abdominal skin is removed with the attached subcutaneous adipose tissue.
In a few cases,resection of the infraumbilical surplus tissue will be suf?cient,but usually a complete abdominoplasty with umbilical translocation must be performed to achieve optimal results.
In this procedure,tightening of the periumbilical area is also extremely signi?cant, for example,with extreme fold formation following pregnancies.
Rarely, there is also slackening of the abdominal muscles.
This should be treated prior to tightening of the abdominal wall (e.g.,by physiotherapy).
The patient’s skin type and age play an important part in this operation. 
In many cases,it is not possible to remove all the folds and striae and this must be explained to the patient.
Furthermore,female patients must avoid pregnancy in the foreseeable future.
It is not necessary to achieve a speci?c weight for this procedure,but a few conditions relating to this should be ful?lled.
The body weight should have stabilized several months before the procedure,and this should be at a level the patient can maintain after the procedure.
Tightening of the Abdominal Wall
An experienced aesthetic surgeon must look carefully at the indications for liposuction and for tightening of the abdominal wall.
At present, unfortunately,a decision is taken to carry out liposuction too often,and the patient is later disappointed if the skin then hangs down loosely. 
Frequently,tightening of the abdominal wall is requested by patients who have increased skin accumulation around the umbilical area and a slack lower abdominal wall following pregnancies
.It is also frequently requested by patients who have lost a lot of weight (20–40kg) and by older patients who have a slack abdominal wall.
If performed correctly,the operation itself will be successful in the longterm and satisfactory for the patient.
In relation to the surgical technique,in addition to precise dissection of the abdominal fascia with immediate hemostasis,the incision line in the bikini area must be marked carefully and the repositioning and reconstruction of the navel must be performed well so that the result is satisfactory for the patient.
It must be ensured that there are no umbilical or abdominal wall hernias.
For reconstruction of the navel,we have described the method that we ?nd the easiest and most comprehensible and has provided the best results.
When making the incision in the bikini area,it should be ensured that no “dog-ears”are formed at the side and that,following complete dissection as far as the costal arch with the upper body slightly angled, resection of the skin is carried out in stages with key sutures in such a way that the skin ?ap is resected precisely,section by section,and without any signi?cant tension so that necrosis is avoided.
The video shows that the fat is resected obliquely,also stage by stage,to avoid any postoperative retraction of the ?ap.
Immediate hemostasis is important so that the Hb value does not fall below 8mg/dl.
It is recommended that obese patients give an autologous donation of blood 4weeks before the operation.
Patients must also be given thrombosis prophylaxis and infection prophylaxis intra-operatively and for 10days after the operation.
Duplicate Patient Information
The patient is ?rst given comprehensive information about the objectives and risks of the procedure on the day of the ?rst consultation. 
A written record is kept of this. 
One day before the surgical procedure,the patient is again given comprehensive information on two separate occasions:once by the surgeon and once by the surgical resident.
All the risks are set down in writing at this time. 
Severe blood loss requiring a transfusion of blood or blood components occurs rarely.
An autologous blood donation may be very sensible for obese patients and for extensive reconstructions of the abdominal wall.
It is possible to avoid damaging the internal abdominal organs by carrying out an ultrasound examination before the operation and by ruling out hernias.
Otherwise,if there is an umbilical hernia,the abdominal cavity may be opened up during the dissection of the navel.
As the wound surface is large,the patient must be made aware that postoperative bleeding,hematomas,and wound-healing disturbances may occur following the operation.
Therefore,the operation must be performed in the hospital,careful postoperative wound checks must be carried out, and thrombosis and antibiotic prophylaxis must be given.
If the scars are taut,they may enlarge and this may result in thick, distended,discolored,painful scars.
Preliminary Examinations 
■ Current preoperative routine laboratory tests,ECG,chest X-ray 
■ Clinical examination of the patient with ultrasound ?ndings to rule out hernias 
■ Possibly two autologous blood donations
Photographic Documentation 
■ Patient in standing position from the front 
■ Patient in standing position from two sides 
■ Patient in standing position from behind
Surgical Planning
Tightening of the abdominal wall is indicated if the skin no longer shrinks following substantial weight loss,or after a pregnancy that has overstretched the abdominal skin and,as a result of this,the elastic ?bers of the skin have been destroyed (cellulite) or the abdominal muscles have been strained and have moved away from one another in the center, which has resulted in divari?cation with a midline hernia.
Retracted and painful scars following a gynecological operation (caesarian section) can also be a reason for tightening the abdominal wall.
If the patient is severely overweight,weight loss before the operation is necessary.
In rare cases,tightening of the abdominal wall may be combined with liposuction.
The operation is performed under general anesthesia.
The type of incision depends on the type and amount of surplus skin.
On the day before the operation,the surgeon has a discussion with the patient about the changes requested by him/her and the performance of the operation itself.
The incision is marked precisely on the patient,who should be in a standing position.
When doing this,it should be ensured that a median line runs from the xiphoid process over the navel to the mons pubis and that there are no differences in the sides when drawing the line.
A vertical incision is to be avoided.
If there is not too much surplus skin,it is better to site the incision slightly more cranially.
The incision line is usually to be marked through the layer of fat and the surplus skin.
A good estimation of how high the incision must be to avoid the necessity of a vertical incision can be made before the operation.
This is the surgeon’s art. 
Whether the incision line is horizontal or W-shaped is not important. 
The important factor is the patient’s individual anatomical characteristics,and the individual incision line should be adapted to these.
Thrombosis prophylaxis with s.c.fractionated heparin given once daily should be started the day before the operation.
This thrombosis prophylaxis should be continued for 10days after the operation,as one of the main risks in tightening of the abdominal wall is the danger of thrombosis and embolism.
Intraoperative infection prophylaxis with cefaclor 2g.
Postoperative Treatment
In order to relieve the pressure on the sutures,it is necessary to position the bed in a speci?c way for the ?rst 3days after the operation.
The knees should be at an angle and the upper body slightly raised.
The patient should be mobilized as early as the ?rst day after the operation to prevent blood clots forming.
Initially,there should be no extension of the upper body,so that wound healing is not impaired.Frequent movement of the legs is good,as this promotes the return blood ?ow.
On the second day after the operation,the Redon drains are removed,the dressing is changed,and a special compression girdle is ?tted.
Thrombosis prophylaxis (fractionated heparin s.c.) and antibiotic protection (oral cefaclor) should be carried out for 10days after the operation.
The compression girdle should be worn for 4weeks;then intensive care should be taken of the scar with silicone gel and/or silicone plasters.
It is possible to resume sporting activities after 8weeks.
Typical Findings:Indications for Tightening the Abdominal Wall 
The limit of the indications for liposuction in the area of the abdomen/hips is exceeded if either the skin is slack and cracked (severe cellulite) following pregnancies or all the skin of the lower abdomen is slackened as a result of the aging process or extreme weight loss. 
The incision line is marked through the surplus skin and should not be extended beyond this laterally and cranially in the bikini region.
Marking the Individual Incision Line 
■ Before the operation,the midline from the xiphoid process to the mons pubis and the W-shaped or arched horizontal incision line will be marked on the patient,who should be standing.
The horizontal incision line should be marked in the pubic hair boundary to approximately 3–4cm caudal to the anterior superior iliac spine on both sides or steeper/straighter according to the requirements and the patient’s characteristics.
Therefore,the most wide-ranging incision variations are possible,depending on the individual ?ndings for the patient.
It is important that the incision line is marked in the relaxed skin tension lines,preferably does not extend beyond the bikini region,and is selected in such a way that a vertical incision is not required.
It may also be useful to mark the course of the costal arch for orientation.
Positioning,Disinfection 
■ The operation is performed with the patient in a supine position.
The upper body is raised by 30°and the hips and knee are slightly ?exed.
It should be ensured that the extremities are well padded and positioned. 
An indwelling catheter is inserted that should be left in place for 24h.
Tumescence 
■ Following disinfection and sterile draping,the incision is tume?ed with 500ml tumescence solution (0.9% NaCl 500ml,1% prilocaine 250mg=25ml,epinephrine 0.5mg,8.4% NaHCO3 5mEq).
The tumescence solution (500ml) should not be injected more than twice,and this will not be necessary.
Larger quantities of tumescence solution given under general anesthesia may increase the danger of thrombosis and cause hypervolemia and even pulmonary edema.
Incision 
■ Following the individually marked incision line,a sharp incision is made with the size 10 scalpel as far as the rectus fascia.
The scalpel should be introduced at an angle of 30°so that the resection edges can be brought together later,section by section,without the formation of cavities below and depressions above.
The subsequent scar is a sign of a wellperformed abdominoplasty.
Preparation of the Lower Abdomen 
■ After the abdominal fascia has been identi?ed,the cutaneous/fatty ?ap is dissected cranially along the super?cial fascia.
The correct layer can be easily dissected with both sharp and blunt instruments.
The perforating vessels are electrocoagulated. 
■ Dissection must be performed with careful hemostasis,as otherwise there may be a drop in the Hb value later owing to the large wound surface.
The abdominal fascia must be handled carefully and perforations must be avoided.
Purse-string suturing can also be carried out if there is more severe bleeding.
If the fascia is damaged,this must be closed immediately with 3.0 Vicryl interrupted sutures.
Incision Around the Navel 
■ If dissection is performed in the lower abdomen as far as the level of the navel,a circular incision should be made around the navel.
The assistant holds the cranial and caudal areas of the region taut with two singlepronged retractors so that the incision can be made easily.
Mobilization and Dissection of the Navel 
■ Here the dermofat ?ap is mobilized away from the navel.
The assistant then holds the dissection area taut with the two single-pronged retractors and using surgical tweezers.
In the further dissection with the Metzenbaum dissection scissors it must be ensured that the umbilical stalk is suf?ciently thick and that a wide base is created during the dissection to prevent later perfusion disorders of the navel. 
Bleeding should be stopped carefully with the bipolar tweezers.
Vertical Splitting of the Dermofat Flap as Far as the Base of the Navel 
■ To facilitate further cranial dissection,the dermofat ?ap is incised longitudinally in the median line from the edge of the wound to the navel.
The assistant pulls the edges of the wound upwards with two Backhaus clamps.
A large wound retractor can also be used for obese patients. 
■ The length of the median line between the two points a and b is precisely such that later,after resection of the skin,the edges of the wound meet section by section without a vertical incision being necessary.
In relation to this,point a,the border of the incision edge,varies depending on the surplus skin,i.e.,the more surplus skin that is present,the deeper point a is located.
If there is less surplus skin,this point (a) must be correspondingly higher so that later there will be only a horizontal scar.
Complete Mobilization of the Umbilical Stalk 
■ By vertically dividing the dermofat ?ap,it is easy to dissect the umbilical stalk cleanly and with a broad base while it is in view.
The supplying vessels must be retained at the base.
If an umbilical hernia or hernias of the abdominal wall have been diagnosed before the operation,these should be treated appropriately during the operation.
The wound surfaces and the navel should be covered during the procedure with moist, warm compresses.
Dissection of the Upper Abdomen
■ Following mobilization of the cutaneous/fatty ?ap,dissection is continued in a lateral direction as far as the xiphoid process and the costal arch (forming the waist). 
■ The lateral dissection can be performed deeply and bluntly.
To do this,a moist compress should be wrapped around the right middle and index ?ngers and the entire lateral section,from the lateral costal arch to the iliac crest,can thus be pushed away bluntly.
■ The assistant must ensure immediate hemostasis at all times by using the bipolar or monopolar tweezers.
Depending on the surgeon’s preference,sharp dissection can be done with the size 10 scalpel blade or with large dissection scissors. 
It may be useful to use an illuminated retractor in the vicinity of the xiphoid process and at the base of the ribs.
There is an increased possibility of bleeding with dissection of the xiphoid process in the area of the costal arch using a sharp instrument.
The bleeding must be controlled by immediate and rapid coagulation or purse-string suturing.
Doubling of the Rectus Abdominis Fascia 
In patients who have lost a lot of weight after being severely overweight, there is sometimes overstretching of the abdominal muscles so that these move away from one another in the center.
In extreme cases,a midline hernia occurs.
Appropriate surgical treatment should then be carried out for these. 
■ In order to achieve a good result for the tightening of the abdominal wall,doubling of the fascia longitudinally is routinely carried out with 0 Vicryl sutures (interrupted mattress sutures) and,depending on the ?ndings,doubling obliquely.
This doubling of the fascia must be based on the individual ?ndings.
This allows a good base to be created for the later skin/fat tightening. 
■ For body contouring,suction can also be carried out in the area of the hips during the operation via the open abdominal wall.
There are many variations in aesthetic/plastic surgery for optimizing the result.
However, a basic requirement is good basic knowledge and mastery of standard operations.
De?ning the Resection Boundaries with Upper Body Flexed at 30° 
■ Following prior precise wound revision and hemostasis,the entire cutaneous/fatty ?ap is pulled down under traction with the upper body ?exed (30°) to de?ne the boundaries for later resection.
In an ideal case,point b will meet point a.
This ensures that a vertical excision will not be necessary and therefore no troubling scar will occur.
If the abdominal wall is very slack,the distance may be greater.
In such cases,it is important that the later scar is formed section by section,without tension and that it is not retracted and there is no surplus skin with a distended overhang.
Repositioning of the Navel Using a V-shaped Incision 
■ To ensure the scar is aesthetically pleasing a V-shaped incision is made at the new insertion site of the navel following prior con?rmation of the correct position.
The easiest method of doing this is for the surgeon to feel the umbilical stalk beneath the dermofat ?ap with his middle ?nger, to determine the position by exerting slight pressure in a cranial direction with the middle ?nger and by marking a point corresponding to the tip of the ?nger with a marking pen using the other hand.
Pulling the Navel Out of the V-Shaped Incision with Curved Forceps 
■ With the aid of long curved forceps the navel is gripped at the holding sutures and pulled upward.
Positioning the Navel 
■ The navel is positioned outwardly and ?ts into the correct position in the external cutaneous incision without tension.
Trimming of the Skin of the Navel and Adaptation to the V-shaped Incision 
■ To interrupt a circular navel scar line the lower third of the navel is removed to correspond with the V-shaped incision in the abdominal wall.
This simple and effective method of reconstruction of the navel prevents disturbances to wound healing,necrosis of the navel,and cosmetically unpleasant changes in the area of the navel.
The navel thus has a natural appearance.
Closure of the Navel in Three Layers 
■ In order to avoid later disturbances to healing and necrosis,the navel must be ?xed in place in three layers.
At the base,this is with deep ?xation with absorbable suture material of strength 3.0.
To allow further perfusion and stabilization of the navel using the peri-umbilical adipose tissue,5.0 Monocryl interrupted sutures are then inserted.
The skin is adapted with continuous intracutaneous suturing with 4.0 Monocryl. 
This ensures that the navel is well stabilized,has contact with the dermofat ?ap on all sides and that no serous swellings can form in spaces.
Fixation of the Surplus Sections of Skin with 2.0 Monocryl Key Sutures 
■ The surplus skin is pulled down under slight traction to de?ne the resection boundaries.
2.0 Monocryl key sutures are placed at equal intervals, and this allows the surgeon to identify as early as this stage of the operation how far the resection must be taken laterally if“dog-ears”are to be avoided.
The incision can be extended in a lateral direction at this stage of the operation,depending on this.
The trick for all tightening operations is that the amount of skin that must be removed can be de?ned exactly prior to resection by positioning key sutures.
This ensures that the later result will be good and the scar pleasing. 
■ The individual key sutures are placed one after the other so that individual corrections can be made at any time.
Resection of the Skin in Stages 
■ Resection of the skin is performed with regular checks on the tension of the remaining skin.
The skin/fat resection should be performed at an angle of 70°so that the lower border of the incision of 30°meets the upper border of the incision section by section with no retraction or bulging. 
■ After the resection has been completed,particles of fat and surplus skin that spoil the result should be removed.
The lateral edges of the incision should also be checked and any “dog-ears”must be evened out.
Insertion of Redon Drains 
■ Two size-12 Redon drains leading out onto the shaved mons pubis are inserted into two sections of the lower abdomen before the skin is closed.
The Redon drains are removed after the second postoperative day and the catheter is removed after 24h.
Wound Closure in Three Layers 
■ Skin closure is carried out layer by layer,?rst with concealed 2.0 Monocryl interrupted sutures,then with concealed 3.0 Monocryl subcutaneous interrupted sutures.
Finally,the wound is closed with running 4.0 Monocryl sutures.
For this,it is important that suturing begins at the lateral ends on both sides so that the two sutures meet at point a.
This prevents the skin being uneven in the lateral area and produces the desired traction in a medial direction.
Dressing 
■ The navel is packed with a ?ne gauze soaked in betadine (Beta-isadona) ointment and covered with Cutiplast.
The other incisions are closed with adhesive Steri-Strip dressings.
These dressings can be removed after 8days when the wound is checked.
The Tensoplast adhesive dressing remains in place until the Redon drains are removed.
A special compression girdle is then ?tted that should be worn for 6 weeks.
The fresh scars are treated with dexapanthenol ointment for 14 days after the operation, then with silicone ointment or silicone plasters for 2months.
Fitting the Abdominal Belt 
■ In addition to a Tensoplast bandage,an abdominal belt is also used until the Redon drains are removed.
This ensures good compression on the detached wound surfaces,which prevents serous swellings and bleeding. 
During this time,the patient should have bed rest in a slightly angled supine position with the upper body raised.
■ The abdominal belt should be ?tted with traction.
It should be loosened if the patient has dif?culty breathing.
Thrombosis and infection prophylaxis must be carried out during the patient’s stay in the hospital.
Note: For safe dissection of the navel,it is important to ensure that the tissue is fully supplied with blood.
However,if too much adipose tissue is left,this may cause elevated pressure on the repositioned navel.
In addition,the ‘steal phenomenon’may result,since the adipose tissue left behind may require part of the blood supply. 
Compression of the abdominal wall using the abdominal bandage should not be too severe,as this may cause necroses of the distal end of the ?ap (“most poorly perfused area”).
The distal end of the wound must never be undermined! 
Deep ?xation of the navel requires precise localisation of the navel opening.
A two-layer wound closure may be used if desired.
Results 
Patient I:This is a 46-year-old female patient after three pregnancies with divari?cation of the recti and fat ?ap.
Doubling of the fascia was carried out in addition to the skin/fat resection and repositioning of the navel. 
Twelve months after the operation.Normal wound healing, good contouring of the abdomen and hips.
Patient II:This is a 49-year-old female patient following substantial weight loss (40kg). 
Twelve months after the operation.Healthy scar.
Introduction 
This is a delicate and often unsatisfactory area of aesthetic surgery.
The operation is requested by women over 50,and usually the patients expect too much.
In horizontal and inguinal tightening of the thigh,the traction component is often so high that it later results in an unsightly scar,and after only a few months the inner side of the thigh develops creases.
In the case of skin that has signi?cant cellulite and slackness of the thighs as far as the knee area,it may be possible to carry out tightening in a vertical direction in a similar way to upper arm tightening,and this can be discussed with the patient.
It should be made clear to the patient, however,that this may produce an unsightly scar.
The technique in an inner thigh lift is similar to that used with the upper arm,namely,a deep,subcutaneous dissection on the fascia and a stepby-step skin resection that has previously been drawn precisely.
The crucial point when it comes to horizontal,inguinal thigh lifts is the strong traction forces.
It is important in this operation that the thigh ?aps are “hung”at two points in order to reduce the traction forces on the skin.
First,this subcutaneous cutaneous/fatty ?ap is ?xed to the periosteum of the pubic bone with a nylon suture.
Laterally the inguinal ligament must be visualized.
This is where the second anchorage takes place in order to prevent dehiscence and subsequent descent of the scar. 
Yet despite hanging at these two points,long-term results are often unsatisfactory.
Patients should be told this when they are given information about the operation.
Nevertheless.the distress of patients is often so great that they are prepared to put up with these disadvantages and therefore often still want the operation.
When tightening the inside of the thigh,after ?xing the two anchoring sutures with the upper body slightly ?exed,the excess cutaneous/fatty ?ap is resected without tension and without steps,so that after the operation a tension-free wound in the bikini area is produced,which must be treated appropriately postoperatively using ointments and silicone plasters.
For an additional 3 weeks,antibiotic protection must also be given and the patients must wear a specially adapted girdle.
The same applies to the buttock lift.
In this operation the problem is the incision line and the visible scar.
With a buttock lift,the incision line should not be much beyond the buttock crease,since this scar is very unsightly.
Similarly,the resection must be carried out in a wedge shape in the form of an equilateral triangle,so that the deepest point,the socalled zero point of the fascia corresponds exactly to the changed crease and the resulting suture lies in what will be the new buttock fold.
Otherwise there is problematic scar formation that is very dif?cult to correct.
In general,one should not combine liposuction with lifting operations, since this may impair the healing process and increase the risk of thrombosis and embolism.
When the skin is still young and elastic,it is possible to remove smaller limited deposits of fat by means of isolated liposuction.
If skin has lost its elasticity through aging or major weight loss,a lifting operation is recommended to achieve cosmetic improvements.
Often,the loose skin on the inner side of the thigh is operated on together with the loose skin on the buttock,since this is a cosmetic unit.
This operation,which is frequently requested,is also demonstrated in the video.
Generally,the operation is largely without complications.
Nevertheless, there may be isolated cases of complications during or after the surgical intervention,despite taking the greatest care.
More severe bleeding is stopped immediately during the operation.
Pressure damage on nerves and soft tissues resulting from incorrect positioning should be avoided. 
These injuries recede,however,after a few days in most cases.
This also applies to skin damage resulting from disinfectant.
After the operation there may be pain and tension that can sometimes last for a lengthy period.
There is also sometimes swelling in the area of the joints,which may last for up to 6 months and can be treated easily by lymph drainage.
The risk of thrombosis is extremely rare since bloodthinning measures are used,surgical stockings are worn,and there is early mobilization.
The main complication is permanent scar formation as a result of impaired wound healing.
Occasionally,if there is a predisposition to this, thick,bulging,discolored,and painful scars are produced (scar proliferation;hypertrophic scars).
With prompt treatment of the scar changes using injections of 40mg triamcinolone,a corrective operation can be avoided.
Duplicate Patient Information
The patient is ?rst given comprehensive information about the objectives and risks of the procedure on the day of the ?rst consultation.
A written record is kept of this. 
One day before the surgical procedure,the patient is again given comprehensive information on two separate occasions:once by the surgeon and once by the surgical resident.
All the risks are set down in writing at this time. 
Although one tries to achieve symmetry before the intervention by precisely drawing the areas of skin that are to be removed,after the operation there may still be small differences between the sides.
If this is very unsightly,it is possible to compensate by making a small extra intervention under local anesthesia without a need to admit the patient.
During the ?rst few weeks after the operation,the scars frequently move caudally. 
If the patient is also given a buttock lift,he/she must be made aware that the shape is primarily determined by the musculature and cannot be substantially changed by the intervention.
Preliminary Examinations 
■ Current preoperative routine laboratory tests,ECG,chest X-ray if the patient is over 50. 
■ Clinical examination of the patient.
Photographic Documentation 
■ Frontal view of patient standing,torso and legs 
■ Side view of patient standing 
■ Rear view of patient standing
Surgical Planning
The operation is performed under general anesthesia with endotracheal intubation.
Before the intervention the affected area is shaved.
The day before the operation the surgeon carrying out the operation discusses with the patient in detail what he/she wants in terms of changes and how the surgeon can achieve this,and draws the incision lines and resection boundaries precisely.
The patient must be warned about having unrealistic expectations and be given detailed information about postoperative measures in order to avoid scar formation as far as possible.
Intraoperative single-shot infection prophylaxis with cefaclor 2g,treatment in the hospital,Steri-Strip dressing,thrombosis (fractionated heparin 1 ampule i.m.preoperatively and 3 days postoperatively) and embolism prophylaxis,special girdle.
If the loss of elasticity and slackness of the skin is con?ned to the upper third of the thigh,the operation may be carried out in a half-moon shaped skin/fat resection in this area (a).
The scar is then located in the groin and runs into the buttock crease.
There is no scar on the inner side of the thigh.
This is the operation that is wanted most frequently and is also presented in detail in the video.
If the overstretched and therefore loose skin stretches over the whole inner side of the thigh as far as the knee,then it is necessary to carry out additional vertical removal of skin/fat,depending on the extent of the skin on the inner side of the thigh (b).
The scar is then located in the groin and on the inner side of the thigh,depending on how far the slackness of the skin extends,to just above the knee.
If there is also pronounced wrinkling of skin on the buttock,then a skin/fat resection must be carried out here as well.
The scar then will be in the buttock crease and runs forwards into the inguinal region.
The resection lines are drawn before the operation with the patient in a standing position.
It must be kept in mind here that the incision line in the area of the inguinal fold should be relatively high (two ?ngerwidths in the cranial direction) since the scars always descend slightly over time and then could be visible in the upper leg area.
The incision in the groin,which is at the height of the pubic hair boundary laterally,generally runs above the inguinal fold to the thigh-perineal crease and ?nishes at the innermost part of the buttock crease,which is lengthened accordingly if there is also a buttock lift.
If only a buttock lift is carried out,then only the resection in the area of the buttocks is drawn according to the extent desired.
Positioning,Disinfection 
■ For the operation,the patient is placed on the operating table in a supine position with the knees as far apart as the shoulders and the hips ?exed at an angle of 30°.
If extensive removal of skin is required, for example,if there has been extreme weight loss,then it may be necessary to use a urinary catheter both during and shortly after the operation.
Tumescence 
■ After shaving and careful disinfection of the whole operating area,the tumescence solution (0.9% NaCl 500ml,1% prilocaine 250mg=25ml, epinephrine 0.5mg,8.4% NaHCO3 5mEq) is in?ltrated into the skin area to be resected along the predrawn incision and dissection boundaries. 
For each side,depending on the extent of the ?abby skin,one needs between 250 and 500ml of tumescence solution.
The tumescence solution is pumped in manually,until a taut elastic skin tension and the typical blanching effect are noted.
The resection area (a) is,as in all tightening operations,only established when,following dissection (b),the exact super?uous skin has been ?xed using key sutures.
Consequently,the same basic principle always applies that before the skin ?ap is resected one makes the incision on the resection line that has been pulled over and only then carries out the whole dissection.
Dissection boundary is dependent on how far the loose skin extends.
Incision of the Skin 
■ The incision is made according to the marks made preoperatively.
Note that the incision line runs for approximately two ?ngerwidths to the cranial side of the groin,since the scar moves caudally owing to the later traction. 
■ The incision is made using a size 10 scalpel,radically,as far as the subcutaneous adipose tissue and may,without repositioning the patient,be continued as far as the middle third of the buttock region.
If no buttock lift is indicated,the incision should be as far as possible into the buttock region so that the posterior part of the thigh is also tightened and modeled.
Preparation 
■ When dissecting away the cutaneous/fatty ?ap,the assistant uses two sharp retractors and holds these under tension so that the dissection using sharp instruments can be carried out without any problems.
It is rigorously dissected off as low down the thigh as the extent of the slackness demands.
Deep Dissection and Hemostasis 
■ Deep dissection is carried out using the Metzenbaum dissecting scissors by pulling the cutaneous/fatty ?ap caudally.
Bleeding is stopped using bipolar or monopolar tweezers.
If dissection is carried out in the correct layer,precisely above the thigh fascia,no vessel ligatures are required. 
■ Deep dissection is taken as far as was drawn on the day before the operation (dissection area) and discussed with the patient. 
Only in rare cases do we carry out a vertical incision in addition to the inguinal incision,since most patients when they are given detailed information about the operation have problems with the prospect of what is usually a visible scar.
If,however,there is very loose skin as far down as the knee,this incision line cannot be avoided.
De?nition of Resection Boundaries 
■ The assistant pushes the area of skin that has been dissected away in a cranial direction.
Similarly,the cutaneous ?ap is pulled upwards with a sharp retractor and surgical tweezers in a cranial direction.
The thigh is rotated inwards by the assistant so as to achieve as straight a position as possible,as is it would be in the standing position.
The skin incisions are made precisely in these positions so that step by step the incision points (a) correspond with the cranial inguinal incision.
Skin Resection 
■ Skin resection is performed with precise monitoring of the resulting tension on the cutaneous suture.
The resection boundaries are dictated by the positions of the key sutures,which are taken out again after the resection,because the cutaneous ?ap – and this is the most important part of the operation – needs to be anchored deeply at two points with permanent sutures in order to achieve a satisfactory long-term result. 
■ After the skin resection residual areas of fat are removed.
In the process it should be noted that subcutaneous fat is removed in the shape of a wedge,so that later joining can be step by step without any excess material.
For all lifts concerning skin and extremities,it is important to have wedge-shaped joining in the form of an equilateral triangle.
This prevents formation of seromas,promotes good wound healing,and therefore scar healing.
Fixation Suture on the Pubic Bone with 2.0 Monocryl 
■ Following skin resection the inguinal ligament is dissected deeply using dissecting scissors.
The same applies to the pubic bone further caudally. 
The periosteum of the pubic bone can be felt easily.
Suturing to connect the subcutaneous fascia and adipose tissue of the cutaneous ?ap with the periosteum of the pubic bone may be carried out using a 2.0Monocryl suture.
We have the best experience with Monocryl and there has never been any impairment to wound healing.
Owing to the long absorption rate,Monocryl has the same life as a mono?lament cutaneous suture.
Second Fixation Suture on the Inguinal Ligament 
■ After the deep demonstration of the inguinal ligament has taken place over its whole length using dissecting scissors,the subcutaneous adipose sheath with the subcutaneous fascia is anchored to the inguinal ligament using 2.0 Monocryl interrupted sutures,to distribute the main weight, avoid secondary descent of the scars and divari?cation of the labia majora.
Deep Wound Closure and Insertion of a Redon Drain (no.10) 
■ Before deep wound closure,the ?ap is trimmed and the excess fatty tissue is resected.
After dissection of the subcutaneous fascia (Scarpa’s fascia) this is closed by means of deeply concealed 3.0 Monocryl interrupted sutures.
This suture and the two ?xation sutures on the inguinal ligament and the periosteum of the pubic bone ensure that little tension is placed on the ?nal subcutaneous and cutaneous suture.
This is important to ensure good healing of the scar later on.Redon drains size 10 are inserted.
Intracutaneous Skin Closure 
■ After subcutaneous adaptation using 3.0 Monocryl interrupted sutures, the skin is closed without tension with a running intracutaneous 4.0 Monocryl suture.
Dog-ears should be avoided and if they are present, they should be corrected at the caudal end of the incision line running into the buttock crease. 
■ If,following a thigh lift,a buttock lift is carried out,the patient is turned onto his/her stomach,but in the same position. 
■ The intervention is completed with a 4.0 running intracutaneous Monocryl suture.*
Dressing 
■ Dressing is with Steri-Strips that are removed after 8days once the wound has been checked.
For the ?rst 2 days after the operation compression dressings and Cutiplast with special girdles are used.
The Redon drain can be removed on the ?rst or second day after the operation,depending on the results.
Antibiotics and thrombosis prophylaxis should be given.
Note: If the ?xation shown here appears to be too static,then it is possible to suture the thigh fascia to the deep pubic fascia for dynamic anchoring instead of ?xation to the periosteum of the pubic bone.
Buttock Lift:Positioning,Disinfection 
■ It is crucial,as with all lifting operations,to ensure that the preoperative drawing is correct,so that the wedge-shaped resection later produces a scar that lies exactly in the buttock crease.
This means that later on it will be scarcely visible.
Tumescence Tumescent pretreatment of the tissue is the norm in aesthetic operations today.
When buttock lifts are carried out,approximately 200ml of the tumescence solution (0.9%NaCl 500ml,1% prilocaine 200mg=20ml, epinephrine 0.5mg,8.4% NaHCO3 5mEq) is suf?cient.
If the buttock lift is combined with a thigh lift,which is something frequently wanted upwards of a certain age,both the incision lines are joined in such a way as to achieve a homogeneous radial tightening of the whole thigh and buttock area.
Unfortunately,patients often have too high expectations and forget that the shape of the buttock is primarily determined by the shape of the musculature and not by fatty accumulations and loose skin.
Owing to the tumescent in?ltration,the operating area is free from blood,thereby ensuring safe,simple,and quick dissection.
Incision Line 
■ Preoperatively the incision line is drawn precisely with the patient in a standing position.
The intended line of the subsequent buttock crease is marked,and the distances to the caudal and cranial incision margin are measured to ensure they are of the same length.
By pinching together the buttock crease with both hands the extent of resection can be determined.
It is recommended that one should always be conservative at the beginning.
Over time one must explore the limits as an aesthetic surgeon,but one should always bear in mind that it is easier to correct excesses than it is to correct de?cits.
Incision 
■ Using a no.10 scalpel a wedge shape is cut at an angle of approximately 70°downwards as far as the fascia of gluteus maximus.
The deepest point of the wedge excision on the muscle fascia should be at the level of what will be the new buttock crease.
The resection boundaries should be equivalent to an equilateral triangle,which later,following buttock lift and closure,produces the new buttock crease.
Wedge-Shaped Dermolipectomy 
■ After the deep fat layer has been cut through in the shape of a wedge with a 70°angle using the no.10 scalpel,the cutaneous/fatty ?ap is deeply dissected away in full using dissecting scissors from the fascia of the gluteus maximus.
ransverse Incision Through the Resected Area 
■ The deepest point of the wedge excision must be on the buttock crease that is to be de?ned later.
The resection boundaries correspond to an equilateral triangle (a–b=a–c) that after tightening and closure produce the new buttock crease.
Hemostasis,Deep Wound Closure,Insertion of a Redon Drain 
■ Following precise hemostasis and insertion of a no.10 Redon drain,the ?rst deep 3.0 Monocryl sutures are positioned in order to ?x the buttock crease.
Two-Layer,Tension-Free Wound Closure 
■ 3.0 Monocryl subcutaneous interrupted sutures are used.
This removes the tension from the ?nal,running,intracutaneous 4.0 Monocryl suture. 
This suture material has the major advantage that it heals without irritation,hardly produces any suture granulomas,does not need to be removed,has a long life,and produces excellent aesthetic results.
Dressing 
■ A Steri-Strip dressing is applied directly to the wound.
Eight days after the operation,this is removed once the wound has been checked.
For days,Cutiplast and compression bandages are used to prevent edema and thrombosis.
Postoperatively,a special girdle that has been made to measure prior to the operation should be worn for 4weeks.
Infection prophylaxis should be 2g cefaclor.
Note: The method of buttock lift shown here is indicated where there is surplus skin coverage.
If,however,there is little surplus skin and the rede?ning of the buttock crease is a priority,then a more timeconsuming surgical technique is required.
In this case,the epithelium is removed from the skin area which has been marked out and the skin area is separated at the level of the new buttock crease as far as the gluteal fascia. 
After thinning out the caudal and cranial dermofat ?aps,these are anchored to the gluteal fascia thus de?ning the new buttock crease.
Postoperative Treatment: Course of Action After the Operation;Precautionary Measures 
■ Correct postoperative treatment after thigh and buttock lifts is very important to ensure long-term satisfactory results. 
■ For 24h after the operation there should be bed rest and monitoring on the ward.
Careful mobilization aided by a nurse starts the day after the operation.
Moving the thighs apart should be avoided so as to prevent unnecessary traction on the wound.
So as not to impair wound healing, any tension on the sutures should be avoided when the patient stands up. 
Legs should be moved regularly to promote the return blood ?ow. 
■ The Redon drains are removed painlessly after 1–2days.
While the patient is on the ward,lymph drainage and physiotherapy are recommended. 
■ The fresh scars are treated postoperatively for 3 weeks using dexpenthanol ointment and subsequently treated with silicone plasters for 2 months.
The made-to-measure compression girdle should be worn for 4 weeks after the operation to prevent swelling and edema.
After this one can resume sport activities. 
■ Antibiotic prophylaxis with cefaclor and embolism prophylaxis using low-molecular-weight heparin is only indicated during the stay on the ward.
Results 
Patient I:This is a 62-year-old female patient with typical wrinkling in the upper third of the medial thigh.
In this case inguinal tightening has been carried out without a vertical incision.
The cutaneous ?ap was anchored on the periosteum and the inguinal ligament.
Intensive scar treatment was carried out for 6months.
Twelve months after the operation.
Weight gain of the patient and sports activities in the gym.
Healthy scars owing to good wound healing and intensive treatment of the scar.
Introduction
In 1921,a French surgeon carried out curettage on the knee area of one of his patients in order to achieve an improvement in the shape.
This procedure was later combined with suction,until in the end curettage was abandoned.Prof.
Fournier introduced the cross technique in 1987, achieving impressive results with regard to the evenness of the skin.
The shape and size of the cannulas used for liposuction have continued to change and develop.
The pioneers of liposuction were Ilouz,Fournier, and Klein.
An ultrasound-assisted method was ?rst introduced in 1982. 
Another technique that protects the tissue by using vibrating cannulas was introduced by an American,W.P.Coleman,in 2000.
As this book is intended to impart basic knowledge,the tumescence technique demonstrated in the accompanying video is manual liposuction,as this is most suitable for learning the new technique of liposuction from the beginning.
Admittedly,this technique is time-consuming, but it achieves good results and can be learned reliably.
Of all the additional instruments used at the Bodenseeklinik,the best when it comes to large areas of liposuction has proved to be the MicroAire (MicroAire Surgical Instruments,Charlottesville,VA,see ?gure on p.162) system (tissue-sparing;suction without much bleeding; comfortable for the surgeon to operate;almost pain-free suction;timesaving).
The size of cannulas varies between 2 and 4mm;at the beginning of suction 3mm cannulas should be used (extremities,saddle area). 
In very corpulent patients,4mm cannulas can be used in the abdominal area.
For delicate modeling in the neck,buttock,knee,and ankle areas, 2mm cannulas are suf?cient.
The protective technique of tumescent liposuction has considerably reduced the high risks of dry suction under general anesthetic (thrombosis,blood loss,embolism,infection,scarring,skin unevenness, hematoma).
If the tumescence solution containing local anesthetic as well as vasoconstricters is injected beforehand general anesthesia is not necessary.
The patient receives only sedation and intraoperative monitoring (IV access,pulse,blood pressure,O2 saturation,and ECG monitoring).
Adding adrenaline to the solution as a vasoconstricter reduces the risk of the patient losing a large amount of blood and prevents large hematomas from developing.
In addition,the incidence of complications can be drastically reduced by perioperative thrombosis and embolism prophylaxis [single-shot cefaclor 2g,Mono Embolex IM (low molecular weight heparin) before, during,and after the operation].
In a study carried out by the American Society of Dermatologic Surgery there were no cases of embolism, thrombosis,or infection in 15,336 patients treated with tumescent liposuction.
Problems can result,however,from the use of too much tumescence solution,which can place considerable strain on the circulation.
The decisive factor is the tumescence solution used.
The ?rst tumescent local anesthesia with lidocaine was described and documented by Klein as a local anesthetic solution.
Mang’s solution uses prilocaine as a local anesthetic in an even smaller dose (the smallest dose allowing almost painless suction was determined in a clinical study),as it exhibits the least toxicity.
The prilocaine plasma levels were considerably below those for lidocaine.
Duplicate Patient Information
The patient is ?rst given comprehensive information about the objectives and risks of the procedure on the day of the ?rst consultation.
A written record is kept of this.
All the risks are set down in writing at this time.
It should be made clear that the patient may experience pain during the operation and that occasionally pressure damage may occur to the nerves and soft tissue.
This will subside again in the space of a few weeks.
The loss of a large amount of blood necessitating blood transfusions does not normally occur when the tumescence technique is used. 
Bloody effusions and a feeling of numbness in the operation site can occur after the procedure.
Dimpling and the limits of the possibilities of liposuction must also be explained to the patient,as must the risk of thrombosis and embolism as well as the small scars that will occur at the insertion sites.
In rare cases allergic reactions can occur in the skin, mucous membranes,heart,circulation,kidneys,or nerves.
For this reason liposuction should be carried out on an inpatient basis with standby and monitoring.
If there are considerable irregularities in contour,the patient should be advised to have a corrective operation.
Preliminary Examination 
■ Current,preoperative routine laboratory tests with APC resistance and glucose-6-phosphate dehydrogenase.
ECG and chest X-ray if the patient is 49 years old or over.
The patient should undergo a clinical examination, in particular to identify hernias in the abdominal region and varicose veins,congestion of the lymphatics,etc.in the lower extremities. 
■ Photographic documentation according to the problem zone:images taken from the front,side and from behind with the patient standing.
Surgical Planning
The operation enables deposits of fat to be reduced in a de?ned area of the body surface that cannot be reduced by dietary measures or sporting activity alone.
Surplus fat is removed by suction in order to reduce the thickness of the fatty layer of the skin.
The amount of fat removed is limited by the loss of body ?uids and blood.
For this reason liposuction is not a procedure for reducing general obesity.
On the day before the operation the surgeon discusses with the patient in detail which changes he or she wants and how this will be achieved.
The areas to be removed by suction and the tumescence borders are marked exactly.
In order to keep the operation risk as low as possible the patient should be made aware that he or she should not take any anticoagulants such as acetylsalicylic acid before the operation.
The patient should also not smoke before the operation as this causes a reduction in perfusion. 
The risk of blood clots forming in the body also increases if the patient is taking contraceptives.
In such cases the patient should stop smoking 2weeks before the procedure and for the duration of the wound-healing period at the very least.
Intraoperative single-shot infection prophylaxis should be carried out with 2g cefaclor and inpatient treatment and thrombosis/embolism prophylaxis before the operation and for 1day after the operation with one ampule of fractionated heparin s.c.
A special girdle should be ?tted.
Anatomy of Liposuction of the Abdomen,Hips,Thighs 
Liposuction of the abdominal/hip region is the most frequently requested procedure,particularly by men.
Only individual zones should ever be treated with liposuction,i.e.,abdomen/hips or outer and inner thighs and buttock region (saddle area),as ?rst the amount of tumescence that can be injected is limited (maximum 6l) and second the procedure would be too stressful for the patient.
As the navel region is particularly sensitive,a lot of tumescence must be used here.
Liposuction of both hips or the upper and lower abdomen is carried out in a fan shape with the patient frequently changing position.
Liposuction should be carried out carefully in the upper abdominal area,and a thin layer of fat should be left below the skin,as otherwise dimples will form and there can be loose skin.
Anatomy of Liposuction of the Hips,Back,Thighs,Buttocks (Body Contouring)
Liposuction of the so-called saddle area is the procedure requested most by women (body contouring of the hips,the lateral and medial sides of the thighs,buttocks).
After the fat deposits have been marked precisely, an aesthetic result is achieved by carrying out liposuction homogeneously through 360°without the formation of dimples,by changing the patient’s position on the operating table,and by checking again at the end of the operation,with the patient standing up,whether the contours have been suctioned well.
The more experienced a surgeon is,the more he or she can remove.
Novices must be very cautious and restrained,as dimples are more dif?cult to correct than residual deposits of fat,which can be removed without any problems after 6 months.
Successful liposuction of the back can only be achieved if tunneling is carried out cautiously using a low-level vacuum (maximum 0.4 at), leaving a layer of fat on the subcutaneous tissue,and through a ?brotic/tightening effect being achieved by the tunneling.
Caution must also be exercised when carrying out liposuction of the buttock region since if too many fat cells are removed,dimples can form and there can be loose skin.
Modeling of the hips and the medial and lateral sides of the thighs can be achieved very successfully using liposuction,as the skin here generally produces a good tightening effect.
Anatomy of Liposuction of the Axilla,Chest,Hips,Lateral Side of the Thighs
In principle,liposuction can be carried out in any area of the body where there are aesthetically intrusive deposits of fat.
This is the main advantage of the tumescence technique.
Because of the anatomical situation of the axilla,the surgeon has to be very careful.
It is better to leave out the axillar region to prevent injuries.
Anatomy of Liposuction of the Medial/Lateral Side of the Thighs,Knee
The contours of the lower extremities are very well suited to liposuction, in particular the deposits of fat on the lateral and medial sides of the thighs and the knees.
Before the operation varicosity of the long and short saphenous veins and any lymphatic diseases must be taken into account.
The thighs must not be skeletonized,i.e.,all the fat must not be removed, as this leads to a very poor cosmetic result.
A suf?cient subcutaneous layer of fat must be left.
As long as pure fat is appearing;the procedure can be continued without risk.
When the fat becomes mixed with tumescence solution and ?nally only tumescence solution appears in the tube;the procedure should be ended in order to prevent skeletonization and the formation of dimples.
Liposuction in this region is shown in detail on the DVD.
Anatomy of Liposuction of the Medial Part of the Thighs,the Knees, Calves,Ankles
Liposuction of the lower extremities is usually carried out as two separate procedures:?rst the lateral and medial sides of the thighs and the knee area,then the calf and ankle region.
If only the medial side is to be altered,the medial side of the ankle,calf,knee,and thigh can be treated in one procedure;particular attention must be paid to thrombosis and embolism prophylaxis during this procedure.
The patient should be mobilized immediately after the operation.
Anatomy of Liposuction of the Calf and Ankles
Unfortunately,fat calves often result from muscular hypertrophy.
When performing liposuction of the calves the surgeon must have a lot of experience and be very careful to avoid causing dimples.
For this reason caution must be exercised during liposuction of the calves and ankles. 
A 2-mm cannula with a vacuum that is not too high must be used (no higher than 0.6 at).
After the operation immediate mobilization and the ?tting of a compression girdle are advisable.
Anatomy of Liposuction of the Breast,Axilla,Upper Arms
Gynecomastia in men can be treated very well by means of tumescent liposuction.
Preoperative investigation of the breast area by means of mammography or ultrasound is necessary.
The entire breast area can be removed by suction by means of two small incisions that are not visible.
Axillary fat can be removed during the same operation if required.
Anatomy of Liposuction of a Double Chin
Two small submental incisions and a retroauricular incision are made. 
With a quantity of tumescence solution of 300–500ml the entire submental region extending deep into the neck area can be removed by liposuction.
If required,the lateral cheek areas can also be removed. 
The procedure is often combined with a facelift.
After the operation a compression dressing is worn for approximately 1week so that the submental skin that has been detached in the neck area can adapt after liposuction to the areas where fat has been removed. 
Just by tunneling with the 2mm cannula,scar contractions occur,which result in a tightening effect.
Mechanical and Manual Tumescence
Tumescence solution can be applied either manually with an injection syringe or mechanically with a pump.
In the manual technique the injection syringe is connected to the tumescence solution via a one-way cock. 
The manual technique requires a lot of time and effort and has the same results as the mechanical injection of solution via a pump.
In this technique the pump is connected with the system via a three-way or six-way cock so that the tumescence solution can be applied evenly and homogeneously via three or six cannulas,also saving time.
For liposuction in the abdominal/hip area about 6l of tumescence solution is needed.
Manual application of the solution takes 90min;application using the pump takes 45min.
After applying all the tumescence solution,it should be given at least 30min to take effect.
During this time disinfection and sterile draping of the patient are carried out.
Mang’s tumescence solution (0.9% NaCl 3,000ml,1% Prilocaine 1,500mg=150ml,epinephrine 3mg,Na HCO3 8.4% 30mEq,triamcinolone acetonide 30mg) should still be limited to 6l for patients weighing up to 80kg.
If the patient weighs more than this and is in good general condition,the amount of tumescence can be increased to 7l.
The best temperature for the solution is 30°C (warm cabinet). 
The prepared tumescence solution should be injected within 1h of preparation.
The solution must only be prepared (sterile preparation) by a quali?ed person supervised by a doctor.
The surgeon must apply the tumescence himself/herself,as in so doing he/she can see exactly how much tumescence solution ?ows into each fat deposit.
He/she can therefore already begin to estimate during tumescence from which regions the most fat cells will need to be removed. 
Tumescence solution that has been opened must not be reused under any circumstances.
Location of the Incision Sites from the Rear 
■ Shoulders:Three incisions.
At the lateral,medial and caudal ends of the collection of fat. 
■ Buttocks:Three incisions.
One in the upper quadrant and two in the lateral and medial parts of the gluteal fold. 
■ When treating a problem zone a general rule of thumb is that at least three incisions are necessary,one of which should be at the lowest point to allow the tumescence solution to drain.
This prevents congestion as well as prolonged swelling and infection.
If it becomes apparent during liposuction that another incision is necessary,this can be made without problem,as these are microincisions that will not be visible after 6months.
Instead of sutures,Steri-Strips are applied to the incisions for 8days.
Location of the Incision Sites from the Front 
■ Submental region:Four incisions – two in the submental area,two on the earlobes. 
■ Upper arms:Lateral condyle and ventral muscle belly ofthe biceps muscle. 
■ Breast:At three o’clock laterally,at six o’clock caudally where the collections of fat protrude. 
■ Upper abdomen:Three ?ngerwidths caudal to the costal margin on each side. 
■ Hips:Four incisions divided between the individual quadrants. 
■ Lower abdomen:Four incisions,two in the bikini area and two at the level of the navel half-way between the iliac crest and the navel. 
■ Lateral side of the thighs:Three incisions,one below the trochanter,one at the lowest point of the collection of fat and one in the gluteal fold. 
■ Medial side of the thighs:Two incisions,one incision midway between the inguinal region and the knee at the lowest point of the collection of fat and one dorsally in the gluteal fold. 
■ Knees:Two incisions located cranially and caudally to the fat deposit. 
■ Calves:Four incisions.Two lateral,two medial. 
■ Ankles:Three incisions.
Two dorsal (caution:Achilles tendon!),one ventral at the area of attachment of the tibialis anterior tendon.
Schematic Diagram of Mang’s Tumescent Liposuction Technique
Cross-Section of the Skin Before Tumescence
The diagram shows normal fat cells,embedded in the infrastructural connective tissue (ICT).
In dry liposuction under anesthesia,these connective tissue structures are largely destroyed,causing blood loss, hematomas,and the formation of dimples under the skin.
This is avoided by using the tumescence technique.
Cross-Section of the Skin Following 
Tumescence Tumescent local anesthesia (TLA) refers to the in?ltration of the skin and subcutis with a large quantity of very diluted local anesthetic (below 0.1%) with adrenalin (less than 1mg/l) and NaHCO3 until the tissue swells suf?ciently. 
TLA results in good anesthesia and hemostasis and means that the patient is responsive and mobile.
Using TLA the procedure can be carried out without additional anesthesia. 
Removing the tissue that is full of tumescence solution during liposuction does not cause any blood loss and,in particular, preserves the surrounding tissue.
Cross-Section of the Liposuction Technique 
Liposuction is carried out with 2.0–4.0mm cannulas.
Because the fat cells are hygroscopic they are softened by tumescence and can therefore be removed by suction atraumatically and selectively without damaging the surrounding tissue (infrastructural supporting tissue).
With a movement similar to that of a violin bow,moving constantly in a 180°radius and never stopping in one place,the entire area of fat is removed by suction,starting at the bottom and working upwards towards the epidermis.
The skill is in leaving a thin layer of fat below the epidermis so that dimples are not formed later and a good tightening effect is achieved.
Cross-Section of the Tissue 6Months After Liposuction with Preservation of the Infrastructural Connective Tissue (ICT) 
Six months after liposuction using the tumescence technique and cannulas less than 4.0mm in size you can see that the infrastructural connective tissue has been preserved.
The endoscopic image shows the intraoperative ?ndings.
The most important point when carrying out liposuction is that a so-called fat ?lm is preserved in the upper section and that the connective tissue below it is preserved.
This causes the “chewing gum”effect whereby the undamaged connective tissue septa contract after liposuction,tightening the skin. 
You can see from the aspirate,which contains almost entirely fat with no blood,that only a small amount of tissue has been destroyed.
Technique 
■ The full extent of each fat deposit is marked precisely on the standing patient.
The problem zones must be marked with small circles,increasing in size until they reach the edges.
By doing this you can start to plan before the operation where the largest quantities need to be removed.
Disinfection 
■ Disinfection is carried out before tumescence.
Manual Liposuction 
■ The injection into the adipose tissue can be done by hand,in which case the quantity ofsolution used must be constantly checked and attention must be paid to achieving an even distribution.
This method takes about 1.5h.
Mechanical Liposuction 
■ The injections can also be carried out with an electric pump.
When doing this,you must always ensure that the cannulas are in the correct position.
The pump transfers the tumescence solution via a distribution system (3–6 connectors);it must always be ensured that the solution is injected evenly and not too rapidly.
As the patient is responsive and mobile,tumescence/liposuction of any part of the body is possible.
Tumescence can be discontinued when the areas to be treated show the so-called blanching effect,i.e.,are white and elastic.
A maximum of 6l of solution should be injected in order to avoid cardiac or neurological irritation.
The process lasts approximately 45min.
Tumescence and liposuction should be carried out with anesthesiology monitoring and stand-by.
Procedure 
■ After thorough disinfection,again an incision is made with a size 11 scalpel.
This incision is not sutured later and cannot be seen.
This process is completely free of pain because of tumescence.
The liposuction cannulas can be inserted without much pressure,and the openings should point towards the subcutis.
At the beginning of the procedure the cannula should not be more than 4.0mm.
At the end of the procedure, after the majority of the fat has been removed,a 2.0–3.0mm cannula is used for delicate modeling.
The tumescence technique allows the procedure to be carried out with almost no bleeding. 
■ Tumescence allows the tissue to be tunneled without much effort. 
Novices should not initially use the assisted system,but should carry out liposuction manually in order to get a feel for the tissue.
In order to achieve an even result,the same amount must be removed from all sides at angles of 90,180 and 360°.
The fat should be removed using smooth, constant,forward and backward movements,similar to the movement of a violin bow.
The fat should always be removed from within the predetermined level and in a fan shape.
Several incisions are necessary to reach the problem zones well,and one of these should always be at the lowest point of the problem area to allow the tumescence to drain.
As long as pure fat appears the procedure can be continued without risk.
When the fat becomes mixed with tumescence solution and then only tumescence solution appears,the procedure should be ended in order to avoid skeletonization and the formation of dimples.
Ideally,a “fat ?lm”should be left directly under the skin during liposuction.
Liposuction should therefore always be carried out from the deepest layers to the upper ones. 
■ Because the procedure is carried out under local anesthesia it is possible for the patient to roll over;therefore,all areas can be reached easily and evenly. 
This is a particular advantage for achieving homogeneous liposuction,as it brings about a tightening effect without the formation ofdimples. 
■ Because the patient is mobile all problem areas on the face and the body can be treated.
It should be ensured that suction is carried out evenly and in one plane in order to avoid contour irregularities.
This is harder to even out than residual persistent deposits,which can be corrected without any problems. 
■ To make sure the wound is well drained,an incision must be positioned at the lower pole of the area to be removed during liposuction.
Contouring can also be carried out from here.
If the patient experiences pain, a strong,fast-acting analgesic can be given via the venous cannula. Synthetic opioids,e.g.,piritramide (Dipidolor?),have proved effective in these circumstances. 
■ Liposuction should be carried out on an inpatient basis and requires a lot of experience.
An experienced surgeon will preserve a thin layer of fat below the skin. 
■ When using the aspirator it is important that there is a constant vacuum of about 0.8 (Atmos Medizintechnik aspirator*).
Dressing 
■ After liposuction,Steri-Strips are applied to the insertion sites.
The wounds are not closed further because of the desired drainage effect. 
The Steri-Strips can be removed by the patient after 8days.
The dressing is applied with the patient standing up.
Absorbent pads take up the ?uid produced in the ?rst few days after the procedure.
A compression girdle is worn for a few weeks after the operation.
Antibiotic cover and thrombosis prophylaxis should be given.
Aftercare 
■ The patient is monitored for 24h after the operation,during which time he or she should move about as much as possible (1h lying down, 20min walking up and down in the room so that the tumescent ?uid drains). 
■ On the 1st postoperative day the entire dressing is changed and a compression girdle is ?tted before counteracts swelling and pain and to help adapt the skin to the changed contours of the body.
This compression girdle also encourages the skin to tighten and should be worn for at least 4weeks after the operation. 
■ Two weeks after the operation the skin can be treated with moisturizing body lotion,massaged gently on a daily basis into the areas of skin treated.
Physical exertion,sport,and exposure to direct sunlight are permitted after 4weeks.
We recommend training in the gym after liposuction.
A “top body”or “washboard stomach”can normally only be achieved by liposuction in combination with strenuous physical training,not by liposuction alone.
With the help of liposuction,fat cells are permanently removed.
Since the fat cells do not grow back,liposuction treatment produces a permanent effect.
However,further changes to the shape of the body are possible. 
The results of the operation are dependent on the patient’s general health,the condition of the skin,the patient’s age and weight,and the hormonal content of the body,among other things.
In particular,signi?cant weight gain caused by nutrition will result in the layer of adipose tissue increasing again even in the treated area,as the remaining fat cells will ?ll out.
Occasionally,wavelike unevenness or dimples become visible on the surface of the skin,but these usually reduce again within 6months.
As with all aesthetic procedures,corrective operations may be necessary if the results of the treatment do not meet the patient’s expectations or if an unsatisfactory aesthetic result is produced because of wound-healing disturbances, infections, postoperative bleeding, etc.
Results 
Patient I:Liposuction in the submental region of a 38-year old patient. 
Side view 12 months later.
Patient II:A major problem for men predominantly aged over 45 is deposits of fat in the chest area.
Good,long-lasting results are obtained using the tumescence technique presented here.
 Side view 12 months later.
Patient III:Saddle area before and 6 months after treatment.
Patient IV:A 39-year-old patient with collections of fat in the hip and abdominal areas,and 12 months after tumescent liposuction of abdomen,hips and mons pubis.
Patient V:Patient with collections of fat around the hips,lateral and medial sides of the thighs and the buttock region,and view after modeling of the abdomen,hips and buttocks,12 months after the operation.
Introduction 
Hair transplantation has been requested by many men since it is known that new methods (micropunch technique,slit technique,laser-assisted) do not leave any visible scars.
The hairs that are transplanted from the back of the head rarely fall out,and the procedure is atraumatic and virtually painless.
A special team is necessary for hair transplantations. 
This is made up of a surgeon and at least two trained assistants who prepare the hair follicles.
Besides precise preparation of the hair follicles, correct insertion of the hair follicles at the correct angle using either the micropunch or the slit technique is extremely important.
This is the only way to achieve a natural result;it is the art of the hair transplant surgeon. 
For this reason we have a dedicated hair transplantation team at the Bodenseeklinik who carry out only hair transplantations.
The only way to produce good,lasting results is practice,experience,and the precise preparation and insertion of the hair follicles.
In the hair transplantation chapter a clear overview is given of what must be done to achieve successful hair transplantation.
In addition to the precise harvesting of an appropriate donor strip from the back of the head with atraumatic closure,successful hair transplantation involves microscopic preparation of the hair follicles and insertion of the implants either by the micropunch technique or the slit technique,using either one or more follicles in either a manual or a laser technique.
The precise insertion technique is determined individually for each patient and each area.
Beauty ideals vary a great deal,but thick,shiny hair is desirable in all cultures because it is a symbol of health and youth.
Even the ancient Egyptians saw it as a catastrophe if someone’s hair became thinner and thinner.
In our society as well,where a youthful appearance plays a very important role,thick,healthy hair is a great advantage.
In the Western world roughly every second man is affected by hair loss.
The most common form of hair loss is so-called androgenetic alopecia,masculine type hair loss.
The hormone dihydrotestosterone plays a key role in androgenetic alopecia.
This hormone is formed from the male sex hormone testosterone under the in?uence of a particular enzyme.
Dihydrotestosterone causes hair to become thinner and thinner in particular places such as the brow,temples and the crown and ?nally to fall out.
The decisive factor when it comes to hair transplantation is that hair on the back of the head (coronal hair),facial hair and body hair are immune to the hormone dihydrotestosterone.
This explains why hairs taken from the back of the head and transplanted to bald patches do not then fall out.
They continue growing and produce healthy hair,which can be washed,blow dried,and dyed normally.
Transplantation of a patient’s own hair is a skillful redistribution of healthy hair follicles to bald patches and,with the new methods available,results in a natural appearance.
Considerations before hair transplantation:The patient’s hair should be allowed to grow as long as possible so that the harvest area can be covered with the remaining hair and is not visible.
The patient should not take any anticoagulants. 
The procedure is carried out under local anesthesia. 
After the operation a loose-?tting hat (e.g.,baseball cap) should be worn.
Preparation of the Patient,Hairline Design
Donor Area 
■ The donor area should not be more than 2cm above an imaginary line connecting the tips of the patient’s ears behind the head.
Be careful not to harvest an overly large skin strip so that you will not have to discard hair follicles later. 
■ When determining the size of the donor area,keep the preparation capacity of your transplantation team in mind! 
Only shorten hairs whose follicles are to be dissected later.
Leave the remaining hairs as long as possible so that they will cover the donor site after transplantation. 
■ Measure follicle group density,i.e.,follicular units per square centimeter. 
■ With this ?gure,the number of follicular units to be transplanted can be calculated from the total area of the donor strip.
Local Anesthesia,Tumescence 
■ Local anesthesia with articaine and adrenaline (e.g.,B.Ultracain DSforte,Septanest with adrenaline 1/100,000) is administered in the form of a ring block below the harvest site,using an intradermal injection technique. 
■ This is followed by intradermal in?ltration anesthesia using 0.5% prilocaine with adrenaline. 
■ Injection of a 0.9% saline solution is employed to achieve tumescence of the donor area. 
■ Caution:Inject the tumescence solution intradermally and subdermally; subgaleal injection is contraindicated! 
This precaution prevents injury to major nerves and blood vessels during the subsequent skin incision.
Donor Strip Harvesting 
■ Remove a trapzoidal donor strip with the base of the trapezoid in a caudal position! 
■ Avoid transection of the hair follicles by making an incision at an angle of about 45°and cutting exactly parallel to the direction of hair growth. 
■ The upper incision angle can vary.
Use a magnifying device with a power of 2?.
Multiple incisions at the same location cause transection,and thus destruction,of the hair follicle. 
■ Cautiously excise the strips;pull gently to detach them below the hair roots in the fatty layer. 
■ Do not injure the vascular-neural bundle.
To avoid injuring the galea at all costs,the best policy is:hands off the galea! 
■ Place the harvested strip into a sterile cooled 0.9% saline solution immediately. 
■ No mobilization.
No opening of the galea. 
■ Hemostasis should be carried out on the galea only and not near the hair follicle. 
■ Pull the edges of the wound together over the donor site using mono?lament absorbable sutures (2?0 or 0),e.g.,Monocryl. 
■ Insert the needle into the skin and out again below the hair roots;use a concealed knot.
With this technique,the wound edges are already optimally adapted;smaller hemorrhages are automatically compressed.
Skin Closure with Continuous Sutures 
■ Perform skin closure with running sutures;use non-absorbable mono?lament sutures (e.g.,Prolene or Resolon 4?0). 
■ Make sure that the cutaneous sutures are not under tension and that the needle is inserted super?cially.
Inserting the needle too deeply may result in hair follicle necrosis and ultimately scar-tissue alopecia. 
■ When harvesting,dissecting or transplanting hair follicles,avoid doing anything that will result in trauma or reduced perfusion.
Follicular Unit Preparation (Minigrafts,Micrografts,Single Hairs) 
■ The donor strip is placed on a non-slip sterile wooden board and sliced into small segments.
Work with magnifying spectacles or a binocular microscope. 
■ Avoid transection.
Fix the skin ?rmly.
Avoid multiple incisions. 
■ The segments are divided further into strips;the follicular units are now arranged in a row on a piece of gauze. 
■ As part of the preparation work,the units are separated and sorted into single-hair units or units containing 2–4 hairs. 
■ For larger numbers of hair transplants,two to three trained surgical assistants are required for the preparation work. 
■ Replace scalpel blades frequently.
Do not crush the hair follicles! 
■ The dissected follicular units are sorted into rows of 10 units each. 
■ A total of 10 rows per gauze strip and Petri dish equals 100 follicular units or grafts.
Cool the saline solution suf?ciently before use.
Keep the transplants moist at all times!
Recipient Area,Holes and Slits 
■ Ring blockade with articaine and adrenaline (e.g.,Ultracain DS-forteor Septanestwith adrenaline 1/100,000).
Be careful to use an intradermal injection technique and avoid subgaleal in?ltration. 
■ In?ltration with prilocaine 0.5% with adrenaline in the treatment area. 
■ In addition,inject 0.9% saline solution to achieve intradermal and subdermal tumescence.
Allow 10–15min for the solution to take effect. 
■ Be careful to work in the direction of hair growth.
The use of a magnifying device with a power of 2–4?is recommended.
Following the hairline design,punch out 0.8 mm holes for transplants containing 1–2 hairs. 
■ After punching between 5 and 10 holes,make a test transplant to determine whether the transplants can be inserted without any problems.
For example,check whether the size and depth of the holes are suf?cient. 
■ Never transplant hair only along the marked line,as this results in an unsightly “pearl necklace effect”.
A feathered hairline is the effect you want to achieve:“irregular regularity”is the key word here! 
Use the laser for bald areas;switch to cold steel methods in areas still covered by dense hair.
Make continual test transplants to check the suitability of the holes.
If necessary,change the laser setting.
Use slender angled tweezers.
Transplantation Channels:Micropunches (a), Microdrills (b) and Erbium YAG-Laser (c) 
■ Use micropunches with a diameter of 0.8mm,1.0mm or,in rare cases, 1.2mm to avoid an unaesthetic tufted “doll’s head”effect. 
■ Be sure to select micropunches that permit lateral skin ejection and have an internal ground surface. 
■ The distance between hairs is increased by tumescence.
The microholes are placed between healthy hair roots. 
■ In patients with very dense remaining hair,employ a slit technique using chisel blades or 15°,30°or 45°Sharpoint blades. 
■ Measure the number of holes or slits per square centimeter for the documentation. 
■ The holes or slits must be counted consecutively to guarantee correspondence with the number of prepared follicular units. 
■ Transplantation of follicular units with a sharp angled microtweezers (e.g.,Micro 2000 made by Medicon).
Perform non-traumatic implantation with no crushing of hair roots.
The follicular units are placed on moist gauze strips draped over the back of the surgeon’s left hand;they are picked up individually with the microtweezers and then transplanted. 
■ Keep the follicular units moist!
Transplantation 
■ Use swabs to keep the transplantation area clean and free of blood. 
Crusted dried blood prevents a clear overview of the surgical area. 
During hair transplantation,a systematic approach is vital! 
■ When placing transplants in holes,the end of the transplant should be ?ush with the skin surface. 
■ When placing transplants in slits,the transplants should project 0.5–1.0mm above skin level. 
Never insert the transplants too deep since cysts are likely to form in 2–3 months in patients with deep transplants. 
Since the effect of adrenaline and tumescence wears off after 2–3h,stay within the time limits for the transplantation procedure.
Aftercare
Postoperative Precautions
No bandage is necessary with modern surgical methods.
There is no permanent visible scarring.
The same criteria apply,however,after a hair transplantation as after any other operation in the facial area. 
■ Infection prophylaxis is given for 3days after the operation.
From the 3rd day the patient can wash his or her hair with a mild chamomile shampoo.
The hair can then be washed daily.
The hair transplants are ?xed securely and ?rmly. 
■ After a maximum of 2weeks all crusts should have disintegrated with washing;crusts delay wound healing.
Rough manipulation should be avoided,particularly in the 1st postoperative week,as there is a risk of postoperative bleeding.
The patient can be professionally and socially active again 1week after the operation.
After 6weeks vasodilating hair lotion should be used.
The crusts disintegrate quickly with regular washing.
Result 
A 50-year-old patient with Norwood type V hair loss,and 12 months after the operation,following two procedures with a total of 3,120follicular units.
Introduction
Adjuvant therapies should be included in the repertoire of every aesthetic surgeon.
It would exceed the scope of this manual to describe all adjuvant therapies in detail.
Anyone who wishes to undertake further training in this ?eld can ?nd detailed information primarily in dermatological textbooks.
Therefore,a few important adjuvant therapies will be dealt with only brie?y in this volume.
Please refer to the texts in Volume I of the manual for the basic information.
Dermabrasion,chemical peeling,and erbium-YAG laser treatment are examined methodically,but only very brie?y to provide an understanding of the basic principles.
Adjuvant therapies are very often combined with surgery,and an experienced aesthetic surgeon will choose appropriate treatments,depending on the types of wrinkles and skin type.
We do not use injectable alloplastic materials,as damage may occur that is extremely dif?cult to correct and,in a few cases,even irreparable.
The use of autologous fat injections (Mang’s spacelift) and biological implants,such as collagen and hyaluronic acid,is preferred.
The decision to use botulinum toxin injections must be based on stringent criteria. 
The results for forehead wrinkles are good and the treatment can be repeated at intervals of 6months.
The euphoria generated by laser therapy in the early 1990s has not entirely satis?ed expectations for the treatment of the “aging face.”
The laser is not a “miracle weapon,”but has now attained an established place in the ?eld of adjuvant therapies.
We primarily use the ultrapulse CO2 laser for skin resurfacing.
This has already been described in detail in the audiovisual aids in Volume I.
The surgeon must decide whether to perform dermabrasion,chemical peeling,or laser therapy for wrinkles in the perioral region on the basis of his/her experience and his/her own judgment.
Dermabrasion with a diamond cylinder gives good long-term results with no scarring or abnormal pigmentation for moderately deep lip wrinkles in younger patients.
Chemical peeling (e.g.,trichloroacetic acid 35%) may be useful for older patients with deeper wrinkles.
Erbium-YAG laser provides the best results for wrinkles in the perioral region and particularly the area of the lower eyelids.
Local Anesthesia
Nerve Exit Points,Supraorbital Nerve,Infraorbital Nerve,Mental Nerve 
If adjuvant therapies are not combined with operations (e.g.,a facelift), they are performed under local anesthesia and as day-case treatment. 
Nerve block anesthesia with Ultracain 1% (articaine) and additional adrenaline have proved to be successful.
When treating the entire face by laser or chemical peeling,light sedation also can be induced with Dormicum (midazolam) with anesthesiology stand-by.
With all operations carried out as day cases,a venous line and,if necessary,antibiotic prophylaxis are recommended.
Biological Implants*
Only endogenous (bone,cartilage,fascia,connective and adipose tissue, etc.) and biosynthetic materials (collagen,hyaluronic acid) are used at our clinic.
We do not use alloplastic materials (e.g.,silicone and paraf?n oils, PMMA,etc.) since they can cause unpredictable and sometimes irreparable damage.
The most important principle in aesthetic surgery is health before beauty.
Avoid all new materials that have not undergone long-term testing.
This applies not only to injectable materials but also to breast implants and suture material.
Injectable collagen is an ultrapuri?ed bovine collagen of type I.
Depending on the concentration (35–65mg/ml),this material is available in various ready-to-use ampules with a local anesthetic.
The injection of the dermal ?ller substance has been given correctly if the aesthetically disturbing area is overcorrected and the skin becomes white (blanching effect).
This technique can be used to treat all wrinkles in the facial area (glabella,eyes,nasolabial folds,lips),acne and accident scars,and also to augment cheeks and lips.
If collagen is to be used,a test must be performed with 0.2ml of collagen on the inside of the forearm 4weeks prior to treatment to rule out allergies.
This test is not necessary if hyaluronic acid is used.
This substance is also fully biodegradable,but it is a polysaccharide,not a protein compound. 
This means there is nearly no allergenic potential and testing in advance is unnecessary.
The indications are the same as for collagen,although hyaluronic acid is slightly more viscous to inject.
Hyaluronic acid is also available in various concentrations,so ?ne creases in the area of the eyes can be treated with material with a lower concentration and nasolabial folds and lips can be augmented with material with a higher concentration.
Injection Technique
The liquid collagen is injected intradermally at an angle of 30°,resulting in over-correction and the “blanching effect.” 
The injection must be strictly intradermal,and it is essential that it is not subcutaneous,as otherwise it will be ineffective and the material will be absorbed immediately.
If the correct injection technique is used,the result will last for 6–8months.
Maintenance injections can then be given.
Report – Technique
Collagen and Hyaluronic Acid 
■ The skin must be thoroughly disinfected prior to the injection.
Nerve block anesthesia with 1% Ultracain and additional adrenaline can be used in patients who are particularly sensitive to pain and when treating large areas.
Surface anesthesia with the anesthesia ointment EMLA? (lidocaine-prilocaine cream) may be given at the patient’s request. 
■ Hyaluronic acid and collagen are injected directly into the wrinkle using Mang’s serial point-by-point technique with overcorrection.
The injection should be made at an angle of 30°.
The patient should be lying down and the doctor carrying out the treatment should be sitting.
Overcorrection can be up to 100%.
If the injections are placed correctly,raising of the skin and a blanching effect will be visible immediately. 
■ The injection should be as close as possible to the surface.
The point-bypoint technique is used to remove forehead wrinkles (glabella),nasolabial folds and lip wrinkles.
Fine eye wrinkles are treated with linear injections. 
The needle is inserted super?cially along the eye wrinkle and pushed forwards;when it is retracted,the material ?ows like water into a riverbed. 
The wrinkle is then massaged immediately to prevent nodules forming.
In principle,all wrinkles in the face and neck area can be treated with these two techniques.
The skin is always pretensioned by applying mild traction. 
■ Fine corrections can be made at the end of the procedure with the aid of a magnifying glass.
All nodules and necklacelike structures should be smoothed and massaged.
The injectable material should spread out, almost as if in a riverbed,if an optimal result is to be achieved. 
■ A high-concentration collagen is used to enlarge the lips.
When carrying out lip augmentation for the ?rst time,it is advisable to begin ?lling-in at the margin of the lip,i.e.,at the transition of the lip from red to white. 
The needle should be inserted along the edge of the lip at an angle of 10–20°,starting at the corner of the mouth and working toward the center.
Ideally,the material should be distributed along the vermilion border,thus rede?ning the contours.
Up to 4ml of collagen may be injected per session,depending on the extent of lip augmentation. 
■ After the treatment is completed,dexpanthenol ointment should be applied evenly to the injection sites and the treated areas should be compressed under slight pressure for approx.15min.
Avoid sun and alcohol for 24h.
Make-up can be worn again 1day after the operation. 
The patient is also able to return to work 1day after the operation.
This is a 38-year-old female patient with a deep nasolabial fold. 
Injection of 1ml collagen on each side. 
Follow-up after four months with smoothed nasolabial fold.
This is a 38-year-old female patient with a deep nasolabial fold. 
Injection of 1ml collagen on each side. 
Follow-up after four months with smoothed nasolabial fold.
Crystalline Polylactic Acid 
Polylactic acid is available as a lyophilisate that is dissolved with water for injections.
In addition to microspheres,polylactic acid contains the products carboxymethylcellulose and mannitol.
Poly-L-lactic acid is biocompatible,immunologically inactive,and biologically absorbable. 
Synthetic production is used;therefore skin testing is not necessary*. 
■ Indication:deep folds,to provide contours and to build up volume,e.g., nasolabial folds,marionette folds,and cheeks,possibly chin,scars,and upper lip.
Also to build up the cheeks in cases of lipoatrophy. 
■ Mechanism:after Sculptra? has been injected,the wrinkle is mechanically ?lled with the injected volumes.
The water contained in the suspension is,however,absorbed by the body within a few days and the wrinkle returns.
A gradual and natural build-up of volume is achieved only after this as a result of the formation of new collagen ?bers.
This provides a lasting effect which,in a good case,may last for more than 2years. 
Induration may sometimes occur. 
■ Contraindications:allergy to one of the components;acute or chronic skin diseases:injections in the vermilion of the lips. 
■ Explanation of procedure:a written declaration of consent must be obtained from the patient regarding possible complications such as hematomas,swellings,reddening of the skin and formation of nodules. 
? Injection depth:deep dermis to the border to the subcutis. 
? Materials required: poly-L-lactic acid (Sculptra?) Water for injections Possibly local anesthetic 
? Storage:at room temperature (not above 30°C)
Usage: 
■ Reconstitute the lyophilisate with 5ml water for injection (note:it can also be dissolved with 4ml water and 1ml local anesthetic).
Add the water to the bottle slowly and allow to stand for at least 2 h so that the water can penetrate the lyophilisate 
■ roduce photographic documentation prior to treatment. 
■ Possibly local anesthesia (cream or regional anesthesia). 
■ Disinfect skin. 
■ Shake the bottle well until the suspension is homogeneous,immediately before use Shake again before opening the bottle in every case! 
■ Use a 26-Ga needle for injection. 
■ Check that the injection needle is unobstructed before every injection is given. 
■ Linear injection technique:?rst insert the full length of the cannula,then inject with a slight punching pressure when withdrawing the needle. 
Inject only small quantities (0.1–0.2ml per injection). 
■ Then massage the area of the face treated (preferably with cream to reduce the friction) and cool if necessary to reduce the swelling. 
■ Aftercare:cooling until the swelling has reduced.
Massage the areas of the face treated for a few minutes over several days.
Contouring Using the Mang Method 
This involves combined treatment with NewFill? for the deeper layers of skin (subcutaneous linear injection technique) and Viscontour? for the super?cial wrinkles (epidermal point-by-point injection technique). 
Our experience has shown that combined treatment with the lactic acid product Sculptra? and the hyaluronic acid product Viscontour? produces good results in the long term although neither material is alloplastic.
Botulinum Toxin
Horizontal lines and glabella wrinkles are often dif?cult to remove surgically.
The forehead is made up of numerous mimicry muscles that cannot be entirely smoothed-out even following a brow lift (endoscopic, coronal,or hairline cut).
Botox is therefore an important resource for removing wrinkles in the forehead region.
Patients are amazed at the results and even accept that the injections will have to be repeated after 4–6months if they want to have a smooth forehead.
Botulinum toxin must be injected by an experienced doctor under sterile conditions in the clinic,with the treatment carried out as day-case surgery.
Otherwise,signi?cant complications may occur,including paralysis of the eyes.
The preoperative marking of the injection sites is particularly important if adverse side effects are to be avoided.
The patient should frown so that it is possible to see the area of maximum muscle activity.
Particular care should be taken in the supraorbital region and lateral to the pupillary boundary (illustrations).
No more than 1.5ml botulinum toxin,corresponding to 60U of Botox, should be injected per session.
Treatment should be repeated after 4months at the earliest.It is safe to give three injections per year.
As the ampules supplied by the company contain 2.5ml botulinum toxin, which is dissolved in non-preserved saline solution,it is advisable to inject 1.2ml per session.
To avoid wasting of the material it is always advisable to treat two patients at the same time.
It is possible to treat periorbital wrinkles,perioral wrinkles,a drooping corner of the mouth,and wrinkles in the chin and neck (platysma),as well as forehead wrinkles,with botulinum toxin.
The platysma can extend over the thorax as far as beyond the second rib and is above the fascia here.
Diagonal neck wrinkles can be treated via 6–12 injection sites.
These should be positioned in the shape of an upside-down triangle and 4U of Botox should be injected at each site,at intervals of 1cm with the needle at an angle of 45°.
This treatment can also be combined with a facelift,but we recommend that botulinum toxin is not be given intraoperatively while the patient is under anesthesia.
Botulinum toxin should not be given until the second day after the operation for medicolegal reasons.
Report – Technique 
■ Little material is required for botulinum toxin injections.
The ampule contents are dissolved in 2.5ml of a non-preserved saline solution.
The suction of the syringe plunger is evidence of the vacuum inside the ampule. 
■ For the injection,we use a convention insulin syringe with appropriately ?ne graduations (4U of botulinum toxin correspond to 0.1ml).
It is recommended that the novice use syringes with a volume of 0.3ml so that the dosage of the injections can be even more accurate. 
■ The injection is made directly into the center of the muscle with a 30-Ga cannula.
In the forehead and glabella regions,it is recommended that the injection be made at an angle of 90°,vertical to the periosteum.
The syringe is then pulled back slightly until the center of the muscle is reached.
The material,usually 0.1ml,is then injected.
The injection quantity is lower/fewer units are injected in the perioral and periorbital areas,i.e.,2–3U. 
■ The marking of the injection sites prior to the operation is particularly important if adverse side effects are to be avoided.
The injection must be made under sterile conditions following prior careful disinfection. 
■ In women with highly arched eyebrows,the muscles of the forehead are not highly developed.
They have a lower mass and therefore only a small amount of Botox is required for paralysis.
The ?xed points for the injection in such cases are the midline between the two eyebrows,and on the vertical line from the inner canthus to the upper margin of the osseous orbit as well as 1cm cranial to this. 
■ In women with more horizontal eyebrows,the muscles are more highly developed,and a slightly larger quantity of botulinum toxin is therefore required.
Additional injections can be made 1cm above the osseous margin of the orbit in a line running from the middle of the pupil in a cranial direction.
There is a danger of ptosis if material is injected lower than this. 
■ In patients with pronounced horizontal wrinkles caused by the activity of the frontalis muscle,the injections are made along an imaginary horizontal line between the eyebrows and hairline in the vertical line running from the pupil in a cranial direction.
Further injections are made between these two points.
Additional sites can be de?ned individually depending on muscle activity and the depth of the wrinkles in the forehead area. 
■ Eyebrows that appear too straight and droop at the sides can be lifted with injections.
In this procedure,botulinum toxin is injected into the upper lateral section of the orbicularis oculi muscle at a site close to the orbital margin,1–2cm above the lateral corner of the eyelid.
Applying a counterpull to the frontalis muscle causes slight raising of the lateral eyebrow. 
■ Crow’s feet are treated with one injection 1.5cm lateral to the canthus and two injections cranial and caudal to this point.
The osseous orbit serves as a point of orientation.
Tensioning of the orbicularis muscle can sometimes create a tense or bitter facial expression.
By injecting Botox into parts of the ring muscle,this can be modi?ed to give the patient a more friendly facial expression.
The injections are made directly below the edge of the lower eyelid in the mid-pupillary line.
During the injections,the patient should have his or her eyes open and be looking upwards. 
■ Depending on how vigorously the orbicularis oris muscle is contracted, 2–4 injection sites are distributed in a line along the lip margins,i.e.,one point lateral to the philtrum on the left margin of the lips and one on the right,and one further point. 
■ Furrows develop over the years as a result of the pull of the depressor anguli oris muscle and these run from the corner of the mouth in a caudal direction.
The injection is made into the center of the muscle, which can be identi?ed by palpation,approx.1cm lateral and 1cm caudal to the corner of the mouth. 
■ If the skin is highly elastotic,contraction of the mentalis muscle may result in the chin having a “cobblestone”appearance.
Botulinum toxin (0.1ml) is injected at two paramedial injection points,approx.0.5–1cm above the tip of the chin. 
■ The platysma can be inactivated by botulinum toxin so that the neck appears smooth when tensioned.
Treatment should be started with low doses.
The experienced doctor can then extend the injections to the entire face with the following units. 
■ Twenty units of botulinum toxin,injected into the procerus muscle and the middle of the corrugator supercilii muscle,divided into several individual doses,are suf?cient to smooth “anger wrinkles.”
To reduce the activity of the frontalis muscle,treatment should be with a total dose of around 16 units per session.
The treated areas are compressed brie?y after the injection.
The patient must then keep his/her head upright. 
■ Three units of botulinum toxin per injection site are used to smooth crow’s feet in the area of the eyes.
In the perioral area,1–2U are injected per injection site with the needle at an oblique angle,inserted only slightly and pointing in a cranial direction. 
■ To lift the corner of the mouth,3–5U are injected into the center of the depressor anguli oris muscle.
The center is identi?ed by palpation. 
■ In the chin region,3–5U injected at two injection sites in the area of the mentalis muscle will be suf?cient to achieve a smooth appearance.
The injection should be vertical and in the direction of the periosteum. 
■ When treating the submental region,the platysma should be contracted and held between the thumb and index ?nger (platysmal bands).
Four units of botulinum toxin are injected subcutaneously,directly into the platysma at intervals of 1cm with the needle at an angle of 45°. 
■ There are many indications for the use of botulinum toxin and the aesthetic surgeon must gradually push the boundaries to be able to achieve good results without risks.
A 37-year-old patient with pronounced forehead mimicry. 
Injection of 1.0ml botulinum toxin in the forehead area following prior marking of the injection site. 
Findings 3months after treatment.
Mang’s Spacelift
Introduction
The name spacelift was chosen by the author and protected by patent (no.30323891) as appropriately puri?ed and centrifugated,recycled fat droplets are injected into the entire face,as in a honeycomb,using microinjections.
The fat particles break down but,as a result of the contact with vessels (because they are not injected in large quantities in a bolus dose),they are able to form their own ?broblasts and the catabolized fat cells are augmented with ?broblasts and elastin ?bers.
Virtually no scars are formed and the face stabilizes as a result of the procedure. 
Naturally,injections can be made beneath other wrinkles in the forehead and nasolabial area using a conventional fat injection technique.
Lipotransfer is also recommended for lip augmentation.
Indications
As early as 1893,Neuber reported that adipose tissue transplant material could survive only in the smallest particles.
This is the most important condition for a successful fat transplant.
In 1922,Lexer stated that if the adipose tissue is not damaged by bleeding either when it is removed or when it is implanted,it can survive for 3years.
In 1950,Peer announced that up to 50% of transplanted fat survives if excessive negative pressure is not exerted on the fat during extraction by suction and excessive positive pressure is not exerted on the fat during injection.
Vascularization of the fat droplets takes place after 4days and until that time survival is guaranteed as a result of diffusion.
In 1986,Coleman reported that fat can only survive as a tissue compound and not as an individual cell.
Oil,blood,and local anesthetics must be separated from the structural fat by gentle centrifugation.
The individual particles of adipose tissue must be positioned close to the vessels to be fed to facilitate independent anchoring in the surrounding tissue.
Thus,all the criteria for a stable transplant would be ful?lled.
Indications: 
? To replace atrophied or wasted structures resulting from aging or the sequelae of in?ammatory skin diseases (e.g.,acne) 
? To strengthen existing structures 
? To create harmonious and aesthetically pleasing facial features by replacing wasted tissue with fan-shaped,three-dimensional implantation of autologous fat particles 
? Congenital or acquired deformities of the osseous and connective tissue structures (sequelae of burning, blunt soft-tissue injuries, facial fractures, cleft lips, midfacial hypoplasia, hemifacial atrophies, micrognathia)
■ The overall appearance of the face and the proportions can be improved by emphasizing speci?c facial structures (e.g.,the chin appears smaller when the lips and the margins of the lower jaw are augmented). 
■ The fat must be removed under sterile conditions in the operating room. 
■ Sites for fat removal are those where contours can be achieved without creating hollows (e.g.,double chin,lower abdomen,medial side of the thigh,knee). 
■ Following tumescent anesthesia,the fat is removed using low-vacuum liposuction (–0.2atm;this is approximately 20–30% of the vacuum used with normal liposuction) with a blunt 2ml suction cannula. 
■ The diameter of the cannula openings should correspond to a Luer-Lock so that the fat particles can pass through the equipment without being damaged further during the later transplantation = gentle curettage of the tissue with minimal vacuum.
Technique
■ If suction is performed using a conventional liposuction system,the fat is now transferred to 10ml syringes under sterile conditions.
The plungers are then removed from the syringes.
The syringes are placed in a centrifuge and spun at 3,000rpm for 4min. 
■ This separates the aspirate into three layers: 
? The top layer consists of oil and ruptured fat cells;this is drained and carefully dabbed away.
? The bottom layer consists of tumescence solution and blood;this is drained off. 
? The middle layer is made up of usable subcutaneous adipose tissue; using an adapter,this is transferred into a 1ml Luer-Lock syringe without traumatization.
Injection Technique 
■ The fat should be injected in a fan shape and in two to three layers.
The face is built up and stabilized with fat droplets using a three-dimensional technique,as if in a honeycomb. 
■ The supraorbital,infraorbital;and mental nerves can be blocked to provide anesthesia.T
he individual injection sites may also be treated with local anesthesia. 
■ The fat removed using the tumescence technique is spun at 3,000rpm for 4min so that only vital,puri?ed fat is used for the fat injection.
The fat is transferred into 1-ml Luer-Lock syringes using a special adapter. 
The globules of fat can be positioned,as if they are a string of pearls, using a 20- or 23-Gg needle.
This ensures surface contact with the surrounding capillaries and also allows the fat implants to become ?rmly anchored in the surrounding connective tissue.
■ Three-dimensional implantation of fat globules is particularly effective. 
With this technique,several channels are placed on top of one another in a fan-shaped pattern at various levels within the subcutaneous tissue.
It is best to begin with the deepest fan-shaped layer and then place the fanshaped layers on top of one another.
In addition,particularly pronounced mimicry wrinkles on the forehead and in the nasolabial area can be treated separately using the intracutaneous serial point-by-point technique with a ?ne needle,in a similar way to the point-by-point collagen technique. 
■ It is important that all the areas treated by injection are massaged with the ?nger when the treatment is completed so that there is no bulging and no nodules form.
This applies particularly to sites treated by injection in the lip,nasolabial,zygomatic arch,and forehead areas.
Lip modeling can be performed easily with this technique,but three injections will be required (at 0,6,and 12 months). 
■ The survival of the transplanted fat globules can only be guaranteed if the maximum distance to well-perfused host tissue is 1.5mm.
Otherwise, the fat transplant will die,it will be absorbed,or it will become calci?ed. 
■ First,a tunnel is created at the tip using the cannula and without exerting any pressure.
This is ?lled with puri?ed fat when the cannula is pulled back,by exerting slight,uniform pressure on the plunger.
A row of channels is then created with the cannula,and these are ?lled with fat when the cannula is pulled back. 
■ Compression bandages are only necessary if there is concern about possible displacement of the implant.
Areas with pronounced mimicry, e.g.,the glabella,are immobilized with Steri-Strips.Cooling for 2–3 days is advisable.
Antibiotic cover is given. 
■ Several sessions (up to three) are usually necessary,as the connective tissue septa of the subcutaneous tissue will only allow in a certain quantity of adipose tissue transplants.
Otherwise,the fat globules will be traumatized.
A certain amount of edema also always develops in the host area as a result of the in?ltration.
Possible complications: 
? Edema indicating repair processes in the many small channels created;possible for up to 4weeks. 
? Hematomas (owing to incorrect technique). 
? Overcorrection,undercorrection. 
? The formation of palpable and visible nodules,even in the tissue surrounding the defect,can be avoided if a fan-shaped implantation technique is used. 
? Fat necrosis occurs if too much fat has been implanted in a limited host area. 
Please note:the maximum distance permitted from the center of the fat droplet to the surrounding capillary tissue is 1.5mm.
Otherwise, fat necrosis and possibly calci?cation may occur. 
? Migration of the fat implant is possible if the injection is made into muscle or ?rm connective tissue. 
? Infections. 
? Nerve and vascular damage is virtually ruled out if blunt cannulas are used.
Advantages of lipotransfer: 
? The fat globules can be obtained easily using liposuction. 
? The transplant is autologous. 
? No immunological reactions/complications are to be expected. 
? Fat can be injected below all wrinkles and depressions if the correct technique is used. 
? It is possible to repeat the treatment without any problems. 
? The costs are comparatively low.
Surplus aspirated fat can be frozen (e.g.,2?10ml) and reinjected again in divided doses (at 0,6,and 12 months).
The fat should be stored at –18°C for no longer than 1year.
Remove the syringes ?lled with fat from the freezer 3h before reinjection.
Each fat transplant should be marked with the operation date and the patient’s name and date of birth. 
As a result of the divided and repeated injection of fat cells,increased ?brosis (booster effect) occurs and this ensures a longer-lasting effect.
Diagram of the Fat Injection 
Ideally,the fat will be injected in drops into the infrastructural connective tissue (ICT) in a three-dimensional way.
This ensures surface contact with the surrounding capillaries and allows the fat to become anchored in the surrounding connective tissue.
It is transformed into separate scar and connective tissue as a result of ?broblast activity,which ensures the facial skin is stabilized and acts as a prophylaxis against aging. 
A spacelift is not recommended if there are hanging areas of skin.
A spacelift can postpone the need for a facelift but is not a substitute for one.
Three-Dimensional Diagram of Fat Injection into Subcutaneous Tissue 
The fat droplets lodge themselves in the subcutaneous tissue.
If positioned correctly,and because they are not injected in a bolus dose,they become associated with the capillaries and consequently,following appropriate transformation,they help to stabilize the infrastructural connective tissue (ICT).
Increasing the Density of the Connective Tissue Following Breakdown of Fat Droplets 
The loss of elastin and collagen ?bers caused by aging can be partly offset with the breakdown/transformation of adipose tissue as a result of ?broblast activity.
The absorption rate for fat is different for every patient,so even this procedure must be carefully explained.
Even though this method does not offer eternal youth,the spacelift is a step forward towards the goal of biological anti-aging.
A 39-year-old female patient with drooping eyelids,nasolabial and lip wrinkles,and a tired facial expression. 
Findings 6 months after the operation following two fat injections (First session 15ml,second session 8ml).
Dermabrasion
Introduction 
Dermabrasion demands experience,skill,and concentration from the doctor carrying out the treatment.
If performed well,the results for dermabrasion are very good,particularly in the perioral region and the area of the lips.
The doctor’s experience will determine whether he/she chooses to use chemical peeling,laser treatment,or abrasion treatment. 
This depends on the patient’s age and skin type.
The abrasion head,which is coated with diamond dust,must be supported and held perpendicular to the plane of rotation.
The pressure on the burr should always be the same to avoid creating grooves.
Dermabrasion should not be performed below the level of the dermis.
After-care consists of placing a wound gauze soaked in antibiotic ointment on the wound.
This dressing is removed after 24h.
The face is treated with dexpanthenol ointment for a further 8days.
Make-up may be applied after epithelization of the wound surface.
It is necessary to protect the skin from the sun or even avoid the sun for 3months (pigment abnormalities).
Report – Technique 
■ Protective goggles should be worn during the procedure.
The operation site should be draped and disinfected carefully.
The skin should be tightened by an assistant.
Level/?at surfaces can be created by stretching the skin.
This facilitates abrasion and permits the application of treatment at an exact depth.
Skin tension must be maintained during the entire abrasion procedure.
The abrasion head,which is coated with extremely ?ne diamond dust,must always be kept perpendicular to the plane of rotation.
It should not be guided in the direction of rotation.
Instead,it should be moved over the surface of the skin against the rotation of the abrasion head at an angle of 90°and slight pressure should be applied. 
Punctiform,super?cial bleeding is the most reliable indicator that the grinding procedure has reached the optimal depth.
Abrasion should not be performed at a deeper level. 
■ Dermabrasion is complete when an even wound surface with ?ne,punctiform/diffuse bleeding has been created.
A wound gauze soaked in antibiotic ointment is then placed over the wound.
A 54-year-old patient with wrinkles in the perioral and upper lip areas. 
Findings 12 months after dermabrasion.
Chemical Peeling
Introduction
Chemical peeling falls into the dermatologist’s sphere and can be studied in full in textbooks covering this ?eld.
The same applies to all types of laser treatment.
These two procedures are therefore discussed only brie?y in this manual.
Chemical peeling includes various types of peeling,which differ in terms of the intensity (e.g.,fruit acid,glycolic acid,alpha hydroxy acid, trichloroacetic acid,phenol).
The application of the agents appears simple,but experience is vital and an expert assessment of the skin areas is essential.
The key to successful peeling is to apply the solution evenly and homogeneously,to provide accurate information about the risks (scarring and abnormal pigmentation),and to carry out the correct follow-up treatment.
Report – Technique 
■ The most practical,most effective,and safest method of chemical peeling for the novice is to use 30% trichloroacetic acid.
This removes the entire upper layer of skin,down to the reticular dermis.
Nerve block anesthesia of the infraorbital and/or mental nerves can be used in patients who are particularly sensitive to pain,but local anesthesia using an occlusive dressing is usually suf?cient. 
■ Following disinfection,the skin is treated with acetone to remove super?cial skin scales.
This allows better penetration of the acid into the skin. 
After the acid has been applied,the area to be treated is marked.
The acid is applied homogenously over the entire surface at a consistent pressure.
This is the true art of any type of peeling.
The application of the acid may be repeated several times,depending on the depth of the wrinkles,using slight pressure.
Each area of skin must be treated with the same intensity so that the skin relief does not vary later.
The typical blanching,which is a sign that the treatment has started to take effect (frost effect),begins before the treatment has been completed. 
■ Follow-up treatment is with Vaseline as this reduces the sensation of tautness.
Herpes prophylaxis with acyclovir 400mg three times daily is recommended for 5days as well as antibiotic cover.
Female patient with numerous wrinkles in the mouth region. 
Findings six months after chemical peeling with trichloroacetic acid.
Erbium-YAG Laser
Introduction
The euphoria generated by laser therapy in the 1990s has dissipated somewhat,as the long-term results of treatment for the aging face did not live up to all the expectations.
Laser surgery will develop further in the future and the repertoire of the aesthetic surgeon is unimaginable without it,but its use must be considered very carefully.
Skin resurfacing with pulsed CO2 laser treatment was explained in detail in Volume I of the manual,so only pulsed erbium-YAG laser treatment will be described brie?y here.
The advantage of using erbium-YAG laser treatment instead of CO2 laser treatment is that there is less necrosis and the treated area heals more rapidly because of the lower thermal impact on deeper tissue layers.
The lack of a coagulation effect,however,limits the treatment of wrinkles as it is presumed that the collagen structure will not change because the ablation is virtually non-thermal.
In principle,pulsed CO2 laser treatment can be used in all cases where erbium-YAG laser treatment is recommended,so an aesthetic surgeon should only purchase an erbium-YAG laser if his work focuses on antiaging surgery of the face.
Report – Technique 
■ Crow’s feet in the lower-lid area can be treated well with the erbium-YAG laser.
The advantage of this non-invasive procedure,which can be carried out on an outpatient basis,is the rapid healing of the treated sites. 
Following disinfection and anesthesia of the operation site (e.g.,blocking of the infraorbital nerve),the boundaries of the section to be treated by laser are ?rst de?ned.
The laser is then guided evenly,section by section,over the area to be ablated.
Slight overlapping will not be harmful.
The use of the erbium-YAG laser as an additional resource during plastic/aesthetic procedures,e.g.,facelift or blepharoplasty,is an elegant, non-invasive way of treating wrinkles and creases in aged and sundamaged facial skin quickly,especially around the mouth and eyes and on the forehead and cheeks.
When used correctly,possible risks such as abnormal pigmentation and scarring are virtually ruled out.
The effect achieved is good when smoothing super?cial and medium-depth skin wrinkles.
When treating deeper skin wrinkles,there is de?nitely an improvement in the overall appearance,but the wrinkles cannot be completely removed.
In this case,CO2 laser treatment is more effective. 
Wound discharge and crust formation are less pronounced following erbium-YAG laser treatment and do not persist for as long as with CO2 laser treatment.
There is also less postoperative skin reddening and this reduces more quickly.
■ Use of the erbium-YAG laser for patients who have aesthetically disturbing skin changes in the facial area that are not yet too severe can therefore enhance the spectrum of practical work performed by surgeons with an interest in skin surgery.
A 39-year-old female patient with deep lower-lid creases. 
Six weeks after erbium-YAG laser treatment. 
Hyal System
Introduction 
The Hyal System makes use of the fact that native hyaluronic acid has a high level of biointeractivity and can therefore increase ?broblast activity and the neosynthesis of endogenous hyaluronic acid,elastin and collagen.
Unlike highly cross-linked,chemically changed hyaluronic acids which are used exclusively as dermal ?llers,the Hyal System* injection technique attempts to create attractive tissue by building up the extracellular matrix of the skin areas in three dimensions using small droplets,a method similar to that used in a spacelift.
The desired effect is achieved in 6 weeks at the latest.It is intended more as prophylaxis against aging skin and can also be used in the area of the neck,chest and hands.
In 1934,Karl Meyer and John Palmer isolated hyaluronic acid (a glucosaminoglycan) from the vitreous body of a cow’s eye.
Hyaluronic acid, a linear polymer,is made up of the disaccharide units D-glucuronic acid and N-acetyl-glucosamine.
It occurs naturally in human eyes,in joint surfaces,and in the skin.
In the skin,it serves as a substrate of the cell structure and the extracellular matrix.
In the dermis,it is associated with the elasticity and hydration of the skin.
It also increases ?broblast activity and the neosynthesis of endogenous hyaluronic acid,elastin and collagen.
Until very recently,hyaluronic acid was considered to be only a space-?lling substance with a purely mechanical function.
We now know that hyaluronic acid speci?cally modulates biological processes in humans and animals via endogenous membrane receptors.
Depending on the area of application,we can therefore regard hyaluronic acid both as a medication with a long-term pharmacological effect and as a medical product when only the viscoelastic properties of this macromolecule are used.
In aesthetic medicine,it is used to reduce skin wrinkles,to increase regional volume,and to treat scarring,as well as to improve skin tautness and strength.
In general,it is possible to distinguish the two products. 
■ 1. Dermal ?ller 
? Highly cross-linked,chemically modi?ed hyaluronic acid 
? Molecule inertia 
? Static skin implant 
? Mechanical increase in volume 
■ 2. Hyal System 
? Native hyaluronic acid 
? High level of biointeractivity 
? Homogeneous distribution in the skin layers/surfaces 
? Biorevitalization with long-term effect
Hyal System is available in 1.1ml ready-to-use syringes.
This is a natural, chemically unchanged hyaluronic acid polymer (polysaccharide).
The solution is highly concentrated and has a low viscosity and therefore has good ?ow properties in comparison with dermal ?llers.
Report – Technique 
■ Following surface or nerve-block anesthesia (supraorbital,infraorbital, mental) and disinfection,injection of the Hyal System into the papillary dermis via a 30-guage cannula is started. 
■ The angle of insertion is normally 10–15°and the cannula should then be advanced parallel to the surface of the skin.
Blanching of the skin will be visible if the injection has been given correctly.
A cross-link,tunnel,or fan injection technique is used depending on the anatomical region. 
A serial point-by-point injection technique can also be used with appropriate indications (nasolabial).
In the cheek region,a cross-link injection technique is used,i.e.,following an imaginary,diagonal framework; injections are given either at every or at every second horizontal and vertical point of intersection,and the entire area to be treated is thus undermined.
The needle is inserted at an angle of 10–15°and then moved so that it is parallel to the surface of the skin.
This ensures the correct injection level (the papillary dermis) is reached.
The injections are ?rst made in a horizontal direction and the area being treated is then brie?y compressed.
The injections are then continued in a vertical direction. 
■ At the sides of the eyes,the tunnel technique is most suitable.
Injections are made into the upper dermis in parallel lines. 
■ The cross-link technique is most suitable for treating the glabella and the upper area of the forehead because of the large area coverage.
In modi?ed form,this technique can be applied laterally.
■ To achieve a rejuvenating effect in the upper perioral region,the Hyal System is injected parallel to the upper lip in droplets.
Similar injections are made parallel to the lower lip to complete this treatment. 
■ The Hyal System can also be used to tighten larger areas of the neck,the d?collet? region and the hands,and a modi?ed cross-link technique must be used in these areas,i.e.,systematic,even,and fan-shaped injections must be given over the entire area to achieve a satisfactory result. 
The aim is to establish ?broblast activity and neogenesis of endogenous hyaluronic acid,elastin and collagen. 
■ Depending on the size of the areas to be treated,multiple syringes of 1.1ml may be injected.
We use 2ampules per session. 
■ In young patients who still have ?rm skin tone,three injections at intervals of 4weeks will be necessary initially.
Subsequent injections should be repeated every 4–8months to maintain the result.
In older patients with atonic skin and insuf?cient elasticity,three injections should be given at fortnightly intervals and boosters should then be given every 3–6months.
Follow-up Treatment 
■ Following treatment,the undermined area should be compressed for approx.15min.
The Hyal System is an innovative method to restore better quality to the aging skin.
In the future,it is certain that there will be many useful developments in aesthetic surgery.
Prospects – What Is the Future of Aesthetic Surgery?
There has been a boom in aesthetic surgery all over the world and the rate of growth has doubled.
The age of patients ranges from 14 to 80 years and every ?fth cosmetic operation is now requested by a man. 
Research into new materials,implants,instruments and equipment,even robot-controlled operation modules,is important for the further development of aesthetic surgery,but these can never replace the skill of the aesthetic surgeon.
A ?rst-rate aesthetic surgeon must not only be welltrained;he must also be a psychologist and an artist if he wants good results.
The fundamental requirement,however,is correct training.
Aesthetic surgery is high-tech surgery.
It has a ?xed position in society and must establish itself as an independent,interdisciplinary specialty. 
Aesthetic surgery must no longer be taught as an appendage to the specialties of surgery,plastic surgery,ENT surgery or maxillofacial surgery, but must be taught over a 3-year advanced training period following high-quality surgical or plastic surgery training and acknowledged as a specialty with a recognized title.
This is my hope for the future,as only this will make it possible for us to achieve worldwide quality assurance and make aesthetic surgery a recognized specialist surgical discipline.
Aesthetic surgeons should work together with specialists in all disciplines whom they could learn from,and with whom they should exchange their knowledge at conferences throughout the world,never forgetting the Hippocratic oath.
Aesthetic surgery should not be “alteration surgery”but rather “well-being surgery.”
We have understood our profession correctly if we are able to make patients feel good.
As president of the International Society ofAesthetic Surgery (ISAS*),in the future I would like to give all young colleagues with an interest in this ?eld an opportunity to become members and make the specialty of aesthetic surgery accessible in a yearly “exchange of ideas.”
Only when the range of treatments is improved and developed further internationally,and there is a spirit of cooperation among surgeons,will we be able to gain better recognition within society for this ?eld.
I hope that this manual can play a part in this and my dream one day,of standardized training leading to the title “aesthetic surgeon,”will become a reality.
Aesthetic surgery is a specialty of the future.
Young doctors are extremely interested in this ?eld.
Doctors from all over the world visit Prof.Mang’s clinic every day.
The Manual ofAesthetic Surgery,Volumes I and II,forms the basis for comprehensive training in the ?eld of aesthetic surgery.
The Bodenseeklinik offers an opportunity for interested doctors to apply the knowledge described in the two volumes of the manual in practical aesthetic surgery.
A hospitality fee of 250 US dollars per day is charged for this.
This money will be used by the Prof.
Mang Foundation charity to help needy children.
The skin is composed of three layers: epidermis, dermis and subcutaneous tissue. 
The thickness of the layers varies with different anatomical regions. 
The epidermis is thickest on the palm and soles, and very thin on the eyelids, while the dermis is thickest on the back. 
Keratinocytes are the main component of the epidermis. 
Melanocytes are the cells located in the epidermis whose function it is to produce pigment. 
The ratio is about one in every ten basal keratinocytes. 
Differences in skin color according to race are explained by the number of melanosomes. 
Langerhans cells represent 3–5% of the cells of the stratum spinosum where they are situated between the keratinocytes. 
The dermis consists of a supporting matrix (ground substances) in which polysaccharides and proteins act to produce proteoglycans. 
The protein fibers inside the dermis are represented by collagen, elastin and other components, such as fibrillin and microfibril proteins. 
The blood supply to the skin comes from the deep plexuses located at the fascia and subcutaneous level. 
With aging, there is a decrease in total collagen content in the skin, an increased amount of type III collagen, decreased number and diameter of elastin fibers, and a lack of interaction between water and surrounding molecules which contribute to the dry and wrinkled aspect.
The skin is composed of three layers: epidermis, dermis and subcutaneous tissue. 
The epidermis is the outer layer and is formed mainly by keratinocytes whose main function is to synthesize keratin. 
The dermis is the middle layer and its main component is collagen. 
This layer lies on lobules of lipocytes. 
The thickness of the layers varies with different anatomical regions. 
The epidermis is thickest on the palm and soles, and very thin on the eyelids, while the dermis is thickest on the back.
The epidermis is the outer part of the skin and is composed of three basic cell types: keratinocytes, melanocytes and Langerhans cells. 
Merkel cells can be found on the palms and soles and are located directly above the basal membrane.
Keratinocytes are the main component of the epidermis. 
Their function is to produce keratin, a complex filamentous protein that forms the stratum corneum of the epidermis.
The epidermis is composed of several layers, beginning with the innermost as follows: basal layer, malpighian layer, granular layer and horny layers (stratum corneum). 
The palms and soles have also a clear layer called stratum lucidum (above the granular layer). 
The horny layer and granular layer are the thickest on the palms and soles and are almost absent on the flexor aspect of the forearms. 
Cycling stem cells, located at the basal layer, provide a pool for epidermal regeneration. 
As the basal cells divide, they flatten and move upward. 
The process of desquamation implies degradation of the lamellated lipid from the intercellular space and loss of desmosomal interconnections. 
The keratinocytes play an important role in the immune function of the skin.
Melanocytes are the cells located in the epidermis whose function it is to produce pigment. 
The ratio is about one in every ten basal keratinocytes. 
The face and genitalia have a greater amount of these cells. 
The melanocyte cell is a dendritic type, extending for long distances within the epidermis and in close contact with the keratinocytes. 
Together they form the “epidermal melanin unit”. 
Melanin is synthetized by melanocytes in the basal layer of the epidermis and transferred to surrounding keratinocytes in melanosomes. 
Differences in skin color according to race is explained by the number of melanosomes. 
People with fair skin have fewer melanosomes which are smaller and packaged within membrane complexes. 
People with darker skin have more melanosomes which are larger and not packed. 
Sun exposure stimulates melanocytes to produce larger melanosomes.
Langerhans cells represent 3–5% of the cells of the stratum spinosum where they are situated between the keratinocytes. 
They are responsible for the immunological response of the skin.
The dermoepidermal junction represents the junction between the epidermis and the dermis. 
It is located at the basement membrane zone and resembles a semipermeable filter which allows cells and fluids to travel between epidermis and dermis. 
It also serves as a structural support for the epidermis.
The eccrine and appocrine glands, ducts and pilosebaceous units constitute the skin adnexa. 
All have a role in epidermis regeneration (reepithelization). 
When an injury occurs, the keratinocytes from the adnexa migrate to the skin surface.
These glands have three main components: 
? The intraepidermal spinal ducts which open directly onto the skin surface 
? The straight dermal portion of the duct composed of cuboidal epithelial cells
? The secretory zone located in the superficial panniculus. 
In the back region, this zone is situated in the deep dermis
The role of these glands is also to produce sweat which is similar in composition to plasma with regard to the electrolytes. 
They are important in thermoregulatory function and are present in great amounts in the palms, soles and axillae. 
Some eccrine glands from the axillae have widely dilated secretory coils in patients with hyperhidrosis.
Appocrine glands develop on the infundibular upper portion of the hair follicle. 
They are intimally related to the pilar units. 
The coiled secretory gland is present at the junction of the dermis and subcutaneous fat. 
Appocrine secretion is odorless and episodic.
The appocrine units of the human body are generally confined to the axillae, areolae, genital region, ear canal and eyelids. 
The glands start to function after puberty.
Hair follicles develop in rows of three. 
Primary follicles are surrounded by the appearance of two secondary follicles. 
The amount of pilosebaceous units decreases throughout life mainly because of poor formation of secondary follicles. 
The hair follicle has three main components:
? The lower part beginning at the base of the follicle and extending to the insertion of the arrector pili muscle 
? The middle portion, also called the isthmus, from the arrector pili to the entrance of the sebaceous duct 
? The upper part, called the infundibulum, extends to the follicular orifice
The lower part of the hair follicle is also subdivided into five components: the dermal hair papilla; the hair matrix; the hair; the inner root sheath and the outer root sheath. 
The formation of the hair starts at the level of bulb, from the pluripotential cells. 
The melanin produced by the melanocytes is incorporated into the cells of the future hair through phagocytosis. 
At the level of the isthmus, the outer root sheath is no longer covered by the inner root. 
The outer root undergoes keratinization. 
The bulge cells posses stem cell properties, having the proliferative capacity to regenerate not only hair follicles but also sebaceous glands and epidermis.
The rate of hair growth depends on the mitotic activity of the cells of the bulb matrix. 
Hair growth is a cycle having three phases: anagen, catagen and telogen. 
The histological aspect of the hair follicle is different for each of the phases. 
The anagen is the growth phase, the catagen represents the regression phase, and the telogen is the rest phase. 
The hair follicle is the most susceptible to IPL treatment during the anagen phase. 
During the anagen phase, the stem cells differentiate into eight different cell types. 
From the bulge area, the stem cells ascend into the outer root sheath. 
Those which reach the hair germ transform into matrix keratinocytes to rebuild the hair shaft. 
The pigmentation and hair shaft synthesis take place in this phase. 
Three types of melanosomes are present in the hair. 
The erytomelanin granules are seen in red hair while the pheomelanin granules are found in blond and dark hair. 
In dark hair there are more melanosomes than in light hair.
In white or grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes. 
Melanin synthesis and pigment transfer to bulb keratinocytes depends on the precursors and their regulation is receptor dependent.
The transition from the anagen to the catagen phase varies from one skin region to another. 
There are several molecular regulators of this transition. 
The catagen phase consists of involution of the hair follicle, apoptosis and terminal differentiation. 
The first sign of catagen is the cessation of melanin production in the hair bulb. 
As the lower follicle recedes, a temporary structure, called the “epithelial strand”, forms and is considered to be unique to this phase.
After the catagen phase, the hair follicles enter into the telogen phase. 
In this phase, the follicle has a depigmented proximal hair shaft called “club hair”. 
This club hair most often remains in the hair canal. 
The transition from telogen to anagen occurs when a few stem cells at the base of the follicle near the dermal papilla are activated. 
The new follicle takes place adjacent to the old pocket. 
The hair cycle is a process influenced by many mediators and receptors. 
The same author suggested an inhibition disinhibition system that has the epithelial stem cells from the bulge region as the central pacemaker. 
It seems that the hair cycle clock is located in the dermal papilla.
The hair follicle has a strong influence on skin biology and plays an important role in the reparative process, especially in the outer root sheath which provides epithelial cells to cover wounds. 
The hair follicle has regenerative proprieties also. 
It has the ability to regenerate itself with the initiation of each cycle. 
The regenerative potential is demonstrated after massive damage during chemotherapy treatment.
It has been shown that the hair follicle influences the angiogenesis process. 
The dermis in the proximity of anagen follicles is more vascularized than that around telogen follicles. 
Blood vessel changes in the skin during the hair cycle are also controlled by the follicle.
The dermis consists of a supporting matrix (ground substances) in which polysaccharides and proteins act to produce proteoglycans. 
The protein fibers inside the dermis are represented by collagen, elastin and other components, such as fibrillin and microfibril proteins.
The collagen fibers within the dermis are 2–15?m wide. 
The thin, finely woven meshwork of collagen fibers is found in the papillary dermis. 
The collagen fibril diameter increases progressively with the depth of the dermis. 
The rest of the dermis, called the reticular dermis, has collagen fibers united into thick bundles. 
This part is composed primarily of type I collagen. There are several types of collagen. 
Type I collagen is predominant in the postfetal skin. 
Type III is found mainly in reticular fibers and is prevalent in early fetal life. 
In postfetal life, it is mainly located in the subepidermal area. 
Type IV collagen is present in the basement membrane. 
The fetus has predominantly type III collagen while the skin of the adult contains mainly type I collagen. 
Collagen is primarily responsible for the skin’s tensile strength. 
In young adults, collagen from the papillary dermis is organized as a meshwork of randomly oriented thin fibers and small bundles.
Elastin fibers are mixed collections of various distinctive glycoproteins which have a microfibrilare structure. 
They are thin in comparison with collagen bundles and measure from 1–3?m. 
The fibers are thickest in the lower portion of the dermis. 
At the level of the papillary dermis, they form an intermediate plexus of thinner elaunin.
During life, the elastic fibers undergo significant changes. 
In young children, the fibers are not fully mature, so the microfibrils predominate. 
With aging, there is gradual decrease in the number of peripheral microfibrils and the surface of elastic fibers appears irregular and granular. 
In very old people, some elastin fibers undergo fragmentation and disintegration.
The ground substance is an amorphous structure present between the collagen fibers and the collagen bundles.
It consists of glycosaminoglycans and mucopolysaccharides.
In healing wounds, the ground substance contains sulfated and nonsulfated acid mucopolysaccharides.
Smooth muscles are present as arrectores pilorum in the tunica dartes of the external genitalia and in the areolae of the breast. 
The muscle fibers of the arrectores pilorum start in the connective tissue and insert in the hair follicle in an obtuse angle below the sebaceous glands. 
By contraction, they pull the hair follicle into a vertical position. 
Aggregates of smooth muscle cells are present between the arterioles and the venules. 
They are called “glomus bodies” and serve to shunt blood from the arterioles to the venules.
 Most are located in the digits. 
Striated muscles are present in the skin of the neck as platysma and the skin of the face (superficial face muscles of expression). 
Their origin is the fascia or periostum and travel through the subcutaneous tissue into the lower dermis.
Skin, like any other organ, undergoes alterations with aging. 
Several changes have been proved. 
The collagen matrix starts to defragment although the cross-links prevent complete removal of collagen fragments. 
The fragments cannot be incorporated into new collagen fibrils and cause defects in the collagen matrix. 
The fibroblasts cannot attach to the fragmented collagen and the loss of attachments leads to collapse. 
This will produce less collagen and more collagen-degrading enzymes. 
In aged skin, the collagen networks appear to be increased but this is due to adherence to ground substance. 
Increased age is associated with decreased collagen content and straightening of collagen fibers organized in loose bundles. 
There is also an increase of type III collagen observed mainly in subjects over the age of 70. 
The elastin component starts to show degradation of fibers, resulting in decreased number and diameter. 
In photoexposed areas, there is an increase in abnormal elastin which is predominantly localized in the upper dermis. 
Increasing age does not alter the water structure of the skin. 
However, there is an increase in total water content in photoaged skin. 
This is paradoxical as aged skin seems dry. 
The lack of interaction between the water and the surrounding molecules in photoaged skin contributes to its characteristically dry and wrinkled appearance.
The blood supply to the skin comes from the deep plexuses located at the fascia and subcutaneous level. 
Once the vessels enter the space between the subcutaneous tissue and corium they branch out to various cutaneous appendages. 
The ascending arterioles supply a subpapillary plexus and form capillary loops in the papillary layer between the ridges. 
From these capillaries, the blood is drained by venules which descend to the plexuses. 
The blood flow through the superficial layer of the dermis is controlled by arteriovenous anastomoses which can act as shunts to short circuit the flow. 
These anastomoses are well demonstrated at the level of the fingers.
The peripheral nerves influence the pattern of blood vessel branching and differentiation by secreting the vascular endothelial growth factor.
The small arteries of the deep vascular plexus and the arterioles present in the dermis have three layers: (1) intima, composed of endothelial cells and internal elastic lamina; (2) media, with at least two layers of muscle cells in the small arteries and one layer of muscle cells in arterioles; and (3) adventitia of connective tissue. 
The capillaries located in the dermis have a layer of endothelial cells and a layer of pericytes. 
The walls of the veins are thinner than those of the arteries and do not have a clear structure of three layers. 
The postcapillary venule has endothelial cells, pericytes and a basement membrane. 
A special vascular structure called glomus is present within the reticular dermis of the nail beds, fingers and toes, ears, and face, and is important in thermal regulation. 
It represents a special arteriovenous shunt that connects the arterioles with the venules.
With aging, there is a dependent reduction in the total number of papillary loop microvessels, decreased thickness of microvessel basement membrane and decreased number of perivascular cells. 
These changes lead to decreased perfusion and increased capillary fragility. 
The clinical manifestation of these changes are purpura, teleangiectasia, pallor, angioma and venous lake formation. 
The function of the skin microvessels is affected by the aging process and leads to decreased vasoreactivity and impaired wound repair.
Dermal lymphatics are often hard to see in the normal skin because they do not have the well-developed walls that blood vessels have. 
They first appear at the subpapillary dermis. 
When they are seen in the dermal papillae, it is considered abnormal. 
The initial lymphatic vessels are cylindrical microtubules and are composed of attenuated endothelial cells. 
They form a mesh-like network of about 200–500?m in the human scalp. 
Occasional valves can be seen emerging from the endothelial lining. 
The dermal lymphatics are easily detected in conditions associated with increased lymphatic drainage, as occurs in urticaria or inflammations.
The skin is supplied by sensory nerves and autonomic nerves which permeate the entire dermis. 
The sensory nerves have a myelin sheath. 
The face and extremities have the highest density of sensory branches. 
These branches have two main endings: corpuscular, which embrace non-nervous elements, and free, which do not. 
Examples of corpuscular branches are: Pacinian, Golgi-Mazzoni, Krause or Meissner. 
In the Ruffini structures, (abundant in human digits) several expanded endings branch from a single myelinated afferent fibre. 
The “free nerve-endings” are located in the superficial dermis and in the overlying epidermis. 
In the dermis, they are arranged in a tuft-like manner. 
Hair follicles also have nerve terminals which run parallel to and encircle the hair follicles.
The thickness of the epidermis is variable. 
It is very thick on the palms, soles and other friction surfaces. 
These areas are more resistant to treatments using light sources. 
The thickness of the dermis is also variable. 
In the eyelid, the dermis is thinnest; on the back, it is the thickest. 
This variable is important when considering IPL treatment in different anatomical regions. 
People with fair skin have fewer melanosomes which are smaller and packed, while people with dark skin have more melanosomes which are larger and not packed. 
IPL has the best results in fair skinned people. 
The hair follicles and vascular dermal elements are not uniformly distributed at the same level. 
This is important to take into consideration when choosing IPL parameters.
In white and grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes. 
They are the most resistant to IPL hair removal. 
Hair follicles in the anagen phase are the most susceptible to IPL treatment. 
With aging, there is a decrease in total collagen content in the skin, an increased amount of type III collagen, decreased number and diameter of elastin fibers, and a lack of interaction between water and surrounding molecules which contribute to the dry and wrinkled aspect.
The face and the hands have the highest density of sensory nerves and are the most painful areas in IPL treatment.
The effects of light on skin are due to various degrees of absorption of electromagnetic radiation. 
The visible light spectrum has a 400–760 nm wavelength. 
The light-tissue interaction effects are due to absorption and excitation of photons. 
The Intense Pulse Light is situated in the visible light of the electromagnetic spectrum. 
Once the light reaches the skin, part of it is absorbed, part is reflected or scattered, and part is further transmitted. 
Selective photothermolysis is the basic principle of Intense Pulsed Light treatment. 
It consists of matching a specific wavelength and pulse duration to obtain optimal effect on a target tissue with minimal effect on the surrounding tissues. 
The structures of the tissue that absorb the photons are known as chromophores. 
They have different wavelengths of absorption. 
The most common chromophores encountered in the skin are: hemoglobin and its derivates, melanin, water and foreign pigmented tattoos. 
The main target structures for Intense Pulsed Light treatment are melanin and blood vessels. 
The fluence delivered to the chromophores must be high enough to destroy them. 
In order to enhance the photodynamic therapy effect which is based on selective phothermolysis, photosensistizers can be used as adjuvants.
The effects of light on skin are due to various degrees of absorption of electromagnetic radiation (EMR). 
The EMR represents the fundamental form of energy having wave and particle properties. 
According to Plancks law, long wavelength photons carry less energy than short wavelength photons. 
The EMR includes radiowaves, microwaves, infrared radiation, visible light, ultraviolet radiation and x-rays (Fig. 2.1). 
EMR is generally classified according to wavelength. 
The visible light spectrum has a 400–760 nm wavelength. 
The light-tissue interaction effects are due to absorption and excitation of photons. 
The Intense Pulse Light is situated in the visible light of the electromagnetic spectrum. 
To understand the effects of light on tissue, it is necessary to define some terms:
? Fluence (F) represents the amount of energy measured in Joules (J) per unit area, measured in cm2: F = J/cm2. 
? Power measured in watts (W) represents the amount of energy delivered over a certain period of time: W=J/s.
? Thermal relaxation time (TRT) is the time necessary for an object to cool down to 50% of its original temperature. 
TRT is further detailed in this chapter. 
? Wavelength influences selective light absorption by a certain target and also influences the depth of tissue penetration. 
The majority of light systems have different filters which allow certain wavelengths to enter the tissue, thus producing the selection of the desired light spectrum. 
? Footprint (device spot) size has an important role in light penetration into the tissue. 
When a small spot size is used for light emission, only a small part will reach the deep target structures. 
A larger footprint offers a more planar geo metry of light penetration and better efficacy. 
A spot size of about 7–10 mm is needed for maximal light penetration to the mid-dermal structures. 
The bigger the spot, the deeper the level of penetration). 
? Pulse duration. 
Light can be delivered in a pulsed or continuous wave. 
The intense pulsed light devices are based on pulsed delivery that allows more selective tissue damage. 
Pulse duration represents the time of exposure to the light beams. 
Laser and pulsed light systems enable the selection of pulse duration, which is influenced by the TRT of the target. 
? Pulse delay represents the time that allows the skin and blood vessels to cool down between pulses, while the heat is retained inside the targets. 
When the pulse is shorter than the thermal relaxation time (TRT), the heat will act mainly on the target structures. 
When the pulse is longer than the TRT, the heat will be conducted to the surrounding structures. 
It is recommended that the pulse timing be higher than the skin cooling time to avoid damage to the surrounding structures.
Heating is one of the effects induced by light ab sorption. 
It is not uniformly distributed inside the skin. 
This process is more representative around the target cells. 
The temperature is directly related to the excitation of molecules. 
As the temperature is raised, different changes take place at the molecular level. 
DNA, RNA and some proteins are affected by the heat which causes them to unwind or even melt at varying temperatures. 
The final result would be denaturation and coagulation of the above- mentioned structures. 
These effects are dependent on temperature and length of exposure. 
Depending on the target tissue, the light-tissue interactions will cause tissue necrosis, blood coagulation and structure alterations. 
Some of the heating effects are beneficial at the level of the target tissues but are dangerous to the surrounding tissue. 
This should always be kept in mind when choosing the treatment parameters.
The coagulation damage depends not only on the temperature but also on the exposure time. 
For instance, a high temperature and a short exposure can be less aggressive than a lower temperature with a longer period of exposure. 
The dermis, being rich in collagen and elastin, is more thermally stable than the epidermis, mainly due to elastin proprieties.
Once the light reaches the skin, part of it is absorbed, part is reflected or scattered, and part is further transmitted. 
The scattering process takes place when the photon particles change the direction of propagation. 
This phenomenon takes place inside the skin where different structures have different indices of refraction. 
The scattering effect makes the light spread out and limits the depth of light penetration. 
It seems that the dermal collagen is responsible for most of the scattering. 
The amount of scattering is inversely proportional to the wavelength of the light. 
Some (4–7%) of the light is reflected, this phenomenon being produced by a change in the air and stratum corneum refractive index. 
The amount of light that is reflected decreases with the decreasing angle of incidence. 
The least reflection occurs when the light is perpendicular to the tissue. 
A very small amount of light is further transmitted. 
It has been proved that transmission of the light varies according to the skin type. 
The white dermis transmits from about 50% at 400 nm to 90% at 1,200 nm, while the black epidermis transmits less than 40% at 400 nm and 90% at 1,200 nm. 
In general, there is a gradual increase in skin penetration at longer wavelengths.
Most of the light is absorbed by the skin. 
This phenomenon is responsible for the desired effects on the tissue. 
The structures of the tissue that absorb the photons are known as chromophores. 
They have different wavelengths of absorption. 
The most common chromophores encountered in the skin are: hemoglobin and its derivates, melanin, water and foreign pigmented tattoos. 
Once the light is absorbed, the chromophores become excitated. 
For wavelengths varying from 300–1,200 nm, melanin is the dominant absorbent.
Light-tissue effects can be grouped in:
? Photothermal – represented mainly by coagulation or vaporization of tissue based on absorption 
? Photomechanical – tissue disruption often encountered by pulsed laser beams 
? Photochemical – direct breakage of chemical tissue bonds or chemical interaction with an applied drug 
? Photobiostimulation – tissue stimulation with very low level laser light 
? Selective photothermolysis – The concept of photothermolysis was introduced for the first time by Parrish and Anderson in 1983. 
According to their description, three effects are necessary to produce selective photothermolysis 
? Absorption of a specific wavelength by the target structures 
? The exposure time should be less than or at least equal to the time of cooling of the target structures 
? There is a need for enough fluence to produce a damaging temperature within the target structures
The main target structures for Intense Pulsed Light treatment are melanin and blood vessels. 
To understand the relation between exposure time and extent of thermal damage, it is important to detail the “thermal relaxation time” (TRT). 
This represents the time required to cool a small target structure. 
The cooling is achieved by conduction, convection and radiation. 
Conduction is the main component of cooling. 
Smaller objects cool faster than larger objects. 
The TRT is proportional to the square of the size.
To allow enough time for the epidermis and other skin structures to cool down, the pulse duration should be shorter than the cooling time of the target but longer than the cooling time of the skin. 
This has clinical implications especially for hair removal. 
The hair follicles are grossly grouped as coarse and fine. 
They have different sizes and consequently different TRTs. 
An epidermal thickness of 0.1 mm has a TRT of about 1 ms while a vessel of 0.1 mm has a TRT of about 4 ms. 
A vessel three times bigger (0.3 mm) has a TRT of approximately 10 ms. 
Larger structure targets cool down slower and need increased delay time and multiple pulsing. 
Theoretically, most vessels smaller than 0.3 mm require only a single pulse. 
It is recommended that pulses be spaced at 10 ms or longer to accommodate normal epidermal TRT. 
Patients more prone to thermal injuries should have at least 20–30 ms of TRT. 
When the pulse width is greater than the TRT, nonspecific thermal damage occurs because of heat diffusion. 
The fluence delivered to the chromophores must be high enough to destroy them.
In order to enhance the photodynamic therapy effect which is based on selective phothermolysis, photosensitizers have been introduced as adjuvants. 
There are topical and systemic photosensitizers. 
The first generation of photosensitizers was developed about 30 years ago and belongs to the porphyrin family. 
5-aminolevulinic acid (ALA) and methyl aminolevulinate (MAL) are the most common sensitizers. 
Second generation photosensitizers have the advantage of having a limited effective period. 
ALA is not a photosensitizer by itself, but it is metabolized to photosensitizing protoporphyrin IX. 
The spectrum of absorption of protoporphyrin IX is in the visible spectrum. 
The peak of absorption is 405 nm. 
Systemic sensitizers are administered intravenously since they do not penetrate the skin. 
Hematoporphyrin and photofrin have been thoroughly studied with regard to their peak of absorption. 
Applications of these photosensitizers in association with Intense Pulse Light may increase the efficacy of the treatment. 
This concept of combining light with a photosensitizing agent known as photodynamic therapy has wider applications, including tumor treatment.
The human skin has several major ultraviolet radiation absorbing endogenous chromophores. 
Among them are urocanic acid, aminoacids, melanin and its precursors. 
The chromophore identification can be done by action spectroscopy. 
Theoretically, an action spectrum for a given photobiological endpoint will be the same as the absorption spectrum of its chromophore. 
The skin chromophores have an overlying spectra. 
From all chromophores present in the skin, the melanin and hemoglobin with its derivates are the most important regarding light pulsed treatment.
The term melanin is widely used to describe the skins red-brown pigment which resides in the epidermis. 
The biosynthesis of melanin within melanocytes is a complex process and is incompletely understood.
It is believed that they are polymers with multiplemonomer units linked by non-hydrolysable bonds. 
There are two major classes of natural malanins: the black-brown eumelanin and the yellow-red pheomelanin. 
They are differentiated by their molecular building blocks. 
Eumelanin is the dominant pigment.
Human skin coloration is dependent on spatial distribution of the melanin and haemoglobin chromophores. 
Eumelanin plays a fundamental role in skin appearance and photoprotection. 
A weak correlation was noticed between the scattering properties of skin and tissue type with the average scatter size higher in patients with higher melanin content. 
The skin has a multilayered structure. 
The two main chromophores in the skin, melanin and hemoglobin, are present in different layers, with the melanin found in the top layer (mainly epidermis) and the hemoglobin found in the bottom layer (vascular network of the dermis). 
To avoid skin damage, higher cut-off filters, multiple pulses and increased delay time should be chosen for darker skin types. 
The Fitzpatrick skin typing system from I to IV has different skin colors according to pigment intensity. 
Although it is a widely used scale, it has been criticized that human eye evaluation is subjective and confounded by the presence of hemoglobin. 
Although the human eye can distinguish adjacent brown and red colors, it is almost impossible to distinguish the relative contribution of melanin and hemoglobin when they overlay one another, as often happens in young and photoprotected skin.
There are elaborated methods which try to evaluate skin color objectively. 
These are based on spectrophotometric or colorimetric techniques. 
Although these methods are more objective, they still cannot completely separate the individual contributions of the chromophores.
Exogenous chromophores can be administered to the skin to prevent sunburn (exogenous chromophores from sunscreens) or in combination with ultraviolet radiation for therapeutic benefit.
The intense pulsed light is situated in the visible light of the electromagnetic spectrum. 
Heating is an important effect induced by light absorption. 
This often leads to cell necrosis, blood coagulation and structure alterations. 
The light interacts with the skin and part of it is absorbed, part reflected or scattered, and part is further transmitted. 
The absorption is responsible for the desired effect on the tissue. 
The two main skin chromophores present in the skin and responsible for the light effects are melanin and hemoglobin. 
Selective photothermolysis is the basic principle of Intense Pulsed Light treatment. 
It consists of matching a specific wavelength and pulse duration to obtain optimal effect on a target tissue with minimal effect on the surrounding tissues. 
Melanin is located within the top layer of the skin (epidermis) and hemoglobin is found in the bottom layer (vascular network of the dermis).
Light and laser devices have common considerations and include hazards both to the patient and to the medical staff. 
The operating manual of the IPL device should be read by all personnel manipulating the device. 
Personnel in the treatment room should have protection against accidental exposure to the IPL, either directly or indirectly from a reflecting device. 
The visual hazard seems to be the main danger. 
Inadvertent exposure of the eyes during treatment may damage some eye structures. 
During treatment, wearing specially designed protective eyeglasses is important not only for the patient but also for the staff present in the room. 
Due to inadvertent “advertising” of IPL or laser technologies and unrealistic expectations by the public, physicians may run the risk of being sued for the results. 
Avoiding malpractice lawsuits implies acting correspondingly and adapting the treatment to the patient’s needs. 
Informed consent for any treatment is a must. 
Although there are reports of informed verbal consent, written consent is mandatory in today’s litiginous society. 
Protection against lawsuits lies also in the ability of the physician to recognize problematic patients.
Light and laser devices have common considerations and include hazards both to the patient and to the medical staff. 
Intense Pulsed Light (IPL) is widely used in many medical and aesthetic centers. 
IPL wavelengths range from 550 to 1200nm. 
Most IPL devices have the ability to perform self-testing when the system is turned on. 
If an error occurs, the message is displayed on the screen. 
The newest devices automatically shut down when exposed to a light overdose. 
Some devices have an emergency shutoff knob. 
It is recommended that treatment be done by a trained physician or at least by a trained nurse supervised directly by a physician. 
The main responsibility belongs to the physician who should be the one to adjust the device parameters.
The operating manual of the IPL device should be read by all personnel manipulating the device. 
Personnel in the treatment room should have protection against accidental exposure to the IPL, either directly or indirectly from a reflecting device. 
Handling the treatment head should be done cautiously to avoid discharges into free space. 
Since some of the devices that emit IPL also have laser treatment heads, the warning and hazards should also be addressed to them. 
The devices should comply with international standards.
Treatment room. 
Treatments should be carried out in a specially designed room that respects the safety of light and laser radiation. 
The entrance should be clearly labeled with signs indicating high intensity light. 
The number of people in the treatment room should be limited and related to the procedure. 
The system should not be used in the presence of flammable materials. 
The doors of the treatment room should be closed when the device is in use and a special sign reading “Danger” should be placed outside the treatment room.
Optical safety. 
The visual hazard seems to be the main danger. 
Inadvertent exposure of the eyes during treatment may damage some eye structures. 
The light beam danger comes when the applicator is directed by mistake at the eye or is reflected off an instrument. 
The treatment head should be directed only to the treatment area. 
Reflective objects, such as watches, jewelry, and shiny instruments, should be kept away from the light beam. 
Do not look directly at the light emission head. 
During treatment, wearing specially designed protective eyeglasses is important not only for the patient but also for the staff present in the room. 
Usually, the patient wears goggles which allow the doctor to perform treatments in the periorbital area easily.
Electrical safety. 
Some devices produce high voltages which can be retained by some components after the power supply has been turned off. 
IPL devices need appropriate electrical safety precautions. 
Fluid containers should be kept away from the devices. 
Any repairs to the IPL device should be done by authorized and trained people. 
Keep the device covers closed during functioning. 
An emergency shutoff knob is often present and it bypasses the controlled power. 
When the machine is not in use, always turn the system off. 
Untrained personnel should not operate the IPL devices. 
Doctors, midlevel providers and technicians should work together to monitor the equipment, the patient and the environment for safety.
Theoretical potential risk of infection transmission is another hazard. 
To diminish this risk, in addition to wearing regular gloves, footprints are cleared using chlorhexidine solution between treatments. 
Although some authors raise the question about the long-term safety of lasers and IPL, including the possible risk of melanoma, no reports of this association can be found in the medical literature. 
While there are no reports on the use of IPL treatment in pregnant women, we do not recommend its use under these circumstances.
Due to inadvertent “advertising” of IPL or laser technologies and unrealistic expectations by the public, physicians may run the risk of being sued for the results. 
Avoiding malpractice lawsuits implies acting correspondingly and adapting the treatment to the patient’s needs. 
In the last decade, the cost of medical malpractice and lawsuits has been impressive and continuously increasing. 
Informed consent for any treatment is a must. 
Although there are reports of informed verbal consent, written consent is mandatory in today’s litiginous society. 
The goals are to include the patient in the decision-making process, to inform the patient of the various methods and instruments, and to inform the patient about the potential benefits and hazards of the treatment. 
Most informed consent dealing with aesthetic procedures includes the possibility of patient photography or videotaping. 
Photodocumentation as well as record storage are important for follow-up and possible liability problems. 
The majority of the devices are built to store this information. 
We advise introducing as much data as possible into the patient record (anesthetic type, reason for treatment, treatment parameters, cooling method, side effects, complications, recommendations, etc.).
Protection against lawsuits lies also in the ability of the physician to recognize problematic patients. 
These are patients with Body Dysmorphic Disorder (BDD) or “Beauty Hypochondriasis”. 
BDD represents preoccupation with an imagined defect in a normal appearing person or, if a mild physical anomaly is present, the concern is disproportional. 
“Beauty hypochondriasis” refers to a preoccupation centering usually on one part of the body that is experienced as repulsive and deformed. 
Both conditions lead to impairment in social and occupational activities and distress. 
These patients have also a feeling of inferiority, guilt, or altered body image. 
The incidence of BDD in the general population was found to be up to 2.4%, with a higher prevalence of 7–15% among patients seeking cosmetic surgery procedures. 
Since these patients have an emotional rather than a physical problem, they are rarely satisfied with cosmetic procedures.
The obligation of a doctor performing IPL treatments is to do his work in accordance with the standard of care. 
It is important to be on the safe side and avoid lawsuits. 
The ‘standard of care’ is often described by some as whatever an expert in the field says it is, and the jury believes that. 
For instance, in a case against an IPL procedure, the doctor performing this procedure must have the skills ordinarily possessed by a specialist in this field. 
The standard of care should be included in the patient’s record or informed consent form and refers to the explanations that a reasonable medical practitioner would provide patients. 
The term of ‘negligence’ requires fulfillment of four elements: duty, breach of duty, causation and damages. 
Duty refers to the treatment performed by another reasonable physician by the same method. 
Breach of duty refers to the fact that the negligent physician did not perform the same type of treatment in the same manner as another reasonable physician would. 
Causation refers to the relation between duty and damage. 
Damages can be economic or non-economic, such as emotional. 
In some instances, there can be two or more methods for treating the same pathology. 
In this situation, the doctor does not fall below the standard of care with any of the acceptable methods even if one is less effective than another. 
For instance, someone may be sued after using IPL for hair removal instead of Nd:Yag laser. 
Since both are accepted and recognized methods, the physician is within the standard of care.
Inevitably, IPL as a laser procedure has adverse effects and complications. 
These can be the trigger of malpractice lawsuits. 
Complications, such as skin thermal injury that can appear after IPL treatments, are not by definition medical malpractice. 
It often happens in these cases that the patients seek legal advice. 
In such a situation, the patient who likes the doctor and communicates easily with him is less likely to sue even when a complication occurs.
Professional errors can be related to deficient training, inadequate patient information, or inappropriate treatment. 
To diminish professional errors, guidelines and instructions are necessary. 
Training for IPL technology or laser procedures refers not only to device-handling and indications but also to a wider area such as: identifying possible skin lesions (malignancies) which should not be treated in this manner or skin conditions that need further attention (e.g., blisters, crusts, minor burns) after IPL. 
Greve underlines the importance of continuous medical education and board examinations.
Although there is an increase in the involvement of mid-level providers with these procedures (physician assistants, nurse practitioners), there are some concerns that this may decrease the overall quality of treatment as these people may have less experience. 
Without appropriate training and supervision, physician extenders can have a higher incidence of complications. 
When a physician extender is involved in performing treatments, he might be found liable for negligence according to the law of that area. 
It is mandatory to know beforehand if an extender is allowed to perform the treatments and under what circumstances. 
Nevertheless, when treatments are performed by physician extenders, this does not release the doctor from malpractice liability. 
In most cases, the physician is sued along with the extender.
Following is the informed consent that we suggest for IPL treatment.
Intense Pulsed Light Treatment. Informed Consent
The Intense Pulse Light Treatment is based on the light emitted by a flash lamp. 
Using different wavelengths, the device has proved to be useful in the treatment of vascular lesions, pigmentary lesions and hair removal. 
Partial skin rejuvenation can be obtained sometimes. 
More than one treatment may be needed in order to obtain the desired effect.
Patients should not be tanned at the treatment. 
If they are tanned, delaying the treatment for a few weeks is recommended to diminish the rate of complications. 
Immediately after the treatment, blue or red discoloration may appear. 
Usually this disappears within a few days. 
Most procedures do not necessitate anesthesia. 
Topical anesthetic creams can be used before the procedure. 
Eye protection will be used by the patient and the staff for the entire treatment period. 
Although no reaction on a developing fetus has been reported, the procedure is not recommended for pregnant women.
No guarantees can be made of the exact results from this treatment. 
Although the treatment is safe, some complications may appear:
? Pigmentary changes can be either of increased pigment (hyperpigmentation) or decreased pigment (hypopig-mentation). 
Most of the time, these color changes are temporary and resolve over several weeks to months. 
Permanent pigmentary changes may also appear. 
? Pain. 
The level of sensation during treatment varies from person to person. 
A warm or burning sensation can be reduced by using topical anesthetics before the procedure and ice packs after the treatment. 
? Excessive redness or swelling. 
In some instances, excessive redness or swelling can persist for up to a few days after treatment. 
In certain cases, mild topical steroids can be used to hasten recovery. 
? Infection is extremely rare as the technology does not break the skin. 
? Blisters can be encountered in certain people, especially in those with higher sensitivity.
? Scarring is possible. 
Normally, the IPL technology does not produce scarring. 
However, there are a few reports in the medical literature of scarring.
? Lack of satisfaction. 
Different patients respond differently to IPL treatment. 
Most people report significant improvement after a series of treatments. 
While positive changes can be expected, no changes may occur for reasons beyond the physicians control.
To obtain the best results, the skin should be thoroughly protected from sun exposure after the treatment, using sunscreens with SPF 30 or higher. 
There is no restriction on washing the treated area right after the procedure. 
I declare that the above treatment procedure has been explained to me, along with alternative methods of treatment and the risks of the procedure, and all my questions have been answered.
I consent to photographs of the treatment areas before and after in order to document the treatment process.
The visual hazard is the main danger when performing IPL treatments. 
Because of “inadvertent advertising” and unrealistic expectations by the public, physicians may run the risk of being sued for the results. 
Photodocumentation is as important as record storage. 
Written informed consent is mandatory in today’s litiginous society. 
Identify problematic patients (Body Dysmorphic Disorder, beauty hypochondriasis) – and stay away from them. 
Communication with the patient is essential.
A patient who likes the doctor and communicates easily with him is less likely to sue even when a complication occurs. 
When treatments are performed by mid-level providers, the doctor is not released from malpractice liability.
The prices for IPL equipment vary from a few thousand dollars to more than $100,000, depending on the producer and the properties of the device. 
Acquisition of the equipment can be made by purchase, lease or rental. 
In analyzing which method is most feasible for his/her office, one must take into consideration the capital investment, maintenance costs, costs of treatment, and an estimation of the number of patients expected. 
Before purchasing the device, the physician should compare vendors, extent of warranties and service availability. 
The room should be large enough to accommodate the treatment table, IPL device, stand tables, small stores cupboards, refrigerator and anesthesia equipment. 
Written informed consent, medical history, physical examination findings, and data on previous treatments should be recorded. 
Digital cameras replace in most cases 35 mm cameras for private offices. 
Although there are simulation programs to show the patient the possible result, these should be used cautiously since the result might not match the simulation.
The prices for IPL equipment vary from a few thousand dollars to more than $100,000, depending on the producer and the properties of the device. 
Acquisition of the equipment can be made by purchase, lease or rental. 
In analyzing which method is most feasible for his/her office, one must take into consideration the capital investment, maintenance costs, costs of treatment, and an estimation of the number of patients expected. 
If the number of treatments is not significant, one might consider rental of the equipment. 
Before purchasing the device, the physician should compare vendors, extent of warranties and service availability. 
Renting the device has the advantage of obtaining the latest technology while, after purchasing, it might not be worthwhile economically to renew the equipment.
Protective devices include ocular protection, gloves, other disposables and warning signs. 
Ocular protection is available as glasses or goggles. 
When several devices or lasers are available in the same room, attention should be paid not to mix the protective devices between them. 
Many goggles are wavelength specific and should be used only with the proper device. 
Several pairs of goggles or glasses should be available for the patient, physician, assistant and all other persons in the room. 
Plastic eye shields are recommended. 
These come in several sizes (small, medium and large) and are light-weight. 
They are used when eyelid treatment is performed. 
A topical corneal anesthetic should be used prior to eye shield insertion. 
Glossy metal eye shields, as other glossy instruments, should be avoided in the laser room as they might reflect the light. 
We strongly recommend plastic shields and non-reflecting surgical instruments.
Non-sterile gloves are suitable for performing the treatment. 
Warning signs should be posted inside the room as well as on the door outside. 
Doors should be locked when the device is in use.
The room should be large enough to accommodate the treatment table, IPL device, stand tables, a cupboard for small stores, refrigerator and anesthesia equipment when needed. 
Each country will have its own regulations regarding the size of the room that should be used. 
A minimum of 30 m2 is desired if general anesthesia is to be performed. 
If the treatment room has windows, drapes should be used to cover them to avoid IPL scattering or reflection. 
If there are mirrors in the room, they should be hidden from the light beam.
The treatment table should be placed so as to allow enough space around it for movement. 
A central position is better when a general anesthesia machine is used. 
Various types of tables are available, from simple to flexible. 
The more flexible the table, the greater the patient’s comfort. 
Manually controlled tables provide flexible articulated posturing of the patient. 
Some tables can be operated by a pedal shaft selector and foot pump.
Other equipment that is used such as trays and holding devices should be mobile so they can be located easily as needed. 
The anesthesia machine and additional monitors should be mobile as well, to adjust their position when treating the head or extremities. 
A recovery room with the necessary equipment should be available next to the treatment room. 
A specialized nurse is required to take care of the patient until he/she becomes ambulatory. 
A refrigerator is used to store the transparent gel, cooling gels and other medications. 
A powerful light should be mounted on top of the table for better lighting. 
A magnifier can be attached to the table side to enhance precision. 
Several cupboards for storage of disposable products should be available. 
Among the important items are:
? Razor blades for completing hair removal in cases where epilation was not properly done by the patient
? Gauze, sterile and non-sterile, in various sizes
? Cotton pads
? Make-up removal solutions
? Anesthetic creams
? Plastic sheaths to cover the anesthetic cream on the area prior to treatment 
? Rolls
? Gloves
? Spatula for spreading the anesthetic cream and the gel
? Transparent gel for application as interface between the device head and skin; using the gels provided by the company is advised
? Gel masks, usually made of propylene glycol and water with plastic coverings; there are different designs (eye mask, full face mask) which provide the cooling needed immediately after the treatment. 
Wet gauze or rolls placed in the refrigerator present a cheap alternative for cooling the treated area.
? Disposable panties, bras, bikini briefs
 Written informed consent as well as medical history, physical examination findings, and data on previous treatments should be kept. 
Except for the informed consent, all other information can be stored on a computer program. 
Treating children requires general anesthesia in most cases. 
A meeting with the anesthesiologist, blood tests and informed consent for general anesthesia should be considered for these cases.
A treatment report should be recorded either on a special chart or on the computer. 
Treatment parameters, such as fluence, pulse duration and delay, should be recorded. 
It is important to assess and correlate the parameters of the previous treatment with the result. 
The parameters should be adjusted according to the result obtained. 
Written instructions should be given to the patient after the procedure - verbal instructions are not always remembered.
A digital camera is mandatory. 
Digital cameras have replaced in most cases 35 mm cameras. 
The digital image can be immediately seen on a computer with an excellent view of the details. 
The higher the resolution of the digital camera, the better the view of the details. 
We recommend using at least 3 mega pixel digital cameras. 
A computer and monitor are necessary to process and view the digital images. 
Both laptop and desktop computers can be easily used.
Several software programs are available for accessing the pictures, arranging and editing them. 
They also have the advantage of adjusting brightness, contrast and gamma corrections. 
Annotation on pictures and measuring tools are also possible. 
Although there are simulation programs to show the patient the possible result, these should be used cautiously since the result might not match the simulation. 
A printer is helpful to obtain hard copies of the patient record, recommendations after treatment, and pictures before and after treatment.
The acquisition of IPL equipment can be made by purchase, lease or rental. 
One must analyze which method is best for his/her office. 
If the number of treatments is not significant, one might consider rental of the equipment. 
When several devices or lasers are available the same room, attention should be paid not to confuse their protective devices (goggles or glasses). 
Plastic eye shields are recommended when treating the periorbital area. 
The room should be large enough to accommodate the treatment table, IPL device, stand tables, small stores cupboards, refrigerator and anesthesia equipment. 
Written informed consent, medical history, physical examination findings, and data on previous treatments should be recorded. 
Digital cameras replace in most cases 35 mm cameras for private offices. 
Although there are simulation programs to show the patient the possible result, these should be used cautiously since the result might not match the simulation.
Patient selection is one of the most important parts of a successful aesthetic procedure. 
There are two main categories that make a patient an unlikely candidate for cosmetic procedures. 
One is anatomical unsuitability and the other is psychological unsuitability. 
Problematic patients are usually those with high expectations, excessive demands, indecisive or immature personalities, secretive or “surgiholics”, those with factitious diseases, and those with familial disapproval. 
Patient evaluation regarding health status should be done thoroughly and include a search for conditions that contraindicate IPL treatments. 
A pregnant woman or a patient with significant venous insufficiency and dilated veins might not be suitable for IPL treatment. 
The local area examination can also reveal conditions, such as skin malignancy, for which IPL would not be the proper treatment. 
Conversing with the patient and getting to know his/her expectations might be the key to avoiding liability. 
All patient data and photodocumentation are kept in a separate record for each patient.
Patient evaluation regarding health status should be done thoroughly and include a search for conditions that contraindicate IPL treatments. 
A pregnant woman or a patient with significant venous insufficiency and dilated veins might not be suitable for IPL treatment. 
The local area examination can also reveal conditions, such as skin malignancy, for which IPL would not be the proper treatment. 
Particular care should be paid to pigmentary changes. 
Dermatoscopy or skin biopsy can help in making the correct diagnosis before treatment. 
Sometimes patient expectations might be higher than the possible IPL results. 
A woman with severe rhytides is not a suitable candidate for IPL treatment if the expectation is to be rid of the wrinkles.
Conversing with the patient and getting to know his/her expectations might be the key to avoiding liability. 
All patient data and photodocumentation are kept in a separate record for each patient. 
The discussion with the patient should include explaining the diagnosis (e.g., why pigmented spots appear), the principle of IPL treatment, treatment alternatives (laser, peelings, surgeries), anesthesia type, length of treatment, recovery period, long-term results, possible side effects and complications, and expected costs. 
After the first consultation, the patient takes the informed consent home, reads it carefully, and completes it. 
Very rarely do we perform treatment the same day. 
We prefer to do a test and invite patient to return in one week for reevaluation. 
When larger areas (face, hands, legs) are planned for treatment, the test is mandatory. 
The device is set with the patient parameters and a single light pulse is applied to the area. 
The reason for doing this test is not to see the possible result but to evaluate the possible side-effects and complications. 
This test helps in preventing professional errors. 
In the presence of complications, the treatment parameters are adjusted (e.g., decrease the fluence; increase the pulse delay) and a second test is performed on a different area. 
Patients should understand that multiple treatments are needed and permanent results should not be expected even after multiple treatments. 
More precautions should be taken when treating patients with Fitzpatrick skin types IV–VI. 
The possibility of more complications should also be explained before treatment. 
Although topical anesthesia will be used before every treatment, patients should be told that some amount of pain can be expected during treatment. 
A written informed consent is obtained before any treatment.
It is important to maintain post-treatment communication. 
A patient who experiences a difficult posttreatment course or complications needs more contact with the physician. 
These patients are usually more demanding and the temptation to avoid them should be resisted.
The basic treatment protocol is herein described. 
Specific differences for hair removal, rejuvenation or vascular treatment will be described in the corresponding chapter.
Once the test result shows no sign of complications, the patient is accepted by the assisting nurse. 
The area that needs to be treated is cleaned with wet gauze. 
Special attention is paid to removing make-up from the face. 
Make-up can interfere with light transmission and absorption. 
Topical anesthetics are widely used for these procedures. 
Pain perception varies from individual to individual. 
We have encountered patients who did not need topical anesthetic before IPL treatment as well as patients who complained of pain after topical anesthetics were used. 
We have found that longer wavelengths and higher fluences are associated with more pain.
Topical anesthetics are typically constructed of three main components: an aromatic ring, an ester or amide linkage, and a tertiary amine. 
They prevent the initiation and transmission of nerve impulses by targeting free nerve endings in the dermis. 
Although there are many topical anesthetics, such as Betacaine-LA, Tetracaine, Topicaine, and S-Caine, EMLA (Astra Pharmaceuticals) and ELA-MAX (Ferndale Laboratories) are the most widely used for topical anesthesia. 
Although many topical anesthetics are effective in reducing pain associated with cutaneous procedures, many necessitate a prolonged application time (more than 1 h). 
ELA-MAX and EMLA have superior anesthetic effects 60 min after application when compared to Tetracaine and Betacaine-LA ointment. 
Invasive anesthesia methods, such as nerve blocks or intravenous sedation, is not needed for IPL treatment.
EMLA cream is a 5% mixture of lidocaine and prilocaine. 
It consists of 25mg/mL lidocaine and 25 mg/mL prilocaine in an oil-in-water emulsion cream. 
Most dermal anesthesia under occlusive dressing is obtained after 60 min. 
Inadequate analgesia after application for only 30 min has been reported. 
The analgesic effect of EMLA cream was shown to increase 15–30 min after its removal, probably due to continuous release from a reservoir of anesthetic located in the stratum corneum. 
ELA-MAX is made up of 4% lidocaine cream in a liposomal vehicle. 
No occlusion is required and the application time is 15–45 min. 
ELA-MAX is less expensive than ELA.
The use of topical anesthetic is helpful before the procedure and provides effective dermal anesthesia with rapid onset of action and minimal side effects. 
The most encountered side effects are erythema, edema and skin blanching. 
Among the patients who used EMLA, Alster found 10% erythema and 90% skin blanching. 
Among the most serious EMLA complications is the possibility of hemoglobin conversion to methemoglobin and consecutive tissue hypoxia.
It seems that this complication is more frequent in infants, patients with glucose-6phosphate dehydrogenase or methemoglobinemia inducing drugs.
Melanin and hemoglobin are the two dominant chromophores in the skin, both having a significant impact on the reflection spectra. 
Immediate posttreatment bluish appearance, perilesional erythema, blanching or “urticariform” reaction are signs of good response for vessels. 
The different forms of hemoglobin exhibit different characteristic absorption spectra. 
Any change in hemoglobin concentration will affect the absorption spectra. 
Arildsson postulated that there is an increase in perfusion in the deep vessels in anesthetized skin, compensating for the decrease in number of physiologically active capillaries. 
A different study demonstrated that the blood flow in EMLA analgesized skin increased through dilatation of larger deeper skin vessels. 
We have observed that EMLA works faster on the face than in other areas, most probably due to higher vascularity and greater absorption in this area.
Once the area is anesthesized, the patient is brought into the treatment room and laid on a special table to be comfortable during the treatment. 
The anesthetic cream is removed and the area cleaned with wet gauze. 
A thin layer (2–3 mm) of cold transparent gel is applied to the skin. 
Skin cooling during and/or after treatment helps to protect the epidermis from unwanted thermal injury. 
Contact skin cooling is sometimes used for anesthesia during dermatological procedures. 
The cooling process is important for most IPL applications. 
The epidermal temperature is decreased by the cooling method, while the chromophore temperature remains unchanged and effective for the treatment. 
The cooling method also allows the delivery of higher fluencies with fewer side effects.
There are three main methods of surface cooling during IPL or laser treatment: precooling, parallel cooling and postcooling. 
Precooling refers to decreasing the temperature of the epidermis immediately before the pulse. 
Parallel cooling takes place at the same time as the pulse. 
It is preferable for devices with a longer pulse duration. 
Postcooling refers to decreasing the temperature immediately after the treatment, usually done with ice packs. 
Spray and contact cooling are the main methods used for most light pulsed and laser devices. 
Both methods necessitate control of precooling time to achieve selectivity and to prevent the epidermis from frost injuries. 
The precooling time of the spray cannot be easily controlled. It seems that an external cooling medium around – 50 for 1 s of precooling is ideal to avoid frost injuries. 
The size, energy and discharge specifications of most IPL devices require a cooling circuit where water is pumped around the flash lamp to cool it.
Protective eyeglasses are used by the patient and medical staff for the entire period of the treatment. 
Particular attention should be paid to selecting proper parameters, taking into consideration the test result. 
Choosing too short treatment intervals can lead to more complications. 
At the end of the treatment, the area is wiped and cooled with ice packs for about 15 min. 
When larger areas are treated, the ice packs are placed immediately as each anatomic region is completed. 
For instance, when IPL is used for leg hair removal, the ice packs are applied as soon as one anatomic area is treated (i.e., anterior or posterior calf, anterior or posterior thigh). 
Cooling during and after treatment is essential for most procedures. 
When cooling is not performed, the thermal injury can affect not only the chromophores but also the surrounding tissue. 
Epidermal damage can be seen easily.
The patient is allowed to use make-up immediately. 
Avoiding sun exposure or photosensitizing medication is strongly recommended between treatments. 
We usually perform treatments 1 month apart but, in cases of complications, this interval is lengthened. 
The relatively short time for the procedure and the quick recovery have led IPL treatments to be considered a “weekend procedures”.
A well-motivated patient seems to have better satisfaction. 
Identifying the anatomical or psychological unsuitability of the patient is the key to patient selection. 
Problematic patients are usually those high expectations, excessive demands, indecisive or immature personalities, secretive or “surgiholics”, those with factitious disease, and those with familial disapproval.
Particular attention should be paid to ruling out skin malignancies in the area that needs to be treated. 
Conversation with the patient, getting known his/her expectations, might be the key to avoiding liabilities. 
A short test before starting the treatment provides details about skin reactivity and response. 
In the presence of side effects, the treatment parameters are adjusted. 
Posttreatment communication with the patient is also important in avoiding liabilities. 
EMLA and ELA-Max are the most used topical anesthetics for IPL procedures. 
Skin cooling during and/or after treatment helps to protect the epidermis from thermal injury. 
Particular attention should be paid to selecting proper parameters, taking into account the test result. 
Avoiding sun exposure or photosensitizing medication is strongly recommended between treatments.
The term ‘photorejuvenation’ describes the simultaneous improvement of various epidermal changes related to aging. 
Sun exposure and smoking are the main factors that induce premature skin aging. 
Rhytides are due to a decrease in facial skin elasticity causing accentuation of lines and wrinkles. 
There are three main mechanisms of non-ablative technology involved in skin rejuvenation:
? Heating that leads to fibroblast activation, remodeling of collagen and increased synthesis of pro- collagen III 
? Dermatologic regression, represented by displacement of photodamaged dermis and improvement of epidermal and dermal parameters 
? Endothelial disruption, cytokine activation and collagen remodeling.
Hemoglobin and melanin are the primary chromophores involved in skin rejuvenation. 
Type I photorejuvenation refers to vascular anomalies, pigmentary changes or pilosebaceous changes, while Type II is related to dermal and subcutaneous senescence. 
The main advantages of IPL skin rejuvenation are minimal downtime recovery, fast and easy to perform, minimal complications, minimal interference with lifestyle and long-term improvement.
The term ‘photorejuvenation’ describes the simultaneous improvement of various epidermal changes related to aging. 
Sun exposure and smoking are the main factors that induce premature skin aging. 
With age, there is increased sun exposure. 
Among the ultraviolet (Bernstein et al.) radiations, UVB is considered the most damaging. 
UVA can also produce burns if it is administered at high levels. 
The extent of sun damage is proportional to the amount of exposure. 
Thus, as one ages, areas such as face, neck, upper chest and hands are more prone to photoaging. 
These alterations are more frequent in persons who are fair-skinned.
Intrinsic skin aging refers to structural changes that are independent of environmental influences. 
Often the skin has a mottled appearance due to a decrease in melanocytes.
Over the age of 30, the melanocytic number decreases 10–20% per 10-years. 
However, there is an irregular melanosome distribution to the adjacent keratinocytes. 
Xerosis is typically found with aged skin and is due to decreased sebaceous and eccrine gland function. 
It is especially evident on the hands and face. 
The rough aspect of photoaged skin is due to changes in the stratum corneum and the amount of glycosaminoglycan in the dermis. 
Dermal changes include accumulation of fibrous material, especially in the superficial reticular dermal layer. 
These changes are known as elastosis due to the high uptake of the elastic tissue stains. 
Degenerative changes are evident in the collagen structure also. 
All these changes produce various clinical presentations represented by mottled pigmentation, teleangiectasia, wrinkled and dry skin. 
The changes in the epidermis are represented by irregular pigmentation, atrophy and cellular atypia. 
Both extrinsic and intrinsic aging is associated with the production of excessive amounts of free radicals.
The three main expressions of aged skin are rhytides, pigmented lesions and vascular lesions.
Rhytides are due to a decrease in facial skin elasticity causing accentuation of lines and wrinkles. 
Dermal elastic fibers initially thicken. 
Because the skin loses its elasticity, gravity leads to a sagging effect, especially visible on the neck and jaw line. 
Repeated facial muscle movements accentuate the lines of expression.
Lentigines are light-to-medium brown benign hyperpigmented macules. 
Lentigo simplex arises in childhood and does not have a predilection for sun-exposed areas. 
The pigment is uniformly distributed throughout the lesion. 
Solar lentigo is an acquired lesion present on sun-exposed areas such as face, chest, and hands. 
They usually appear in middle age and are due to an increased number of melanocytes and melanin deposition in the basal layer. 
Histologic examination reveals parakeratosis and epithelial acanthosis.
Caf?-au-lait macules are light tan-to-brown hypermelanotic flat lesions with a clear demarcation from surrounding skin. 
They can appear at birth or later, especially in the first 2 decades of life. 
Histology shows hypermelanosis in the basal layer of the epidermis including basal melanocytes and keratinocytes. 
These lesions do not have a malignant potential.
Poikiloderma of Civatte appears as a rusty-brown hyperpigmentation and telangiectasia. 
It is more frequently located on the neck, chest and lateral side of the face. 
Although its origin is suggested as a hormonal imbalance associated with menopause, its location on sun-exposed areas suggests that sun has an important contribution. 
Pulsed light or laser treatments have proved to be useful in treating these lesions.
Ephelides, commonly called freckles, are small tan-brown macules that occur on sun-exposed areas. 
Histology shows hypermelanization confined to the basal cell layer. 
The melanosomes and melanocytes appear to be enlarged.
Melasma is represented by irregular brown or grayish facial hypermelanosis and is more often present in women with Fitzpatrick skin type IV to VI. 
The condition is more evident in UV-exposed areas, worsening in the summer and improving in the winter. 
Genetic predisposition, oral contraceptives, pregnancy or endocrine dysfunction have been related to its appearance. 
When it is related to pregnancy, it usually resolves within a few months after delivery.
Nevus of Ota is a bluish-gray macular lesion present on the face, in the area innervate by the trigeminal nerve. 
It is more commonly seen in Asians and Blacks. 
The lesion often varies in color and the edges are usually not well-demarcated. 
Histology shows bipolar dermal melanocytes distributed largely in the upper part of the dermis. 
The epidermis and dermis are usually normal.
Nevus of Ito is a grayish-blue discoloration with histological aspects similar to nevus of Ota. 
It is frequently located on the shoulder or upper arm and is seen more often in Japanese.
Baker nevus is a light to medium brown patch, usually of a few centimeters, that appears frequently in childhood. 
The lesions are hyperkeratotic and covered by coarse hair. 
The histological aspect shows acanthosis, hyperkeratosis, rete ridge elongations, increased number of melanocytes and thickening of the dermis. 
This lesion is considered to be an organoid hamartoma.
Telangiectasia refers to superficial cutaneous vessels typically up to 1mm in diameter. 
The vessels can be of arteriole, capillary or venule origin. 
The arteriolar type is bright red and protrudes above the skin surface. 
The capillary type is red. 
These lesions are often located on the face in light skinned patients. 
They are mainly distributed on the nose and mid-cheeks. 
They are also associated with rosacea, pregnancy, steroids or actinic damage. 
There are four clinical types: simple or linear, arborizing, spider and papular. 
The red/blue linear and arborizing lesions are often present on the face and legs while the papular type is part of syndromes such as Osler-WeberRender or associated with collagen vascular diseases.
Venous lakes are dilated venules in the upper dermis. 
They are commonly located on the ears or lips. 
They appear as dark-blue soft nodules of a few millimeters size. 
They are present in severe solar elastosis when the stromal support is diminished.
Senile purpuras are purple-red echymoses due to the loss of subcutaneous tissue and a predisposition to vascular damage. 
Their fragility is due to flattening of the dermal-epidermal junction.
Antiaging treatment, such as lights, lasers and creams, stimulate the production of new collagen. 
It seems that the fibroblast attachment to the new collagen allows stretching and balances collagen production. 
Many methods of improving photoaged skin have been reported. 
Intense Pulsed Light is a non-coherent light produced by a flash lamp. 
This is a relatively recent technology used for skin rejuvenation.
The quality of aging skin can be improved by ablative or non-ablative treatments. 
The difference between these two methods is that the epidermis is not disrupted in non-ablative treatments, and the recovery time is incomparably faster than in ablative treatments. 
The appearance and quality of skin is improved by IPL through stimulating the body’s natural wound healing mechanism. 
The light targets the microvasculature and the pigmented lesions; and is responsible for initiation of the described process. 
Hemoglobin and melanin are primary chromophores involved in skin rejuvenation. 
The peak of hemoglobin absorption is around 580 nm, while for melanin it ranges from 400 to 750nm.
Photorejuvenation can be categorized in two types: type I refers to vascular anomalies, pigmentary changes or pilosebaceous changes, while type II is related to dermal and subcutaneous senescence. 
Type I may be categorized into three subtypes. Type 1a includes rosacea and telangiectasis, Type 1b refers to pore size and skin roughness, and Type 1c includes pigmentary changes. 
There are three main mechanisms of non-ablative technology involved in skin rejuvenation:
? Heating that leads to fibroblast activation, remodeling of collagen and increased synthesis of pro- collagen III 
? Dermatologic regression, represented by displacement of photodamaged dermis and improvement of epidermal and dermal parameters 
? Endothelial disruption, cytokine activation and collagen remodeling
Several authors have reported the histological changes after IPL treatment. 
Most reported collagen improvement. 
In an animal study (Kunning mouse model), it was found that non-ablative laser improved the thickness of the dermal layers and collagen fiber density. 
The amount of hydroxyproline content and collagen synthesis increased. 
Biopsies from three patients after five treatments showed significant deposition of collagen in the superficial layer of the dermis. 
Collagen type I and III were identified. 
The activation of intracellular fibroblast activity and collagen proliferation is initiated by thermal injury to the collagen fibers caused by heat conducted from the chromophores. 
The collagen fibers are also damaged by their light absorption and by the non-selective heating of the dermis. 
Negishi considered that wavelengths between 400 to 600nm are absorbed by the collagen fibers and cause the injury. 
An increase of procollagen type I, III collagenase, elastin and hyaluronate receptor has been noticed after IPL. 
New collagen formation was observed by Goldberg after treatment. 
One study examined the malar skin histologically one week after IPL treatment. 
The telangiectasia, inflammation, elastosis changes, epidermal atrophy, rete ridge flattening and basal cell necrosis were found to be improved. 
The epidermal thickness increased to a range from 0.01–0.03mm. 
The greatest improvement was observed in the degree of elastosis. 
The effect of IPL on the skin structure of five women was evaluated by Prieto. 
He analyzed skin punch biopsies before treatment, 1 week, 3 months and 12 months after five treatments. 
In three patients he found at least one follicle containing Demodex organisms and perifollicular lymphoid infiltrate but no significant perifolicular infiltrate 1 week later. 
Biopsies done later showed Demodex and mild perifolicular lymphoid infiltrate. 
The author concluded that IPL induces coagulation necrosis of Demodex organisms. 
It seems that Demodex contains some chromophore that makes the parasite more sensitive to IPL. 
On a fibroblast culture, it was shown that IPL inhibits the MMPs. 
MMPs are a family of zinc-containing proteases with different substrate specificities and inducibility.
The mechanism by which IPL improves pigment lesions was investigated by Yamashita. 
Solar lentigines were treated with three sessions of IPL and observed on consecutive days, using reflectance-made confocal microscopy and optical coherence tomography. 
It was found that the melanosomes from the epidermal basal layer migrated towards the skin surface. 
Electron microscopy of the desquamated crusts showed numerous melanosomes.
Skin rejuvenation should achieve reduction of visible pigmentation and vessels and improve skin texture. 
The physician must thoroughly explain to the patient the difference in the expected results between IPL technology and other ablative technologies (i.e., CO2 laser, chemical peelings). 
The fact that vascular and pigmented improvement will be noted a few months later and the fact that minimal wrinkle and skin texture improvement will be seen almost one year later should be emphasized during consultation. 
During the physical examination, special attention should be paid to ruling out skin malignancies. 
If the patient is taking retinoids (isotretinoin) or other photosensitizing medication, delaying treatment for at least 6 months is suggested. 
Pregnant women or the presence of active infectious disease are contraindications to treatment. 
Particular care must be paid to sun-tanned patients. 
Treatment is performed only if the patient is willing to avoid sun exposure or to use sunscreens for the entire treatment period. 
Patients with a history of herpes simplex infection require prophylaxis.
Most of our patients request facial rejuvenation. 
The area should be cleaned and free of make-up before starting the treatment. 
We are in favor of using topical anesthetics (EMLA or ELA-Max) before the treatment. 
The basic treatment protocol is followed, as detailed in another chapter. 
The first parameter introduced to the machine is the skin type according to Fitzpatrick classification. 
Then the SR parameter is set up. 
The treated area is covered by a single pass. 
The mode for dealing with vascular lesions can also be used in a different session to enhance the results. 
A single pass is performed during one session. 
Large footprints are used for large areas. 
Thus, the treatment is faster and the light distribution into the skin is more uniform with better effects. 
Small footprints are used when the anatomic region is curved, as on the eyelids, nose, upper lip or ears. 
When performing eyelid treatment, plastic eye shields are used as protectors. 
The patient is strongly encouraged to keep the eyes closed during the procedure. 
The footprint is always placed perpendicular to the skin. 
In areas with hyperpigmentation, slight pressure is used; in areas with predominant vascular abnormalities, no pressure is applied. 
In this way, the blood vessels are not emptied and the treatment is more effective.
When approaching the hair-bearing area on the face, such as the eyebrows, this is covered by white gauze and the IPL footprint is placed 2–3mm from the edge. 
Unintended hair removal in this area canappear if precautions are not taken. 
At times, uneven edges of the treated area can be noticed in the treatment of Poikiloderma of Civatte. 
Performing treatment of the entire cosmetic anatomical units is recommended in such a situation. 
Treatments are performed one-three months apart.
If almost no change in the pigmentation or vascular lesion is noted after the first treatment, the fluence is increased by 2–4J/cm2 for the next session. 
A good response can be seen immediately after treatment when blanching of the vessels, “urticaria” type reaction or slight darkening of the pigmented lesions appears. 
Treatment time varies according to the anatomical area, from a few minutes to more than 15 min for the neck and chest. 
Ice packs are always used at the end of the treatment and are intended to reduce the burning sensation and decrease the swelling. 
Almost all patients are able to resume normal activities after the procedure. 
Some patients experience a burning sensation that disappears within minutes. 
Erythema and edema are present in most patients and resolve within hours to 2–3 days. 
The reaction of the pigmented lesions usually causes their darkening for the next 7–8 days. 
We do not consider this as signs of complications unless the unwanted effect lasts for more than a few days. 
These are part of the normal skin response after IPL treatment.
The skin is not a uniform structure and lesions are present at different levels of the dermis. 
This is why we prefer to alternate the cutoff filters instead of using a single wavelength for every treatment. 
Regression of the results is a normal process that occurs after any cosmetic procedure. 
The regression is usually visible from one to a few years after treatment. 
Maintenance treatments every year are recommended to continue seeing positive effects.
Many studies have confirmed the effectiveness of photorejuvenation. 
Women seek this treatment more frequently. 
The request for IPL procedures from men is less than 10% of all requests. 
However, men are self-conscious and cautious. 
They are often concerned about a few lesions (i.e. lentigines) although they have diffuse dyschromias. 
Unlike women, they often prefer to have the lesions treated instead of having a fullface treatment. 
Men are less willing to return to work if significant swelling is present after treatment. 
Particular attention should be paid to hair-bearing areas (chin, cheeks, preauricular and perioral areas). 
A lesion located in this area can be treated with the price of hair removal. 
Race also has an influence on skin response to treatment. 
In Asians, pigmentary problems are more frequently encountered than wrinkling. 
Among pigmented lesions, nevus of Ota is more frequently present in Asians.
There are a variety of IPL devices on the market, and parameters vary widely from one device to another. 
Certain fluences which are safe for a particular application in one device may be dangerous with other IPL devices; modern IPL devices deliver a constant spectrum emission at low fluences. 
Former generations of IPL systems had variations of the beam as the pulse progressed, with the end of the pulse more in the red/infrared spectrum; modern IPL devices have a computer system that reduces this socalled “spectral jitter”.
Skin texture improvement has been reported by several authors. 
Non-ablative photorejuvenation is considered to “remodel” the dermis due to the thermal injury to the papillary and upper reticular dermis, sparing the epidermis. 
Collagen remodeling continues for up to one year after the end of IPL treatment. 
In a long-term follow- up study, Weiss reported skin textural improvement in 83% of patients. 
The evaluation was done four years after the IPL procedure, with a chart review of 80 randomly selected patients. 
The face responded slightly better than the chest or neck with a 90% texture improvement. 
After four IPL treatments, Bitter reported wrinkle improvement from a score of 5 (moderate) to 2.83 post-treatment (mild). 
The patients also reported some degree of improvement in skin laxity. 
The level of satisfaction was as high as 88%. 
A higher satisfaction rate after skin rejuvenation was reported by Fodor et al. with the 5-point Likert scale to evaluate the results; 93.2% of the patients felt they had good to very good results, with better improvement in pigmented and vascular lesions compared to skin texture. 
We have not seen significant skin texture improvement after IPL treatment. 
The lighter skin color obtained should not be confused with skin texture and rhytid improvement. 
During consultation, we strongly emphasize that significant skin texture improvement will not be achieved with this method.
If the patient understands this, the satisfaction level is high.
The association of ALA and IPL has been successfully used to improve skin texture. 
5-ALA is a photosensitizing agent often used to treat acne vulgaris, skin carcinomas, psoriasis or other dermatologic conditions. 
Its application was extended recently by using it for skin rejuvenation in combination with IPL. 
The topical application of ALA produces an accumulation of the endogenous photosensitizer protoporphyrin IX (PpIX). 
The maximum absorption of PpIX induced by 5-ALA is at 410, 630 and 690 nm. 
The free radicals resulting from ALA metabolisation have a selective action based on accumulation mainly in the pilosebaceous units and hyperproliferative keratinocytes. 
IPL decreases the amount of Propionibacterium acne and reduces the size of sebaceous glands and the amount of sebum production. 
When ALA is combined with IPL for photodynamic therapy, it is applied for a relatively short period of about one hour before the procedure. 
This short incubation time is enough to improve IPL results. 
The positive sideeffects of ALA and IPL combination were recorded after treatment of actinic keratosis. 
Improvement of skin elasticity, wrinkles and pigmentary changes have been noticed. 
Good results of rejuvenation after ALA and IPL have been recorded for patients with photoaging. 
A split-face comparison study of IPL alone or combined with 5-ALA for photorejuvenation was reported by Alster. 
Better results were observed after two treatments with the 5-ALA-IPL combination although desquamation was observed in these areas. 
The same combination was reported to be useful for treatment of acne vulgaris. 
It proved to be more efficient than IPL alone, although the level of improvement was 66.8%. 
A clearance rate of 71.8% for the same condition was reported in another study. 
There are no data on humans but Hedelund demonstrated that IPL has no carcinogenic potential in mice. 
The main advantage of combining 5-ALA with IPL is a reduced number of treatments and better clinical outcome. 
Photodynamic therapy with ALA is not widely approved and most countries restrict its use to the experimental level.
With its ability to emit a wide spectrum of wavelengths and adjustment of pulse duration, delay and fluences, IPL has proven to be useful for treating various vascular and pigmented lesions. 
There are several reports of vascular lesion improvement when performing skin rejuvenation. 
Most report on telangiectasia improvement. 
When using Vasculight or Quantum to treat telangiectasia, Goldman prefer to use a double pulse of about 2.4–4ms duration, with a delay time of 10ms in light skin and 20–40ms in darker skin. 
The fluences are usually between 28 and 35J/cm2.
Our experience with Vasculight for photorejuvenation shows that fluences between 25 and 45J/cm2, cutoff filters of 560 and 640nm, a pulse duration of 2.4–7ms, and a pulse delay of 15–75ms are the parameters most often employed. 
Using Lumenis One, the fluences delivered are less than with Vasculight. 
Negishi performed photorejuvenation on 73 patients using the original IPL or Quantum IPL. 
The fluences varied from 23 to 27J/cm2, pulse duration varied from 2.8 to 6ms and the pulse delay from 20 to 40ms. 
Excellent results for small red telangiectasias were obtained by using synchronized pulses with an initial short 2.4–3ms followed by a second longer 4–8ms pulse. 
Weiss reported 82% telangiectasia improvement. 
The evaluation was done four years after IPL treatment by reviewing the charts of 80 randomly selected patients. 
The face responded slightly better than the chest or neck with a 90% texture improvement.
There is limited data in the literature regarding treatment of rosacea with IPL. 
Rosacea is a common condition and includes stages such as facial flushing, erythema, edema or rhinophyma, but its exact etiology is not clear. 
Mark reported good results on a small number of patients, and a mean clearance of 77.8% was reported by Schroeter. 
The clearance time persisted for an average of 51.6 months. 
A recurrence rate of about 7% was observed 3 years posttreatment.
A higher cutoff filter, longer pulse duration and longer pulse delay has a better effect on deeper vessels with large diameters, while a shorter cutoff filter, shorter pulses and shorter delay has a greater effect on superficial dermal melanin and superficial small vessels.
Pigmentary improvement when performing skin rejuvenation is almost invariably reported. 
Melanin is the target chromophore of pigmentary lesions. 
The majority of the melanin is concentrated in the basal layer of the epidermis and has the highest absorption spectrum in the UV. 
The melanin pigment is packed within melanosomes which are found within the melanosytes. 
The melanosome has a Thermal Relaxation Time (TRT) of about 10–100ns. 
Watanabe found that melanosomal injury is independent of pulse width at 694, 630 or 532nm, if the pulse is below 1?s. 
He concluded that 1 ?sec is the effective TRT of the melanosome. 
The shorter the pulse width, the more localized the damage. 
The absorption coefficient of melanin decreases as the wavelength increases. 
Thus, greater energy for longer wavelengths is required to injure the melanosome. 
The repigmentation after treatment occurs from residual melanocytes from the adnexal structures or migration from non-treated areas.
When treating pigmentary lesions, the natural response includes the formation of tiny crusts that peel off within a few days. 
Performing an examination using Woods lamp to establish the depth of melanin pigmentation prior to treatment has been suggested. 
There are three histological types: epidermal, dermal and mixed. 
It is important to adjust the device parameters and alternate the cutoff filters and fluences for efficient treatment of resistant melasma. 
Lesions located at different levels respond differently. 
When treating melasma patients with IPL, we always ask the patient to discontinue birth control pills and avoid sun exposure. 
The results of pigmentary lesions are demonstrated in Table 6.1. 
Using a single IPL treatment, Bjerring obtained 96% pigment reduction with a higher clearance rate for lentigo solaris. 
Kawada reported solar lentigines and ephelides improvement after 3–5 sessions of IPL treatment. 
48% of patients reported more than 50% improvement and 20% had more than 75% improvement. 
Better response rate was noticed for small plaques. 
Excellent results are reported for lentigines and other pigmentary lesions. 
When treating pigmentary lesions (solar lentigines and ephelides) using Lumenis One, Konishi obtained clinical improvement by choosing low fluences (12–14J/cm2), double pulses of 4ms and a pulse delay of 20ms. 
He reported a decrease in the melanin index. 
Pigmentary changes were treated by Huang using fluences of 25–35J/cm2, 4ms single or double pulses, 20–40ms pulse delay and 550, 590nm cutoff filters. 
Freckling and lentigines were treated by Kawada using a Quantum IPL. 
He used smaller fluences of 20–24J/cm2, 2.6–5ms pulse duration, 20ms pulse delay and 560nm cutoff filter. 
He also noticed a better response for small lesions. Bitter treated 49 patients with Vasculight for photodamage. 
He used fluences from 30–50J/cm2, pulse durations of 2.4–4.7ms, pulse delays of 10–60ms and cutoff filters of 550 and 570nm. 
Although IPL requires more sessions to treat lentiges, it is associated with a lower risk of post-inflammatory hyperpigmentation. 
In general, patients with epidermal melasma have a better response than those with mixed-type melasma the superficial lesions (caf? au lait, ephelides, epidermal melasma) have a better response to IPL while deeper lesions (nevus of Baker, mixed melasma) are more resistant to the procedure. 
More treatments are needed for deeper pigmented lesions. 
Nevus spilus was successfully treated by Gold  using a 590nm cutoff filter. 
According to Huang, among all pigmentary lesions, freckles seems to respond the best to IPL treatment. 
Poikiloderma of Civatte is a combination of telangiectasia, atrophy and pigmentary changes. 
The recent discovery of familial cases of Poikiloderma of Civatte shows that it also has a genetic component transmitted as an autosomal dominant trait.
Several authors have reported Poikiloderma improvement with IPL treatment. 
Multiple sessions are usually necessary. 
Goldman recommends starting treatment with a 550 or 560nm filter to prevent too much epidermal absorption. 
In a different study, the same author reported good improvement in 42% of patients after an average of 2.8 treatments; fluences between 30 and 34J/cm2 were used. 
When 50% improvement was noticed on the previous treatment, either the same fluence was used or it was increased by 5%. 
Significant improvement of Poikiloderma of Civatte (grade 4: 75–100%) after IPL was seen in 82% of patients. 
Clearance of telangiectasia and hyperpigmentation was noted in more than 75% of patients. 
Paquet obtained an 80% clinical, histologic and spectrophotometric decrease in hypermelanosis in two patients following drug-induced toxic epidermal necrolysis. 
Although the literature is limited, IPL systems with an ability to adjust wavelength, pulse width and delay are useful for treating facial hypermelanosis.
The treatment intervals for skin rejuvenation are reported to vary from 2 weeks to 8 weeks. 
Most physicians perform treatments one month apart. 
We also prefer performing the treatment every month, although this interval is arbitrary. 
For people with posttreatment side effects or higher skin sensitivity, we extend the interval between treatments. 
In our experience, highest patient satisfaction is for pigmented or vascular lesions as a part of photodamaged skin. 
Shorter wavelengths are better for treatment of these lesions; longer wavelengths penetrate deeper and are better for wrinkle reduction and texture improvement.
Noninvasive methods for rejuvenation, such as IPL, need to compete with laser resurfacing, chemical peels and dermabrasion. 
Ablative procedures injure the epidermis and produce changes in the dermis followed by an inflammatory response that stimulates fibroblasts to produce scar collagen. 
In these situations, the skin is more sensitive, there is prolonged healing time and a need for wound care 
The main advantages of IPL skin rejuvenation are the minimal downtime recovery, fast and easy to perform, minimal complications, minimal interference with lifestyle and long-term improvement.
Sun exposure and smoking are the main fac- ? tors that induce premature skin aging. 
Over the age of 30, the melanocytic number decreases 10–20% per 10 years. 
Dermal changes in the aged skin are responsible for various clinical presentations, such as mottled pigmentation, telangiectasia, wrinkles and dryness. 
Hemoglobin and melanin are the primary chromophores involved in skin rejuvenation. 
Type I photorejuvenation refers to vascular anomalies, pigmentary changes or pilosebaceous changes, while Type II is related to dermal and subcutaneous senescence. 
Most histological studies show collagen improvement after IPL treatment. 
Skin rejuvenation is aimed at reducing visible pigmentary changes and blood vessels and at improving skin texture. 
The face is the most frequently treated area. 
Overlapping during treatment should be avoided. 
Large footprints are more efficient for treating large areas. 
The light distribution into the skin is more uniform, resulting in a better effect. 
Hair-bearing area should be protected during treatment. 
Special attention should be paid to men who have large hair-bearing areas.
A good response immediately after treatment is blanching of the vessels, “urticaria” type reaction or slight darkening of pigmented lesions. 
Erythema and edema are present in most patients and resolve within hours to 2–3 days. 
Adjusting wavelengths according to the type and depth of the lesion may improve the results. 
There is a variety of IPL devices on the market. 
The treatment parameters from one device do not fit other devices. 
In our experience, pigmented and vascular lesions respond better after IPL treatment compared with skin texture improvement. 
The association of ALA and IPL has been successfully reported to improve skin texture but it is not widely approved and most countries restrict its use to the experimental level. 
Superficial pigmented lesions, such as ephelides and epidermal melasma, have a better response to IPL while deeper lesions are more resistant. 
The main advantages of IPL skin rejuvenation are minimal downtime recovery, fast and easy to perform, minimal complications, minimal interference with lifestyle and long-term improvement.
Hirsutism is represented by excessive growth of the coarse hairs in women, distributed in a male-like pattern. 
Hypertrichosis is represented by excessive growth of coarser and longer hair than is normal for the age, sex and race of the person. 
The hair growth cycle has three phases: anagen, catagen and telogen. 
The anagen phase is the growth phase, the catagen phase is the regression phase and the telogen phase is the rest phase. 
The hair follicle is the most susceptible to IPL treatment during the anagen phase. 
The melanin is the target chromophore for hair removal. 
There are three types of melanosomes present in the hair. 
Erythromelanin granules are present in red hair while eumelanin and pheomelanin granules are found in varying proportions in blond and dark hair. 
The targets for hair removal are the dermal papilla and the bulge area. 
The heat-induced destruction of the hair shaft leads to hair “dropout”. 
The partial injury to the germinative zone leads to telogenshock response, prolonged telogen dropout, and development of dystrophic hairs which are thinner in texture and have variable pigmentation. 
Multiple IPL treatments are usually needed. If no improvement is obtained after 5–6 sessions, interrupting the treatment should be considered. 
The darker the skin and the brighter the hair, the less effective the treatment will be.
Hirsutism is represented by excessive growth of the coarse hairs in women, distributed in a male-like pattern. 
There are racial and ethnic differences in hair distribution. 
The most frequently used method to grade hirsutism is the Ferriman-Gallwey scoring scale. 
According to Ehrmann, 5% of women in the United States suffer from hirsutism. 
Age also influences hair distribution, and unwanted facial hair is more common in postmenopausal women. 
Endocrine disorders characterized by hyperandrogenemia are responsible for increased hair growth. 
The source of the endocrinological problem can be found in the pituitary gland (Cushing disease), the adrenal gland (hyperplasia or tumors) or in the ovaries (polycystic ovary disease, tumors). 
Exogenous anabolic steroids are also associated with hirsutism. 
The most common hormonal cause of hirsutism is polycystic ovary disease. 
Testing of elevated androgen levels in woman with moderate or severe hirsutism that appears suddenly and is rapidly progressive or associated with menstrual dysfunction or obesity is recommended prior to starting hair removal treatment. 
However, the severity of hirsutism is not well correlated with the androgen level. 
The response of the follicle to androgen excess varies among persons. 
Oral contraceptives and antiandrogen drugs are the most used pharmacological therapy. 
Hirsutism treatment in patients with polycystic ovary disease is difficult and there are reports showing 25% hair growth after 36 months of treatment.
Hypertrichosis is represented by excessive growth of coarser and longer hair than is normal for the age, sex and race of the person. 
Although there are described mechanisms of hypertrichosis, the triggers that initiate these mechanisms are unknown. 
The congenital forms of hypertrichosis include nevocellular nevus, hamartoma, hemihypertrophy, hypertrichosis cubiti, neurofibroma, hairy cutaneous malformations of palms and soles, spinal hypertrichosis, anterior cervical hypertrichosis and several congenital syndromes in which generalized hypertrichosis is a primary feature. 
The acquired disorders associated with hypertrichosis include Becker nevus, hypertrichosis of pinna, hypertrichosis associated with local inflammation, pharmacological hypertrichosis (cyclosporine, cortisone, streptomycin) and other acquired disorders associated with generalized hypertrichosis (dermatomyositis, hyperthyroidism, hypothyroidism).
Sometimes, hair removal can also have non-cosmetic applications. 
For instance, hair removal of flaps or treatment of areas with recurrent folliculitis can be of real benefit for the patient. 
Digestive reconstruction with a hair-bearing pectoralis flap can lead to disfagia and even halitosis. 
Urethral or vaginal reconstruction with scrotal or pudendal hairy flaps may obstruct urinary flow or increase the risk of infection.
Older methods of hair removal include shaving, plucking, waxing, depilatory creams and electrolysis. 
Galvanic, electrolysis, thermolysis and blend methods are three types of electrosurgical epilation. 
Most are temporary methods, relatively inexpensive. 
Among the common side effects encountered are:
? Shaving: dermatitis, minor cuts and pseudofolliculitis
? Waxing: pain, minor burns, irritation, folliculitis, post-inflammatory hyperpigmentation
? Electrolysis: edema, erythema, pain, scarring, post-inflammatory pigmentary changes
? Topical creams: acne, pseudofolliculitis, burning
There are three methods of permanent hair removal: electrolysis, IPL and laser treatment. 
Although widely used in the past, electrolysis is sometimes poorly tolerated by patients and has 15–50% permanent hair loss per treatment. 
The pulsed light and laser treatments seem to be more reliable and more frequently used than electrolysis recently.
Detailed histology and biology of the hair follicle was described in Chapt. 1 (Skin anatomy). 
Herein we emphasize the most important facts that influence treatment. 
There are three main components of the hair follicle: the infundibulum, the isthmus and the hair bulb with dermal papilla. 
The bulge area is located about 1–1.5mm below the skin surface near the follicle bulb. 
Recent evidence shows that follicular stem cells are located in the bulge and the outer root sheath. 
They have the capacity to regenerate not only the hair follicles but also sebaceous glands and epidermis. 
The follicle depth varies according to the anatomical area.
The hair growth cycle has three phases: anagen, catagen and telogen. 
The anagen phase is the growth phase, the catagen phase is the regression phase and the telogen phase is the rest phase. 
The hair follicle is the most susceptible to IPL treatment during the anagen phase. 
This phase is variable in duration and can last up to 6 years. 
The catagen phase is the relatively constant phase, usually lasting for about 3 weeks. 
Most follicles, most of the time, are in the anagen phase (80–85%) while the remaining follicles are either in the catagen (2%) or the telogen phase (10–15%). 
The transition from one hair follicle phase to another varies according to the anatomical region. 
The percentage of hair follicles in the telogen phase is about 15% in the scalp and 75% in the extremities. 
The anagen phase duration varies from 2 month to 1 year in the face, from 1 month to 6 months in the extremities. 
This is why more IPL treatments are needed for each area in order to catch the hair follicles in the anagen phase. 
Factors such as age, gender, anatomical region and hormones affect the duration of anagen phase.
During the hair cycle, there are also changes in vascularization. 
These changes seem to be related to the hair cycle regulation process. 
The hair follicle is well vascularized during the anagen phase, while vascularization is much reduced during the catagen phase.
The lights as lasers have a similar mechanism of acting on the chromophore. 
The melanin is the target chromophore for hair removal. 
For selective damaging of the hair follicle, the light energy is absorbed by the melanin (endogenous chromophore) present in the hair shaft, outer root sheath of the infundibulum and matrix area. 
There are three types of melanosomes present in the hair. 
Erythromelanin granules are present in red hair while eumelanin and pheomelanin granules are found in varying proportions in blond and dark hair. 
In white or grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes. 
Eumelanin and pheomelanin have different wavelength absorption peaks. 
It has been shown that the absorbance rate is 30 times lower at a wavelength of 694nm for pheomelanin compared to eumelanin. 
The light absorption of pheomelanin is very low at wavelengths from 750 to 800nm. 
Because blonde or whitegrey hair has a paucity of melanin, they are less susceptible to IPL treatment. 
The targets for hair removal are the dermal papilla and the bulge area. 
The heatinduced destruction of the hair shaft leads to hair “dropout”. 
The partial injury to the germinative zone leads to telogen-shock response, prolonged telogen dropout, and development of dystrophic hairs which are thinner in texture and have variable pigmentation. 
Dark-skinned people have a high content of melanin within the epidermis. 
This absorbs the energy, resulting in possible heating and damage of the surrounding skin. 
Extra care must be taken when treating patients with Fitzpatrick skin type V and VI.
A histological examination study performed on nine subjects after a single IPL treatment showed clumping of melanin, hair shaft follicles and coagulative necrosis of the hair shaft. 
At 48 h, half the follicles contained apoptotic keratinocytes and had perifollicular edema. 
Some hair follicles presented perifollicular hemorrhage.
At a longer posttreatment interval (2 weeks–20 months), many follicles had apoptotic keratinocytes, perifollicular fibrosis and melanophages.
During consultation, taking a detailed medical history can be of extreme importance. 
Specific questions to identify endocrinological problems leading to hirsutism should be asked. 
Obese people, those with polycystic ovary syndrome or other endocrinological disorders should be referred first to an endocrinologist. 
This does not mean that they cannot benefit from IPL treatment. 
Most authors refrain from using light or lasers for patients undergoing isotretinoin therapy. 
It is also our protocol to delay treatment from 6–12 month after stopping drug intake. 
The reasons for delaying treatment are seen in several reports that showed delayed healing and scarring. 
However, Khatri reported good results in six patients taking isotretinoin, and no complications were reported. 
It is our recommendation not to perform treatment in these patients until large studies demonstrate its safety. 
Other contraindications to treatment are patients with a history of keloids and connective tissue disorders.
The physical examination should be done carefully for the desired anatomic region. 
It is important to rule out skin malignancies and active skin infection. 
Particular attention should be paid to the presence of pigmented lesions or tattoos in the area. 
Treatment can alter the pigment. 
We recommend covering the lesions with a small white pad during treatment. 
Treatment to tanned people is delayed for a few weeks to diminish the chances of side effects, especially hypopigmentation. 
A careful analysis of the distribution of unwanted hair should be done. 
The quantity, color and quality of hair follicles should be compared with healthy people having normal hair distribution. 
All this information should be explained to the patient, as his hair distribution, perception or expectations can be disproportional.
People coming for epilation desire definitive hair removal. 
According to the FDA, “permanent hair removal” refers to a significant reduction of hair follicles, stable for a period of time longer than the complete growth cycle of the hair follicle. 
This should be explained to the patient, as most interpret the same sentence as no hair regrowth ever. 
Educating patients and explaining the expected outcomes and possible complications is very important. 
We explain to patients that multiple treatments are needed and even then, a permanent result should not be expected. 
The results of each treatment are marked on the chart. 
If no significant improvement is obtained after 7–8 treatments, we suggest stopping treatment.
Any method of hair removal except shaving should be stopped at least 2 months prior to treatment. 
Shaving is the only method which does not remove the hair bulb. 
With other methods, the target structures are removed and treatment is in vain. 
Two or 3 days before the treatment, the area should be shaved. 
Performing treatment on an unshaved area can lead to more complications. 
The long dark hair lying on the skin absorbs the energy and may burn the epidermis. 
For bikini area treatment, patients are told to wear white undergarments as black ones are more prone to reacting to the treatment. 
If small areas are treated, this can be done without topical anesthesia. 
The bikini and periareolar areas are the most sensitive. 
In these areas or other large areas, we always recommend an EMLA or ELAMax application one hour prior to treatment. 
When larger areas are treated, necessitating more time, breaks for ice pack cooling are taken. 
Cooling is continued for 15 min after finishing the treatment. 
A test is always performed before starting the procedure.
The IPL device is relatively easy to handle. 
The computer software provides suggested treatment parameters based on patient hair color, type, and skin type. 
The degree of contrast between skin and hair, the type of hair color and the amount of melanin content are important factors in the success of IPL hair removal. 
The light penetration depth is limited by irradiating areas of the skin that are too small. 
To avoid the effect of radial dissipation of energy, the spot size should be larger than the light penetration depth into the tissues, about 5–10mm.
The possibility of double or triple pulse distribution causes the hair follicle to heat up in a stepwise fashion. 
Lengthening the pulse duration carries a risk of epidermal damage. 
A pulse delay over 3ms is recommended to allow the epidermis to cool down. 
Longer wavelengths are preferred, as the chromophore is situated deep in the skin. 
The longer the wavelength, the deeper the light penetration into the skin. 
Shorter wavelengths are more effective for light and thin brown hairs. 
Applying slight pressure on the skin is recommended when performing the treatment. 
This will empty the blood vessels from underneath and minimize the absorption of light energy by hemoglobin.
Treatment parameters need to be adjusted according to the skin response from the anterior session. 
When side-effects or complications are encountered after one session, the fluence is decreased by about 2–4J/cm2 and the pulse delay is increased by 10%. 
Future treatment parameters are adjusted according to the previous response. 
We always recommend recording the patient evaluation and side-effects for the whole treatment period. 
The presence of certain side-effects as a paradoxical effect indicates interruption of the treatment. 
For further details, please see Chapter. 9 on Complications.
The timing of multiple treatments varies according to the hair growth cycle in that region and the hair type. 
In general, treatments to the face, neck, axilla and bikini area are done at 5–6 weeks intervals. 
The extremities and thorax are treated with a 7–8 weeks interval. 
Almost all patients experience edema and erythema for a short period of time after treatment, which is considered a normal response. 
Patients should be reminded that they will have hair growth in the days after treatment. 
This is a normal response and represents the extrusion of the damaged hair from the follicle. 
It should not be interpreted as failure of the treatment. 
Dark skin phenotypes remain problematic for IPL-assisted treatments. 
Sunscreens are essential to protect the skin from sun during the treatment period.
Haedersdal identified controlled clinical trials of hair removal between 1990 and 2004 and compared the results of hair removal using lasers and light by studying nine randomized controlled trials and 21 controlled trials, which included only two studies on IPL. 
It is difficult to integrate the data as there are many factors that can influence outcome: fluence, wavelengths, spot size, pulse duration, presence or not of skin cooling, and patient parameters. 
Many studies confirmed the long-term hair removal efficacy of the IPL system.
Most literature studies report on hair removal for patients with skin type I–IV. 
The clearance rate after IPL hair removal varies widely from 20–93.5%. 
As can be seen, various cutoff filters and a wide range of fluences are used by different authors. 
These vary also according to the IPL device. 
Performing two treatments with fluences of 40–42J/cm2, Weis noticed a 33% hair count reduction at 6 months. 
A reduction in the remaining hair follicles was also recorded. 
A relatively low hair reduction (27%) was reported by Goldberg after one to three treatments. 
The fluences used ranged from 6.25–6.45J/ cm2 with a pulse duration of 35ms. 
Using high fluences of up to 55J/cm2, Gold obtained a 60% hair reduction at 12 weeks post hair removal. 
80.2% hair clearance at 8 months post-treatment was obtained by Troilius. 
The parameters used were a cutoff filter of 600nm; mean fluence of 19.3J/cm2 and a pulse duration of 44.5ms.
No significant difference in hair loss after single (54% reduction) or multiple treatments (64% reduction) was observed by Sadick 6 months post-treatment. 
The fluence used varied from 40–42J/cm2 and cutoff filters used were 590nm for skin type I, 615nm for skin type II, 645nm for type III, and 695nm for type IV. 
In a different study, the same author reported 76% hair removal after a mean of 3.7 treatments. 
He used 615nm cutoff filters and 39–42J/cm2 for Fitzpatrick skin type II; 645 nm and 34–40J/cm2 for skin type III-IV, and 695nm and 38–40J/cm2 for skin type V. 
Maximal benefit of photoepilation was achieved from the initial 1–3 treatments.
The level of patient satisfaction is hard to anticipate. 
In a retrospective study, Lor evaluated the satisfaction level of 207 patients: 22% were very satisfied, 45% satisfied and 33% unsatisfied. 
Using fluences between 35–39J/cm2, 645 and 695nm cutoff filters and pulse delays <40ms (63.8% cases) and >40ms (36.2% cases), Fodor evaluated the satisfaction level of 80 treated patients. 
The patients who had fewer treatments were more satisfied than those who had more than seven treatments. 
The author’s clinical impression was that the best response was noticed after first few treatments, which explained the satisfaction level.
One of the limiting factors that prevent the physician from applying higher fluences to make the treatment more effective is pain. 
Shorter wavelengths are more painful, probably because the epidermis absorbs most of them. 
It has been shown on skin biopsies that light produced by “Photoderm” will reach a depth of 1.3mm.
There are recommendations to perform at least three treatments but there are no recommendations about when to stop the treatment. 
Usually we stop after 7–8 treatments, unless significant improvement is gained. 
When treating various body areas, the interval between treatments should be adjusted according to the resting period of the hair follicles. 
Most authors prefer to perform treatments at 4–6 weeks intervals.
Studies on IPL hair removal for dark skin types have been reported. 
Most IPL devices enable a wide range of wavelengths by choosing different cutoff filters, thereby sometimes being effective in dark skins. 
Johnson reported a 85–100% clearance in three patients with skin types V and VI. 
Long pulse delays (>80ms) were used. 
Temporary hyperpigmentation was encountered in one case. 
Lee evaluated the results after treating 28 Asian patients who have a higher epidermal melanin content than Caucasians. 
A higher clearance of axillary hair of 83.4% was observed for the group with higher cutoff filters (645–950nm). 
The average fluence for this group was 17.1J/cm2. 
For dark skinned patients, the pulse duration should be extended, thereby producing gradual heating and less damage to the epidermal layer. 
When the same fluence was distributed to the skin at a duration of 15ms compared to 30ms, it was found that the shorter duration had a 6°C higher temperature of the skin surface. 
Low fluences and longer pulse delays are recommended for dark skin types. 
A device combining the optical energy and radiofrequency was used in a study to perform hair removal in darker skin types. 
Although less optical energy was needed for treatment, only 46% hair removal was obtained 3 months after a single treatment.
There are only limited studies on this topic. At present, we recommend IPL hair removal without reservations for patients with skin types I–IV and fine or coarse black hair type. 
The darker the skin and the brighter the hair, the less effective the treatment will be. 
We do not perform IPL hair removal for skin types V or VI or for blond or white hair. 
For darker skin types, some authors prefer using Nd:Yag laser. 
Identification of patients with unrealistic expectations increases the satisfaction level.
Both IPL devices and lasers are currently used for hair removal. 
The effectiveness of different devices varies according to fluence, wavelength, pulse duration and delay. 
It is hard to compare the results of different studies as different devices, fluences and cutoff filters are used.
The efficacy of IPL, diode laser and Alexandrite laser was studied on 232 patients with skin types II–IV. 
At 6 months, optimal hair removal reduction was noticed with no significant differences between the sources (IPL: 66.9% clearance; Alexandrite: 68.7%; diode: 71.7%). 
Amin evaluated the results of epilation by comparing two IPL devices (Palomar/Starlux Rs, Palomar/ Starlux Y) a diode laser and an Alexandrite laser. 
The results were evaluated 210 days later by photographing the treated area. 
There was about 50% hair count reduction in all four areas but the Alexandrite laser had the highest pain score. 
Eleven patients were treated by Goh in a site-by-site manner using IPL and Nd:Yag laser. 
No significant differences were noticed in the results. The Nd:Yag laser was more painful than IPL. 
Bjerring evaluated side-by-side the IPL and the Ruby laser for hair removal. 
After three treatments, hair reduction was obtained by 93.55% of IPL treated patients and by 54.8% of Ruby laser treated patients. 
Additional IPL treatments resulted in only 6.6% further hair reduction. 
The pain level in the Ruby laser group was 3.5 times higher than with IPL treatments.
Having a wide spectrum of wavelengths (500– 1,200nm), the IPL device has better penetration than Alexandrite or Ruby lasers. 
Shorter wavelengths can be used to target red-brown hair in individuals with light skin type, although the result is not as good as for dark hair.
Most studies report hair removal from body areas that are most requested for treatment, such as the face, axilla and bikini. 
However, successful treatment with IPL of a relapsing hairy intradermal nevus after shave excision was reported by Moreno-Arias. 
IPL was also successfully used to correct improper hairline placement after hair transplantation; three treatment sessions were enough to correct the problem. 
IPL applications have been extended to treat hairy grafts and flaps. 
Four patients who needed facial or breast reconstruction with flaps after cancer excision were successfully treated for hair removal. 
The authors noticed simultaneous improvement of skin coarseness, pigmentation and erythema. 
Excellent results were reported by Schroeter, who obtained 90% hair removal in transsexual patients. 
The average follow-up period was 44 months. 
The same author reported a negative correlation between hair removal and age of patient. 
This seems to be the single study that reports a correlation between age and amount of hair clearance.
PTD implies the application of a photosensitizing drug (e.g., ALA) and appropriate selection of wavelengths to cause selective tissue destruction. 
More details about photosensitizing drugs are described in Chapter 2. applied the principles of PDT to treat 11 hirsute patients. 
The area was first epilated and 20% topical ALA was used. 
Three hours later, the area was treated (wavelength of 630nm; fluence of 100–200J/cm2). 
A 50% reduction in hair regrowth was obtained after 3 months.
Nahavandi evaluated the efficacy of VPL in the treatment of unwanted hair in 77 volunteers. 
VPL delivers a pulsed train of light, each train containing up to 15 micro pulses. 
More than 50% hair clearance was observed in 88.3% of patients.
Hirsutism is represented by excessive growth of coarse terminal hair in women and distributed in a male like pattern. 
Hypertrichosis is represented by excessive growth of coarser and longer hair than is normal for the age, gender and race of the person. 
The hair follicle is most susceptible to IPL treatment during the anagen phase. 
The transition from one hair follicle phase to another varies according to the anatomical area. 
The anagen phase varies according to the anatomical area. 
Melanin is the target chromophore for hair removal. 
In white or grey hair, the melanocytes of the hair matrix are much reduced and show degenerative changes. 
These types of hair are less susceptible to IPL treatment. 
The targets for hair removal are the dermal papilla and the bulge area. 
Identify endocrinological problems before treatment. 
Refrain from using IPL in patients currently taking isotretinoin. 
Treatment of tanned skin is delayed for a few weeks. 
Defining the term “permanent hair removal” before starting treatment might increase the satisfaction level. 
Multiple treatments are usually needed. 
If no improvement is obtained after 5–6 sessions, interrupting the treatment should be considered.
Shaving is the only recommended method before IPL treatment. 
Treatment parameters need to be adjusted according to the previous results. 
Most physicians perform treatments 4–6 weeks apart. 
Hair removal efficacy increases with the darkness of the hair color and with the amount of fluence. 
The darker the skin and the brighter the hair, the less effective the treatment will be.
According to the International Society of the Study of Vascular Anomalies, vascular anomalies can be classified as vascular tumors (origin in the endothelial hyperplasiate and vascular malformations (normal endothelial turnover). 
Hemangiomas are the most common benign vascular tumors of infancy. 
Portwine stains are present in 0.3–0.5% of newborns and are congenital malformations of the superficial dermal capillaries. 
The vascular lesions that most benefit from IPL treatment are: hemangiomas, PWS, angiomas, telangiectasias, leg veins, rosacea and Poikiloderma of Civatte. 
Angiofibroma, cutaneous lesions of Kaposi sarcoma, Blue Rubber Nevus syndrome, hereditary hemorrhagic telangiectasias and stria distensia may also have some benefit. 
The main chromophores are oxyhemoglobin and deoxyhemoglobin. 
Superficial red vascular lesions have a high amount of oxyhemoglobin. 
The pulse duration should be shorter than the thermal relaxation time of the chromophore to preferentially protect the surrounding tissue from heat damage. 
The need for multiple treatments should be emphasized to the patient. 
For deep hemangiomas, IPL treatment alone is not effective. 
Capillary malformations on the limbs have less response to treatment compared to those on the head and neck.
Vascular lesions have been reported as treated with technologies that emit green light (532 nm), yellow light (578–600 nm), red light (755–810 nm), near infrared light (1,064 1993nm), and broad-spectrum IPL (range 500–1200 nm). 
To understand the effect of IPL on vascular lesions, it is important first to become familiar with these conditions.
Hemangiomas are the most common benign vascular tumors of infancy. 
They are proliferative, have plump endothelium and can appear on the skin, mucosa or other soft tissues. 
Most are located in the head and neck areas and occur with a higher frequency in females. 
There are three types of hemangiomas: superficial, deep and mixed. 
Superficial hemangiomas are found in the papillary dermis and have a bright red color. 
Deep hemangiomas are present in the reticular dermis and subcutaneous fat and have a bluish appearance. 
The overlying skin might have a network of telangiectasias. 
At first, it can be difficult to distinguish hemangioma from vascular malformation. 
Hemangiomas are rarely present at birth. 
They appear after 3–4 weeks and have a rapid growth during the next few weeks. 
Vascular malformations are usually present at birth and increase in size as the child grows. 
Hemangiomas have a bright red color that deepens by the second half of the first year of life, while the hue aspect of a vascular malformation persists. 
Usually hemangiomas have a firm rubbery consistency while vascular malformations are soft and easily compressed.
Hemangiomas have usually three stages: a growing, rapid proliferative phase usually during the first six months of life; a stable period and an involution period. 
During the involution phase, there are color changes and superficial lesions have a flaccid waxy yellow skin. 
About 30% of involuting hemangiomas will leave some marks of atrophy, fibrosis or telangiectasia. 
It has been estimated that hemangiomas involute by 10% of their volume per year. 
Lesions on the nose and lips involute more slowly. 
If there are no signs of regression by age 6–8 years, they are not likely to completely regress. 
Adult hemangiomas consist of mature capillary-size vessels of about 100 ?m.
At times, hemangiomas may complicate. 
About 5–11% can ulcerate, become infected or bleed. 
Usually these complications appear during the proliferative phase. 
However, in certain circumstances, they can lead to significant morbidity, impairing vision (in the periorbital area), interfering with feeding or respiration (in the nose or mouth areas), impairing hearing (in the auditory canal) or can even be life threatening, necessitating early intervention. 
Skeletal distortion is rare but can appear as a mass effect of large hemangiomas. 
IPL or lasers (Argon; Pulsed Dye Laser- PDL; Nd:Yag) have been reported as treatment tools for hemangiomas.
Port-wine stains are present in 0.3–0.5% of newborns and are congenital malformations of the superficial dermal capillaries. 
The ectatic capillaries have different sizes and depths, most varying from 10–150 ?m in diameter and 300–600 ?m in depth. 
Videomicroscopy analysis of PWS shows three types of vascular ectasia located at the vertical loops of the papillary plexus, deeper horizontal vessels in the papillary plexus and combined vertical and horizontal vessels involvement. 
Clinically, they appear as pink macules which progressively dilate to become red. 
These lesions do not spontaneously resolve. 
They should be differentiated from other pink stains as nevus flammens or salmon patch; these lesions usually disappear within the first year of life. 
PWS are predominantly located in the head and neck area, are well delineated and commonly involve the distribution area of the trigeminal nerve. 
PWS lesions can be associated with other medical conditions. 
SturgeWeber syndrome is one of the most common. 
They also can be associated with varicose veins and skeletal tissue hypertrophy in Klippel-Trenaunay syndrome.
Telangiectases are characterized by permanent dilation of vessels with diameters ranging from 0.1–1 mm. 
Most originate in a dilated venule but capillaries and arterioles are sometimes affected. 
The arteriolar type has a bright red color and protrudes above the skin surface. 
The capillary type is red. 
These lesions can be seen in numerous conditions such as collagen vascular diseases, post-trauma, after sun damage or radiodermatitis. 
Most often they are present in the upper part of the body. 
There are four clinical types: simple or linear, arborizing, spider and popular. 
Entities in which telangiectasias are the main pathologic process are: unilateral nevoid telangiectasia, generalized essential telangiectasia, hereditary benign telangiectasia and cutaneous collagenous vascular diseases.
It has been shown that a red telangiectasia has a higher concentration of oxygenated hemoglobin while a blue venulectasia has a higher concentration of deoxygenated hemoglobin. 
Most telangiectases tend to become darker and larger with advancing age, due to the progressive vessel ectasia.
Cherry angiomas are often present in the trunk during adulthood. 
They are small red papules which do not change color on compression. 
They consist of dilated capillary blood vessels located within the superficial dermis.
Spider angiomas are present in about 10–15% of adults and children. 
They are predominantly located on the face, neck and upper trunk. 
Pregnant women or patients with liver diseases have a higher incidence of these lesions. 
Spider angiomas have a main vessel located in an arteriola, from where the blood flows to the peripheral capillaries. 
They have a central slightly elevated red punctum from which the blood vessels radiate (“spider legs”).
Rosacea is a chronic inflammatory eruption of the flushing areas of the face. 
In a histological study it was found that deranged connective tissue is secondary to damaged capillaries. 
The primary cause of the damage seems to be the environment, mainly the sun. 
Most often the lesion involves the nose and cheeks. 
In the mild form, it appears as slight flushing of the area but, as the process becomes more severe, the lesions are deeper (red-purple) with dilated superficial capillaries. 
In severe cases, pustules may develop.
Piogenic granuloma is an acquired vascular lesion, usually solitary and bright red colored. 
The lesion is considered to be a hyperplastic process. 
It grows rapidly, especially in places of trauma and can easily bleed. 
Cutaneous lesions are most often encountered but mucosal location is not rare.
Venous malformations are easily recognized due to their blue hue appearance and are easily compressible. 
Small venous malformations have a good response to IPL treatment.
Leg veins are caused by gravitational dilatation, reflux and incompetent valves. 
These veins are connected to larger reticular or a varicose “feeding” vein. 
Their structure is similar to telangiectasias or venous lakes. 
They have a thicker adventitia and increased basal lamina when compared to facial veins.
Venous lakes most often appear in the fourth or fifth decade of life. 
They are commonly located on the face, neck and oral mucosa. 
With time they tend to enlarge and may bleed. 
They are venous ectasia.
Scar telangiectasias.
Frequently, hypertrophic or keloid scars have telangiectasias on their surface. 
This is a result of neovascularization initiated by angiogenic stimuli. 
As the scar matures, the angiogenesis decreases. 
Sometimes the scar has a red color for a longer period of time due to persistence of stimuli or delayed regression of capillaries.
The vascular lesions that most benefit from IPL treatment are: hemangiomas, PWS, angiomas, telangiectasias, leg veins, rosacea and Poikiloderma of Civatte. 
Angiofibroma, cutaneous lesions of Kaposi sarcoma, Blue Rubber Nevus syndrome, hereditary hemorrhagic telangiectasias and stria distensia may also have some benefit.
The IPL system acts on the principle of selective photothermolysis and has proved to be useful in treating many vascular lesions. 
The main chromophores are oxyhemoglobin and deoxyhemoglobin. 
Superficial red vascular lesions have a high amount of oxyhemoglobin. 
The wavelength absorption peaks of oxyhemoglobin are: 418, 542 and 577 nm. 
Deoxyhemoglobin is predominantly located in deeper vascular lesions and mainly in the lower extremities. 
It has an absorption spectrum in the 600–750 nm range. 
However, oxyhemoglobin and deoxyhemoglobin are not the only chromophores present in the skin. 
The light absorption by the melanin causes some limitations in penetration depth. 
The “perfect” wavelength of different lasers used in the past (e.g., Argon 577 nm) were recently replaced by other lasers (e.g., Pulse dye, Alexandrite, 1,064 nm Nd:Yag) or IPL devices. 
Based on a mathematical model, Ross concluded that, with an optimal set of parameters, IPL devices and lasers are comparable in the treatment of vascular and pigmented lesions regarding the efficiency and safety. 
However, unlike lasers, IPL devices have a wide spectrum of wavelengths with different depth penetration, different absorption by the skin and more complex tissue response.
The pulse duration should be shorter than the TRT of the chromophore in order to preferentially protect the surrounding tissue from heat damage. 
The long delay between pulses and the long pulse durations offer enough cooling of the epidermis and small vessels without a significant decrease in temperature for large vessels. 
As a consequence, high fluences can be applied for heating large vessels without injuring the epidermis. 
For a vessel of 0.1 mm diameter, the TRT is about 4 ms, and for a 0.3 mm vessel the TRT is about 10 ms. 
This shows that larger vessels cool more slowly than epidermis for a single pulse. 
For these vessels, multiple pulses are preferred (longer than 10 ms).
Baumler elaborated a mathematical model for investigating the effect of IPL on blood vessels of 60, 150, 300 and 500 ?m. 
The two extremities of the IPL spectrum (near infrared and near visible range) were studied. 
Both provided homogenous heating of the blood vessels. 
Small vessels (<60 ?m) had only a moderate increase in temperature. 
The effective time interval to raise the temperature in larger vessels (>60 ?m) was shorter than the pulse duration. 
Effective coagulation was difficult to achieve at the bottom area of the vessels. 
This can explain the refractory of some lesions to treatment. 
It was postulated that coagulation of the blood occurs at temperatures higher than 70°C.
The initial consultation should establish the correct diagnosis of the vascular lesion. 
In case of a vascular malformation, parental education about the lesion, treatment options and possible results should be addressed. 
The need for intravenous sedation or general anesthesia for multiple treatments should also be emphasized. 
We always refer a child with a vascular malformation to a pediatric consultation. 
The possibility of associated abnormalities including neurological disorders should be ruled out first. 
In certain conditions, such as Sturge-Weber syndrome, patients may have seizures. 
Because the epilepsy can be initiated by the intense light, it is our protocol not to perform treatment in these situations unless an informed release from the neurologist is obtained. 
Patients with PWS distribution to the lower limbs should be evaluated for underlying Klippel Trenaunay syndrome. 
Patients with a history of oral conceptive use, pregnancy, recent thrombophlebitis, or lower extremities venous insufficiency are not good candidates for IPL treatment, and we refrain from performing it in any of these circumstances. 
Patients who are tanned, have a history of keloids or post inflammatory hyperpigmentation are also not good candidates for treatment. 
Although there are authors who recommend bleaching agents prior to treatment, we prefer delaying treatment for 4–6 weeks.
In most cases, the treatment of vascular lesions is mainly cosmetic. 
Only when the lesion interferes with the functioning of an organ (eye, mouth) does the IPL treatment have a functional correction component. 
It is important to correctly diagnose the vascular lesion and evaluate the suitability of the patient for IPL treatment. 
Special attention should be paid to patients with unrealistic expectations. 
They are not good candidates for IPL treatment. 
The success rate can also be affected by previous treatments, such as intralesional steroid injection for hemangiomas or previous irradiation. 
These produce fibrotic changes which make the lesion more resistant to treatment. 
Some patients have undergone previous treatments with lasers and have pigmentary alterations or scarring at the time of examination. 
These side effects should be mentioned and noted in the patient’s record, explaining that this may alter the efficacy of treatment in that area. 
There is no clear definition of when to start treating PWS lesions. 
We prefer starting treatment early in childhood when they are smaller and more superficially located. 
With age, they become thicker, darker and harder to treat.
Local anesthetics that produce vasoconstriction are to be avoided in order to enhance to the maximum the light distribution to the chromophores. 
In children, intravenous sedation or general anesthesia is employed. 
Most of the time, teleangiectasias and superficial reticular leg veins can be treated without anesthetics. 
We prefer to use only ELA-Max as a local anesthetic as it causes minimal vasoconstriction. 
Other factors that induce vasoconstriction, such as decreased room temperature, should be avoided prior to treatment. 
After entering into the IPL device the patient’s skin type and lesion type, the computer automatically selects the wavelength, pulse duration, delay and fluence. 
These parameters can be further adjusted from treatment to treatment. 
Sometimes it is difficult to categorize a certain lesion in a category (e.g., PWS can be superficial, medium or deep). 
Treatment parameters need to be adjusted to the clinical response. 
For superficial lesions, the transparent gel to use should not be cold to avoid vasospasm. 
Most IPL devices are equipped with a cooling facility to decrease the epidermal temperature during treatment. 
Applying cooling on small superficial vascular lesions may cause vasoconstriction and result in a less beneficial therapeutic effect. 
We do not use cooling in these situations but always use it immediately after treatment. 
The immediate appearance of local bruisingor a bluish aspect is a sign of a good clinical response to the treatment. 
Perilesional erythema, blanching or “urticariform” reactionor vein thrombosis are also signs of good response for linear vessels. 
When performing the treatment, the hand piece is placed in contact with the transparent gel without any pressure. 
Even small pressure can empty the vessels by diverting the blood into collaterals and causing the treatment to be less effective. 
Care is taken to avoid overlapping the treated areas. 
Larger spot sizes have deeper penetration into the lesion with a better response. 
The usual treatment interval is 4–6 weeks. 
Avoiding sun exposure between treatments is important. 
There is no restriction to using make-up immediately after treatment.
To be efficient in treating vascular lesions, the IPL device should produce a wavelength having the best absorption by the target (oxyhemoglobin, deoxyhemoglobin), have the ability to reach the depth of the blood vessels, produce enough energy to damage the vessels with limited harm to the surrounding tissue, and enough exposure to coagulate the vessel. 
Pulses that are shorter than the TRT of a vessel will not produce enough heating of the vessel to be therapeutically effective. 
On the other hand, excessively long pulse durations produce heat diffusion to the surrounding tissues. 
Patients with superficial vascular lesions, such as teleangiectasias, require a few treatments (usually up to three) to achieve result. 
Other lesions, such as PWS and hemangiomas, require many more treatments, often more than ten to achieve the desired result. 
The treatment period will take more than a year, and this should be emphasized to the patient before starting treatment. 
Larger and deeper vessels require higher fluences and usually have a poor result.
IPL devices with a wide range of wavelengths (500– 1200 nm) by using different cutoff filters are able to eliminate shorter wavelengths and allow deeper dermal penetration. 
By selecting multiple pulses and longer pulse durations, more heating is produced which is important for the treatment of large caliber vessels.
The literature is limited in describing the treatment of hem angiomas with IPL. 
Therapeutic tools for hemangiomas include pulsed light devices, pulse dye lasers, Nd:Yag lasers and other methods such as cryotherapy and local or systemic steroid injections. 
Although there is a debate between the “wait and see” strategy and the active method, there is no question about treating hemangiomas with functional and structural impairment. 
Some authors strongly recommend treating the hemangiomas at the very early stage (macular stain) in order to stop their growth. 
Treatment may be useful even during the active proliferative phase (month 3–9), when they show ulceration and bleeding. 
Two cases of ulcerated hemangiomas were treated by Jorge. 
Good results were obtained after two to four sessions. 
Complete epithelization was obtained at between 1 and 2 months.
Less efficient is treatment performed during the involution phase due to the altered fibrofatty structure. 
It is our belief that superficial hemangiomas, especially in the proliferative phase of growth, respond better to treatment. 
It is for this reason that we prefer to treat these lesions as soon as possible. 
For deep hemangiomas, IPL treatment alone is not effective. 
In this situation, we combine IPL, Nd:Yag laser and intralesional steroid injections.
The results of PWS treatment with IPL are various as reported in the literature. 
Most PWS lesions are located in the head and neck. 
These lesions do not regress over time and usually hypertrophy in adulthood, making treatment more difficult. 
Twentytwo patients with PWS were treated by Ho, five to seven times, using cutoff filters of 550, 570, and 590 nm and fluences from 35 to 75 J/cm2. 
Most patients (81.8%) obtained little to moderate improvement. 
Little improvement was also reported by Reynolds, who treated 12 subjects with IPL (Lumina device). 
At fluences lower than 26 J/cm2, there was no clinical response. 
The patients who failed to show any response had pink PWS. 
According to the author, the darker the PWS, the better the fading that was seen. 
Moderate improvement was reported in 47% of the patients treated by Ozdemir with IPL (Lumina, Lynton). 
Complete clearing was seen in only one patient of 12.
On a small number of patients with mature PWS treated with a 515 nm cutoff filter and fluences from 25 to 30 J/cm2, Cliff reported at least 50% improvement after three treatments. 
Some of the patients with PWS had previous laser treatment. 
Bjerring reported the results in a series of 15 patients with PWS resistant to PDL. 
After four treatments, about half the patients obtained clinical clearance. 
Eight patients had less than 25% clearance after IPL treatment. 
In these cases, the PWS was located in the central part of the face (second branch of the fifth cranial nerve).
It seems that the lesions in this area are more resistant to treatment. 
It was reported by the patients that IPL was less painful than PDL treatment. 
Raulin successfully treated with IPL a PWS resistant to PDL. 
Dealing with previously treated PWS is difficult because the lesions usually have hypertrophic scarring and skin textural changes. 
Higher energies are required to be efficient and the results cannot be anticipated.
Some PWS lesions or congenital vascular malformations may be resistant to therapy (Verkruysse et al. 2008). 
It seems that the depth and heterogeneity of lesions causes an unpredictable response. 
The deeper and smaller the capillary malformation, the more heterogenous, the harder to treat. 
It is believed that vessels smaller than 50 ?m are less suitable for treatment due to insufficient intravascular heat generation. 
The need to predict the results of treatment was behind the drive to find a device suitable for this task. 
Pulsed photothermal radiometry is a noncontact technique by which the skin is exposed to laser light. 
The temporal evaluation of the surface radiometric temperature is evaluated with an infrared detector. 
The laser light being absorbed by the lesion chromophores causes a spatial distribution of temperature. 
Although promising results have been reported, as with any diagnostic tool, it is recommended to have a realistic overview of its accuracy.
There are some reasons why PWS are resistant to treatment: inadequate depth of light penetration (most PDL have up to 1 mm penetration), inadequate conduction of heating from the chromophore to the vessel wall, inadequate blood volume (small diameter capillaries do not have enough hemoglobin) and inadequate fluence entering the capillary.
Capillary malformations on the limbs have a poor response to laser treatment compared to those located on the head and neck. 
There is little evidence to explain this phenomenon. 
However, it was proved that cutaneous blood flow of the lesions situated in the head and neck increased with the ambient temperature, unlike those present on the limbs. 
Those observations might suggest a reason for the better response of capillary malformations of the head and neck to light and laser therapy.
Pink PWS are more difficult to lighten than mature red PWS. 
Deep and nodular PWS are more resistant to treatment. 
Photodynamic therapy has also been used for treating PWS. 
The principle is to add an exogenous chromophore into the capillaries, either transcutaneous or systemically. 
Most chromophores used have porphyrin precursors. 
Porphyrins have a wide spectrum of absorption with large peaks in the blue and red spectrum and a smaller peak in the yellow range. 
The light acting on the capillaries generates a photochemical reaction. 
It was reported that capillary destruction is more efficient in this way.
The flashlamp PDL has been proved to be effective for facial vascular lesions, including telangiectasias. 
However, significant side effects have been reported, such as pronounced purpura and changes in pigmentation. 
Angermeier reported his experience in treating the following facial vascular lesions: 79 telangiectasias, 74 rosaceas and 45 hemangiomas. 
Facial telangiectasia was treated with double pulse, 550 nm cutoff filter and fluences of 36–45 J/cm2. 
Most patients required single or double treatments in order to achieve 75–100% clearance. 
Less aggressive parameters were correlated with a higher number of treatments.
One of the largest studies on facial telangiectasia treatment with IPL was reported by Clementoni. 
He evaluated 518 consecutive patients who had between one to nine treatments (average 1.6). 
Large facial veins were treated with triple pulses, 590 cutoff filter and a fluence rate of 50–56 J/cm2. 
Fine lesions were treated with double pulses, 570 nm cutoff filter and 40–43 J/cm2. 
Significant clearance (75–100%) was obtained in 87.6% of patients. 
In a different study, the same author evaluated the results after treating 1,000 consecutive patients with facial telangiectasias. 
89.7% had a clearance rate of 75–100%; 23.8% had lesion clearance after a single treatment, while 45.2% required two treatments to achieve the same result. 
According to the author, there was no correlation between the skin type and the clearance rate, but the result was influenced by the operator experience.
Other authors reported good results for telangiectasia. 
Raulin reported on the treatment of essential telangiectasia and Poikiloderma of Civatte with IPL. 
Ten of fourteen patients showed excellent results and three had good results. 
The single treatment of lower extremity telangiectasias is not enough, according to Green. 
Only 10% of lesions had complete clearing. 
The study was performed at the beginning of the IPL era. 
The same study showed a 21% scarring rate, which was not even close to the complication rate in other studies.
Among facial or leg telangiectasias, spider nevi, erythrosis interfollicularis and senile angioma treated with IPL, the highest clearance (90%) was observed for facial telangiectasias and erythrosis interfollicularis. 
Facial telangiectasia is easier to treat than leg veins. 
The forehead location when associated with rosacea had the best clearance (87%), as reported by Schroeter. 
According to Goldman, bright red lesions are better treated with 515 and 590 nm filters and blue lesions with 590 nm or higher filters.
Leg veins with different diameters respond differently. 
Most IPL studies were done on leg veins having a less than 3 mm diameter. 
The larger the vein, the lesser the response to treatment. 
Sclerotherapy is known to be effective in the treatment of vascular lesions located on the legs. 
However, some patients are fearful of needles, and there are patients with superficial vessels smaller than the diameter of a 30 gauge needle or are resistant to sclerotherapy and who would benefit from light or laser treatment. 
The pulse duration should mach the diameter of the vascular lesion and be about the same as the thermal relaxation time for the lesion diameter. 
If the pulse duration is too short, the heating will be located mainly in the upper part of the skin and might not reach deep lesions. 
Unlike PDL, the IPL system has the advantage of using longer pulses. 
In order to destroy blood vessels larger than 100 ?m in diameter, it has been calculated that the pulse duration should be in the 3–10 ms range Goldman reported 94% clearance of leg veins for more than 50% of his patients, and 79% had a high rate of clearance (75– 100%). 
The treated lesions and parameters used were as following: leg veins <0.4 mm: 550 nm cutoff filter and 50 ms delay; leg veins between 0.4–1 mm: 570 nm cutoff filter and 50–100 ms delay; leg veins between 1–3 mm: 590 nm cutoff filter and 150 ms delay. 
In all the lesions, the least responsive to treatment were leg veins with a 1–3 mm diameter. 
Shorter wavelengths (500–600 nm) are preferred for treating class I superficial red telangiectasias, while longer wavelengths (>750 nm) are effective for class II–III, deeper blue reticular veins. 
Superficial and small sized vessels are best treated with longer pulses. 
Triple pulses and higher fluences are also preferred.
Using a dual wavelength approach, Sadick obtained a 75–100% clearance of leg veins in 80% of patients. 
An average of 2.5 treatments were needed, using 550 nm (Photoderm) and 1,064 nm (Vasculight). 
The short wavelength was addressed to the red vascular lesions and the long wavelength was addressed to the blue vascular lesions. 
The overall satisfaction level was reported to be 76%. 
When leg veins do not respond well to IPL or have a deeper location or larger caliber, Nd:Yag laser can be of real benefit. 
Some IPL platforms are also equipped with Nd:Yag laser.
The results of treating Poikiloderma of Civatte and rosacea were presented in Chapter 6 (Skin rejuvenation). 
Treatment of tufted angioma is usually unsatisfactory. 
However, Chiu reported a case of tufted angioma that was successfully treated with IPL. 
Four treatments were performed at 3–4 weeks intervals. 
The fluence used was 40 J/cm2 with a 560 nm cutoff filter. 
Facial and neck erythrosis were treated by Terracina with IPL.
Complete clearance was obtained in 24 patients while another two had some improvement. 
When treating venous malformations with IPL, Raulin was able to obtain a 70–100% clearance in eight malformations smaller than 100 cm2. 
Three malformations larger than 100 cm2 needed more treatments (up to 18 sessions). 
A 590 nm cutoff filter and an average 80.4 J/cm2 were most often used parameters. 
Small venous malformations have a good response to IPL. 
Large lesions require sclerotherapy, embolization or surgical excision. 
Lym phatic malformations, and deep venous or venolymphatic lesions do not respond well to IPL treatment. 
We do not perform IPL treatment in these conditions.
Striae distensae on 15 women was treated by Hernandez-Perez by IPL. 
After five treatments spaced at 2 weeks intervals, a decrease in the number of striae from 117 to 94 was noted. 
Microscopic changes were found. 
Improvement of elastosis, edema and atrophy was reported. 
Inflammation and collagen fiber quality were also improved. 
From all parameters, the dermal thickness had the best improvement. 
We refrain from treating striae with IPL.
Red scars, and hypertrophic or keloid scars which often contain telangiectasias may benefit from IPL treatment. 
The concept is to reduce the number of containing blood vessels (neocapillaries) which can stop the growing process and improve the color. 
Bellew compared in a side-by-side manner the effect of PDL and IPL on hypertrophic scars after breast reduction and mastopexy. 
After two treatments, improvement was obtained in both groups with no significant differences between them. 
Erol treated with IPL 109 patients with hypertrophic scars after surgeries, trauma, acne and burns. 
Five patients had keloids. 
The average number of treatments was eight and they were performed at 2–4 weeks intervals. 
Overall clinical improvement was found in 92.5% of the patients, while 65% had good to excellent results.
Acne vulgaris is frequently encountered in young people. 
Several factors have been incriminated in its pathogenesis including; abnormal desquamation of the follicular keratinocytes and presence of bacterial infection caused mainly by Propionebacterium acnes. 
Acne scarring is produced by the destruction of the collagen fibers and subsequent fibrosis formation. 
Increased sebum production and inflammatory response are considered to be the main cause of the disease. 
The most vulnerable lesions for the IPL treatments are the red macules as reported by Chang. 
A side-by-side study was performed by Rojanamatin who compared the effect of the IPL alone or in combination with the ALA on inflammatory facial acne vulgaris. 
Although reduction in the number of acnea lesions was present on both sides, the combined ALA and IPL treatments had better results after three sessions compared to IPL alone. 
Several other authors reported good results using IPL-ALA for the management of acne vulgaris. 
Pretreatment of acne lesions with methyl aminolevulinate is also postulated to respond better than the IPL alone. 
On an evidence-based review of lasers and lights, Haeders - dal found that photodyna - mic therapy is superior to other methods for acnea treatment.
Inflammatory lesions are responding better than non-inflammatory lesions. 
It should be emphasized that Acne vulgaris responds well to systemic therapy using antibiotics and retinoids. 
The photodynamic therapy is a good alternative for the treatment of resistant cases of acnea or for patients who refuse to take systemic retinoids.
There is scant literature comparing the effect of IPL and laser on the same vascular lesions. 
A comparison of different devices - PDL, Alexandrite, KTP, Nd:Yag and IPL - on previously treated capillary malformations was made by McGill. 
The study was performed on 18 patients and the results were evaluated by videomicroscopy and color measurements. 
Four patients failed to respond to any technology. 
The Alexandrite laser had the largest mean improvement in color but it was associated with more complications (scarring and pigmentation) than the others. 
The IPL was better than KTP and Nd:Yag laser. 
On a split treatment of patients with dyschromia (vascular and pigmented lesion), it was found that KTP laser and IPL achieved marked improvement. 
At 1-month post-treatment, patient evaluation showed a 65.5% improvement for IPL and 60.8% for KTP laser. 
The KTP laser caused slightly more discomfort.
One of the challenges is treating vascular lesions in dark skinned patients. 
When the lesions are deep, the chance of success is minimal. 
On one side, skin with a high amount of melanin needs to be protected, but on the other side, low fluences or changes in pulse duration and delay reduce the efficacy of treatment. 
These patients have the highest risk of pigmentary alterations. 
Higher fluences are needed to produce similar effects in dark skinned patients but it should be used cautiously so as not to injure the epidermis. 
Longer pulse durations and longer pulse delays are preferred. 
Large footprints are preferred for large lesions for a more uniform light distribution. 
A decrease in the fluence by 10–20% is recommended when treating areas prone to scarring, such as the anterior chest.
There are very few studies on psychological scoring before and after treatment of vascular lesions. 
The psychological distress was significantly reduced after treatment of less severe facial vascular lesions (telangiectasia, spider vein, cherry angioma). 
Patient satisfaction after PWS treatment is rarely reported in the literature. 
Hansen carried out a satisfaction survey for these patients and found that most noted little or no change in texture or dimension after PDL treatments, although 62% had color improvement. 
Most patients were satisfied or neutral with regard to satisfaction with therapy. 
Men were more likely to be dissatisfied. 
Fodor reported that 72% of patients treated with IPL considered the results as mild to excellent. 
In the same study, when comparing side-by-side with Nd:Yag for the same lesion, higher satisfaction was reported by the patients for the laser treatment area. 
However, this was more painful than IPL. 
There are hybrid devices that combine the IPL and Nd:Yag laser treatment for a better result and a higher level of satisfaction.
Superficial red vascular lesions have a high amount of oxyhemoglobin.
Deoxyhemoglobin is predominantly located in deeper vascular lesions and mainly in the lower extremities.
The initial consultation should establish the correct diagnosis of the vascular lesion.
Do not hesitate to refer a child with vascular malformations (especially of the head) to a pediatrician for a thorough check-up. 
Associated abnormalities including neurological disorders are sometimes present.
The need for multiple treatments should be emphasized to the patient. In children, there is need for sedation or general anesthesia.
The pulse duration should be shorter than the TRT of the chromophore to preferentially protect the surrounding tissue from heat damage.
The success rate of the treatment can be altered by previous other treatments which produce fibrotic changes. 
Any factor that produces vasoconstriction should be avoided prior to treatment. 
The immediate occurrence of local bruising, a bluish aspect, perilesional erythema, blanching or “urticariform” reaction are signs of a good clinical response. 
No pressure should be placed on the hand piece during treatment. 
During the involution phase of hemangioma, treatment is less effective. 
For deep hemangiomas, IPL treatment alone is not effective. 
Capillary malformations on the limbs have less response to treatment compared to those on the head and neck. 
Deep and nodular PWS are more resistant to treatment. 
Most cherry angiomas and telangiectasias have excellent results from IPL treatment. 
Facial telangiectasia is more responsive to treatment when compared to leg veins. 
Superficial and small sized leg veins are best treated with shorter pulses. 
Deeper and large size vessels are best treated with longer pulses. 
In dark skinned patients, longer pulse durations and longer pulse delays are preferable.
As with any other medical technology, side effects and complications can occur after IPL treatment. 
Some complications can be prevented by knowing the principles of therapy and treatment strategies, and from having experience with the device. 
The complications caused by IPL treatments may be divided into two groups: those which are due to errors in handling of the device and those which are patient dependent. 
Improper training of operators and insufficient experience may lead to undesirable results. 
Not infrequently there are “profit motivated “cosmetic centers” where IPL technology is used by people with minimal training and background. 
The second type of complication which is related to the patient’s skin reactivity is harder to be anticipated. 
The major complications are permanent pigmentary changes, hair stimulation, paradoxical effect, leukotrichia, uveitis and iritis and scarring. 
The minor complications are erythema and purpura which last more than three days, blisters, temporary pigmentary changes and temporary hair discoloration.
As with any other medical technology, side effects and complications can occur after IPL treatment. 
Some complications can be prevented by knowing the principles of therapy and treatment strategies, and from having experience with the device. 
The following side effects and complications are the most often encountered after IPL treatments:
? Erythema, characterized by redness that usually appears a few minutes after the treatment, which may last for a variable period of time. 
It is the most common reaction after this treatment. 
? Edema is characterized by local swelling which appears within minutes after the treatment and usually is discrete. 
It is more visible in areas with lax connective tissue, such as the eyelids, and it subsides in a few days.
? Purpura/bruising is the appearance of a bluish discoloration in the treatment area. 
It turns yellow within days, as the hemoglobin metabolizes. 
It may take a few days up to 2 weeks until it disappears. 
? Hematoma is caused by a small amount of blood that accumulates in the subcutaneous tissue. 
It is a rare phenomenon, but may occur when treating vascular lesions, especially leg veins. 
It is self limited and takes days to weeks to resorb. 
? Blisters are the consequence of the accumulation of clear fluids at the dermo-epidermal level or within the dermis. 
? Crusts are the brown scaling tissues which may easily peel off from healthy skin. 
? Infection is characterized by redness, increasing local pain and edema, with or without fever. 
Reactivation of herpes simplex infection can be encountered in some patients. 
? Hyperpigmentation is a darkening of the skin, usually transitory, fading spontaneously within a few months. 
Patients with darker skin are more prone to this reaction. 
? Paradoxical effect is defined as growing of new fine hair in the proximity of the treated area. 
? Leukotrichia represents the growth of white hair following IPL treatment. 
This phenomenon is explained by the difference in thermal relaxation time of the melanocytes and the germinative cells. 
It can be temporary or permanent (Radmanesh et al. 2002). 
? Temporary hair discoloration is a very rare phenomenon and refers to a yellow appearance of black hair after IPL treatment. 
? Scarring is also a rare complication after IPL treatment. 
Although an exact explanation is not yet available, post-treatment blisters, infection or high energies may lead to scar healing.
The complications caused by IPL treatments may be divided into two groups: those which are due to errors in handling of the device and those which are patient-dependent. 
Improper training of operators and insufficient experience may lead to undesirable results. 
Not infrequently there are “profit motivated “cosmetic centers” where IPL technology is used by people with minimal training and background. 
Complications like the “zebra” appearance can easily be avoided by proper training of personnel. 
The second type of complication which is related to the patients’ skin reactivity is harder to be anticipated. 
It is obvious that patients with darker skin should be treated more cautiously. 
Another measure that should be adopted is readjusting the parameters of the device according to the response during the previous treatment.
Patient-related complications may also be subdivided into major and minor complications.
Most of the major complications may appear within weeks from the treatment and include: 
Permanent pigmentary changes. 
The incidence of pigmentary changes varies widely in the literature. 
These studies were not performed under standardized conditions and many parameters differ from one study to another. 
Most commonly, hyperpigmentation is caused by vessels destruction and, hence, hemosiderin deposits within the dermis. 
Dark-skinned patients are more prone to pigmentary changes; it seems that their melanocytes are more reactive to the heating stimulation.
Hair growing stimulation following IPL and laser treatment has been reported in 10.5% of patients coming for epilation. 
This phenomenon was mainly observed in areas with fine hair, such as the face and neck. 
The new growing hair appears to be thicker and darker. 
This reaction has also been reported to be induced when the IPL was used for the treatment of vascular lesions or tattoo removal.
Paradoxical effect. 
The exact cause of this phenomenon is not known but it is believed that the light energy activates the dormant hair follicles. 
The incidence of this very unpleasant side effect was reported to be up to 10.2% in one study. 
It seems that hormonal imbalance has an influence.
Leukotrichia: the incidence of this complication is reported to be up to 3.5% in patients treated with IPL for hair removal; 31% of the patients have this condition temporarily and return to their previous color within a few months.
Uveitis and iritis can be induced by treating lesions on the eyelids, or by avoiding the use of eye protection. 
It is more often encountered after long wavelength applications. 
Iris melanin absorption seems to be responsible for this effect. 
The treatment might be performed under the supervision of an ophthalmologist.
Scarring is seldom reported in the literature. 
There is only one study on dealing with telangiectases removal from the lower extremities which reported a 21% incidence of scarring. 
This study was performed in the beginning of the IPL era and newer literature fails to report such a high incidence of this annoying complication. 
The same study reported a 50% rate of hyperpigmentation which is much higher than other reports on this complication.
Most of the minor complications occur within minutes to days after the completion of the treatment. 
Pain or local discomfort during treatment is not considered to be a complication and depends on the pain threshold of each patient. 
It can be easily lowered by using local anesthetics.
Erythema and purpura: Some articles mention redness and purpura as side-effects. 
We prefer to consider them as side effects only when they persist for more than 3 days. 
Otherwise, it is a normal skin response to the IPL energy; purpura, or minimal bruising which are described as “urticariform” reactions, may be considered as signs of the effectiveness of treatment. 
Those signs are seen immediately during the treatment mainly after treating vascular lesions. 
Erythema and perifollicular edema are the most common side effects after hair removal. 
A shorter pulse duration has a higher risk of epidermal injury. 
Purpura is rarely encountered, and it is scattered and associated with short pulse duration.
Blisters: Studies have demonstrated the presence of subepidermal necrosis in areas of blistering induced by lasers. 
These histological findings are similar to those observed in burns.
Temporary pigmentary changes. 
The occurrence of hypopigmentation after IPL or laser treatment seems to be related to the suppression of melanogenesis and is not due to melanocytes destruction. 
This might explain the temporary character of the hypopigmentation. 
The mechanism of hyperpigmentation was described above. 
Often, this side effect is transitory and disappears once the hemoglobin and the hemosiderin are metabolized.
Temporary hair discoloration.
Only one case of temporary yellow discoloration of the hair after IPL treatment has been reported. 
The growing proximal part of the hair was yellow, which makes it difficult to differentiate from the distal hair bleaching induced by sun exposure. 
A decrease in eumelanin production and an increase in the pheomelanin amount seems to explain this result.
Other complications. 
Temporary alopecia is the result of IPL treatment in hair bearing areas.
With modern IPL devices, the incidence of side effects and complications is reduced. 
It is always better to be cautious and recognize those patients who are prone to develop complications. 
Dark skinned patients and those with a history of complications after IPL treatment belong in this category. 
Careful adjustments of the IPL parameters should be made, and this was described in previous chapters.
Most often, the erythema and the edema are selflimited to hours or days. 
In patients with a history of prolonged edema, topical steroid creams help to make the recovery shorter. 
The crusts after pigmentary lesions treatment or after blisters tend to peel off. 
Usually, there is no need for a topical moistener to hasten the process.
In the presence of perilesional erythema or oozing, we recommend topical antibiotics.
Antiviral prophylactic treatment is prescribed for patients with a past history of herpes. 
Treatment of the new hair growth is not easy but shorter cutoff filter may improve the result. 
Treatment of scars caused by the IPL is not well defined. 
Usually these scars are slightly depressed and hypopigmented. 
CO2 lasers, dermabrasion or chemical peelings can help to make the skin color uniform and improve the aesthetic result.
The “zebra” appearance is due to poor footprint application when overlapping is avoided and strips of untreated area are seen between the treated areas. 
This unpleasant appearance can be improved by treating the previous sparse area. 
The size of the footprint should be adjusted to match the area.
In the presence of complications, extending the time intervals between the treatments is recommended, to allow skin recovery. 
There are no clear recommendations in the literature for the optimal time interval to the next treatment after the occurrence of any complication event. 
We postpone the next treatment for a few weeks. 
The fluence and pulse delay are also adjusted to reduce the energy inflicted on the skin. 
More details can be found in previous chapters. 
The cooling methods and avoidance of sun exposure before and after treatment are important to avoiding side effects.
Practical Points There are two types of complications: one which is due to errors in handling of the device and another which is patient-related. 
The major complications are permanent pigmen- ? tary changes, hair stimulation, paradoxical effect, leukotrichia, uveitis and iritis and scarring. 
The minor complications are erythema and purpura which last more than 3 days, blisters, temporary pigmentary changes and temporary hair discoloration. 
Purpura, minimal bruising or “urticariform” reaction are signs of effective vascular lesions.
Dark skinned patients are more prone to suffer from side effects. 
In the presence of complications, the treatment parameters need to be adjusted.
The eyelids are highly specialized structures with peculiar anatomic components.
The ocular globes are allocated in two symmetrically bony cavities called orbits, consisting of seven bones that develop the orbital walls.
The roof is composed mostly of the orbital plate of the frontal bone and posteriorly of a minor part of the sphenoid bone.
The lateral wall comprises the orbital surface of the zygomatic bone and the sphenoid bone.
The floor is composed of the orbital plate of the max- illa anterolaterally of the zygomatic bone and pos- teriorly of the palatine bone.
The medial wall consists of the ethmoid, frontal, lacrimal, and sphenoid bone.
The der- mis contains elastic fibers, blood vessels, lym- phatics, and nerves.
The underlying fat is scant or not present in the subcutaneous tissue, where the hair follicles and pilosebaceous glands are located.
The apocrine glands of Moll are located near the lid margin, and the sebaceous glands of Zeiss are associated with the follicles of the eye- lashes.
The eyelids function to protect the eye globe from local and external injuries.
Furthermore, they regulate the light that reaches the eye and uniformly distribute the tear film, mucus, and oil during blinking, of great impor- tance for the health of the cornea.
The eyelids are divided into upper and lower eyelids, which are similar but with different characteristics mainly in the lid retractor arrangement.
The space between the open lids is known as the palpebral fissure, which measures 7–12 mm, while the normal excursion of the lids is 14–17 mm.
In the normal adult fissure, the highest point of the upper lid is just nasal to the center of the pupil, while the low- est point of the lower lid is just temporal to the center of the pupil.
In youths, the upper lid margin rests at the upper limbus, whereas in adults it rests 1.5 mm below the limbus.
The lower eyelid mar- gin rests at the level of the lower limbus.
The lateral canthal angle is 2 mm higher than the medial canthal angle in Europeans, but is 3 mm higher in Asians.
The distance from the medial canthus to the midline of the nose is approximately 15 mm.
The lateral canthus lies directly over the sclera, and the medial canthus is separated from the eye by the lacrimal lake and caruncle, a yellowish tis- sue containing sebaceous and sweat glands.
The lid margins are 2 mm wide and form the junction between the skin and the conjunctiva, the mucous membrane of the lids.
They meet at the gray line, near the posterior edge of the lid margin, the junc- tion of the anterior and posterior lamellae of the lids.
The eyelashes are located anteriorly and the openings of the meibomian glands posteriorly.
There are approximately 100–150 eyelashes on the upper lid and about 50–75 on the lower.
The follicular structure of eyelashes includes the 2 sebaceous (Zeiss) and sweat (Moll) glands, while the tarsal glands (Meibomian) open posteriorly to the lid margin.
The tears that appear at the tips of the small papillae are drained from the surface of the eyes through the openings by a pump mechanism.
The lacrimal secretory system con- trols the amount of tears and is divided into the basic and reflex secretors.
The basic secretor is composed of three sets of glands. (1) Conjunctival, tarsal, and limbal mucin-secreting goblet cells; the overlying aqueous layer is spread more uni- formly because of this inner layer (precorneal tear film). (2) The accessory lacrimal exocrine glands of Krause and Wolfring, located in the subcon- junctival tissue. (3) The oil-producing Meibomian glands and the palpebral glands of Zeiss and Moll.
The reflex secretor is divided into two parts by the lateral horn of the levator palpebrae superioris.
The first fold of the upper eyelid is represented by the superior palpebral sulcus, 9–10 mm (indi- vidual and racial variations) above the lid margin, and represents the junction of the levator palpe- brae superioris with the orbital septum and the fibrous insertion of the levator aponeurosis into the skin.
There is a thin fascial layer between the skin and the orbicularis oculi muscle, with no fat tissue.
The eyelid normally is located at the supe- rior border of the tarsus, and the skin below the lid is attached to the underlying tarsus with the levator aponeurosis, which has projections ante- riorly through the pretarsal orbicularis to the skin and posteriorly to the inferior portion of the anterior tarsus.
The skin of the upper eyelid is more freely movable because of the lack of supe- rior aponeurotic attachments and underlying orbital septum.
The second layer of the eyelid is the orbicularis oculi muscle, which is divided into orbital and pal- pebral parts that function independently.
The orbital part is a voluntary muscle while the palpe- bral part is both voluntary and involuntary.
The orbital portion extends in a wide, circular fashion around the orbit, interdigitating with other muscles of facial expression.
It has a curved origin from the medial orbital margin, being attached to the super- omedial orbital margin, maxillary process of the frontal bone, medial palpebral ligament, frontal C Rigoni process of the maxilla, and inferomedial orbital margin.
The palpebral portion is further subdi- vided into pretarsal and preseptal portions.
The preseptal orbicularis muscle covers the orbital sep- tum and originates medially from a superficial and deep head associated with the medial palpebral ligament.
The fibers from the upper and lower eye- lid join laterally to form the lateral palpebral raphe, which is attached to the overlying skin.
The pretar- sal portion lies anterior to the tarsus, with a super- ficial and deep head of origin intimately associated with the medial palpebral ligament.
Fibers run horizontally and laterally to extend deep to the lat- eral palpebral raphe, to insert in the lateral orbital tubercle through the intermediary of the lateral canthal tendon.
The peripheral fibers sweep across the eyelid over the orbital margin in a series of concentric loops, the more central ones forming almost complete rings, interdigitating with other muscles of facial expression.
In the upper lid the orbital part extends as far as the forehead, covers the corrugator supercilii muscle, and continues lat- erally over the anterior temporal fascia.
The third layer of the lids in the upper portion is the orbital septum, a fascial membrane that separates the eyelid structures from the deeper orbital structures, and attaches to the orbital mar- gin a thickening called the arcus marginalis, the point of confluence for the facial bone perios- teum and the periorbita.
With age, the septum weakens and bulging of the orbital fat pad becomes visible.
Its removal is important in blepharoplastic surgery.
The fourth layer of the upper lid is the post- septal fat pad, contained within the orbit by the orbital septum.
In the lower lid, the orbital part lies on the origins of the elevator muscles of the upper lip and nasal ala, and continues to cover partially the masseter muscle (Figs. 1.1 and 1.2).
Asians have different periorbital anatomic characteristics, the eyelid being one of the most prominent features of the face.
Moreover, there is also a wide variety of eyelid shapes, mostly with regard to the presence and location of the supra- tarsal fold and/or presence of an epicanthal fold.
The most obvious feature of Oriental eyelids is the absent or very low supratarsal fold with relatively "full"?periorbital tissues.
Only a very small percentage of Orientals have a manifest supratarsal fold.
In fact, at this location in other ethnic groups the levator aponeurosis sends fibers to the overlying skin, anchoring it down to the eyelid, creating the fold.
In Orientals this fusion is scarce, making the supratarsal fold closer to the eyelid edge.
Because the septal-levator fusion is so low on the eyelid, retroseptal fat descends in the fold and creates an impression of a fuller upper eyelid.
A submuscularis fibroadipose tissue layer and a more lowly positioned transverse ligament were recently identified and found exclusively in the Asian eye (Fig. 1.3).
The conjunctiva is a smooth, translucent mucous membrane of stratified columnar epithelium, situated on the inferior surface of the tarsus, from the mucocutaneous junction of the lid margin to the tarsal plate border.
The conjunctiva is reflected at the fornix on the globe as the bulbar conjunctiva.
Tarsal conjunctiva is adherent to the tarsus, while a submucosal lamina propria under- lies orbital palpebral conjunctiva and allows dis- section from the vascular M?ller muscle.
The ciliary muscles of Riolano are situated anterior to the tarsus and near the cilia.
The arteries of the eyelids develop from the internal carotid artery through the ophthalmic artery and the external carotid artery through the facial and superficial temporal branches.
The branches of the internal carotid are later- ally, the lacrimal artery and medially, the supratrochlear and medial palpebral branches of the ophthalmic artery.
The veins of the eyelids are called the pretar- sal and posttarsal veins.
The pretarsals are super- ficial and are connected medially to the angular vein and lateroposteriorly to the superficial tem- poral and lacrimal veins.
The posttarsals are deeper, and connect the orbital veins with the deeper branches of the anterior facial vein and the pterygoid plexus.
The lymphatics of the eyelids, like the veins, have pretarsal and posttarsal systems.
The lateral vessels drain the lateral areas of the lids and the deeper vessels the conjunctiva of the upper folds and lacrimal glands, which drain into the superfi- cial and deep preauricular nodes.
The temporal branch of the facial nerve inner- vates the upper region while the zygomatic branch of the facial nerve innervates the lower region.
Sensory innervation of the eyelids is sup- plied by terminal branches of the ophthalmic and maxillary divisions of the trigeminal nerve.
Within the superior orbit, the frontal branch of the ophthalmic division of the trigeminal nerve arrives anteriorly between the periorbita of the roof and the levator muscle.
Here, it divides into a larger supraorbital nerve and a smaller supratrochlear nerve.
Terminal branches of these nerves supply sensation to the upper eyelid and forehead.
The lips are subjected to numerous movements, so their aspect varies according to movement.
Furthermore, from their shape (motion) we can guess whether a person is happy or sad.
Their function, together with the mouth and the oral cavity, is supported by a complex system of structures and muscles to participate in the process of mastication, speaking, and especially nonverbal communication.
They are so pliable and elastic that they are capable of wide excursions of movement.
The lips form the mouth and surround the oral cavity.
They lie in the central portion of the inferior third of the face.
The upper lip corresponds superiorly to the inferior margin of the base of the nose and extends laterally to the nasolabial fold, and inferiorly to the free edge of the vermilion border.
The lower lip extends from the superior free vermilion edge superiorly, to the commis- sures laterally, and the mandible inferiorly.
The upper and lower lips join at the oral commissures.
Inferiorly the limit of the lips in the central region is the mentolabial sulcus, which intraorally cor- responds to the depth of the gingivolabial sulcus.
From the anatomic viewpoint, the philtrum and its pillars belong to the upper lip.
The phil- trum lies in the central region and extends from the base of the nose to the upper lip border.
It is a depression between two raised vertical columns of tissue known as the pillars.
The surface of the lips is composed of hairy skin, vermilion border, vermilion, and oral mucosa.
The shape of the lips varies with age and ethnicity.
The vermilion is the red part of the lips and is covered with a mod- ified mucous membrane, which continues with the oral mucosa of the gingivolabial sulcus, and is dry as it contains no salivary, sweat, or oil (sebaceous) glands.
The vermilion border is the edge of clearer skin that borders the vermilion.
The Cupid's bow is considered the contour of the line formed by the vermilion border in the central region of the upper lip.
The philtrum is formed by a combination of longitudinal collagen condensa- tions supported by a rich elastic tissue compo- nent and interdigitating orbicularis oris muscle fibers.
The oral mucosa consists of stratified squa- mous non-keratinized epithelium and covers the part inside the oral cavity of the lips.
The oral commissure represents the point at which the lateral borders of the vermilion of the upper and lower lips join.
The external surface of the lips is rich in seba- ceous glands, whose secretion prevents dryness and desquamation.
The labial glands are minor salivary glands situated between the mucous membrane and the orbicularis oris muscles around the orifice of the mouth.
The labial glands are circular in form and about the size of small peas; their ducts open by minute orifices on the mucous membrane The perioral orbicularis oris musculature, the intrinsic and circumferential muscle of the lip, provides the center of the coordination of muscular activity.
The orbicularis oris muscle, a voluntary, mimic striated muscle, has no bony attachment and is not supported by bone or cartilage, and has a sphinteric function.
Into this mus- cle insert the antagonistic and synergistic elevator, depressor, and retractor muscle groups that create coordination between contraction and relaxation of the movements of the buccinator, levator anguli oris, depressor anguli oris, zygomaticus major, and risorius that insert into the modiolus.
This is formed by several retractor muscles converging to act on the angle of the mouth.
Lip elevator muscles insert into the upper lip: levator labii superioris, levator anguli oris, levator labii superioris alaeque nasi, and zygomaticus minor and major.
The lip depressors are the: depressor labii inferioris, mentalis, and platysma.
The motor innervation to the perioral muscu- lature uniformly comes from the seventh cranial nerve, the facial nerve.
The buccal and marginal branches primarily supply innervation to the perioral musculature.
The fibers supply the majority of the muscles of the face from their undersurface.
The lips are abundantly provided with sensitive nerve endings.
Sensory innervation is supplied to the upper lip by the infraorbital branch of the maxillary division of the trigeminal nerve.
The nerve runs beneath the levator labii superioris and superficial to the levator anguli oris to supply the lateral nasal sidewall, ala, colu- mella, medial cheek, and upper lip.
The mental nerve, a branch of the mandibular nerve, innervates the lower lip.
The arterial vascularization of the lips, origi- nating in the external carotid system, is supplied by the superior and inferior labial arteries that arise from each facial artery lateral to the commissure.
Venous drainage occurs via the anterior facial vein and partly via the submental veins.
The lymphatic drainage of the lips occurs through submandibular and submental nodes.
Lymphatic drainage from the upper lip is unilateral except for the midline, where some drainage is available to the submental nodes.
The upper lip and lateral lower lip drain to the submandibular nodes.
The average age of the population is constantly rising all over the world, in particular in the industrialized nations.
Therefore, the geri- atric population represents the fastest growing segment of Western countries.
It has been esti- mated that the elderly will constitute up to 25 % of the US population by 2025 and up to 34 % of the European population by 2050 and that the average life span is expected to extend another 10 years by 2050 worldwide.
The effects of human aging are also primarily visible in the skin with alterations such as atrophy, increased wrinkling, sagging, skin laxity, and changes in skin pigmentation.
In this context, it is well known that humans have always been fascinated by conserving youth.
Indeed, there has been an extraordinary spreading of both surgical and nonsurgical aesthetic and cosmetic pro- cedures in the last two decades.
Particularly, according to statistics from the American Society for Aesthetic Plastic Surgery, since 1997, there has been an increase of 444% in the total number of cosmetic procedures in the United States with surgical and nonsurgical ones being increased by 119% and 726 %, respectively.
Therefore, understanding the mechanisms of skin aging is the key point in order to correctly and effectively counteract and reduce the time effects on the skin through the use of proper and safe intervention modalities.
We can perceive the age of people from the appearance of their face as this is the part of the body which is the most exposed to environmental factors such as ultraviolet (UV) radiation above all; therefore it is not surprising that it represents one of the body areas where the signs of skin aging initially appear.
For example, wrinkles, which constitute the most common and worrying sign of skin aging, are usually particularly concentrated around the eyes and lip.
As regards the eye area, it is well known that few of the first signs of aging appearing in the late 20s and early 30s are usually located around the eyes.
In this area, the skin undergoes numerous morphological and structural changes lead- ing to the typical aging alterations observed in the orbital region such as brow ptosis, dermatochalasis, blepharochalasis, periorbital wrinkles, fat pad, malar bags, etc..
The considerable enhancement in skin thinning is involved in the appearance of dynamic rhytids at the lateral canthi known as crow's feet, whereas increased laxity on the upper lid leads to hooding and occa- sionally pseudoptosis, a condition generally known as dermatochalasis.
Moreover, lower lid skin and orbital septum laxity are able to guide to the formation of bags which may also be favored by edema and skin stretching (malar bags).
When both the skin and the orbicularis muscle are involved, the presence of redundant folds of loose skin, muscle, fat, and interstitial edema which extend from beyond the lateral cheek often past the midpupillary line, or even from canthus to canthus, may develop defining a condition commonly known as festoons.
Apart from skin alterations, also muscle and sub- cutaneous tissue modifications contribute to the development of other noticeable signs of aging in the periorbital area.
For example, contraction of the orbicularis muscle drives to changes in the overlying skin supporting the formation of the condition known as crow's feet; changes in fat amount and position are also strictly linked to aging variations observed in eye surrounding area, whereas important transformations in the laxity of the connective tissue structures and the canthal tendons may lead to a smaller appearance of the eyes, scleral show, or even ectropion.
Apart from the periorbital area, lips, which are part of the aesthetic unit that involves the mouth and the perioral tissue, represent another face site particularly susceptible to manifest aging signs.
While during puberty the lips become fuller because of the hypertrophy of the orbicularis muscle and glandular components, they progressively lose definition as a person ages, tending to become flatter and presenting also upper lip elongation.
The oral commissures tend to descend and vertical wrinkles develop at or above the vermillion border due to skin thinning and orbicu- laris muscle atrophy.
Aging of this area is also characterized by perioral fine lines, mario- nette lines, and flattening of the cupid bow.
The dynamics of lip movement change with age too.
The smile, for instance, gets narrower vertically and wider transversely.
Moreover, the consequences of the aging process are also the most evident along the mandible area where loss of subcutaneous fat tends to create a prejowl sulcus between the chin and sagging lower cheek and anterior to the masseter muscle.
As already mentioned, aging affects the human face by provoking an array of microscopic and macroscopic complex volumetric changes.
These changes are exacerbated and/or accelerated by bad habits (e g , smoking) and environmental factors.
Therefore, both intrinsic and extrinsic factors are responsible for skin aging, together leading to reduced structural integrity and loss of physiological function.
Intrinsic aging is defined as the amount of corpo- ral changes that develop during the normal aging process affecting all body areas as a result of genetic factors.
As regards the skin, the intrinsic aging process leads to epidermal and dermal thinning; intrinsically aged skin appears to be thin, dry, and transparent, presenting with fine wrinkles and irregular hair growth and touring out to be unable to sweat sufficiently.
As a consequence, skin effectiveness to act as a first barrier against environmental and exter- nal factors gradually decreases.
Other cutaneous intrinsic alterations are linked to a reduction in the number of nerve endings and in the production of sex hormones which are responsible for decreased skin sensibility.
Concerning the histopathological modifications, general atrophy of the extracellular matrix (ECM) with decreased elastin and disintegration of elastic fibers represents the most common features of intrinsically aged skin.
All these events may vary in relation to body site, differing also per ethnic group .
Moreover, in intrinsically aged skin, there is a decrease in vessel size without a significant difference in the vascular density .
However, even in subjects living strictly indoor all their life, skin that is aged only by intrinsic factors does not exist.
Obviously, aged skin always reflects a variable impact of extrinsic aging, superimposed on the level of intrinsic aging.
One of the major determinants of intrinsic aging is represented by reactive oxygen species (ROS), which are continuously produced inside our body as a result of the aerobic metabolism in the mitochondria.
Indeed, in the skin, about 1.5–5 % of the consumed oxygen is converted into ROS by intrinsic processes, with keratinocytes and fibroblasts being the main cutaneous producers .
The reactive superoxide anion radical (?O2?) is the principal ROS type formed in mitochondria, being able to harm numerous different cellular functions leading to nuclear and mitochondrial DNA damage, telomere shortening, protein glycosylation, lipid and protein oxida- tion, collagen and elastin degradation, downregu- lation of collagen synthesis, increased expression of matrix metalloproteinases (MMPs), as well as neovascularization.
Moreover, not only ROS production increases with age, but also human skin cell ability to repair DNA damage steadily decreases over the years, potentiating ROS effects.
Apart from ROS production, other main factors which play an important role in intrinsic skin aging are the reduction in repli- cative ability of cells (cellular senescence) and the enhancement of ECM degradation.
The replicative capacity of human cells decreases with time, and in the skin, this is particularly true for keratinocytes, melanocytes, and fibroblasts.
Thus, senescent cells not able to undergo cellular division are found in higher levels in aged skin.
This is due to telomere shortening: with each cellular division, a small fragment of the telomere is definitively lost at the chromosome ends, and after 25–30 cellular divisions, they become so critically short that DNA loss during subsequent cell divisions leads to decline of somatic cell function, cell cycle arrest, and senescence.
Finally, an additional factor involved in intrinsic skin aging is represented by the increased expression of enzymes which act degrading ECM of the dermis; for example, an increase in MMP expression together with the reduction of the MMP inhibitors has been shown in aged fibroblast.
Notably, all these extracellular alterations of ECM may be triggered by ROS production.
Extrinsic aging is caused by external environmental factors such as solar radiation, cigarette smoking, pollutants, etc.
Particularly, UV exposure is believed to be the primary factor involved in extrinsic skin aging, through a process known as photoaging.
This is especially true for exposed body sites such as the face.
Indeed, about 80 % of facial aging is due to photoaging.
The rate and the intensity of UV radiation effects on skin aging are related to several factors such as frequency, duration, and intensity of solar expo- sure as well as the different phototypes, being more prominent in fair skin individuals (skin types I and II) and less noticeable in subjects with skin type III or higher.
Photoaging is a cumulative process which shows a wide range of effects on the skin.
Photoaged skin is commonly characterized by the presence of wrinkles, pigmented spots and pigmentation disorders, verrucous papules, dryness, telangiectasias, loss of elasticity, laxity, and rough-textured appearance.
Particularly, the formation of wrinkles and small brown pigmented sharply demarcated spots, known as lentigines, seems to be the most common hallmark of photoaging; for these rea- sons their development mechanisms are discussed in detail in the following subheading.
However, photoaging damage predominantly occurs in the connective tissue, also referred to as ECM whose most important and abundant structures being collagen, elastin, and glycosaminoglycans (GAGs), all essential to maintain the strength, the elastic- ity, and the hydration of the skin.
Indeed, regarding histopathological changes, progressive disorientation of dermal collagen and elastic fibers bundles is a common feature of photoaged skin.
A significant increase in space between fiber bundles, thinning of fibers, and increased disorga- nization of fiber proteins are also present.
Finally, photoaged skin is characterized by a loss of mature collagen, and basophilic degeneration of connective tissue, evidenced by denatured elastin fibers and collagen fibers.
Typical for a photoaged skin is the deposition of abnormal elastin with histological examina- tion revealing deranged and highly branched elastic fibers that form aggregates of elastotic material formed by a combination of UV- or ROS-induced degradation of elastin and biosynthesis of amorphous and dysfunctional elastin and fibrillin.
Moreover, an age-dependent decrease in the cutaneous vascularity of sun- exposed facial area together with a reduction in vessel size and vascular number compared to younger skin is also reported.
UV radiation is the main actor of extrinsic aging, being able to damage various cellular structures both directly and indirectly, thereby accelerating the aging process.
An important role is played by UVB which is mainly responsible for direct cell damage.
Indeed, even if a great amount of UVB is absorbed in the stratum corneum, attenuated UVB radiation also reaches viable epidermal cells, determining biological damage.
Particularly, the most dangerous and critical type of biological damage is represented by DNA alteration.
Actually, upon UVB cellular absorption, various DNA mutations may be set up through the formation of bonds between adja- cent pyrimidines which cause the development of cyclobutane–pyrimidine dimmers and pyrimi- dine–pyrimidone (6-4) photoproducts.
Thus, mutated DNA and RNA bases are able to affect cellular protein synthesis and accumulation of unrepaired mutations can cause cell cycle arrest and apoptosis.
However, at the same time, mutations can impair the cell apoptotic ability, enhanc- ing skin malignancies' development.
All these events are deeply influenced by the skin cell type, the cumulative UV dose, and the UV wavelength type which impact the final outcome.
Moreover, UV radiation is also able to induce biological damage and accelerate aging through indirect pathways with endogenous or exogenous photosensitizers that absorb UVA and even visi- ble (VIS) wavelengths from both the sun and arti- ficial sources.
As a result, ROS such as singlet oxygen or direct photochemical changes to biomolecules may be performed.
Therefore, even if UVA and VIS radiation are less absorbed by epidermal components and hence penetrate deeper into the dermis, they should not be ignored as potential source of photoaging.
In addition, aging modification is also indirectly caused by UV through ROS-induced damage which is able to stimulate the synthesis of MMPs.
Thus, other important factors of photodamage are also increased MMP overex- pression and activity, being responsible to the degradation of dermal connective tissue.
Particularly, MMP upregulation is able to occur after low UV exposure doses, less than one mini- mal erythema dose.
Therefore, even daily exposures to a low-dose solar UV radiation below sunburn are thought to be sufficient to induce MMP upregulation and their related photoaging consequences such as degradation of skin colla- gen and elastic fibers above all.
Notably, MMP production is not only induced by ROS but also by inflammatory cells (macrophages and neutro- phils) which infiltrate the skin after UV-induced inflammatory effects.
Apart from ECM degradation through MMPs, UV-induced ROS are also able to damage GAGs, important structures to give support, strength, and flexibility to the connective tissue and keep the tissue hydrated.
For example, the most known member of GAG family, hyaluronic acid, is strongly reduced in the dermis after chronic UVB exposure .
Furthermore, UV is also able to increase the expression of fibromodulin, a small leucine-rich repeat protein which interacts with type I and II collagen fibrils, thereby affecting ECM metabolism through the alteration of the balance between collagen synthesis and degradation, leading to collagen deficiency observed in photoaged skin .
Therefore, as described above, UV radiation plays a major role in extrinsic aging (photo- aging).
Particularly, wrinkles and lentigine formation represent the two most classical examples of the key role played by UV radiation in determining the skin effects of extrinsic aging (photoaging).
Indeed, regarding wrinkles, UV-induced degradation of skin collagen and elastic fibers through MMP activity is one of the main mechanisms involved in their formation.
Particularly, UVR-induced ROS are able to activate signaling kinases (activator protein-1 and MAPK signaling) which control the tran- scription of MMPs in epidermal keratinocytes and dermal fibroblasts.
Moreover, keratinocytes exposed to UVB radiation produce and secrete cytokines such as interleukin (IL)-1α, IL-6, and tumor necrosis factor (TNF-α), which stimulate epidermal keratinocytes and dermal fibroblasts and enhance MMP-1, MMP-2, MMP- 9, and MMP-12 levels leading to wrinkle formation through damage of dermal collagen and elastic fibers.
Furthermore, UVB radiation is also able to induce MMP-1, MMP-3, and MMP-9 in normal human epidermis, whereas UVA stimulates the expression of MMP-1, MMP-2, and MMP-3 in fibroblasts.
In addition, UVB radiation may also contribute to wrinkle formation by inducing fibroblast elas- tase via cytokines released by exposed keratinocytes .
Consequently, several mechanisms are con- sidered to be involved in wrinkle development such as the decrease of collagen and elastin fibers in dermis, the degradation of basement mem- brane at the dermal–epidermal junction, and a decrease in the three-dimensional organization of the ECM.
Hence, UV radiation has been implicated in wrinkle formation through its exacerbation of the decline in tensile strength and elasticity and its ability to cause the degradation of the supporting structural components of the dermal ECM.
The key role of UV radiation in extrinsic aging is also showed by their strong involvement in the development of solar lentigines, another classical marker of skin aging together with wrinkles.
These brown pigmented lesions may be induced by mutations of keratinocytes and melanocytes which both play a role in pigment formation and transfer.
In this context, UV radiation is considered the principal actor in their formation process.
Particularly, through its ability to induce mutations in cutaneous cells, UVB radiation is thought to be the extrinsic factor most responsi- ble for pigment spot development.
Mechanism Overlap Mechanisms of intrinsic aging and extrinsic aging share substantial overlap, both featuring DNA damage.
For example, critical shortening of telomeres, which cause cellular senescence and organism aging overall, is related to finite number of cell divisions, depending to passage of time in proliferative tissues which also characteristically increase after injury, including UV irradiation.
ROS production represents another common executor of both intrinsic and extrinsic aging, being strictly linked to DNA damage and senescence.
Indeed, it is well known that ROS can be produced by both intrinsic aerobic metab- olism and extrinsic UV exposure.
Moreover, when a cell enters senescence, p53 functions such as enhanced DNA repair capacity and stimulation of antioxidant defenses cease, leaving viable but nonproliferative cells (e g , dermal fibroblasts) in a state of chronic oxidative stress that promotes the pro-inflammatory environment characteristic of old skin, making them also more susceptible to UV radiation- induced damage.
As a result of these common alterations, it is not surprising that both intrinsic and extrinsic aging are able to determine some similar qualitative and quantitative changes in ECM, leading to loss of tensile strength and recoil capacity, wrinkle formation, dryness, impaired wound healing, and increased fragility .
Nevertheless, not all aging-related ECM modifications are analogous between intrinsic and extrinsic pathways; e.g., globally, intrinsically aged skin preferentially shows atrophy of dermal structures, whereas photoaged skin is predomi- nately characterized by the accumulation of aber- rant elastin fibers and GAGs, together with damaged and diminished collagen.
Patients often present with many reasons for wanting to obtain lip augmentation or restoration; invariably, the majority complains of an aging look or thinning to the perioral region and requests lip reshaping due to loss of volume.
The commonly encountered signs of perioral aging include decreased vermillion showing, blunting of the Cupid's bow, less visible white roll, verti- cal rhytids, marionette lines, formation of a men- talis crease, and deep nasolabial folds.
Younger patients present for lip augmentation in order to obtain the ever-changing look that is desirable at the moment.
It appears that atrophy and not descent accounts for most of the aging of the face.
There is a loss of glycosaminoglycans and pro- teoglycans in the dermis and a simultaneous decrease in the amount of collagen and elastic fibers.
The repeated contraction of facial muscles also leads to rhytid formation in the perioral region.
On the macrolevel as a person ages, the lips become flatter, the upper lip elongates, the Cupid's bow is lost, and the oral commissures descend.
Resorption of the facial bones with ensuing soft tissue repositioning has also been implicated as a cause of aging in the perioral region.
Injection of hyaluronic acid, a glycos- aminoglycan, acts to increase the water content of the lips for a plumper, fuller appearance.
Normal lip aging can be exacerbated by sun exposure and smoking.
Hyaluronic acid (HA) is a commonly used temporary filler for lip augmentation due to its hygroscopic properties and resulting natural appearance.
The effects last between 3 and 6 months.
Some patients may experience long- term results from HA fillers due to neocollagenesis induced by mechanical tension on fibroblasts from HA injection.
It is the author's opinion that the trauma induced by injection leads to an inflammatory process that also extends the effects of HA fillers.
They do not require skin testing unlike the collagen- based fillers.
HA fillers consist of an uncross- linked soluble HA phase and an insoluble cross-linked fraction of HA particles of a predetermined size.
HA is cross-linked in order to increase the half-life after injection.
The degree of cross-linking within the HA filler corresponds to the firmness of the resulting gel.
The firmness of HA fillers is measured by the elastic modulus (G’), and higher numbers cor- respondtofirmerproducts(Restylane > Juvederm Ultra > Belotero Balance).
Physicians must keep in mind the firmness of the product they are injecting in order to achieve natural feeling lips.
They have desirable safety profiles due to the reversibility by enzymatic degradation using hyalurodinase.
Currently, there are two FDA-approved HA fillers specifically for lip augmentation: Restylane Injectable Gel and Restylane Silk (Galderma S A , Lausanne, Switzerland).
However, off- label uses of Juvederm Ultra (Allergan, Inc., Irvine, CA), Captique (Inamed Corporation, Santa Barbara, CA), and Belotero Balance (Merz North America, Greensboro, NC) include lip aug- mentation.
Restylane, Captique, and Juvederm are bacterially derived from Streptococcus equi and thus have low risk of immunogenicity and allergic reaction.
Restylane is a cross-linked HA gel that is clas- sified as a nonanimal stabilized HA filler.
It can be used to treat nasolabial folds, marionette lines, and glabellar lines and to augment the lips.
Side effects of injection with Restylane can last up to 1 week and include redness, swelling, bruising, and induration.
It is firm filler that does not spread out after injection because of its viscosity and higher elastic modulus.
Captique replaced Hylaform and Hylaform Plus from the Inamed Corporation seeing as they are no longer used. Captique is also classified as a nonanimal stabilized HA.
Juvederm Ultra (classified as Hylacross HA) is a less viscous long-chain HA gel with a lower elastic modulus that tends to spread more after injection.
It is also more concentrated and hydrophilic than Restylane and thus will absorb more water from the surrounding tissues.
Belotero Balance (classified as cohesive polydensified matrix HA) is the newest HA  filler to come to market and has the lowest vis- cosity and elastic modulus between Restylane and Juvederm.
It has the greatest capability  to spread after injection, which is desirable  when performing lip augmentation in order to preserve pliability of the lips.
It’s especially effective as a superficial filler when used to restore areas of vertical rhytids to a more youth- ful appearance.
When preparing to inject a patient with any filler, the physician should bear in mind the important anatomy surrounding the perioral region (Fig. 3.2).
The lip is mainly composed of the orbicu- laris oris muscle with an overlying fascia.
However, many muscles insert into the angle of the mouth and should be considered when injecting.
The corresponding vermillion or cutaneous layers sit on top of the fascia.
The vascular supply of the perioral region consists of the facial artery and its direct branch into the lip, the labial artery.
The infraorbital and mental nerves provide this area with sensation and motor function.
The operator must keep in mind the aesthetics of lip augmentation, which is subject to constantly changing social pressure, in order to achieve high patient satisfaction and cosmetically acceptable results.
The lower lip should be fuller with more vermillion show than the upper lip.
In Caucasian women, it is advisable to follow the golden ratio of 1:1.618 in terms of volume in the upper and lower lip.
Black and Asian women may have proportions that approximate 1:1.
When viewing the patient in profile, the upper lip should project slightly farther than the lower lip.
The white roll separates the facial skin from the vermillion of the lip.
It must be continuous and smooth because a misalignment as small as 1 mm can be noticeable to observers.
The Glogau- Klein point (the elevation or ski slope in the upper lip where the skin turns into red vermillion at the arches) can be enhanced to project the upper lip and create the ski slope to look charac- teristic of younger lips.
There are natural prominences in the upper and lower lips that must be maintained to achieve the pouty look.
These include the two tubercles that lie lateral to the midline on both sides of the lower lip, the tubercle that lies in the midline of the upper lip, and the two tubercles that lie in the lateral corners of the upper lip.
When performing lip augmentation, it is essential that the doctor appropriately fill lips to satisfy patient expectations but not overfill them so as to create a "duckbill"?appearance.
It is preferable to treat again later if the desired cosmetic effect is not achieved.
In order for the patient to observe the chang- ing lip proportions, it is useful to have a hand mirror available and pre- and post-procedure photographs taken from the anterior and lateral view.
Swelling will not occur symmetrically after injection so the injector should treat each side of the lip for each step before moving onto the next step.
Additionally, injectors need to be cognizant of the amount of volume that has been used at each step of the procedure in order to avoid the unwanted consequence of running short of prod- uct before completing the augmentation.
In patients who only agree to pay for a certain amount of product, this amount must guide and limit the extent of augmentation.
Viscous fillers such as Restylane should be injected more deeply to avoid visible nodules and the Tyndall effect.
Less viscous fillers such as Juvederm and Belotero can be used more superficially to achieve natural results.
Patients should be educated and counseled on realistic expectations of results.
Visual scales are used to grade lip augmentation pre- and post- procedure such as the lip fullness scale.
Prior to any lip augmentation procedure, it is essential to understand the importance of facial proportions and anatomy.
While some studies have shown that facial symmetry is an important factor to define a more desirable face, it has also been shown that for a given individual there were statistically significant lower ratings of attractive- ness for perfectly symmetrical computer-generated left-left and right-right faces compared to natural faces.
Clearly, the goal of lip augmentation should not be complete symmetry.
Natural asymmetry makes a face and its expressions unique and attractive.
Injectors should bear this in mind when performing augmentation of facial features and exercise the best scientific and artistic skills that will lead to aesthetically pleasing results.
Firstly, it is vital to gauge the expectations of the patient prior to beginning injection.
Patients should be counseled to expect subtle improvement of their facial appearance with the help of lip augmentation within the boundaries of their individual natural features.
Patients presenting with a desire to completely change their appear- ance or to change their lips to resemble a celebrity's have unrealistic goals.
This should be discussed and clarified at the first visit.
Appropriate expectations help achieve good outcomes and satisfied patients.
Following a discussion on expectations, patient should be provided with a hand mirror to allow them to point to areas of concern.
This helps the clinician understand the exact areas that need augmentation in the patient's mind.
For example, a patient may suggest that her upper lip is too thin in the middle or the corners of the mouth are downturned.
Doing this exercise with the patient helps build good rapport, puts the doc- tor on the same page as the patient, and prevents dissatisfaction after the procedure.
The doctor should pay special attention to the elements of concern as the patient sees it.
Photographs must be taken from the front and side profiles under standard lighting and background before and after procedures.
This allows for appropriate follow-up, understanding and managing compli- cations, guiding future treatments, and providing documentation.
Once the patient is ready for the procedure, topical anesthesia is used to anesthetize the treatment site.
This author prefers topical anesthesia instead of nerve blocks as the former allows for maintenance of lip movement during injection, thus helping to assess the amount of product injected and its effect on appearance.
Nerve blocks cause loss of lip movement and affect real-time assessment of results.
The anesthetic of choice is 30 % lidocaine in petrolatum ointment for 30–40 min pre-procedure.
If the treatment involves the nasolabial folds, cheeks, and/or upper cutaneous lip, these should be augmented first followed by the lips, seeing as the lidocaine will spread from these areas toward the infraorbital nerve and help with anesthetizing the lips.
Once the area is anesthetized, the patient is seated on the treatment chair in a partially inclined, well-supported position, comfortable to the patient and the doctor.
This is necessary for a slow, well-controlled injection.
The needle is primed with a bolus of the product.
Anterograde injection with this drop helps to roll any vasculature out of the way of the needle instead of puncturing through them.
The eyesight and tip of needle are in one line with the lip for clear view of the injection and its immediate effect.
To enhance the vermillion border, the needle is inserted at the initial point such that it enters parallel into the natural tunnellike space between the white roll and vermillion with constant anterograde pressure.
The initial point will depend on the plan of augmentation for an individual patient and on their natural lip architecture.
Some patients may require a more lateral starting point while others can be started more medially.
The tunnel-like space is between the wet and dry sides of the lip.
It is important to deliver augmentation into the correct anatomical region to gain optimal aesthetic effects and avoid poor outcomes.
Injection is continued slowly with small volumes injected with steady pressure for even results.
If the overall lip volume is being augmented, this author's preferred method is to inject from the vermillion border with the needle angled parallel into the red pulp.
This leads to accentuation of the tubercles and less pain than experienced when injecting directly into the red pulp.
Alternatively, the injections can be continued in the pulp area of the lip in the same manner as above, layered underneath the first layer and using it as a support.
For a more pouty appearance (Paris lip), dermal filler is first placed along the border of the upper lip, adding definition.
Then the Cupid's bow is accentuated to create a dis- tinctive"V"?shape.
Afterward, the vertical arches between the upper lip and nose are built up.
This creates the distinctive peaks that are the signature of the Paris lip.
Finally, when augmenting the lower lip, focus on the middle third as the area of injection.
If you augment the entire lower lip, a rounded, duck-like appearance will result.
If the patient has a previous scar in the area of injection, the technique should be modified such that the scar area is bypassed.
The scar prevents proper flow of the product across the scar tissue.
In certain patients, onabotulinum toxin may be injected into the orbicularis oris in combination with lip fillers to produce elevation of the lip along with augmentation and reduction in perioral rhytids.
To prevent bruising, light pressure is applied to the injection sites.
The pressure should not be firm as this can cause displacement of the filler product.
Patient is also advised to hold an ice pack on the area for 15–20 min or longer if on a blood-thinning medication.
Patients should be instructed that HA absorbs water and causes some swelling in addition to that caused by the trauma of the injection itself.
This edema should subside by 10–15 % in 48–72h.
If bruising is noted on follow-up, pulsed dye laser may be used 48 h post-procedure to lighten the color of the bruise and speed up the healing process.
Hyaluronic acid fillers are well tolerated and rarely result in adverse reactions for patients due to their temporary nature and low immunogenicity .
Commonly experienced reactions due to injection include local inflammation, hyperemia, bruising, redness, warmth, tenderness, and ecchymosis.
Hypersensitivity and an angioedematous swelling can be seen in some patients.
Bruising and swelling usually abate within 7 days.
Erythema and telangiectasias may persist more than 2 weeks after injection and can be treated with hyaluro- dinase Infection from filler injection is also a cause for concern and can present as induration, erythema, itching, and tenderness.
The clinician should use an alcohol swab to prepare a sterile site for the injection, thus avoiding the risk of transdermally acquired bacterial infection from the presence of biofilms.
Patients with a his- tory of herpes simplex labialis can have reactivation of infection after injection and thus should be given prophylaxis with antiviral medications (acyclovir or valacyclovir) 2 days before their procedure and for 5 days after.
Painful, red nodules that present within 3–14 days after injec- tion are suspicious for infection and should be cultured.
Antibiotic treatment may be indicated depending on culture results, and steroids may be added depending on the amount of inflammation.
It is not recommended that injectors store leftover product due to increased infection risk.
Some complications arise from the inherent technique and expertise of the operator.
The Tyndall effect can occur with certain HA fillers when the filler is injected too superficially, and thus a bluish discoloration results at the injection site.
Vascular occlusion of the blood supply of the lips can result when injecting directly into an artery or vein or from compression.
The operator should take care to avoid the superior and inferior labial arteries when injecting the lips.
Hyalurodinase should be immediately injected locally with flooding of the area if severe localized pain or unusual blanching is noted.
Firm massage to the area is also indicated. 
Necrosis of the occluded area can occur if this is not recognized and treated promptly.
Immune-related adverse events include delayed-type hypersensitivity and the development of foreign body granulomas.
Foreign body granulomatous reactions are rare when using hyaluronic acid but lead to the presence of lumps or small nodules on the lips.
Differentiating between an immune process and a normal reaction has largely been based on the intensity of the reaction and clinician preference.
Hyaluronic acid fillers are an effective treatment option for patients who want to augment and revitalize their lips.
Injectors must keep in mind the natural aesthetics of the patient and patient preferences when providing this procedure.
Major adverse effects are rare, and thus HA fillers are a first-line treatment modal- ity for the nonpermanent augmentation of lips.
Lip wrinkles are fine or deep lines that can be observed around the mouth.
They appear as vertical lip lines perpendicular to the vermillion border and can be divided in static and dynamic wrinkles.
Static wrinkling can be caused by several factors, such as age, sun exposure, cigarette smoking, as well as unknown causes like genetics, gender dif- ferences, and intrinsic soft tissue characteristics.
Dynamic perioral wrinkles are caused by muscle contractions, which can be voluntary (e g , smoking or playing wind instruments) or involuntary (e g , smiling or grimacing).
Many aesthetic procedures for lip wrinkles are available: static wrinkles can be treated through facial skin resurfacing, laser, mechanical derm- abrasion, skin needling, chemical peels, and soft tissue fillers; for dynamic wrinkles, BOTOX? injections can be very useful.
This wide selection of techniques allows us to choose those with higher efficacy, minimal adverse effects, and quick healing time.
In particular skin needling and BOTOX? injections are the newest procedures that share all the advantages listed above.
A good knowledge of perioral region’s anatomy is essential for a careful approach to aesthetic procedures, in particular to provide the best treat- ment options for each patient and to avoid side effects.
The perioral muscles are arranged in interlac- ing and decussating bundles organized in several layers.
They can be classified into three groups based on insertion.
Group I muscles insert into the modiolus; they are orbicularis oris, buccinator, levator anguli oris, depressor anguli oris, zygomaticus major, and risorius.
Group II muscles insert into the upper lip; they are levator labii superioris, levator labii superioris alaeque nasi, and zygomaticus minor.
Group III muscles insert into the lower lip; they are depressor labii inferioris, mentalis, and platysma.
Skin needling, also called dermarolling, percutaneous collagen induction (PCI), or collagen induction, is an efficient technique used since 1995 in many aesthetic procedures.
To date, skin needling, alone or combined with other methods, has been proposed as an effective method to treat scars and wrinkles, but also to enhance penetration of topical sub- stances in dermatologic pathology such as melasma.
The device used is a drum-shaped roller stud- ded with a variable number of fine microneedles, which penetrate a depth of 0.5–3 mm into the skin creating thousands of micro-wounds without damaging the epidermidis.
The micro-holes, in fact, are about four cells in diameter so that the stratum corneum remains intact.
The needles must be rolled in four directions: vertically, horizontally, diagonally right to the left, and diagonally left to the right.
Needling should be performed maintaining a mild pressure over the affected area, for a total of 10–14 passes.
Skin needling is effective in minimizing scars (acne scars, burn scars) and wrinkles and by pro- moting the neocollagenogenesis and the wound healing process through a cascade of growth factors.
Despite ablative laser treatment, skin needling does not cause thermal damage, and no signs of dermabrasive reduction of epidermal thickness are evident 24 h after the procedure so that neither increased nor decreased the number of melanocytes.
For these reasons, it is a procedure suitable for all skin types, it can be repeated safely, and it is also applicable in some skin areas that are not suitable for laser treatments and deep peels.
Skin needling represents a useful tool for the treatment of perioral wrinkles, especially for ver- tical lines, also called "bar code"?and for perioral wrinkles, typical of smokers; it can also be an adjuvant treatment, in association with other techniques (such as filler injection), for the"mar- ionette"?wrinkles.
With repeated sessions, new collagen is gradually produced, plumping and filling, in a physiologic way, wrinkles, lines, and depressed scars.
It is a minimally invasive procedure with rapid healing and little downtime.
The epidermis is not damaged, so that it can be repeated.
???Risks of postinflammatory hypo- or hyperpig- mentation are minimal.
It is suitable for all skin types, even thin and previously lasered skin.
It can be performed on all areas of the face, neck, and body.
It costs less than laser treatments.
Botulinum toxin injection for treatment of facial wrinkles has been one of the most frequently performed aesthetic treatments in these last years.
Since botulism was first described in the eigh- teenth century, the botulinum toxin type A has been used first for skeletal muscle hyperactivity, and then it was being investigated for the treatment of many other conditions, until its approbation for temporary improvement of moderate to severe glabellar lines.
It was approved for human use under the name of Oculinum??? first and then after acquisition by Allergan, Inc., under the name of BOTOX?.
Botulinum toxin type A acts by inhibiting the exocytosis of acetylcholine on cholinergic nerve endings of motor nerves.
In fact after binding to the membrane of the nerve terminal, it is translocated into the neuronal cytosol where it cleaves one or more of the SNARE (soluble N ethylmaleimide-sensitive factor attachment protein receptor) proteins.
Since these proteins are necessary for vesicle docking and fusion, botulinum toxin type A reduces neurotransmitter release.
This induced weakness of the muscle starts after 3–7 days and lasts for a period of 3–4 months .
Botulinum toxin type A is most often injected into muscles that are overactive.
It results in decreased muscle activity.
For cosmetic use, the target of BOTOX? is the muscles of facial expression.
In fact, with repeated contraction of these muscles, the skin overlying the muscle can develop wrinkles.
It is very important to distinguish dynamic wrinkles, caused by muscle contraction, from static wrinkles, caused by photo- and chrono- aging, because the latter is not affected by treat- ment with BOTOX?.
To distinguish them, physician can ask patients to grimace.
Botox can be used, for example, to correct glabella wrinkles, frown lines in the forehead, perior- bital lines, hyperactivity in the muscles of the upper lip, and hypertrophy of the musculus masseter.
Many studies show that efficacy of botulinum toxin type A after several treatment sessions per- sists for many years without decrements in safety and without necessity of increased doses.
We can identify three important muscles to treat in the perioral region.
Its function is to close the mouth by approximat- ing the lips, to bring the lips together against the alveolar arch, and to protrude the lips.
For these reasons, its hyperactivity is in part responsible for perioral wrinkle formation.
Because of its circular shape, it is recommended to treat both the upper and lower por- tions to maintain balance.
Injections must be superficial, performing it in the lower dermis and no deeper than the dermo- subcutaneous junction.
The dilution of BOTOX? should be 100 U vial of BOTOX? with anywhere from 1 to 4 ml of normal saline.
In this way, it can spread over the superficial fibers of the orbicularis oris, treat- ing the multitude of vertical lines across the lips.
In this way we can use only 1 or 2 U for each quadrant, with a total treatment dose of 4–6 U for the whole area.
Injections can be performed either into the border between the pars peripheralis and pars marginalis or 3–5 mm above the vermillion bor- der into the lateral pars of the orbicularis oris, at least 1 cm from the mouth corner and avoiding the philtrum column area, for risk of flattening its lateral edges.
The needle should be injected parallel to the skin surface.
Its function is to pull the corners of the mouth downward, moving the marionette lines down.
Injections should be superficial in the lower third of this muscle, with the needle directed laterally.
The dilution of BOTOX? should be 100 U vial of BOTOX? with 1 ml of normal saline.
In this way we can avoid not only aesthetic adverse effects such as an asymmetric smile but also functional disturbances such as drooling, dribbling, or even dysarthria.
It is recommended a total treatment dose of 6 U which must be divided between two injection sites, one per side.
Injections should be per- formed in the projection of the muscle, 1 cm lat- eral and 1.5 cm below the oral commissure.
It is very important to avoid injection into neurovascular structures that lie in this area, such as the marginal mandibular nerve and facial artery and vein.
With this aim it could be useful to lift the skin and muscle with the nondominant hand before injecting BOTOX.
Its contraction raises the chin, elevates the skin of the lower lip upward, and protrudes and everts the lower lip during drinking.
Its hyperactivity can cause a deep wrinkle between the lower lip and the prominence of the mandible.
Moreover, with loss of collagen and subcutaneous fat that occurs with aging, it can appear as chin dimpling.
BOTOX treatment is effective in individuals who exhibit dynamic chin wrinkles.
As for the depressor anguli oris, also for men- talis, the dilution should be 100 U vial of BOTOX? with only 1 ml of normal saline, to avoid the induc- tion of weakness of the depressor labii inferioris, producing in this way muscular aberration of the mouth (inability to speak, drink, and eat).
It is recommended that a total dose of 6 U be divided equally between two injection sites, one per side.
Injections should be performed subcutaneously or intramuscularly at two symmetrical points located close to the chin midline, 1 cm above the lower edge of the jaw.
Even if the use of BOTOX?, according to current regulations, is allowed only for glabellar lines, analyzing the existing literature, we can find several scientific articles that show its use for other facial areas, including the perioral one.
BOTOX injection in the perioral area has two important advantages: it takes only about 20 min to be done; it is a noninvasive technique, with minimal adverse effects if performed by an expert physician.
?A good knowledge of periocular region's anat- omy is fundamental to aesthetic procedures approach of the eye wrinkles area.
This knowledge, including vascular supply, nerve position, and facial compartments, is necessary to provide the best treatment options for patients, manage complications appropriately, achieve optimal results, and avoid unwanted side effects.
First of all it is necessary to define anatomic confines of orbit: the superior margin is delimited by the frontal bone and sphenoid; the inferior margin is bordered by the maxilla, palatine, and zygo- matic; the medial margin is defined by the eth- moid, lacrimal bone, and frontal bone; and the lateral margin is delimited by the zygomatic and sphenoid.
In Table 5.1 we list the bones articulating to form the orbit.
Looking more superficially, the skin covering the orbital opening (mostly composed of eyelid skin) is the thinnest in the body, with minimal or no subcutaneous fat.
Immediately underlying it is the orbicularis oculi muscle.
It is divided into pre-tarsal, preseptal, and orbital components.
Deeper to the orbital part of the orbicularis, along the superior orbital rim, lies the corrugator supercilii muscle.
Orbital parts of the orbicularis and corrugator muscle are brow depressors.
The orbicularis muscle is the only active force that keeps the lower eyelid margin in its normal position.
Deeper to the orbicu- laris lies the orbital septum, which is a thin fibrous connective tissue layer extending from the orbital rim to the eyelid margin.
It is well known that the botulinum target is muscles: in Table 5.2 we summarize the anatomy and func- tion of periocular region muscles.
All muscles of the upper face contribute to brow position.
This must be considered for the aesthetic appearance of the upper face and must be balanced to achieve an acceptable and pleasing result.
All facial muscles of the upper face are innerved by facial nerve (VII cranial nerve).
The periocular region is vascularized by branches of the superficial temporal artery, arising from the external carotid artery: the zygomatic-orbital artery (collateral branch of the superficial temporalartery) and the frontal artery (terminal branch of artery temporal surface).
These anatomic basics are essential for a layered approach, a correct evaluation of the skin, fat, muscle, and bone to determine which procedure is best suited for each patient.
This chapter evaluates clinical application of two aesthetic procedures available for patients presenting for periorbital rejuvenation: Botox and skin needling.
The use of Botulinum toxin A (BoNT-A in cos- metic dermatology has increased in popularity due to the efficacy and relative safety of the treatment.
BoNT-A is a natural substance, made by Clostridium botulinum bacteria; it is a very powerful toxin, which causes a temporary paralysis of the muscle.
It works on the motor end plates of the skeletal muscle.
It also has an action on sympathetic smooth muscle and sweat glands.
Several medical companies have developed synthetic forms of the toxin, with the same effects of natural toxin, but safely in microdoses.
Some of the mainstream brand names include Botox?, Dysport?, Xeomin?, Vistabel?, and Neurobloc?; these are used to treat periocular wrinkles, brow ptosis, blepharospasm, hemifa- cial spasm, and facial palsy rehabilitation.
The short-term safety profile of BoNT-A in cosmetic nonsurgical procedures was confirmed for all the three commercial formulations.
The use of botu- linum toxin A (BoNT-A for aesthetic treatments is growing steadily, and new safety data have been reported in recently published studies.
Since botulism was first described in the eigh- teenth century, this neurotoxin has undergone a slow development to Botox which is now manufactured.
Voluntary muscle contraction is a response to stimulation by action potentials pass- ing along a nerve to the muscle end plate.
Once the action potentials reach a synapse at the neuromus- cular junction, they stimulate an influx of calcium into the cytoplasm of the nerve ending, and mobi- lization of acetylcholine toward the synapse occurs.
Acetylcholine fuses with the nerve ending membrane and then crosses the synapse to bind with receptors on the muscle fiber, which leads to contraction.
BoNT-A inhibits the discharge of ace- tylcholine into the synapse by bonding to the nerve at the neuromuscular ending.
The toxin is then internalized via receptor-mediated endocytosis, and a toxin-containing vesicle is formed within the nerve ending.
These internalized vesicles inhibit the acetylcholine protein (synaptosomal-associ- ated protein-25) that is located on the cell membrane.
This inhibits muscle contraction, which leads to reversible muscle atrophy.
Physiology and mechanism of action are emphasized because the only way to utilize any type of BoNT-A properly is to have an in-depth understanding of how to modify the normal movements of the mimetic muscles of the face.
When injections of BoNT-A are appropriately performed, desirable and reproducible results without adverse sequelae are created.
BoNT-A effect starts from between 3 to 7 days after injec- tion and lasts between 2 and 6 months (average 4 months).
The peak action is at 7–10 days after injection with complete paralysis of the muscle area treated, which then it gradually wears off.
Injections can be repeated.
As with any other types of treatment, before per- forming cosmetic procedures with BoNT-A both the patient and physician should discuss treat- ment expectations, to prevent disappointment.
The areas of dynamic motion, such as the gla- bella, frontal region, and periorbital lines, are the best application areas for BoNT-A because this procedure is ideal for reduction of mimetic effects of wrinkles and folds, while it is less suit- able for static wrinkles and very deep folds.
About the periocular region the best site of application are.
Corrugator supercilii muscle, to correct glabella lines, the vertical frown lines just between and above the two eyebrows.
Excellent results are achieved when injecting these lines with BoNT-A Patients are asked to frown before injection, while the largest mus- cle body of the procerus and corrugator muscles is palpated.
The corrugator supercilii muscle is injected 1 cm above the orbital rim.
With a distance less than 1 cm, diffusion of the material into the medial part of the eyebrow is possible and may lead to local eyebrow ptosis.
This effect is temporary and not treatable.
Female patients require 5 × 4 U (0.1 ml); most males require up to 5 × 6 U (0.15 ml) depending on the muscle tone.
Orbicularis oculi muscle, to correct “smile” wrinkles and lines at the outer corners of each eye.
Lateral canthal wrinkles are caused by the contraction of the lateral side of the orbital portion of the orbicularis oculi and therefore are referred to as dynamic wrinkles.
They are the result of infolding and pleating of the over- lying skin, which radiate away from the lateral canthus.
These wrinkles are perpendicular to the direction of the lateral muscle fibers of the orbital portion of the orbicularis oculi, which run mostly in a vertical direction around the lateral canthus.
Because crow's feet are enhanced during smiling or laughing, the con- traction of the risorius and zygomaticus major et minor also contributes to the formation of these lateral canthal wrinkles.
Consequently, when persons laugh, smile, or grin, they contract the risorius and zygomaticus major et minor, which also can accentuate the lower aspect of their crow's feet.
Three injection sites lateral to each eye are almost always sufficient to give relaxation to the part of the orbicularis oculi muscle that is responsible for crow's feet.
Each injection site receives 4 U (0.1 ml).
This gives adequate response rates up to 16 weeks postinjection.
By choosing the upper injection site just below the eye- brow, an aesthetically pleasing lift of the lat- eral eyebrow can be achieved as a beneficial extra effect of this treatment.
The caudal injection site is 1–2 cm below the medial one and stays away from the orbital rim.
This injection technique gives good aesthetic outcomes with slight elevation of the lateral eyebrow and clear reduction of periorbital lines.
We remember that the palpebral portion of the orbicularis oculi should not be treated with BoNT-A because it can cause loss of the volun- tary and involuntary functions of eyelid closure.
Administration of BoNT-A should be avoided during pregnancy and breastfeeding and in patients with disorders of the neuromuscular junction (such as myasthenia gravis, Lambert- Eaton syndrome) and neurodegenerative dis- eases such as amyotrophic lateral sclerosis.
Simultaneous use of aminoglycoside antibiotics (gentamycin, tobramycin) should be avoided because of their potentiating effect on BoNT-A Other theoretical drug interactions could occur with calcium channel blockers, cyclosporine, and cholinesterase inhibitors.
Highly frequent administration of BoNT-A (more than every 12 weeks) and repeated expo- sure can lead to formation of neutralizing anti- bodies against the toxin which lead to disappointing results.
Thorough preoperative evaluation with meticulous surgical planning to achieve facial aesthetic balance between the forehead, eyelids, and midface is imperative to avoid or decrease potential functional and/or cosmetic complications in cosmetic periocular surgery.
Before performing surgery, the physician should be aware of the patient's history of dry eyes, previous facial trauma, previous injection of Botox Cosmetic, history of previ- ous laser-assisted in situ keratomileusis, and past facial surgery.
Intraoperative and postoperative medical and surgical management of cosmetic periocular surgery complications focus on decreasing the risk of postoperative ptosis, lagophthalmos, lid retraction, and lid asymmetry, with special attention to limiting the risk of visual loss secondary to orbital hem- orrhage.
Skin needling is also called micro-needling therapy or collagen induction therapy.
It is a minimally invasive nonsurgical and nonablative procedure for facial rejuvenation that involves the use of a micro-needling device to create controlled skin injury.
Skin needling is able to treat wrinkles of the periocular and perilabial region, cheeks, neck, and d?collet?.
Other areas of the body can also be treated such as back of the hands and arms.
Skin needling can be used for skin rejuvena- tion: a variety of needle lengths can be used to treat different depths and therefore affect different concerns on the skin.
Rollers with longer needles are used on more difficult problems such as deep ingrained wrinkles around the mouth, whereas shorter needles are used for general rejuvenation.
In case of wrinkles associated with skin aging, one or two skin needling treatments are recommended every year.
The microneedles penetrate through the epidermis but do not remove it; the epidermis is only punctured and heals rapidly.
The needles seem to separate the cells from one another rather than cut through them, and thus many cells are spared.
Because the needles are set in a roller, every needle initially penetrates at an angle and then goes deeper as the roller turns.
Finally, the needle is extracted at a converse angle, therefore curving the tracts and reflecting the path of the needle as it rolls into and then out of the skin for about 0.5 mm into the dermis.
The epidermis, and particularly the stratum corneum, remains intact except for the minute holes, which are about four cells in diameter.
The controlled injury triggers the body to fill these micro- wounds by producing new collagen and elastin in the papillary dermis; in addition, new capillaries are formed.
This neovascularization and neocollagenesis following treatment leads to reduction of scars and skin rejuvenation, i.e., improved skin texture, firmness, and hydration.
Since 1995, this technique has been used to achieve percutaneous collagen induction in order to reduce skin imperfections.
However, to date, skin needling has mostly been proposed as an effective method of treating scars (including hypertrophic scars) caused by acne, surgery or thermal burns, stretch marks, perilabial and periorbital wrinkles, photoaging, and hyperpigmen- tation, e g , in melisma.
For wrinkles of periocular region, skin needling can be considered for the treatment of crown's feet wrinkles and glabella wrinkles with good results.
Generally three or four sessions are needed to obtain satisfactory results.
Skin needling can be combined at a later stage with other noninvasive procedures such as.
Skin needling is carried out by rolling a special device over the skin comprising a rolling barrel fitted with a variable number of microneedles.
There are various skin needling devices including Dermaroller? (Dermaroller GmbH), Dermapen? (Equipmed Pty Ltd; Australia), Derma-Stamps? (Dermaroller USA), and radial disks incorporating fine microneedles of various diameter and length, fabricated from a wide range of materials such as silicon, glass, metals, and polymers. The needles are up to 3 mm in length.
The skin needling procedure takes a few minutes up to an hour to complete, depending on the area to be treated and the severity of the problem. 
No lotions, makeup, or other topical products are applied on the treatment area on the day of the procedure.
The skin is punctured in a specific pattern using a skin needling device.
The device is rolled over the skin multiple times for best results.
As each fine needle punctures the skin, it creates a channel or micro- wound stimulating skin cell regeneration.
Application of local anesthetic cream can prevent procedure pain and help in performing the procedure properly.
A minimum of 6 weeks is recommended between two treatments as it takes that long for new natural collagen to form.
Skin needling is well tolerated by patients, but dryness, scaling, redness, and swelling may be seen after treat- ment, lasting for several days or longer, depending on the depth of penetration of the needles.
Sun protection for several weeks is recommended.
As the microholes close quickly, post- operative wound infection is rare.
Emollients or antibiotic creams may be prescribed, if considered necessary.
Rejuvenation of skin may be seen as soon as 2 weeks and as long as 6–8 months after the medical procedure.
The number of needling procedures depends on the individual skin condition.
Three to four treatments may be needed for moderate acne scars.
Contraindications and Adverse Effects Some clinical condition can be considered as absolute contraindication to skin needling procedure.
Treatment with Roaccutane within the last 3 months.
Presence of open wounds, cuts, or abrasions on the skin.
Radiation treatment within the last year.
A current outbreak of herpes simplex or any other infection or chronic skin condition in the area to be treated.
Areas of the skin that are numb or lack sensation.
Pregnancy or breastfeeding.
History of keloid or hypertrophic scars or poor wound healing.
The observation of all the pre- and postoperative precautions and respect of contraindication reduce the risk of adverse effects that are minimal with this type of treatment and typically include minor flak- ing or dryness of the skin, with scab formation in rare cases, milia, and hyperpigmentation which can occur only very rarely and usually resolves after a month.
Edema and erythema are the most frequent sequelae. Recovery may take 24 h or up to a few days.
Most patients are able to return to work the following day.
Recovery time depends on the treat- ment level and the length of the needles.
Botox and skin needling are two procedures that can give good aesthetic outcome in periorbital wrinkles correction.
Professional skin needling is considered to be one of the safest skin treatment procedures for this area.
Unlike chemical peels, dermabrasion, and laser treatments, skin needling causes minimal damage to the thin skin of the periocular region.
Botox has an ideal characteristic: it is the best treatment to correct dynamic wrinkles as periocular ones.
Moreover if a complication does arise, while not aesthetically acceptable and potentially untoward, it is time limited, and the anatomical area will eventually return to its pretreatment baseline status.
For these reasons, Botox and skin needling can be considered two useful tools that physicians can use for periocular wrinkle correction.
Chemical peeling, or chemoexfoliation, is a dermatological procedure commonly used for both skin rejuvenation and some cutaneous condi- tions.
It consists of the application of one or more chemical exfoliating compounds to the skin to remove and regenerate part of the epidermis and dermis.
This may result in the improvement of the physical appearance of the skin and a decrease in the number of wrinkles, pigmentations (e.g., melasma, lentigo), and inflammatory lesions (e.g., acne, rosacea).
Many chemical compounds may be used as peeling agents and their effects may differ, varying from light to medium and deep regeneration.
This review focuses on the use of peeling in the perioral and periocular region for the treatment of aging, photoaging, and melasma.
Although chemoexfoliation represents one of the oldest cosmetic procedures, described in ancient Egyptian writings and performed by Romans as well as Indian and Turkish women through rudimentary methods to smooth the skin, the concept of peeling acquired a scientific identification in the late 1800s, when phenol was described to lighten the skin.
Soon other peeling agents (e.g., salicylic acid, resorcinol, trichloroacetic acid) were identified, and in the mid-1900s peeling procedures were used for medical purposes.
However, it was only in the 1970s that chemical peeling became popular.
Before focusing on specific peeling for the lip and eye region, a brief classification of generic chemical peeling agents is listed based on of the depth of dermal penetration.
Very superficial (glycolic acid 30–50 %, Jessner solution applied in 1–3 coats, sali- cylic acid 25 % applied in 1 coat, resorcinol, 20 % applied briefly (5–10 min), trichloro- acetic acid (TCA), 10 % applied in 1 coat), in which the area to be treated is confined to the stratum corneum, with no alteration below it.
??Superficial (glycolic acid, 50–70 % applied for 3–10 min; salicylic acid 25 % applied in 4–10 coats, pyruvic acid 40 % applied in 4–5 coats, Jessner solution applied in 4–10 coats; resorcinol, 40 % applied for 30–60 min; TCA 20 %), when part or all of the epidermis is involved.
Medium (TCA 35 %, pyruvic acid 50–60 % applied in several coats, augmented TCA (gly- colic acid 70 %+ TCA 35 %, Jessner solu- tion+ TCA 35 %, salicylic acid+ TCA 35 %), involving both epidermidis and papillary dermis.
????Deep (TCA 50 %, phenol), involving the epi- dermis, papillary dermis, and reticular dermis.
Very superficial and superficial peelings involve the stratum corneum or the epidermis in toto and represent well-tolerated treatments with very low risk of side effects.
Medium-depth peelings involve epidermis and papillary dermis, causing denaturalization of proteins, clinically characterized by skin bleaching (frosting).
Histologic modifications in connective tissue with new deposition of collagen and elastic fibers may be observed after these procedures.
They require a posttreatment procedure and are associated with some side effects.
Deep peelings cause a significant dermal injury, involving the reticular layer.
They also cause a quick and intense frost, resulting in der- mal regeneration with new deposition of collagen and glycosaminoglycans.
Special care is required for this type of peeling since severe complications may occur.
The choice of the most appropriate peeling agent, keeping in mind the related depth of penetration in the skin, is crucial.
Both perioral and periocular regions represent very sensitive anatomic areas and, therefore, in general the use of soft peelings is recommended.
This chapter reviews the types of peeling indicated for these specific areas.
(HSV) infection, prior treatments such as oral isotretinoin, radiation, or laser skin resurfacing, and photosensitizing medications should also be carefully evaluated to avoid scarring or slow reepithelialization.
Skin type and phototype should be also carefully examined.
Thicker and oily skins, for instance, are more resistant to peeling and may require a deeper treatment than other skin types.
Fitzpatrick’s phototypes IV–VI are not recom- mended for medium to deep peeling because of the high risk for pigmentary dyschromias.
A pos- itive history for other skin disorders, such as atopic dermatitis, seborrheic dermatitis, psoria- sis, contact dermatitis, or rosacea must be investigated for their potential exacerbation during the postpeeling period.
Patients with a history of HSV should be treated with antiviral drugs from the prepeel period until complete reepithelializa- tion, especially when medium-depth or deep peelings are performed.
Patients with significant history or current evidence of any psychological disorder, or with immunocompromising diseases or allergies, should not be treated.
Skin priming with topical compounds (reti- noic acid, glycolic acid, pyruvic acid, and hydro- quinone) is usually suggested 2 weeks before the peeling to improve its performance.
Skin priming allows an easier and uniform penetration of the peeling agent, reducing the reepithelialization phase as well as the risk of posttreatment hyper- pigmentation.
However, when treating the periocular and/or perioral area, skin priming should be avoided as it may irritate the skin.
Finally, complications of peeling should be considered before performing a peel, keeping in mind the direct relationship between the frequency of complications and the peel's depth.
Before considering chemoexfoliation, a series of evaluations should be made.
First of all, a thorough patient evaluation including age, sex, skin type, aging, and photoaging severity, in addition to the presence of any psychological discomfort or other skin disorders, must be considered.
Moreover, the patient's history of abnormal or keloid scarring, perioral herpes simplex virus (deeper treatments lead to more complications).
The most frequent changes are pigmentary (hyperpigmentation and hypopigmentation).
Phototypes IV–V are at higher risk especially when medium-depth peeling is performed.
Early sun exposure and/or the use of oral contracep- tives are aggravating factors.
Scarring (atrophic or hypertrophic scars) represents a relevant complication for deep peelings.
Scars usually appear on the lower part of the face (perioral region), probably due to the mechanical stretch- ing occurring in this area during eating and speaking.
Lower eyelid ectropion has also been observed 3–6 months after phenol peeling.
HSV represents a frequent complication in patients with a history of HSV recurrence when undergoing a medium-depth peeling.
HSV prophylaxis is necessary when these procedures are performed but not for superficial peeling.
Bacterial infections are not common but can be observed, Pseudomonas infection is the most problematic.
Other possible pathogens include Staphylococcus, Streptococcus, and Candida.
Persistent erythema is considered a physiological event when skin remains erythematous for up to 3 weeks after the peel.
Erythema is caused by angiogenic factors stimulating vasodilatation.
When erythema persists for more than 3 weeks and is associated with pruritus, it could be indicative of scarring formation, requiring the use for a short period of potent topical corticosteroids or systemic steroids.
Silicone sheeting or pulsating dye laser represent other therapeutic options, especially in cases of evident thickening or scarring.
Milia may occur after a period of 8–16 weeks after a procedure, probably resulting from occlu- sive postpeeling treatments.
Acneiform eruption may be observed in a small percentage of patients during the reepithe- lialization phase or immediately after, owing to an exacerbation of preexisting acne-prone skin or the use of occlusive products on the skin during the postpeeling period.
Systemic antibiotics are usually administered to obtain satisfactory results.
Allergic reactions are relatively rare and most commonly associated with the use of resorcinol.
Allergic reactions may be misdiagnosed as the clinical presentation (erythema, pruritus, edema) resembles normal postpeeling reactions.
Antihistamines together with steroids may be used to manage these complications.
Cardiotoxicity is a potentially severe compli- cation that may occur during phenol peeling.
It has been demonstrated that phenol can be responsible for cardiac toxicity, including tachycardia (arrhythmia), premature ventricular beats, bigeminy, and atrial and ventricular tachycardia, in addition to liver and kidney side effects.
It is therefore important that a phenol peel is performed by qualified physicians in an operat- ing room with cardiopulmonary monitoring of the patient.
Alpha-hydroxy acids (AHA) are a group of car- boxylic acids characterized by a hydroxyl group attached to the alpha position of the carbon atom.
AHAs increase epidermal thickness and dermal glycosaminoglycan content and are used to treat photoaging, acne, pigmentary, and keratinization disorders.
Glycolic acid represents one of the most commonly used AHAs, used both in topical creams at low concentrations (5–20 %) and as a peeling agent at concentrations up to 70 %.
Because of its small molecular weight and size, it has high skin penetration.
It is considered a relatively safe, effective, and well tolerated peeling agent.
Glycolic acid causes superficial peeling with few complications, although dermal wounds similar to those caused by 40 % TCA have been reported with the use of higher concen- tration (70 %) or in cases of prolonged exposure.
Neutralization with any alkaline solution (generally sodium bicarbonate 8–15 %) is required after glycolic acid peeling to avoid any further penetration through the deeper skin layers.
Glycolic acid can be used for both perioral and periocular regions, avoiding deep penetration or long exposure and providing prompt neutral- ization with a solution of sodium bicarbonate as soon as erythema appears.
Particular care should be taken for vulnerable areas, such as nasal ala, lips, lateral canthus, and oral commissures, which can be protected with an ointment.
Treatment can be repeated every 3–4 weeks for a total of six treatments.
Later on, moisturizers, emollients, and sun- screens must be applied for 5–7 days during the healing process.
No other particular medication is required; in addition, cream containing AHAs should be avoided for 2–3 days following the procedure.
Mandelic acid is an AHA derived from almonds.
The large size of the molecule causes a slow and uniform penetration, making mandelic acid, at 30–50 %, the ideal treatment for sensitive skins.
Although it is not specific for perioral and peri- ocular areas, it can be used with no precautions or restriction in these areas. 
Tretinoin peel is a solution of tretinoin at a high concentration, varying from 1 to 5 %, in propylene glycol.
It is applied by gauze or a brush in one or more coats and left on the skin for 4–8 h after which it is removed with water.
In consideration of its potential irritative effects, this kind of peeling should be managed with particular care in the perioral area affected by melasma, restricting the time of exposition.
Because of its teratogenicity, this type of peeling should be avoided in women at any stage of pregnancy.?
Salicylic acid is an organic carboxylic acid with a hydroxyl group in the beta position.
Its lipophilic structure allows it to easily penetrate through sebaceous glands and corneous cells, with consequent destruction and exfoliation of the upper layers of the epidermis.
It is mainly indicated for superficial and medium acne scars, particularly for those with a remarkable hyper- chromic component; inflammatory acne, rosa- cea; melasma; and photoaging.
It is not a specifically designed peel for perioral and periocular areas, but can be used in these regions with some precautions.
Patients suffering from salicylate allergy cannot receive salicylic acid as a peeling treatment.
Yellow peel (YP) is a combination of retinoic acid with phytic acid, kojic acid, and azelaic acid, which block the synthesis of melanin at different levels.
Vitamin C bisabolol, and salicylic acid are also contained in this formulation.
The name of this peel originates from the particular yellow coloration of the skin after its application.
YP allows a sort of modulating peeling involving both superficial and medium epidermis.
Furthermore, it induces new epidermis regeneration with few risks for potential dyschromia.
Mainly indicated for melasma and hyperpigmentation in general, it can be used in perioral and periocular areas, using a gentle massage and leaving on the skin no longer than 15–30 min.
Resorcinol, or m hydroxybenzene, is a compound structurally and chemically similar to phenol.
It is a reducing agent, used in concentrations ranging from 10 to 50 %, and is able to break keratin bonds and induce both epidermal regeneration and dermal fibroblast proliferation.
Resorcinol is usually applied with a spatula and left on the skin for 25–60 min, increasing by 5 min each week, according to different authors.
After the paste has been removed, the skin appears burned and exfoliates for the following 7–10 days.
Postpeel care with antibiotic and corticosteroid creams together with sunscreen is important to prevent complications (pigmentary changes and allergic reactions).
The main indications for a resorcinol peel are acne, including comedonic acne, along with pigmented lesions, melasma, and superficial scars.
It can be used in the perioral area affected by melasma.
Jessner's solution (JS) is a combination of salicylic acid (14 g , resorcinol (14 g , lactic acid (85 %, 14 g and ethanol (95 %, up to 100 ml), which can be used either alone for superficial peeling or in combination with other agents to facilitate medium-depth procedures.
Its efficacy in the treatment of comedonic and inflammatory acne and dyschromias depends on both its keratolytic and anti-inflammatory activity.
JS causes keratinocyte dyscohesion as well as intrand intercellular edema.
JS is usually applied in two to three coats with wet gauze, sponges, or a brush.
The application of the solution is typically accompanied by mild erythema and an intense burning sensation, followed by a faint frost presenting as a whitening of the skin with a dust-like aspect.
Postpeel exfoliation usually occurs within few days and may persist for up to 8–10 days.
It can be used in the perioral area affected by melasma.
Among medium-deep peeling, trichloroacetic acid (TCA) represents a good option for perioral or periocular areas affected by advanced photo- aging.
Usually used at concentrations ranging from 10–20 % to 35–50 % for superficial and medium-depth peeling, respectively, the use of TCA in concentrations higher than 35 % is not suggested because of potential scarring.
The procedure may be painful.
TCA can be applied with cotton tips, brushes, or small gauzes.
Peeling depth is easily monitored by erythema and frosting degrees.
In particular, minimal erythema represents a very superficial peeling, involving mostly the stratum corneum; mild erythema with light frosting patches corresponds to superficial peeling, causing 2–4 days of exfoliation.
White frost with a background of erythema shows a medium-depth peel and solid white frost is indic- ative of a deep peel, extending down the papillary dermis.
When TCA is applied in several coats, a deeper peeling is obtained.
In such instances it is better to use lighter TCA concentrations.
An intense burning sensation is typical of TCA peelings and requires the use of wet cold compresses at the end of the procedure.
Afterward, a cream or ointment with 1 % hydro- cortisone may be applied to soothe the skin.
Sun exposure must be avoided for 4–5 months after the procedure.
Patients should be informed about darkening skin color and potential swelling.
The exfoliation usually begins 3–4 days after the peeling procedure.
During this period the skin must not be removed to avoid postinflammatory hyperpigmentation.
If erythema persists for 2 or 3 weeks after exfoliation, the use of light cortico- steroid or zinc oxide paste is suggested.
TCA is variably responsible for changes in epidermal thickness, epidermal and dermal protein denaturation, and coagulative necrosis, resulting in epidermis revitalization, an increase in both fibroblasts and collagen types I and III, and reduction of the elastic component.
TCA should be avoided in patients with phototype V–VI because of potential darkening and scarring.
An innovative formulation of TCA, 3.75 % combined with lactic acid 15 %, specifically designed for periocular and perioral areas, has recently become available.
This combination peel was successfully used to improve periorbital hyperpigmentation with very low risk.
Perioral and periocular peelings, in consideration of the anatomic areas characterized by thin skin and sensitive skin, should be soft and never aggressive.
Radiofrequency (RF) as used in the field of medi- cine refers to the use of electromagnetic waves at radio frequencies to produce heat.
RF has been used in surgical and non-surgical aesthetic medicine for more than 70 years.
Radio frequencies between 30 and 30 MHz are generally used to produce heat at various skin levels, and hence can be used in the treatment of skin laxity and cellulite.
RF treatment makes use of a fundamental concept in the theory of electricity, namely, if a given quantity of electric current encounters a resis- tance (for DC current) and/or impedance (for AC current), heat is produced in direct proportion to the current and the resistance and/or impedance.
If RF treatment is used to destroy tissue it is referred to as "ablative RF."?If it does not destroy tissue it is referred to as "non-ablative RF"?
RF ablation procedures most commonly employ a radio scalpel when it is necessary to destroy a limited volume of skin in a controlled and reproducible manner.
RF ablation therapies are used to treat neoplasms and hepatic, pancreatic, bone, and pulmonary metastasis by means of thermoablation.
They have also been successfully used in treating pain and cardiac arrhythmia.
It is noteworthy that the introduction of an RF-ablative probe directly into a blood vessel permits the closure and destruction of the target vessel in much the same way as does laser therapy.
This technique is recommended for treating rectilinear veins such as the great saphenous vein.
?Non-ablative RF procedures have many fields of application in aesthetic medicine, especially where the common denominator is the treatment of skin laxity.
In November 2001, the Food and Drug Administration (FDA) approved RF therapy as the preferred method for the treatment for skin depressions.
The so-called "aesthetic"?effects of RF ther- apy operate on thermally damaged collagen and elastin by breaking their intermolecular bonds, which in turn brings about a re-structuring of the dermal fibers over the following weeks and, hence, elasticizing of the skin.
Monopolar RF handsets apply RF energy generated by an RF unit to one point of the skin to be treated, and a metal plate, also connected to the RF generator, is placed at another point.
Until recently the handsets used in non- ablative therapies have been of two types, monopolar and bipolar, but tripolar and quadripolar handsets are now available for the application of RF therapy .
The RF monopolar handset requires a metal plate to be placed near the area to be treated by the handset.
The RF bipolar handset does not require the use of a metal plate, since both poles of the RF generator pulses are in the handset itself.
The impedance that an RF circuit encounters depends of the conductivity of the tissue to be treated, e g , the thickness of dermis, the quantity of fat, and the thickness and structure of the con- nective and glandular tissue.
The higher the impedance of the tissue to be treated, the greater are the heat produced and the thermal effects .
Furthermore, owing to the impedance of the skin, the deeper the penetration of the RF electro- magnetic wave, the more heat it produces.
The heat induced by the RF wave travels from the skin surface to the hypodermis producing tem- peratures that vary from 30 to 35 °C at the sur- face, and from 60 to 65 °C at 9 mm.
The increase in temperature causes an increase in blood flow through vessels, leading to drainage in the adipose tissue.
In addition, the heat generated by this increase in tempera- ture shrinks the collagen fibers, creating a progressive regenerating effect during the following weeks.
New collagen results from the heat produced by RF waves through a series of intermediary steps.
The RF heat produces mediating heat- shock proteins, which in turn stimulate the T lymphocytes and monocytes to produce cyto- kines and fibroblast growth factor 1, which in turn stimulates the fibroblasts to produce the new collagen.
Histological studies conducted 4 months after treatment showed an increase in collagen density and a reduction in volume of the sebaceous glands.
Numerous studies have shown that RF treatment can be safely used on both dark and light phototypes since it does not interfere with melanogenesis.
RF treatment is indicated for skin laxity of the face and body, and has recently been indicated for the treatment of cellulite and stretch marks.
In addition, more recent studies indicate that RF can reduce hyperhidrosis.
Contraindications are pregnancy, arrhythmia, use of a pacemaker, epilepsy, anticoagulant drug use, and skin infections.
The treatment protocol prescribes one or more passes over the area to be treated depending on the complexity of the case, and each therapy ses- sion can last from 15 to 35/45 min.
The treatment requires the application of a simple gel, or a gel to which either hyaluronic acid or other active ingredients have been added to enhance the anti-aging effect (Fig. 7.3).
The heat transmitted by RF therapy can provoke an unpleasant sensation depending on the intensity of the heat, the area treated, and the sensitivity of the patient.
Immediately after treatment a slight erythema may appear over the treated area (in 35 % of patients), which disappears after 2–3 h and allows the patient to continue with normal daily activity (Fig. 7.4).
It should be noted that there are now systems for the cooling of skin that limit the dispersion of heat toward the epidermis and hence reduce the risk of skin burn.
It is advisable to apply a lenitive mask after treatment and subsequently a repair cream together with a strong sunscreen.
Very rarely tiny vesicles form, which subsequently transform into crusts that exfoliate in 4–5 days.
To facilitate this process one can apply a hyaluronic acid-based cream.
It is important to note that the patient should not be exposed to the sun in the 2 weeks following treatment, and in any case should apply a strong sunscreen whenever outdoors.
Fractional RF, termed “fractional” in analogy with the fractional laser, produces short, intense electric pulses at adjustable frequencies that travel from one electrode to another on the hand- set, thus generating heat on/in the skin to be treated.
Bipolar RF is one of the most innovative, non- invasive treatments for the face and body in the field of aesthetic dermatology.
Skin applications of fractional RF have two principal effects.
Selective vaporization of superficial layers of skin less than 1 mm.
A series of microholes in the skin which, upon healing, produce tighter skin.
The distance between holes can be varied by varying the frequency of impulse repetitions; the size and depth of the holes can be varied by varying the energy generated and emitted by the handset.
There are many types of handset used in fractional RF, which can have from a minimum of 5 to a maximum of 225 microneedles.
Treatment with these microneedles causes a series of damaged micropoints on the skin, which initiate a regenerative process.
The needles are equipped with “shock absorbers,” which allow the technician to adapt to all facial and body contours while maintaining a constant and repeatable pressure.
Fractional RF treatment involves the deep layers of the dermis and epidermis.
The skin generates in a totally natural manner without pain, thus making an immediate return to a normal social life possible.
Indications for fractional RF are facial and body skin laxity, acne scars, wrinkles at all depths, and stretch marks.
The handset is applied to each area to be treated only once.
A few minutes after treatment an erythema appears over the treated area, which then disap- pears in the course of a few hours.
It is advisable to apply a lenitive mask after treatment followed by a repair cream together with a strong sunscreen.
Three or four treatments are advisable, with a 2-week period separating each treatment.
After the initial treatment cycle, monthly maintenance treatments are advisable.
Visible results are evident after 4 months.
Two treatment cycles per year are advisable.
Given that burn points that heal in 5–7 days are a possible collateral effect of fractional RF treatment, it is advisable to apply an antibiotic ointment and hyaluronic acid cream.
In addition, the application of a strong sunscreen is necessary for at least 1 month after treatment.
Techniques Biorejuvenation is a common term to indicate mesotherapy for skin rejuvenation (also called bio- revitalization or mesolift).
It's a technique used to rejuvenate and tone the skin by means of an injection in the superficial dermis of suitable products, perfectly biocompatible and totally absorbable.
The goal of this technique is to increase the biosynthetic capacity of fibroblasts, inducing the reconstruction of an optimal physiologic environment, facilitating interaction between cells, and increasing collagen, elastin, and hyaluronic acid (HA) production.
The desired final effect is a firm, bright, and moisturized skin.
Chronoaging is responsible of clinical and histologic changes because of the intrinsic aging, like alterations in skin texture, elasticity, pigmenta- tion, and modifications of subcutaneous tissue and the vascular system.
Clinically, aged skin is characterized as thin, dry, and pale, with noticeable wrinkles and decreased elasticity.
Histologically, the epidermis becomes atrophic; there's the accumulation of elastotic material in the papillary and mid-dermis, a process known a"solar elastosis"?and quantitative changes in collagen, which are reflected in a decline in biosyn- thesis and content.
The degree of changes is genetically determined and so different in each individual.
Chronoaging can be worsened by cumulative environmental damages, such as chronic UV exposure (photodamage), pollution, and smoking.
The effect of photodamage, termed "photoaging" is characterized by wrinkles, shallowness, laxity, patchy pigmentation, and rough- textured skin that histologically are signs of hyperplasia or atrophy.
Dermal features include elastosis, degeneration of collagen, anchoring fibrils, and dilated and twisted blood vessels.
UV exposure activates free radicals and matrix-degrading metalloproteinase enzymes, including collagenase.?
The mesotherapy can be performed in cases of mild to moderate chronoaging and photoaging, aging prevention, and preparation to sun exposure and smokers.
The treatment is indicated for both young skin, yet elastic and vital, to reduce the physiological aging process, because the used substances ensure deep hydration that delays the onset of age-related imperfections and counteracts oxidative damage that is caused by environmental factors and exposure to sunlight, and for mature skins, to reduce the signs of chronoaging by reactivating the cellular functionality.
Biorevitalization performs three main functions.
??Restructuring: it promotes cell turnover and the production of collagen, elastin, and hyaluronic acid.
????Antioxidant: it protects the skin from free radicals that are released as a result of environmental factors and solar radiation.
?????Moisturizing: it promotes the rapid recall of water in the tissues.
It allows to obtain substantial improvements in terms of (Fig. 8.2).
Mesotherapy injection is a minimally painful procedure and requires no anesthesia.
The sessions are performed in cycles and do not involve side effects except in rare cases, a slight temporary redness or a small bruise in the area due to the trauma of the needle insertion, which tends to disappear spontaneously in 2–3 days, and usual activities can be resumed immediately.
The main advantages/disadvantages and con- traindications are listed in Table 8.1.
The desired effect – firm, bright, moisturized skin – can be achieved by microinjections in the superficial dermis of products  containing only one active ingredient or “cocktails” of dif- ferent compounds that are biocompatible and absorbable.
The products available in mesotherapy for skin rejuvenation are Hyaluronic acid alone (1.35–3 %), Hyaluronic acid 0.2, 1, or 3 % plus other active ingredients like vitamins, amino acids, miner- als, coenzymes, nucleic acids, and β-glucan, Macromolecules,  Organic silicium, Autologous cultured fibroblasts, Growth factors, Homeopathic products.
The most frequently used substance is natural non-cross-linked hyaluronic acid (Fig. 8.4).
Chemically HA is the major nonsulfated glycosaminoglycan of the connective tissue scaffold, synthesized by fibroblasts within the cell membrane and then released in the extracellular space.
Interestingly, the injection of simple HA not only provides enrichment of one of the main ECM compounds and deep hydration of the skin but also stimulates fibroblasts, acting on specific receptors (CD44, RHAMM, and ICAM-1)4 to synthesize new scaffold compounds.
One gram of HA can bind up to 6 L of water.
This means that the higher the percentage of HA is in a composition (milligrams of HA per milliliter), the higher its capacity to retain water will be.
Derived either from rooster combs or from bacterial fermentation, HA has no species specificity, and the risk of a hypersensitivity reaction is so low that skin testing is unnecessary.
Hyaluronic acid used in mesotherapy is not cross-linked, it is not much stable, it is very fluid, and it has a short half- life, even shorter than the one used in fillers.
The great versatility of biorevitalization lies in the different biological effects of the injected active substances.
The synergy of different func- tional ingredients can treat skin in a more com- plete way, acting on various age-related marks caused by both intrinsic and extrinsic aging fac- tors, with a preventive and curative action.
In a mesotherapy cocktail, vitamins are the most important active component.
Vitamin A regulates the epidermis turnover and it is an antidrying agent.
The “vitamin B complex”—usually indicating a group of vitamins that includes vitamin B1 (thi- amine), B2 (riboflavin), B3 (niacin), B5 (panto- thenate), B6 (pyridoxine), B9 (folic acid), and B12 (cyancobalamin)— includes coenzymes involved in several metabolic processes that help the scavenging of free radicals.
Vitamin C is a well-known antioxidant and it induces collagen synthesis.
Vitamin E is an antioxidant and moisturizer.
Vitamin K has an effect on microcirculation.
Vitamin D, vitamin H (biotin), vitamin B10, and vitamin I (inositol) are important too.
The amino acids build polypeptides constituting the matrix of cell architecture.
Sodium, potassium, calcium, and magnesium act as catalysts in numerous cell functions.
Coenzymes are nonprotein organic components that help the enzymes in their catalytic function.
They are"activators"?of biochemical reactions and help the dermis turnover.
DNA and RNA are bound to proteins, and they give information for the regulation of protein synthesis.
β-Glucan acts as a free radical scavenger.
Polynucleotidic macromolecules favor skin hydration increasing water retention; they act as scavengers of free radicals, and they enhance the physiologic activity of fibroblasts.
There are different injection techniques in the superficial dermis (Fig. 8.5) that can be per- formed always keeping the needle with an incli- nation of 45°
Picotage: it’s more useful in younger people who want to prevent skin aging due to sun exposure and tanning sunbeds.
It consists of microinjections, is very superficial, is practi- cally painless, and is spaced at 2 mm, and the needle penetrates the treated area at 2–2.5 mm.
During the procedure the physician maintains a constant pressure on the plunger. The mostly cured areas are the face, neck, decollete, and less frequently hands (Fig. 8.6).
Cross-linking: it is recommended for the pre- vention and treatment of skin aging (patients with a more advanced stage of chronoaging, compared to the prior technique).
It consists in performing intradermal linear infiltrations with a complete penetration of needle verti- cally and horizontally, spaced at 1 cm, to form a grid.
The product is injected during the extraction of the needle from skin dermis.
Linear threading: either vertical or horizon- tal injections are performed.
Vertical injections are useful to prepare the nose-labial and glabellar wrinkles 10–15 days before injecting dermal fillers and botulinum toxin.
Horizontal injections are useful in treating neck wrinkles.
To reduce the burning sensation, the physician can apply anesthetic cream 1 h before the treatment.
It is recommended to avoid injecting products containing also vitamin C After the treatment, a gentle massage with a vitamin K cream can be given.
The procedure generally takes about 20 min, but it may vary depending on the treated area.
Sun and smoking avoidance are recommended for the next 48 h There is no downtime or recovery time with this procedure (Fig. 8.7).
Treatments should be done once every 2 weeks for 3–4 weeks, then once a month for 3–4 months.
The results are maintained by touch-up treatments once or twice a year.
This protocol may vary according to the patient's age, clinical presentation at first visit, and response to initial treatments.
Typically, 2–3 treatments are necessary to see some results, even if the bright- ness is visible after the first treatment, due to a vascular stimulus by the microinjections.
The number of treatments can vary from patient to patient and depends on the treated area and patient's expectations.
It is important to remem- ber that mesotherapy is not a filling technique, but it permits the rejuvenation of the skin by increas- ing its hydration and by reconstructing an optimal physiologic environment for the fibroblasts.
Sessions of biorevitalization can be performed in combination with other treatments, surgical or not, such as peeling, face lift, eyelid surgery, fillers, infiltration of botulinum toxin, and laser treatments.
Biorejuvenation can be used to prepare the skin 2 weeks before the injections of other products.
This is because biorevitalization works improving globally the skin unlike other treatments that act more locally.
Among these are: Peelings The purposes of chemical peelings are to erase shallower wrinkles, restore tone, give freshness and radiance to the face, eliminate dark spots and scars, etc.
Peelings represent an accelerated form of exfoliation induced and controlled by the use of one or more caustic chemicals applied to the skin.
Depending on the agent used, its concentration and the time of application, these preparations cause a partial or total programmed destruction of the epidermis.
The effect is the stimulation of cellular turn- over through the removal of the horny layer and, simultaneously, the induction of the synthesis of new collagen in the dermis.
The result is the replacement of old tissue with a healthier and less corrupt one.
There are three broad categories of peelings which act in different ways depending on the depth of penetration of exfoliating: the superficial peelings, middle, and deep ones.
Superficial peelings: they allow the immediate resumption of work and social activities.
The treatment is ambulatory and is composed of cycles with more spaced sessions (intervals of 7–15 days apart), also can be performed twice a year, for example, glycolic acid peels, salicylic acid peels, and retinoic acid peels.
Medium or deep peelings: they are suitable for individuals with badly damaged skin by the chrono- and photoaging or for skin that pres- ents wrinkles and rather deep furrows and spread discoloration.
This kind of peelings requires a recovery period at home during which skin exfoliation occurs and is much stronger than after a superficial peel.
An example is trichloroacetic acid peel that may be superficial, medium, or deep depending on the concentration of acid used.
The results depend on the type of peel made; for example, a deep one has a definite result and only one treatment is required, while the medium peel and the superficial ones are less invasive, but allow less lasting results and therefore need to be repeated regularly.
All types of peels require careful and meticulous aftercare treatment, consisting basically in no sun exposure until healing has occurred (or cycle ended) and the use of sunscreens, emollient creams, and products based on alphahydroxy acids for home use.
Fillers In cosmetic medicine "fillers" are materi- als that are injected into the dermis or subcutaneous tissue in order to fill a depression or increase the volume.
They may be transient, when their cosmetic-clinical effect ceases after some time, and permanent, remain where injected, for life.
Hyaluronic acid gel fillers are now the most used and safe and they are completely resorbable.
Another widely used material for particular anatomical areas is the calcium hydroxyapatite (this filler is usually composed for 30 % of micro- spheres of synthetic calcium hydroxylapatite (CaHA) and 70 % from an aqueous gel solution).
No one of the so-called "permanent"?fillers has been approved by the FDA.
The permanent fillers (non-resorbable) were basically created for the need to make a correction very durable.
Unfortunately, experience has shown that very often this intent is illusory, not because the substance does not remain long in the skin tissue but because it has its own weight and density that lead it slowly to migrate from the implant site following the force of gravity.
So there is a progressive appearance of the filler in a different region from the injection site.
More serious is the frequent appearance, years after the implantation, of very serious local inflammation, abscesses, and granulomas or thick areas of fibrotic tissue that follow for months and years tormenting the patient's appearance, his/her health, and his/her normal social life.
The best known is the liquid silicone, however, banned in Italy by ministerial decree in 1993.
Fillers can be used to treat facial wrinkles, after a restrictive and low-calorie diet or after a prolonged period of illness, when we see the area of the cheeks gaunt; very satisfactory is the instal- lation of fillers in the lips for young women and even older women to give volume and firmness to the face, to redesign the profile of the nose (rino- filler), for reconstructive purposes, depressed scars, results of acne and chicken pox, asymme- tries, and facial atrophies, and in all cases where we want to take care of ourselves from the aes- thetic point of view.
The hyaluronic acid gel is injected into the dermis with thin needles of different diameters and lengths depending on the viscosity of hyaluronic acid and the area to be treated or with ago cannulae.
The aesthetic result is very natural and the absorption of the substance is gradual.
The material is fully resorbable, and its duration is very satisfactory, generally 8–12 months or more, depending on the areas treated, the individual characteristics, and lifestyle.
After the injections mild redness is frequent, but disappears in a matter of hours without a trace, and variably, a slight swelling.
You could also have the formation of some bruisings or hematomas (caused by rupture of a small capillary during injection) which resolves spontane- ously and in a short time with the local application of creams based on vitamin lactoferrin.
It is not advisable to expose the treated area directly to the sun or sunlamps.
It is also advisable not to rub and massage the site for 24 h and not to apply any makeup for at least 3–4 h after.
Botulinum toxin The botulinum toxin is a protein produced by the bacterium Clostridium botu- linum that, by blocking the transmission of nerve impulses, reduces muscle contraction.
Only a fraction of the toxin (type A is used in aesthetic medicine, purified and diluted in saline.
After a careful study of facial expressions of the person, the physician practices many small injections in the chosen areas, paralyzing the underlying muscles producing a "lifting effect." The areas of choice of Botox are wrinkles around the eye and the eyebrow, but also the wrinkles of the forehead.
In other words, the Botox is suitable for correcting the wrinkles arising from facial muscle movements (facial expres- sion muscles).
The effect is temporary, 4–6 months, and starts a week after the infiltration.
The microinjections of botulinum toxin which, of course, are not toxic are not painful and do not cause swelling.
There is a theoretical risk of a hypersensitivity reaction to the product itself or to the additives contained in it, which in any case is directly pro- portional to the amount administered.
In particular, the current formulations of botulinum are contraindicated for people with allergies to milk, because they are used as a preservative albumin.
Furthermore, the botulinum toxin is not? recommended during pregnancy and lactation.
The "mesobotulino"?is one of the most interesting methods in the field of rejuvenation.
It consists of microinjections of botulinum toxin in very diluted form, with a cocktail of amino acids and vitamins that aim to correct the oval of the face, cheeks, and sagging chin and neck profile.
The action of vitamins, combined with the par- alyzing botulinum, smoothes the skin and gives a lifting effect.
The treatment is safe and provides only a slight annoyance given by injections.
Laser Fractional CO2 laser is the first choice for sun damage, wrinkles, and texture because it eliminates the superficial layers of the skin, stim- ulating at the same time, the contraction of the fibers of collagen, and elastin in the dermis.
The fractional CO2 laser can shrink the skin and reduce the appearance of fine wrinkles and large pores; it can act effectively even on acne scars and skin discoloration.
It practically eliminates the superficial layer of the skin and, at the same time, strongly stimu- lates the deep layers so as to have an intense process of rejuvenation or tissue repair.
The use of the fractionated scanner instead of the previous type "ablative"?greatly reduces the down time (time to return to social life after the treatment) because the microareas treated are spaced with free areas with the result of a more rapid healing.
Since Albert Einstein first developed the concept of laser radiation, physicians have used lasers along with other components of the electromag- netic spectrum in a variety of medical and cosmetic applications.
Appreciation of the physics behind lasers provides a foundation for understanding its applications.
The electromagnetic spectrum comprises radiation energy spanning short gamma waves to long radio waves, and in between it includes x rays, ultraviolet radiation, visible light, infrared light, and microwaves.
If sufficient electromagnetic radiation is absorbed by resting atoms, their electrons are stimulated to excited states.
When these electrons eventually return to resting states, the atom releases the same absorbed energy at its wavelength in a process known as"spontaneous emission."?Spontaneous emission may be hastened, or stimulated, when an excited atom is irradiated a second time with the same wavelength used to excite it originally.
The second hit may come from a new source of energy or from spontaneous emissions of nearby atoms.
As a result, if atoms are concentrated in a particular medium and confined within a reflective charged cavity, emissions may become markedly amplified because of the interaction of the spontaneous emissions and the surrounding stimulated atoms.
Maiman was the first to demonstrate Einstein's theories of stimulated emission using visible light .
This led to his coining the now familiar acronym LASER, which stands for light amplification by stimulated emission of radiation.
Although light technically refers to the visible spectrum, all laser emissions, whether in the visible spectrum or not, are generally referred to as laser light.
The wavelength of the laser light is dependent on the medium of the reflective charged cavity.
In the original Maiman study, ruby crystal made up the medium, but since that time several other mediums, such as alexandrite, potassium titanyl phos- phate (KTP), and others, have been used to generate other wavelengths in medicine.
Laser light is monochromatic, coherent, and collimated.
Monochromaticity results from its consisting of one wavelength.
Coherence refers to light waves that travel in phase, both in time and space, and collimation relates to the parallel nature and lack of divergence of the light waves.
Use of lasers by physicians was revolutionized by the concept of selective photothermolysis.
Essentially, selective photothermolysis takes advantage of the heterogeneous absorption spectra of anatomic structures, particularly chromophores . such as melanin, hemoglobin, and water.
Laser light energy absorbed by a target chromophore is converted primarily to heat, destroying the chro- mophore itself and the surrounding cell.
The heat created at the site of the target chromophore may dissipate to surrounding cells, causing their destruction.
The preferential absorption of these structures for different wavelengths permits their targeted ablation, coagulation, or thermal damage with important preservation of surrounding structures.
Successful laser use, however, relies on more than wavelength and target.
Training, experience, and management of settings such as fluence, spot size, and pulse width are critical to safe and effective clinical outcomes.
Fluence is a measure of the laser's energy in joules per centimeter squared.
Spot size is clinically important since larger spot sizes may cause peripheral damage around small targets.
It also results in deeper penetration of the laser's effects, but with more scatter.
Pulse width is a measure of laser exposure time and is clinically relevant because of its relationship to ther- mal relaxation time (TRT).
For a given tissue target, TRT is the time required to lose half of its heat.
If the pulse width is longer than the TRT, less ablation and more surrounding damage in the form of coagulative necrosis occurs.
The objective of this chapter is to review common applications of lasers for the treatment of periorbital concerns.
These applications are broad and include resurfacing as well as the elimination of unwanted vascular and pigmented lesions.
Although some of the technologies dis- cussed in this chapter now serve as newer tools in traditional surgery, such as lasers in place of scal- pels for making incisions, the following discus- sion will primarily concentrate on the role of the technologies when employed as the primary therapeutic intervention.
Noninvasive and minimally invasive treatments for periorbital photodamage and rejuvenation have grown markedly in recent years.
Today's strategies commonly employ resurfacing lasers in addition to the related technology of radio frequency, which is discussed in a separate chapter.
These technologies have shown effectiveness improving skin laxity, rhytides, scars, and more recently premalignant changes of the skin, namely, actinic keratoses.
Originally, resurfacing lasers were nonfractional and fully ablative carbon dioxide lasers.
Though they delivered impressive results, they came with substantial risks, particularly for scarring and hypopigmentation.
With regard to periorbital treatments, scarring could further lead to ectropion, entropion, andepiphora.
Nonfractional, non-ablative laser alternatives followed, which were safer, but delivered less impressive results.
With the advent of fractional lasers, meaningful rejuvenation became achievable with far less risk.
The seminal concept of fractional laser delivery was first described in 2004 and has since been applied to non-ablative and ablative devices.
In essence, a fractional system delivers laser in a pixilated pattern, creating zones of injury surrounded by areas of unaffected skin.
Evidence for the efficacy and safety of these systems for periorbital treatment is now supported throughout the literature.
A retrospective study of 31 patients treated with a non-ablative fractional resurfacing laser to the upper and lower eyelids was evaluated for changes in eyelid tightening and eyelid aperture.
The laser consisted of a fractionated 1,550 nm erbium-doped fiber laser and was delivered over 3–7 treatment sessions.
All patients achieved eye- lid tightening, without any concerning adverse effects or downtime.
Just over half, specifically 55.9 %, also achieved increase in eyelid aperture.
Improvement in eyelid tightening and aperture can be seen in Fig. 9.1.
Ablative systems have also been formally evaluated around the eye.
A pro- spective study of 15 patients evaluated the effect of an ablative fractional carbon dioxide laser resurfacing treatment for laxity of the eyelid and periorbital skin.
Investigators found a 53.1 % improvement in rhytides and 42.0 % improvement in skin redundancy.
The only adverse effects reported in the study were two patients experiencing post-inflammatory hyperpigmentation that resolved after 3 months with hydroquinone and sunscreen.
While that study did not report any serious adverse effects, ectropion has been 9 reported following ablative fractional carbon dioxide resurfacing on the lower eyelids.
Overall, improvement in skin laxity and fine rhyt- ides with fractional carbon dioxide resurfacing can be seen in Fig. 9.2.
Surgeons should notably be aware of the value of these rejuvenating laser systems for the improvement of surgical scars, since their efficacy has been shown for a variety of scar types.
One study objectively and quantifiably examined the effect of ablative fractional carbon dioxide laser resurfacing of 19 atro- phic scars resulting from surgery or trauma.
Subjects were treated 3 times and followed for 6 months.
Subjective assessment of treated scars both by investigators and patients found improvement in skin texture.
These findings were confirmed by optical tomographic analysis that quantifiably demonstrated a 38.0 % mean reduc- tion of volume and 35.6 % mean reduction of scar depth.
In addition to the cosmetic enhancements achievable with these technologies, the medical value should not be underestimated.
Periorbital skin cancers commonly challenge ophthalmic and dermatologic surgeons.
Laser resurfacing has recently been shown to be valuable against premalignant changes, namely, actinic keratoses, which may serve as precursors to squamous cell carcinoma.
The mechanism of therapy is not yet understood, but the clinical response is evident, as in Fig. 9.3.
The authors of this chapter frequently employ a non-ablative fractional thulium 1927 nm laser as field treatment to reduce actinic keratoses over the face, including periorbital skin.
Several pigmented concerns of the periorbital skin respond to laser therapy.
Commonly used lasers for pigment include the ruby, alexandrite, diode, and neodymium-doped yttrium aluminum garnet (Nd:YAG), as their wavelengths can target melanin.
These lasers effectively treat periorbital lesions such as ephelides, lentigines,caf? au lait spots, nevi of Ota, congenital melanocytic nevi, and tattoos.
Ephelides, also known as freckles, arise on sun-exposed areas as well-defined circular or oval hyperpigmented macules of just a few millimeters.
While not precancerous themselves, high concentrations of ephelides on the face have been associated with genetic variations in the melanocortin 1 receptor (MC1R).
MC1R gene variants are also associated with fair skin, red hair, and melanoma and nonmelanoma skin cancer.
On pathology, an ephelide demonstrates normal epidermal configuration, but tends to have larger melanocytes in the basal layer with additional dendritic branching.
Lentigines may be characterized as simple or solar and may involve mucosal surfaces, unlike ephelides.
Simple lentigines arise at an earlier age and in any location in contrast to solar lentigines, which arise in adulthood and in sun- exposed areas.
Solar lentigines appear with increasing age and are a sign of photodamage.
Lentigines are well-defined circular or oval hyperpigmented macules and tend to be slightly darker and larger.
Lentigines display elongated rete ridges on pathology, with more numerous melanocytes than typical skin.
The solar lentigo has rete ridges that are more uniform and clubbed in appearance when compared to the rete ridges of a simple lentigo.
Lentigines are associated with several genetic syndromes, including LEOPARD, which also demonstrates ocular hypertelorism, and Peutz-Jeghers syndrome, which often includes periorbital and conjunctival lentigines.
Ephelides and lentigines are treated similarly and effectively with lasers targeting pigment.
A study of 34 pigmented lesions, including lentigines, was performed using the Q switched ruby laser at settings of 694 nm, 40 ns pulse duration, and 4.5 and/or 7.5 J/cm2.
Substantial clearing was appreciated in the lentigines with just one treatment at either fluence.
Long-term follow-up reveals efficacy in the majority of patients with lentigines.
In another study of 10 patients with solar lentigines treated once or twice with the Q switched ruby laser, 77 % demonstrated continued response at 10–21 months follow-up.
Photopigmentation was also found to be effectively treated with a 1927 nm non-ablative fractionated thulium laser.
Treatment produced moderate to marked improvement in overall appearance and pigmentation with high patient satisfaction.
The response to treatment was main- tained at 1 and 3 months' follow-up.
Congential melanocytic nevi are collections of melanocytes presenting as flat or raised blue- brown lesions, with or without excess hair, and with an increased risk of melanoma when giant.
Intervention depends on risk of progression to melanoma, cosmetic disfigurement of the lesion, and complexity of removal.
Laser therapy is helpful, but is also controversial based on questions of dysplastic effects of lasers on nevi and an increased risk of melanoma in some congenital nevi.
In addition, recurrence of lesion and color is not uncommon.
One strategy for treatment is laser ablation.
In a study of 13 patients with medium-sized congenital nevi, as much tis- sue as possible was excised, followed by erbium/ YAG ablation of residua. 83 % of patients were rated as having good to excellent results by the physician global assessment scale, and 77 % of patients reported good to excellent results at 4 months after treatment.
Ablative lasers have also been successful in dark skin types.
Another approach involves pigment-specific lasers.
In a study, 9 patients with medium-sized congenital nevi on the face or upper limbs were treated on average 9.6 times with a Q switched ruby laser.
After treatment, 0–20 % of the lesions' color remained.
However, 8 demonstrated slight repigmentation that responded to additional treatment.
One lesion returned to its original color within a month of its final treatment and therefore was simply excised.
The periorbital pigment concerns in Asian skin can also pose a challenge in terms of correcting nevi.
In one study, 7 small congenital nevi in 24 Korean patients were treated with Er:YAG laser followed by long-pulsed alexandrite laser at 1-month intervals.
At 8 weeks after the final treatment, all treated nevi showed complete removal of pigmentation with only one recur- rence of pigment after 6 months.
A nevus of Ota is a blue-brown patch that usu- ally arises in infancy, around puberty, or in pregnancy.
A favored site is the periorbital skin.
Often the ipsilateral sclera shows blue-brown hyperpig- mentation as well.
Less commonly, other components of the eye can be affected, and, importantly, glaucoma may be seen in 10 % of those affected with nevus of Ota.
The pathology explains the blue hue to the skin, namely, a higher than normal concentration of dermal melanocytes.
Laser treatment is effective against the cutaneous periorbital features of nevus of Ota and has been demonstrated with numerous lasers, including the alexandrite, ruby, and Nd:YAG.
Notably, these same laser measures are not safe as therapy for scleral involvement of the pigment.
One study composed of 602 Chinese nevus of Ota patients found benefits with each additional treatment using a Q switched alexandrite laser.
The study also found poorer response on the eyelid skin, which is referred to by some as the "panda sign."?
They recommend discounting the traditional Tanino classification of nevus of Ota, which is based on clinical distribution, and instead adopting a system based on response to laser treatment.
In addition to the endogenous pigment con- cerns discussed above, exogenous pigment in the form of tattoos can be found periorbitally.
The steady rise in the use of tattooed makeup around the eyes has been accompanied by, not surpris- ingly, an equally steady rise in the number of patients seeking periorbital tattoo removal.
Another study of 119 nevus of Ota patients demonstrated a marked periorbital under-response.
Common challenges to periorbital tattoo removal are preservation of hair follicles, as these tattoos are typically placed along the eyelash and eye- brow lines, and the avoidance of red, white, and beige/brown tattoo pigment since these pigments paradoxically darken with Q switched laser treatment.
The phenomenon of paradoxical darkening is generally attributed to the reduction of ferric oxide (Fe3+) to ferrous oxide (Fe2+) in the pigment.
Because of both challenges, periorbital tattoo removal is often accomplished with the careful use of a Q switched Nd:YAG and/or an ablative laser, particularly a fractionated carbon dioxide laser.
The Q switched Nd:YAG allows for small spot sizes that better target fine eyelid tattoos and lessen risk of adjacent follicle damage.
An effective response to the Q switched Nd:YAG can be seen in Fig. 9.4.
Ablative lasers are incorporated when red, white, and beige/ brown pigments are present, since these lasers do not cause paradoxical darkening.
These ablative lasers effectively clear tattoos via superficial tissue vaporization and subsequent transepidermal elimination of unwanted tattoo pigment.
Another study found that the short- pulse erbium-doped yttrium aluminum garnet (SP Er:YAG) laser was superior to the Q switched Nd:YAG laser and Q switched alexandrite laser for removing cosmetic tattoos of white, flesh- colored, and brown inks.
With the Q switched lasers, all three pigments darkened initially and then resolved gradually requiring up to 20, 18, and 10 sessions to remove white, flesh-colored, and brown tattoos, respectively.
Only six sessions were required with the SP Er:YAG laser.
Numerous vascular concerns of the periorbital skin are effectively treated with lasers, specifi- cally the pulsed dye laser (PDL) or KTP laser, as their wavelengths effectively target hemoglobin.
Common examples include superficial infantile hemangiomas, capillary vascular malformations, venous malformations, spider angiomas, cherry angiomas, telangiectasias, reticular veins, pyogenic granulomas, and purpura.
Hemangiomas are benign proliferative vascular tumors of endothelial tissue that affect 2–3 % of newborns and up to 10 % of infants within the first year.
The majority affect the head and neck, with 16 % of facial hemangiomas involving the eyelid.
They may present as superficial, deep, or compound (superficial and deep) and display many months of a proliferative phase followed by spontaneous involution at rates of about 10 % per year.
Particular attention must be paid to deep and compound hemangiomas around the eye because of potential for amblyopia from anisometropia, strabismus, and obstruction, all of which can be exacerbated during the hemangioma's proliferative phase.
Despite involution, residual cosmetically undesirable effects are common in any form of hemangioma.
Some report textural changes in up to 50 % of heman- giomas after involution.
Long-term residua from hemangiomas are more common when involution occurs over a longer period of time, and unfortunately no methods of identifying rate of involution presently exist.
The hemangioma and potential residua are recognized as caus- ing psychological strain in children and family members.
In general, laser therapy is not the ideal choice for deep hemangiomas because of their limited depth of penetration.
However, for super- ficial hemangiomas, PDL is an excellent treatment option as it is safe and effective and minimizes extent of proliferation and residua if treated early.
A report of 22 patients highlights the value of early treatment of superficial eyelid hemangiomas with the 595 nm PDL.
These patients underwent 2–14 treatments, initiating therapy at 5–28 weeks of age. 
77.3 % received an improvement rating of excellent (7–100 % improvement) and 36 % demonstrated complete clearance.
No scarring, atrophy, hypopigmentation, infections, or ulcerations occurred during the study period, with the only side effect being hyperpigmentation in two subjects.
Catalyzing its resolution and presumably limiting the proliferative phase likely contributed to the patients having no hemangioma residua.
This report is in contrast to historical reports that resulted in side effects, particularly atrophy and hypopigmentation, but these side effects are attributable to the use of higher fluences, smaller spot sizes, absence of epidermal cooling, and different PDL wavelengths.
Two examples of the efficacy of treating superfi- cial infantile hemangiomas with the PDL on the eyelid are shown in Figs. 9.5 and 9.6.
Vascular malformations are localized defects of vascular morphogenesis, which is in contrast to the neoplastic nature of hemangiomas.
They are categorized by their anomalous vessels (e g , capillary, venous, arterial, lymphatic) and by whether they have a fast (arterial) or slow flow.
Capillary vascular malformations (CVMs), often referred to as portwine stains, are observed in 0.03 % of the population.
Facial CVMs classically course along the distribution of trigeminal nerve sensory branches, namely, V1 (ophthalmic), V2 (maxillary), and V3 (mandibu- lar) branches.
When present, especially around the eye, risks of coincident glaucoma and choroi- dal vascular malformations exist, as do concerns for syndromic capillary venous malformations such as Sturge-Weber syndrome, von Hippel- Lindau syndrome, and Bonnet-Dechaume syndrome.
Over years and without treatment, CVMs typically develop vessel ectasia, which corresponds to the thickening, darkening, and cobblestoning appearance in aged lesions.
Exuberant overgrowth can potentially lead to visual field obstruction of the eye or airway depending on location.
The PDL is an important therapy in the treatment of periorbital CVMs and should be considered a treatment of choice for flat or mildly hypertrophic lesions.
Other technologies are helpful, however, as intense pulsed light and the alexandrite lasers, among others, have demonstrated efficacy and even advantage in some situations.
Early treatment has been shown to be safe and more effective.
Although anatomic differences do exist in terms of response to laser and light treat- ments, periorbital CVMs tend to respond well.
Efficacy from treatment with the 595 nm PDL can be appreciated in Fig. 9.7.
Venous malformations are examples of abnormal venous morphogenesis.
While sclerotherapy with or without surgical excision is an important therapeutic option to consider, relatively long- wavelength lasers that penetrate more deeply into cutaneous veins may serve as an effective requiring medically necessary surgical interventions generally expect and accept purpura.
However, purpura from a cosmetic procedure is often more frustrating for patients, as many of these patients demand little downtime or choose to have the procedure before important social events.
Whatever the cause of purpura, the PDL can effectively accelerate the resolution.
This was demonstrated in a study of ten adults with far more rapid resolution of purpura after treatment with a 595 nm PDL at spot size of 10 mm, fluence of 7.5 J/cm2, and pulse duration of 6 ms. 
When faced with appropriate candidates in our practice, the authors of this chapter often utilize a long-pulsed 532 or 1064 nm KTP laser with effective results.
Other collections of superficial vessels, including spider angiomas, cherry angiomas, telangiec- tasias, reticular veins, and pyogenic granulomas, also respond well to laser therapy.
Xanthelasma, or xanthelasma palpebrarum, is a soft, yellow papule and plaque involving the periorbital skin.
Histologically, the lesions consist of foamy, lipidladen histiocytes.
For some, xanthe- lasma is a sign of hyperlipidemia and for a small minority a sign of familial hypercholesterolemia.
While most patients with xanthelasma are nor- molipidemic, there is new evidence that normo- lipidemic patients with xanthelasma have similar cardiovascular risk to hyperlipidemic patients and should therefore be fully investigated in order to allow detection and early management of such risk.
Benefits of diet or medical therapy to treat xanthelasma are minimal, leaving most patients to rely on surgical or laser intervention if removal is desired.
Traditionally destructive methods, such as cryotherapy, chemical peeling, scalpel surgery, and electrosurgery, have not delivered sustained results and bring substantial risks for scar, dyspigmentation, ectropion, and eyelid asymmetry.
Interestingly, several types of lasers have shown efficacy against xanthelasma, including those traditionally used for pigment, blood ves- sels, and resurfacing.
Ablative lasers were studied initially.
One study of 23 patients with a cumulative total of 52 xanthelasma lesions assessed efficacy of an ultrapulse carbon dioxide (CO2) laser with a follow-up period of 10 months .
One treatment cleared all lesions, although three patients developed recurrence and dyspigmentation was found in 17 %.
Importantly, no scarring was reported.
Another study investigated the use of the erbium/YAG laser in 15 patients with 33 xanthelasma lesions.
With one treatment, the authors report complete clearance with- out dyspigmentation or scarring.
Recently, in a case series, 20 lesions were reported to be removed after a single ultrapulse CO2 laser (10,600 nm) treatment with only two patients developing recurrence during the follow- up period of 9 months.
Both these patients had been treated earlier by different modalities in the past.
Side effects included only post-inflammatory hyperpigmentation in two patients.
A recent study of twenty patients compared the efficacy of ablative fractional CO2 laser to super-pulsed CO2 laser and found that downtime was significantly shorter for lesions treated by fractional CO2 compared with those treated by super-pulsed CO2 laser.
Patient satisfaction was also significantly higher for lesions treated by fractional CO2 laser, especially flat plaques of xanthelasma that occupied large surface areas, compared with those treated by super-pulsed CO2.
For giant xanthelasma palpebrarum, twelve patients were treated with ultrapulsed CO2 in three to four ses- sions at 15-day intervals with complete resolu- tion and only one recurrence at 6 months.
Despite success with ablative lasers, non- ablative alternatives are desirable to minimize risks even further as well as to bypass the need for wounding, injection of local anesthetic, and downtime.
Some claim benefits of the 1064 nm Nd:YAG.
However, a controversial subsequent report of 37 patients with 76 lesions found both the 1064 and 532 nm Nd:YAG inef- fective, even with more aggressive parameters.
However, another non-ablative alterna- tive, specifically the PDL, has shown greater promise.
In a study of 20 patients with 38 lesions, patients underwent 5 treatments with the 585 nm PDL at 2–3-week intervals.
About two- thirds demonstrated greater than 50 % improvement and one quarter demonstrated greater than 75 % improvement.
A novel use of the non- ablative 1,450 nm diode laser for the treatment of xanthelasma was reported with 12 (75 %) of the 16 patients achieving moderate to marked improvement.
Additionally, there is evidence that supports non-ablative fractional resurfacing as a means to remedy xanthelasma.
In a report, a 52-year-old woman with 4 years of xanthelasma was treated with the 1550 nm erbium-doped fractional laser.
After 7 treatments at 4–11-week intervals, the patient achieved near total improvement.
Periorbital adnexal structures, both normal and abnormal, can be removed with success using lasers.
These structures include unwanted normal hair, trichiasis, syringomas, and hidrocystomas.
Laser hair removal has become a practical and often permanent means to remove unwanted hair.
Removal generally relies on pigment- specific lasers that target melanin in the hair follicle, although intense pulsed light devices are sometimes used with good response.
Hair follicle elimination and destruction are observed clinically and histologically following laser treatment.
Because pigment serves as the target chromophore, blonde or white hairs are not as responsive to treatment.
Abnormal hair may also be targeted, so long as it is still pigmented.
One report demonstrated efficacy of periorbital laser hair removal in ten patients with eyelid trichiasis after treatment with the ruby laser.
At settings of 3 J and a 3.5 mm spot size, the ruby laser completely eliminated eyelid trichiasis in 6 patients after 1–3 sessions.
Another three patients achieved a partial response.
The tenth patient was lost to follow-up.
Importantly, there were no reported complications and the procedure was well tolerated.
Abnormal tumors of the adnexa, most commonly syringomas and hidrocystomas, are also treatable with lasers.
Syringomas and hidrocystomas are benign adnexal neoplasms that may be solitary, multiple, or eruptive lesions.
Essentially, effective treatment involves lesion destruction.
This could be achieved using excision, electrodesiccation, or dermabrasion, among other destructive methods, but these come with risks for scarring and dyspigmentation.
The benefit of laser resurfacing as a means of lesion destruction is the minimization of complications in tandem with efficacy.
Periorbital syringomas are a therapeutic challenge as one must take into account the number of lesions and skin type to determine which treat- ment is most appropriate for each patient.
In one study using an ablative carbon dioxide laser, ten patients with multiple periorbital syringomas were treated at 5 W 0.2 s scan time, and 3 mm spot size.
Two to four passes over 1–4 treat- ment sessions were performed resulting in elimination of syringomas in all patients over a median follow-up period of 16 months.
Adverse effects included transient erythema lasting 6–12 weeks in all patients and hyperpigmentation in a patient with type IV skin that resolved over 8–12 weeks.
A trial of fractional ablative CO2 laser was performed to treat 35 patients with periorbital syrin- gomas with two sessions of fractional ablative CO2 laser at 1-month intervals.
Laser fluences were delivered in two or three passes over the lower eyelids, using a pulse energy of 100 mJ and a density of 100 spots/cm2.
Clinical improvement after 2 months of treatment showed the majority of patients having some mild to moderate improvement with only three patients having greater than 75 % clearance.
This could be attributed to the nature of fractional devices when treating these lesions.
When employing fractional devices, the pinpoint injury is not wide enough to cause complete lesional destruction.
Therefore, multiple passes and consecutive treatments are needed to effectively reduce lesions.
Erbium laser ablation has shown efficacy against syringomas.
In a study of 104 patients with a variety of skin lesions, some with syringomas, the erbium/ YAG system successfully eliminated the lesions using a 0.350 ms pulse duration and 0.1–1.7 J. 
The syringomas were successfully vaporized with minimal peripheral thermal damage and good to excellent cosmetic outcome.
Other more inventive methods have been published attempting to treat these periorbital syrin- gomas.
One study employed a multiple-drilling method using CO2 laser for 11 patients with syringomas.
Rather than resurfacing or cutting the skin, the clinicians created several relatively deep holes with the ablative laser into the targeted lesions.
This strategy was taken in an attempt to reach the deep components of the adnexal structures.
Eleven patients were treated, 10 with periorbital lesions and one with vulvar lesions, over one to four treatment sessions.
All patients were found to achieve good to excellent clinical responses.
No serious complications were noted.
Another group cleverly integrated temporary tattooing into the treatment of patients' syringomas.
In this report, multiple periorbital syringomas had their surface epithelium removed with a carbon dioxide laser.
Afterward, droplets of black ink were laid on the syringomas and iontophoresis was performed to create a tattoo in the lesions.
Finally, the Q switched alexandrite laser was applied to the lesion with complete disappearance of the syringomas at the 1-week follow-up evaluation.
The only significant adverse effect was hyperpigmentation lasting more than 2 months in a patient with type V skin.
Hidrocystomas have also been treated effectively with lasers.
Surprisingly, some report successful treatment of hidrocystomas using PDL.
This is unexpected since the PDL's target chromophore in a hidrocystoma is not known.
In one report, a 585 nm pulsed dye laser was used at fluences of 7.0–7.5 J cm2 over 6- to 8-week intervals.
After 4 treatments, there was near total resolution of the lesions.
Other reports, however, have not had such success with the PDL, raising questions about the real effectiveness of this strategy.
As would be predicted, however, hidrocystomas can be successfully treated using ablative lasers, such as the carbon dioxide laser.
Conceptually, this makes sense, as destruction of the cyst wall itself could lead to resolution of the lesion.
Despite success with lasers for these adnexal lesions, some groups still rely and endorse electrosurgery and excision.
Certainly, these options are successful in some circumstances, such as cases of giant histiocytomas, and are relatively more accessible to clinicians.
However, the authors of this chapter encourage clinicians not to choose these alternatives simply because laser systems may not be available in their immediate practice.
The use of lasers around the eyes raises a number of serious safety concerns.
Physicians must be fluent in these concerns and know the appropriate measures to protect themselves, their staff, and the patients.
Ocular damage from inadvertent laser exposure is always a risk with lasers.
Ocular melanin and vasculature are at particular risk when using lasers that target those chromophores.
The cornea and sclera are at particular risk when using resurfacing lasers because of the high water content of these structures.
In practice, if any reasonable risk exists to the eyes, everyone must have protective eyewear.
For the physician and staff, wraparound goggles should be worn that are rated as having an optical density (OD) of 4 or greater.
OD is calculated as log (1/T where T is the transmittance of light through the eyewear.
The particular OD for each pair of goggles differs based on wavelength and should be specified directly on the glasses.
One should not rely on the color of the protective goggles alone as a determinant of which pair to wear.
For patients, external or internal eye shields may be used.
When the laser is not in or directed at the immediate eyelid area, external opaque shields should be adequate.
Otherwise, internal shields are required.
When choosing internal eye shields, non-reflective metal shields should be used.
Internal plastic shields used by some surgeons during non-laser procedures do not adequately protect against most lasers, such as the carbon dioxide laser, since they may penetrate the shield.
Pretreatment with ophthalmic anesthetic drops may alleviate patient discomfort, and internal eye shields are generally well tolerated.
Despite available safety protocols, complications from periorbital laser use are reported, especially when the appropriate precautions are not met.
Complications include iris atrophy, posterior synechiae, iris pigment dispersion, anterior uveitis, ectropion, and blindness.
In most reports of these cases, the patient simply closed their eyes, covered their eyes with their own fingers, or inadequately covered the eyes with displaced external shields.
Several of the reports stem from laser hair removal of the lower aspect of the eyebrow.
Often external eye shields were displaced or removed to allow a bulky laser tip to treat the target area.
The laser's proximity in combination with Bell's phenomenon puts the patient's eyes at substantial risk when lasing the lower eyebrow.
Despite proper shielding, patients may still appreciate a flash of light concurrent with each periorbital laser pulse.
The pulse is thought to somehow trigger the retinal photoreceptors.
Safety concerns have been raised but the evi- dence does not show any harmful effects.
In one study, five patients undergoing diode laser hair removal for severe trichiasis were evaluated with pre- and posttreatment ophthalmic exams.
These exams included slitlamp, pupillary, fun- duscopic, and objective retinal electroretinogram studies.
Although 3 of the 5 patients experienced the sensation of flashing lights during treatment, there was no detectable change in any of the listed exams after treatment.
Aside from ophthalmic risks, lasers carry intrinsic safety concerns for fires and burns, par- ticularly when flammable materials such as paper drapes, alcohol, or supplied oxygen are used.
Therefore, flammable materials should be removed from the treatment area.
Additionally, when a sedated patient requires concentrated oxygen and/or nitrous oxygen, use of a laryngeal mask or endotracheal intubation limits release of the flammable gas.
Moist surgical drapes contribute to fire hazard safety and may even be wrapped around the portion of a laryngeal mask or endotracheal tube exiting the mouth.
Aerosolization of infectious agents, like viruses, and tissue particles are also concerns with laser treatment.
These risks are still being clarified, but appropriate ventilation, consistent vacuum use, gloves, and masks may assist in preventing consequences from these risks.
Lasers are invaluable for medical and cosmetic concerns around the eyes.
Rejuvenation and the elimination of pigment, vascular lesions, dark circles, xanthelasma, and adnexal tumors are all possible with the appropriate use of lasers.
With advances of existing technologies and the development of newer technologies on the horizon, periorbital concerns will continue to be more effectively and safely treated.
Platelet-rich plasma (PRP) is an autologous concentration of human platelets contained in a small volume of plasma.
Platelets can be likened to cell reservoirs that produce, store, and, finally, release numerous growth factors capable of stimulating the proliferation of stem cells and the replication of mesenchymal cells, fibroblasts, osteoblasts, and endothelial cells.
PRP is composed of several different growth factors, platelet-derived growth factor (PDGF), transforming growth factor a (TGF-a , vascular endothelial growth factor (VEGF), insulin-like growth factor 1 (IGF-1), epidermal growth factor (EGF), basic fibroblast growth factor (bFGF), transforming growth factor b1 (TGF-b1), and platelet-activating factor (PAF), that are released through degranulation and stimulate bone and soft tissue healing.
The secretion of these growth factors begins within 10 min after clotting, and more than 95 % of the presynthesized growth factors are secreted within 1 h (Fig. 10.1).
The addition of thrombin and calcium chloride activates platelets in PRP and induces the release of factors from alpha granules.
Adult mesenchymal stem cells, osteoblasts, fibroblasts, endothelial cells, and epidermal cells typically express cell membrane receptors to growth factors present in PRP so these ones bind their transmembrane receptors, inducing an activation of internal signal protein.
These processes cause cellular proliferation, matrix formation, osteoid production, collagen synthesis, etc.
It is important to underline that the PRP growth factors are not mutagenic because they don't enter in the cell or nucleus; therefore, PRP does not induce tumor formation.
The phases of the working procedure of platelet gel therapy are collection into a test tube, cell enrichment, activation, quality control test, and record.
PRP is obtained from a sample of patients’ blood drawn at the time of treatment. A 40 cc venous blood draw will yield 7–9 cc of PRP depending on the baseline platelet count of an individual, the device used, and the technique employed.
The blood draw occurs with the addition of an anticoagulant, such as acid citrate dextrose A (ACD), to prevent platelet activation prior to its use.
PRP is prepared by a process known as differential centrifugation.
In differential centrifugation, acceleration force is adjusted to sediment certain cellular constituents based on different specific gravity.
There are many ways of preparing PRP.
It can be prepared by the PRP method.
In the PRP method, an initial centrifugation to separate red blood cells (RBCs) is followed by a second centrifugation to concentrate platelets, which are suspended in the smallest final plasma volume.
WB (whole blood) is initially collected in tubes that contain anticoagulants.
The first spin step is performed at constant acceleration to separate RBCs from the remaining WB volume.
After the first spin step, the WB separates into three layers: an upper layer that contains mostly platelets and WBC, an intermediate thin layer that is known as the buffy coat and that is rich in WBCs, and a bottom layer that consists mostly of RBCs.
For the production of pure PRP (P PRP), upper layer and superficial buffy coat are transferred to an empty sterile tube.
For the production of leukocyte-rich PRP (L PRP), the entire layer of buffy coat and few RBCs are transferred.
The second spin step is then performed.
"g"?for second spin should be just adequate to aid in formation of soft pellets (erythrocyte-platelet) at the bottom of the tube.
The upper portion of the volume that is composed mostly of PPP (platelet-poor plasma) is removed.
Pellets are homogenized in 5 ml of plasma to create the PRP (platelet-rich plasma) high concentration of leukocytes.
Obtain WB by venipuncture in acid citrate dextrose (ACD) tubes.
Do not chill the blood at any time before or during platelet separation.
Centrifuge the blood using a “soft” spin.
Transfer the supernatant plasma containing platelets into another sterile tube (without anticoagulant).
Centrifuge tube at a higher speed (a hard spin) to obtain a platelet concentrate.
The lower 1/3 is PRP and upper 2/3 is platelet- poor plasma (PPP). 
At the bottom of the tube, platelet pellets are formed.
Remove PPP and suspend the platelet pellets in a minimum quantity of plasma (5–7 mL) by gently shaking the tube.
WB should be stored at 20–24 °C before centrifugation.
Centrifuge WB at a “high” speed.
Three layers are formed because of its density: the bottom layer consisting of RBCs, the middle layer consisting of platelets and WBCs, and the top PPP layer.
Remove supernatant plasma from the top of the container.
Transfer the buffy coat layer to another sterile tube.
Centrifuge at low speed to separate WBCs or use leukocyte filtration filter.
There are many PRP systems commercially mar- keted, which facilitate the preparation of ready to apply platelet-rich suspensions in a reproducible manner.
All operate on a small volume of drawn blood (20–60 mL) and on the principle of centrifugation.
These systems differ widely in their ability to collect and concentrate platelets depending on the method and time of its centrifugation.
As a result, suspensions of different concentrations of platelets and leukocytes are obtained.
Differences in the concentrations in platelets and WBCs influence the diversity of growth factor concentration.
It is difficult to assess which kit for PRP preparation is better and which is worse.
PRP devices can be usually divided into lower (2.5–3 times baseline concentration) and higher (5–9 times baseline concentration) systems.
The high-yielding devices include Biomet GPS II and III (platelet count 3–8×), Harvest SmartPrep 2 APC+ (4–6×), and Arteriocyte-Medtronic Magellan (3–7×).
The lower concentration sys- tems include Arthrex ACP (2–3×), Cascade PRP therapy (1–1.5×), and PRGF by Biotech Institute, Vitoria, Spain (2–3×), and Regen PRP (Regen Laboratory, Mollens, Switzerland).
In our experience, in order to prepare a gel that is a homogeneous mass of an adequate volume and yet remains manageable, the platelet concentra- tion needs to be 750,000–1,000,000/μL.
With this concentration of platelets, the gel forms in about 5–7 min.
Once the PRP has been obtained, a full blood count is performed, and on the basis of the platelet count, the PRP is diluted or concentrated under sterile conditions.
The production of autologous thrombin, used as the activator, involves the following steps: collec- tion of another blood sample (in ACD or sodium citrate), centrifugation of the sample for 10 min at 3000 rpm, collection of the plasma supernatant in a new test tube (under sterile conditions), addi- tion of 0.2 mL of calcium gluconate for every 1 mL of plasma, incubation at 37 °C for 15–30 min, collection of the supernatant containing the precursors of thrombin (under sterile conditions), and freezing and storage at 30 °C until needed.
In order to produce the gel, the platelet concentrate is placed in a sterile plate and then the activators are added, i.e., 1 mL of autologous thrombin and 1 mL of calcium gluconate for every 10 mL of PRP.
At this point, the mixture is left to incubate at room temperature.
If the coagulation process takes longer than expected, the preparation can be incubated for about 5 min at 37 °C to facilitate the reaction.
The platelet concentrate must be sterile.
The blood components must be prepared according to the principles of good manufacturing practices.
Each procedure must undergo quality control tests including determination of the volume, platelet count, count of contaminating white blood cells, and assay of fibrinogen levels.
The final product must carry a label indicating the surname and name of the patient, his or her date of birth, type of product, and the date of its preparation.
The patient's personal data and the characteristics of the component are also recorded in the related files stored in the archives of the transfusion center.
Complete physical examination and an analysis of the following clinical information should be obtained: general conditions of hygiene, lifestyle (smoking, alcohol), availability of family support, ability to walk, presence of occlusive arterial disease, past his- tory of deep vein thrombosis, and presence of pain while walking and/or at rest (standing and/or lying).
Thanks to its autogenous preparation, PRP is safe and therefore free from transmissible diseases (HIV, HBV, HCV, West Nile fever, Creutzfeldt- Jakob disease); so, it is well accepted by patients.
Since the gel is homemade, it is probably a cheaper source of growth factors than the indus- trially produced ones and also provides growth factors not otherwise available for clinical use.
The patients show good compliance toward the product and the procedures necessary for  its production.
Angiogenic; antibacterial properties; stimulating the formation of connective and epithelial tissue; osteogenesis stimulators; security (219/05 Law, DD. MM. 3/3/05); nontoxic tissue injury; can be autologous; quick and easy preparation.
Patient thrombocytopenic; vascular access compromise; septic patient; very large lesion; patient too small; patient positive for HBV, HCV, and HIV; emergencies. 
There are two types of contra- indications to treatment with platelet gel: (1) those potentially harmful to the patient, such as hemodynamic instability, pregnancy, malignan- cies, infections, and/or osteomyelitis at the site of application, and (2) those making the autologous product difficult to obtain or of poor quality, such as thrombocytopenia, platelet disorders, and treatment with drugs affecting platelet function and/or coagulation (e.g., oral anticoagulants, heparin, nonsteroidal anti-inflammatory drugs).
After centrifugation, the platelet and fibrin com- ponent of the blood (the top layer) is extracted and reinjected into the area of concern (Fig. 10.2).
In dermatology and cosmetic medicine, PRP has been used to treat.
Venous and arterial leg ulcers.
Diabetic foot ulcers.
Pressure ulcers (bedsores).
Skin graft donor sites.
First- and second-degree thermal burns.
Superficial injuries, cuts, abrasions, and surgical wounds.
Hair loss disorders – PRP has been shown to reinvigorate dormant hair follicles and stimu- late new hair growth.
Posttraumatic scars – PRP combined with centrifuged fat tissue and fractional laser resurfacing improve cosmetic appearance of scars.
Facial rejuvenation– PRP injections can treat wrinkles, photodamage, and discoloration in conjunction together with other treatment modalities.
In the chrono-aging processes, dermal fibro- blasts play a key role, thanks to their interactions with keratinocytes, adipocytes, and mast cells.
Besides, they are also the source of extracellular matrix, proteins, glycoproteins, adhesive molecules, and various cytokines and increase the activation of the fibroblast-keratinocyte-endothelium axis, maintaining skin integrity.
PRP, increasing the length of the dermo- epidermal junction, the amount of collagen, and the number of fibroblasts, can be considered an effective therapy for skin rejuvenation: PRP in fact induces keratinocyte and fibroblast prolifera- tion and typically collagen production amplifica- tion, increasing dermal elasticity.
It is also useful for tightening around the eyes (for thin crepe-like skin and fine lines) (Fig. 10.3) and in the areas as cheeks and midface, thinning skin on the neck, jawline and submalar regions, back of hands,d?collet?, and others (e g , knees, elbows, and upper arms, as well as for post- pregnancy skin laxity).
Besides platelet-rich plasma (PRP) can be used for enhancing, reshaping, and volumizing the lips; it is often used to improve very fine lines around the lips, helping to restore skin hydration and elasticity.
A topical anesthetic or a nerve block will be used for pain management.
There are some additional effects using PRP combined with other aesthetic procedures as fractional laser or lipostructure.
PRP in associa- tion with fractional laser increased skin elasticity and decreased the erythema index; keratinocyte and fibroblast proliferation and collagen produc- tion can explain these capacities.
The use of PRP mixed with purified fat graft has several advantages: PRP increased fat cell survival rate and stem cell differentiation.
This combination has been used for recon- structing the three-dimensional projection of the face contour in patients affected by facial aging characterized by atrophy of subcutaneous and soft tissue with loss of volume and elasticity, restoring the superficial density of facial tissue.
PRP is an easily accessible source of growth factors for supporting bone and soft tissue healing.
PRP can be enriched with the presence of a fibrin matrix (PRFM): fibrin matrices, in fact, enhanced the delivery of platelet growth factors.
It consists of weak thrombin concentrations which entail equilateral junctions.
These connected junctions permit the formation of a fine and flexible fibrin network capable of supporting cytokines and cellular migration that occurs.
This results in an increase in the half-life of these cytokines as their release and use will occur at the time of initial scarring matrix remodeling.
Thus, the cytokines are made available for a mandatory period required by the cells to initiate the healing.
Fibrin meshwork in PRF differs from that in PRP.
In PRP, there are bilateral junctions resulting in a rigid network that does not honor the cytokine enmeshment and cellular migration.
The increased thrombin required for rapid setting of the PRP leads to a rigid polymerized material.
PRFM has been proposed and effectively used in several facial plastic surgery settings: as PRFM can induce dermal augmentation, it can be used for treatment of dermal and subdermal tissues of the nasolabial folds, acne scars, and lip augmentation.
PRFM can be mixed with autologous fat ex vivo and the composite graft injected.
The fibrin matrix associated with platelet-released growth factors should promote better graft take.
This technique has been used for lip augmentation, with good results.
Barbed suture lifting is a minimally invasive surgical technique for facial rejuvenation.
Aging of the face and neck results in ptosis of soft tissues and the appearance of more prominent facial lines.
For correction of these changes, surgeons are devising more procedures with fewer inci- sions and shorter postoperative recovery periods.
Many of these procedures use absorbable and nonabsorbable sutures in the dermis and subcutis to lift lax skin.
Limitations of these implants have included the protrusion of sutures through the skin and asymmetry of the cosmetic effect, often requiring correction with additional sutures, and limited durability of effects.
The treatment by absorbable threads, known as balance lift or nonsurgical face lifting, is an innovative technique used in aesthetic medicine that is useful for supporting and stretching the face and body tissues.
The suspension threads are used to improve eyelid ptosis and the perior- bicular groove, with a significant improvement of the shape of the eyebrows.
They are used also to reduce ptosis of the neck, and middle and lower face.
Aging induces a scaffolding of dermal facial skin as well as a progressively decreasing fat compo- nent, attributable to thinner connective tissue and collapse of elastic fibers.
The affected areas generally include the cheeks, eyebrows, mandibular area, and neck.
Dermatochalasis of the facial and neck soft tissues, including the superficial muscular aponeurotic system (SMAS) and the muscular tissue, is the cause of the distinctive aging signs on the face.
The profile of the mandibular margin becomes unclear, displaying its deterioration (descent of the aging jaw line); the forehead has horizontal wrinkles where other vertical ones are added to the glabellar area; the zygomatic malar region (middle face) displays a downward trend; a lachrymal furrow appears and the nasobuccal and buccomandibular areas deepen; the skin of the eyelid becomes flabby and protrudes in correspondence with the lower eyelid, owing to production of adipose bubbles; and finally, a plasmatic parcel and cutaneous flabbiness appear on the neck.
The facelift to correct facial aging has evolved into an elaborate and complicated procedure requiring a lengthy recovery time.
The recent introduction of absorbable barbed sutures producing a lifting action for this type of aging offers a good alternative to more invasive procedures.
The plugs present on the surface of the wires allow the combination with other nonsurgical rejuvenation procedures, such as botulinum toxin or substances with a transient and volumizing filler effect.
The implant can be performed in an outpatient setting under local anesthesia.
The surgeon first establishes the degree and direction of the desired tightening.
This determines the course and number of sutures that have to be placed to achieve the best result.
Infiltration of local anes- thesia is limited to these lines and the insertion points of the straight needle.
For lifting of the brow and middle and lower face, 3- to 4-mm incisions for insertion of the straight needle are made posterior to the frontal and temporal hair- line.
For lifting of the neck, incisions are made posterior to the sternocleidomastoid muscle of the lateral neck.
To place an individual thread, the surgeon guides the straight needle through the incision and into the subcutaneous plane.
For some anatomic locations it is advantageous to bend the needle to more easily allow it to follow the dynamic face lines.
The needle is advanced in this plane in a zig-zag movement along the marked trajectory.
Once anchored, this zig-zag placement of the suture limits retrograde motion along the suture and results in an implanted suture that is longer than the drawn trajectory.
This maximizes the number of barbs in the subcutis and theoretically provides greater stability of the translocated skin.
Movement of the needle and suture through the subcutis is generally well tolerated by patients.
If the straight needle moves superficially to this plane, it is immediately apparent as linear dimpling of the overlying skin.
If the needle enters into the deep subcutis or approaches the muscle fascia or periosteum, the patient will report the sensation of pain or pressure.
At any point, the straight needle may be partially or completely removed and reposi- tioned.
The straight needle exits the skin inferior to the eyebrow or near the medial face or neck.
It is then cut from the thread after pulling the attached suture through the skin.
This leaves the barbed portion of the thread buried in the subcu- tis with the free ends extending from the proximal insertion point and the distal medial face exit point.
The curved needle on the proximal end of the suture may then be used to anchor the suture near its insertion to the underlying fascia or periosteum.
A 3- to 4-mm incision, 1–2 cm posterior to the insertion points, serves as an exit point for the curved needle after deep suturing to the fascia or periosteum.
Greater security of this anchor point is achieved by tying this suture at its proximal end with a paired suture running a similar parallel course in the skin.
The resulting knot can be seated in this posterior incision by gentle traction on the distal ends of the paired sutures.
When all planned sutures have been placed and anchored, the patient returns to the seated position.
Holding the distal end of the suture protruding from the medial face, brow, or neck with one hand, the surgeon uses the other hand to push the lax skin overlying the suture toward the anchoring point.
The unidirectional barbs catch on the fibrous septae of the subcutis, preventing retrograde movement.
Together, the surgeon and patient decide the degree of tight- ening along any given suture.
The distal end of the suture extending from the medial face, brow, or neck is cut at its exit point and retracts under the skin.
Incisions used for insertion of the straight needle and anchoring heal rapidly by secondary intention.
The translocation of the skin along the suture can cause lax skin folds in the hairline and lateral neck that can be quickly and completely remodeled or redistributed to the scalp and neck in several days or weeks.
Mild complications such as swelling, bruising, and subjective feelings of "tightness"?usually resolve within 1–3 weeks.
Transient neuropathy of the greater auricular nerve has occurred in several patients when using the sternocleido- mastoid muscle fascia as an anchoring point on the lateral neck.
Because this technique may be released with intense pressure, patients must initially avoid strong exercise or movements that could dislodge the tightened skin from the hundreds of barbs along the sutures.
Non-peer- reviewed data from the manufacturer demon- strate that in laboratory rats these sutures develop a fibrous capsule that becomes well integrated into the dermis and subcutaneous tissue over several months.
A similar process in human skin can lead to a long-lasting cosmetic effect.
The actual long-term durability of the tightening effects of these sutures is unknown.
Early adopters of this procedure have demon- strated maintenance of cosmetic effects at 6 months.
The technique will lead to a true firming of the skin affected by laxity if the thread is placed along the traction lines.
The threads are located in a direction perpendicular or at an obtuse angle with respect to the traction lines of the skin, to obtain a tightened effect.
The number of wires implanted may vary according to the material of the thread used and the form chosen by the operator.
A worldwide variety of barbs, with differences in costs and types of materials, are available.
Here we list our experi- ence of the main ones: 1. PDO – Polydioxanone 2. Polylactic acid – Poly(L-lactide)-ε- caprolactone copolymer.
The application of suspension threads can be used at the face level in the following cases: Loose and heavier jaw line Soft tissues descending to cheekbones and cheeks level, with a consequent loss of natural volume and fatigue of the face Presence of pronounced furrows and wrinkles; Breakdown of the skin in the neck area, mainly in the central zone Lifting the eyebrow arch.
Suspension threads can be used at the body level in the following cases: Tissue laxity in the inner arms, Firming the abdomen, Skin breakdown inside the thigh, Sagging skin in the upper area of the knees; Loss of form at the navel due to partial cover- age by the abdominal skin, Mild ptosis of the breasts, Soft ptosis of the buttocks.
PDO (polydioxanone) is a polymer of polylactic caprolactone, a bioabsorbable material and antimicrobial already used in surgery and biocompatible with the dermis.
The indication is for sagging and relaxation, or when preventive treatment is needed.
Biocompatible, antimicrobial, Absorption by hydrolytic action within 6–8 months, suitable for medical use and surgery This material is already used in general and specialized surgery as sutures; it is slowly absorb- able, biocompatible, and antimicrobial.
The threads are implanted in the skin.
In the preorbicular area, they are inserted in a direction along the front lines and/or along the brow for lifting, to improve periocular dermatochalasis.
They are inserted obliquely by hand at the side of the eye down to within 1 cm of the medial canthus.
At the level of the labia, they are inserted to follow along the labia for lip contouring, along the vermilion for improving the firmness of the lips, and at the corners of the lips in a direction perpendicular to the wrinkles to enhance the face expression.
Generally speaking, the shift of the skin tissue through the thread represents a fundamental mechanism in cutaneous tissue repair processes and tissue regeneration.
The cell is stimulated by the presence of several transduction systems mechanically placed at the level of the cell membrane, the best known of which is integrin.
The mechanical stimulus exerted on the outer extracellular matrix determines via integrin the intracellular biological changes that can activate specific genes.
The fibroblasts are particularly sensitive to mechanical stimuli, and when subjected to mechanical stimulation they activate genes for the production of collagen and other proteins.
The biostimulant PDO threads implanted in the dermis are able to stimulate the fibroblasts, activating an increased synthesis of collagen.
The PDO absorbable threads (thickness 0.05–0:19 mm and length 3–16 cm) are positioned inside a needle (26, 29, or 30 gauge).
After a preliminary visit the clini- cian must accurately mark with a dermographic pen the face areas, neck, and d?collet?  that must be treated, according to the situation and the demands of the patient.
Insertion of the needles (29–31 gauge) with PDO threads can then take place without trauma and without any need for local anesthesia.
The needle tips used in this technique are shaped to reduce pain.
The surface of the needle also has a double coating that makes it homogeneous.
The number of threads released into tissues during treatment varies depending on several factors such as patient's age, degree of skin aging, degree of failure of the tissues, and extent of the area to be treated.
Usually 20–60 threads are used.
The needle is inserted fully and advanced, leaving a thread inserted and implanted in the tissues.
Anesthesia is not necessary; cooling the treated area with dry ice will be sufficient.
In the case of more than 10 implants, we recommended a bandage (e.g., Tensoplast) to restrict movement in the first 24 h postoperatively.
Rapid lifting of the treated area is visible immediately after the end of treatment.
The patient can restart daily activities at the end of treatment.
The thread is inserted in directions orthogonal to each other to form a grid that counteracts the gravita- tional vectors that lead to relaxation, behaving like a foreign body coated by collagen, which forms the true support structure desired.
PDO has been used for decades in surgery for the execution of absorbable sutures.
There is a marked improvement after 1–2 months. 
The skin tone also improves, as does the appear- ance of wrinkles.
An innovative technique in the field of aesthetic medicine, with very little pain, which improves the skin tone and its aspect.
After approximately 6–8 months, the threads in the PDO have been completely reabsorbed by hydrolytic action in a totally natural and  harmless  manner,  but  the  biostimulation and lifting effect continues the mechanical support and remains stable for 6–8 months, and generates a significant stimulation of endoge- nous cells whose benefits will last much longer.
Edema and erythema for 24–48 h after treatment, hematomas at implant, hardening small transients.
High sensitivity in the treated area, which usually disappears within 1–3 days following treatment.
In extreme cases the threads can be extracted, within 20 days after treatment, by a small incision and extraction using forceps.
Skin infections, recurrent herpes simplex (requires antiviral prophylaxis), collagen, predisposition to form keloids, pregnancy, lactation, coagulation disorders, exagger- ated expectations of cosmetic surgery.
The Screw is the latest innovation in the field of non-invasive minilifting of the face and body.
Thanks to its special shape the microthread support "screw"?produces greater vascularity with improved macrophage response that makes more effective the biostimulative response, especially for fibroblasts, which become more "active"?and more"flexible"?in the healing process.
The combination between the microthread, a PDO monofilament, and the screw grants significant synergy, which results in better toning action on the connective tissue, as the thread screw stimulates mostly the “cascade effect” of the systems of healing and restructuring  tissue.
Effective in activating the process of restructur- ing the dermoepidermal junction, the fine thread contour technique reshapes the body.
Barbed Threads Barbed bidirectional threads are useful to create a "mini-invasive suspension surgery"?in a treatment that allows lifting and repositioning of tis- sues with greater modeling.
The barbed bidirectional threads bring tissue to the opposite direction through bidirectional pinning, with minimum risk of displacement or migration, thus facilitating the anchorage in the tissue and enhancing the lifting effect.
Multidirectional threads are useful for all ptosis tissues located at the lateral third of the eyebrow, and all applicants requiring a traditional facelift and surgical and aesthetic facial improvement, as well as fillers and lipofilling. 
Nowadays micropipes can be used as an alternative to microneedles and offer greater advantages.
The micropipes must be used carefully, and sometimes have been used to make microtunnels with a fine pipe under local anesthesia or products containing connective micrografts.
Micropipes are recommended only for selected areas and methods.
The micropipe Cogs multidi- rectional (21 gauge × 60–90 mm) are typically indicated for the frontal area as well as the neck.
The lower eyelid (PDO 30 gauge × 27 mm) is very useful with this micropipe, allowing the placement of microthreads in the lower area of the eyelid.
The Short pipe for nose and neck (19 gauge × 40 mm 4D thread) is used for correction of the silhouette of the nose in selected cases, by pulling on the tip and reducing mild disharmonies, creating an interesting volumetric effect.
The 4D screw micropipes allow thread cutting in four dimensions.
In this way they are able to optimize the lifting effect and minimize the damage to tissues.
These threads are biocompatible and fully resorbable.
Polylactic acid and caprolactone also have a revitalizing action and are reported to be long lasting.
Professor Marlen Sulamanidze, a specialist in reconstructive plastic surgery and aesthetics, is recognized by the worldwide medical community as the inventor in 1995 of the first wire for lifting tissue ptosis.
In 2008 he launched on the world market the three types of resorbable wire Nano, Excellence, and Light Lift.
He invented a noninvasive lifting technique using permanent traction threads in polypropylene.
The technique has evolved over 8 years of experience with non- resorbable threads.
Patent Pending and Safety 16 patents over the years.
This is a surgical outpatient treatment carried out with or without local anesthesia according to the medical evaluation of the case.
Threads are inserted subcutaneously through a microhole, along precise lines of skin tension, by means of a thin needle or a needle-pipe blunt tip (tip shape reduces the local trauma), exerting a slight traction to lift the relaxed tissues.
The threads adhere to the skin owing to the presence of special anchors (plugs).
The effect is achieved because the lift-thread insertion follows geometric traction where nothing is left to chance, and in fact the treatment requires, in addition to a certain manual skill, a flawless knowledge of anatomy.
The caprolactone allows the gradual absorption and uniformity of polylactic acid while ensur- ing the mechanical strength and the elasticity of the thread in time; also, the capacity of bios- timulation is associated in time with the effect of traction of these threads in restoring luminosity and color.
The microcirculation capillaries of the proximal threads increase in number compared with the peripheral circulation, and the vessel lumen is more dilated.
Studies have shown that for the entire period after insertion the vessels remain dilated, with constant hyperemia maintaining a trophism of the treated area with formation of new collagen, fibrin, and elastin.
The fibroblasts of the fibrotic tissue created with the placing of the threads are functionally active, observable from increased spread of chromatin in the nucleus and cytoplasm.
The connective tissue layer in which the thread is implanted, treated with the blue dye toluidine, contains an increased number of mast cells, and at the same time show an increased concentration in the vascular channels of the microcirculation.
The granules of mast cells contain hyaluronic acid, a polysaccharide complex, which is a structural component of the papillary dermis granular layer of the epidermis and is also apparent in the superficial vessels of the skin.
There is evidence that reduction of the amount of hyaluronic acid affects the immune status of the skin, and that its inner dermal injec- tion improves the structure of the skin.
The reabsorption process begins after about 180 days after implantation and is completed after more than a year.
The unrolling of sutures takes placed within 3 weeks from the implant, since the thread is composed of two strands.
The process of opening the thread by imbibition in the dermal tissue leads to an affection tensor characteristic unique to this type of thread, i.e., ready-to-use,"pre-filled"?braided and sutured, 4 cm long, 23 gauge.
Anchoring in the medium/deep dermis, on both the face and body, are soon remarkable. 
The results are apparent after 3 months with a progressive improvement in the following months.
This thread is composed of a needle-pipe pre- loaded suture, characterized by a multidirectional microanchor of 12 cm with an indication for treatment of ptotic skin areas more pronounced in various areas of the face.
It is best indicated for the lifting of the cheekbone.
Rubber thread with a double needle without a lifting skin retraction with a microanchored convergence.
Not take food, hot liquids, and solids for 3 days.
Avoid alcohol for 2–3 weeks.
Limit mimicry activity for 7 days.
Limit gym, sauna, swimming, and exposure to direct sunlight for 3–5 weeks.
Use antibiotics for 3–5 days, in the case of lowered immunity or if using more packs of sutures for surgery.
Sleep supine or side to side with a pillow in the case of face, neck, and abdomen surgery.
Hypertension II and III.
Inflammation or cancer in the target area.
Propensity of keloids and hypertrophy.
None of the complications presented herein has generated the appearance of long-term functional disorders and no visible and permanent effects.
Moreover, none of the complications presented required the need for prolonged treatment.
Innovations in operative techniques generally contribute to enhanced results, greater patient happiness, and a decrease in operative morbidity.
The immediate effect is the lifting of the tissue, owing to the mechani- cal action produced by the thread, which con- trasts with the falling of the area treated (Figs. 11.3a–c and 11.4).
This is possible because of the arrangement of thethreads' barbs, disposed in two directions (divergent and opposite), compared with the middle point of the thread.
Once positioned in the subcutaneous tissue, the threads will continue to exert their sustaining action on the tissues.
Therefore, it is possible to claim that the lifting effect is guaranteed and fortified by the cutaneous reaction (fibrosis) that appears along the length of the thread, which remains effective and steady even when the thread is completely reabsorbed (after about a year).
The reabsorption occurs as a result of the action of the histiocytic-reticule system, which concretizes a selective hydrolysis action of the reabsorbable thread from the periphery toward the center.
The most impor- tant limits of this technique are that it is indicated for moderate cutaneous descent.
For overabundant tissue, the prescription remains traditional lifting.
In cases of more advanced and evident signs of aging, patients must opt for traditional surgical options that are more invasive and direct.
Therefore, strict selection criteria must be adopted when selecting patients to be treated with this technique.
Reabsorbable Happy Lift Revitalizing thread constitutes an efficient and safe procedure of mid-face lifting and rejuvenation of the supe- rior cervical region of the face and neck.
It is also possible to combine this with other methods that allow optimization of the facial rejuvenating effect, such as botulinum toxin, fillers, chemical peelers, photorejuvenation with a pulsed light, and lip filling.
These threading procedures do not require general anesthesia, are virtually free of bleeding or pain, and do not produce intra- and postopera- tional scars that are visible on the skin, nor do they require long postoperative recovery times.
The technique is practicable in day surgery, and the patient may immediately return everyday activities shortly following the procedure.
Hyaluronic acid dermal fillers have become a mainstay for soft-tissue augmentation while providing numerous advances in the area of cosmetic surgery.
HA fillers are primarily used for the treatment of facial changes associated with aging, which include thinning of the epidermis, loss of skin elasticity, subcutaneous fat and bony changes, and atrophy of muscle, all of which can result in a loss of volume.
HA fillers are longer lasting and less immunogenic, making them the most common of the tem- porary fillers on the market.
The vast majority of treatments are efficacious and patient satisfaction is generally high.
Despite having a low overall side effect profile, early and delayed complications, ranging from minor to severe, have been reported following HA filler injection.
The most common potential sequelae following HA filler injection result from the injection site reactions and include ecchymosis, edema, erythema, and pain.
Other less common adverse events include nodules (both inflammatory and noninflammatory), hyperpigmentation, telangiectasia, and dyschromia.
More serious adverse events, while rare, include vascular compromise that can result in tissue necrosis and acute vision loss.
Some degree of pain is expected with needle puncture, with thicker gauge needles expected to cause a greater degree of pain due to more extensive tissue injury.
Where the injection is placed can also determine how much pain is experienced, as more sensitive areas tend to be more painful such as injections of the lip, injections of the periocular skin, and perioral injections.
Injection site pain is minimized by the formulation of hyaluronic acid fillers to include lidocaine.
If the HA filler does not include an anesthetic, a topical anesthetic ointment can be applied before treatment.
The topical anesthetic should be applied 20–30 min before injection.
In addition, cold compresses can be applied just before injection to numb the area to diminish pain sensation.
Erythema (i.e., redness) is frequently observed immediately after injection with HA fillers.
Erythema is a local effect due to puncture trauma and associated inflammation.
Erythema is best managed by applying cold compresses postinjection for 5–10 min to reduce inflammation.
After the procedure, patients can be advised to use ice packs at home every few hours on the day of the injection.
Caution must be emphasized to avoid prolonged ice pack usage to reduce the risk of cold injury to the skin.
In addition, vitamin K cream can be useful in accelerating resolution of erythema.
Furthermore, redness can be reduced using a prudent injection technique that will minimize the number of skin punctures during the injection process, thus limiting trauma to the injected area.
Such techniques include placing the filler with a serial injection, using the fanning technique, or using linear tunneling with threading.
The erythema will generally last for a few hours and may persist for a few days.
If the erythema persists longer than the expected duration of a few days, then a hypersensitivity reaction is suspected.
Effective treatments for this hypersensitivity reaction include oral tetracycline or isotretinoin.
For persistent erythema, a medium-strength topical steroid is warranted.
High-potency steroids should not be used as they increase the risk of atrophy and telangiectasia.
Of note, patients with rosacea have a higher risk of developing postinjection erythema and should be warned of this risk prior to commencing treatment.
While not as common as redness and swelling, ecchymosis (bruising) is an adverse effect that can occur in patients after receiving a hyaluronic acid filler injection.
Bruising is caused by the perforation of vessels during filler injection, typi- cally the dermal veins.
Additionally, pressure of the injected material can cause injury to proximal blood vessels, causing bruising.
Common locations for bruising are the upper third of the naso- labial fold, the upper lip, the lateral edge of the lower lip, and the perioral region.
In particular, injections to the lower eyelid often result in bruise formation.
Bruising is frequently observed after injection into the dermal and immediate subdermal planes using fanning and threading techniques.
Bruising may develop soon after the injection, but often is delayed, most notably in those patients who are on anticoagulation therapy.
Therefore, patients should be counseled to discontinue any unnecessary anticoagulation medications or products 1 week prior to treatment to potentially reduce the severity of bruising.
The blood-thinning products to be avoided include aspirin, non- steroidal anti-inflammatory drugs (NSAIDs), warfarin, clopidogrel, dipyridamole, garlic tablets, ginkgo biloba, ginseng, fish oil, St.John's wort, and vitamin E supplements.
Bruising can be mitigated by applying cold compresses and firm pressure to the affected area before and after the procedure.
Furthermore, vitamin K cream can be useful in accelerating the healing of bruising, just as it is for erythema.
Laser treatment may also accelerate the elimination of a bruise.
Furthermore, postinjection bruising may be limited in extent by the incorporation of epinephrine in the filler which causes vasoconstriction and dampens the activity of eosinophils that can cause bruising.
Other recommendations to limit bruising include using the smallest gauge needle possible that can effectively deliver the filler, delivering small aliquots of product utilizing a slow injection technique, using the depot tech- nique at the preperiosteal level and limiting the number of transcutaneous puncture sites.
The use of blunt cannulas may also limit bruising.
The typical time course for resolution of a bruise is approximately 1 week and can range from 5 to 10 days.
Concerned patients should be instructed that the bruise may progress to a darker discoloration for 1–3 days posttreatment before it slowly resolves over 5–10 days.
Patients should be made aware that the development of a bruise will not interfere with the treatment outcome.?
Telangiectasia is an abnormal aggregation of arterioles, capillaries, or venules.
This neovascularization process is an adverse outcome that may occur at the HA filler injection sight.
The proliferation of these vessels is caused by trauma to the tissue due to the product causing tissue expansion.
Telangiectasia can appear within days or weeks following the procedure.
Left untreated, they typically resolve within 3–12 months.
Telangiectasias following dermal filler injection have been successfully treated using a 532-nm laser (532 nm KTP and the 532 nm diode copper vapor) or 1,064 nm laser.
Other forms of effective laser therapy for telangiectasias include intense pulsed light (IPL) and 585 nm pulsed dye laser.
In addition to laser treatment, telangiectasias can also be treated with hyaluronidase.?
The trauma induced by dermal filler procedures, including HA dermal injection, can cause post-inflammatory hyperpigmentation.
Post- inflammatory hyperpigmentation is more common in patients of color as darker colored skin has a greater tendency to hyperpigment following needle trauma.
Hyperpigmentation is particularly seen in individuals with Fitzpatrick skin types IV, V and VI.
Treatment for persistent post-inflammatory hyperpigmentation that occurs following HA dermal filler injection should include the application of topical bleaching agents such as topical hydroquinone (2-8 %) and Retin-A (tretinoin) .
In addition to bleaching agents, consistent daily sunscreen usage must be adhered to.
If the hyperpigmentation is resistant to this first line of treatment, chemical peels can be used .
If these treatments are unsuccessful, then laser treatment should be initiated.
Laser choice will depend on skin type.
IPL is effective in the treatment of Fitzpatrick skin types I–IV, while the Nd:YAG 1,064 nm laser has been effective for treating darker skin tones.
Bluish discoloration under the skin is an adverse reaction seen particularly with hyaluronic acid fillers, usually the result of an improper injection technique whereby the filler in injected too super- ficially (or migrates superficially).
Note that the color observed in patients has also been described as a grayish tint.
The dermal hue change has been explained by the Tyndall effect, in which an optical phenomenon occurs as light is scattered as it passes through colloidal particles in solution.
Since blue light, with a wave- length of 400 nm, scatters more readily than longer wavelengths, this is the predominant color seen when HA filler particles scatter light.
While the Tyndall effect is the commonly accepted explanation for this particular dermal hue change, alternative explanations have been proposed to explain this discoloration.
While the Tyndall effect is known to be caused by a variety of hyal- uronic acid derivatives, BeloteroR, a monophasic, highly cross-linked hyaluronic acid dermal filler, is reported not to cause the Tyndall effect.
This cause of dyschromia can usually be avoided if the product is injected at the correct dermal level.
The more superficial the placement of the HA filler material, the longer the discolor- ation may last.
To correct Tyndall effect discolor- ation due to HA, hyaluronidase is used.
In addition, if necessary, surgical excision can be employed using a surgical scalpel (#11 blade) and then extruding the unwanted filler material.
The Nd:YAG 1064 nm laser has also been used successfully to treat this adverse reaction.
Noninflammatory nodules are small palpable lumps that are oftentimes visible under the skin.
These single, isolated lumps manifest at the injection site a few weeks following filler injection.
Small nodule formation is an adverse effect mainly due to technical error and is commonly seen with superficial injection of HA fillers.
Nodules tend to occur around the mouth and eyes when dermal fillers are injected superficially.
Thus, nodule formation is commonly due to improper superficial injection technique, as is dyschromia due to Tyndall effect discussed prior.
In addition, noninflammatory nodules result from overcorrection, whereby an excessive amount of material has accumulated in the tissue.
Furthermore, nodules may occur due to poor placement within highly mobile areas, such as the lips.
Nodules are less commonly seen with hyaluronic acid usage when compared to the particulate fillers calcium hydroxylapatite (CaHA) and poly-l lactic acid (PLLA).
Proper injection technique is paramount to minimize the formation of nodules.
In the event of HA filler-induced nodules, hyaluronidase is the treatment of choice used to eradicate the subcutaneous nodule and to mitigate overcorrection.
Hyaluronidase is an enzyme that dissolves hyaluronic acid in the skin and is employed to reverse the effects of HA filler injections.
Before treating with hyaluronidase, a skin test must be performed to ensure there is no allergic response to hyaluronidase.
Anaphylaxis is a potential side effect of hyaluronidase, so it is important to ensure a negative allergic response test prior to administration of hyaluronidase.
In contrast to noninflammatory nodules, foreign body granulomas are inflammatory nodules caused by a nonallergic chronic inflammatory reaction.
The resulting inflammatory lesion is predominantly composed of multinucleated giant cells and is caused by granulomatous inflammation after the aggregation of macrophages in response to large foreign bodies that cannot be phagocytosed by macrophages.
Filler- related foreign body granulomas typically occur 6–24 months after filler injection.
Foreign body granulomas are rare, with a reported inci- dence of foreign body granulomas after injection of hyaluronic acid of 0.02–0.4 %, with a peak estimated incidence of 1.0 %.
Clinically, foreign body granulomas caused by hyaluronic acid mainly appear as cystic granu- lomas and can be accompanied by edema and erythema.
Development of a sterile abscess results from a process of encapsulation that prevents the absorption of the injected material into the surrounding tissues.
Characteristic histological findings include palisaded granulomatous tissue composed primarily of giant cells and macrophages.
A differential diagnosis should be performed to distinguish granulomas from noninflammatory nodules.
Filler-induced granulomas are differentiated from nodules in that the size of the granuloma becomes larger than the volume that was injected, and granulomas develop simultaneously at multiple sites of injection.
Since foreign body granulomas are not allergic reactions and are often triggered by a systemic bacterial infec- tion, it is currently not possible to predict which patients are at risk for developing granulomas.
Left untreated, they may remain virtually unchanged for some years and then resolve spontaneously.
The primary treatment of foreign body granulomas caused by HA fillers is intralesional corticosteroid injections (betamethasone, prednisone, or triamcinolone).
The local injection of corticosteroids disrupts the activities of fibroblasts, giant cells, and macrophages.
Depending on the severity of the reaction, 5–10 mg/cc of corticosteroid should be used.
If necessary, repeat the corticosteroid injection 4–6 weeks later.
For intralesional injections it is recommended that a 0.5 or 1.0 mL insulin syringe with a 30 gauge needle be used.
A smaller diameter syringe is advantageous as it allows the resistance of the granuloma to be sensed, which helps prevent corticosteroid- induced dermal atrophy.
As granulomas tend to spread into the surrounding tissue in a finger- like pattern, the preferred technique is to inject a small amount of drugs gradually, moving from the periphery to the central area.
To prevent recurrence, it is preferable to inject a high dose of triamcinolone mixed with lidocaine when performing intralesional steroid injections.
As an alternative treatment for granulomatous reactions, an injection containing bleomycin may worksuccessfully.
Inaddition, 5-fluorouracil, an antimitotic agent, has been used in intrale- sional injections to treat granulomas.
Furthermore, granulomatous reactions to HA fillers have been treated with hyaluronidase.
Finally, systemic oral steroid therapy can be used for recurring foreign body granulomas.
The use of oral prednisone at a starting dose of 30 mg/ day and a maintenance dose and 60 mg/day can prevent the recurrence of granulomas.
Minocycline combined with oral or intralesional steroids is effective in treating widespread inflammatory granulomas.
The excision of foreign body granulomas is not a therapy of first choice because the complete removal of a granuloma is often not possible in many cases as granulomas are invasive and have non-confined borders with the surrounding tissue.
However, in the case of an obvious sterile abscess, an effective treatment is incision and drainage of the abscess.
Edema is a common adverse reaction subsequent to an HA filler injection.
Hyaluronic acid derivatives are particularly hydrophilic and can be associated with localized edema.
Just as with erythema, edema is due to puncture trauma and associated inflammation.
The swelling can be expected to persist for a similar duration as the erythema, sometimes slightly longer.
Depending on the injection site, such as lip injection, swelling can be more profound and last longer, with an expected duration of 2–3 days.
Swelling is managed by applying cold compresses postinjection for 5–10 min to reduce inflammation.
After the procedure, patients can be advised to use ice packs at home every few hours on the day of the injection.
Caution must be emphasized to avoid prolonged ice pack usage to reduce the risk of cold injury to the skin.
Furthermore, swelling can be reduced using a prudent injection technique that will minimize the number of skin punctures during the injection process, thus limiting trauma to the injected area.
Such techniques include placing the filler with a serial injection, using the fanning technique, injecting at the preperiosteal level, or using linear tunneling with threading.
Care must be taken when injecting HA fillers into regions such as the lower eyelids and lips where there is a greater likelihood of undesirable excessive visible edema.
Additional volume may develop in these areas because of excessive water sequestration caused by hyaluronic acid derivatives.
Thus, conservative treatment should be undertaken when injecting the lower eyelids and lips.
Facial angioedema is an adverse event that can occur following HA filler injection.
Facial angioedema results from a hypersensitivity reaction, which is an allergic reaction mediated by T lymphocytes.
This allergic reaction is thought to be related to protein contaminants present in the filler material.
Hypersensitivity reactions related to der- mal fillers are an infrequent complication.
Immune- mediated angioedema is rare, with an estimated incidence of less than one to five in 10,000.
Angioedema normally manifests within approximately 2 weeks posttreatment.
Angioedema is more commonly seen with superficially placed hyaluronic acid derivatives.
A particular area of concern is the lip when injected superficially with HA fillers.
In the event of angioedema, the allergen (hyaluronic acid deriva- tive) which is the inciting factor must be removed.
This is accomplished by injecting hyaluronidase locally.
If necessary, the symptoms of angioedema can be treated with oral prednisone.
Herpes simplex virus reactivation has been reported following HA dermal filler injections, likely associated with the inherent skin irritation caused by injection.
Common sites of reactivation are the perioral area, nasal mucosa, and mucosa of the hard palate.
These case reports are anecdotal and no definitive evidence-based data has implicated fillers in the causation of recurrent herpes infection.
However, for those patients with a history of cold sores, especially after prior filler injections, an antiherpes prophylaxis regimen may prove beneficial.
Prophylactic treatment with valacyclovir should be initiated prior to injection to reduce herpetic reactivation, with a dosage of 500 mg twice daily for 3–5 days.
If a herpetic reactivation occurs in the absence of prophylactic treatment, then 2 g of valacyclovir twice daily for 1 day should be given to tamper the infectious outbreak.
Vascular compromise following dermal filler injection is a rare but very serious potential adverse event, with an incidence estimate of 0.001 % for hyaluronic acid fillers.
Vascular compromise results from vessel injury, compression, or occlusion following dermal filler placement.
Oftentimes vascular compromise results when the intravascular injection of material into an artery occurs, causing an embolism that impedes blood flow.
Vascular injury can cause tissue necrosis and acute vision loss.
To limit the risk of injection procedures, it is imperative that administrators of dermal fillers have a thorough understanding of facial anatomy.
Vascular compromise is an emergent condition that requires prompt action to avoid catastrophic consequences.
Vascular-mediated events may result in skin necrosis following hyaluronic acid filler injection.
Impending necrosis following filler injection is a major, early-onset complication that is likely the result of vascular injury, compression, or obstruction of the facial artery, angular artery, lateral nasal artery, supratrochlear artery, or their branches.
During the injection procedure, filler material may inadvertently be injected into vessels and flow antegrade or retrograde through the vasculature, causing an occlusion leading to local or distal tissue necrosis.
In a review study of necrotic events following dermal filler injection, the most common injection site for necrosis was the nose (33.3 %), followed by the nasolabial fold (31.2 %).
Necrosis can also occur due to vessel injury and compression secondary to the local edema caused by the hydrophilic properties of hyaluronic acid fillers.
The anatomic regions most susceptible to ischemic necrosis are the glabella and the nasolabial fold.
These are regions where the blood sup- ply is poor or is predominantly dependent on a single arterial branch.
The glabella region is supplied by the supratrochlear and supraorbital arteries, terminal branches of the ophthalmic artery.
Retinal artery occlusion can be caused by injections to the glabella, leading to vision impairment and complete vision loss.
The nasola- bial fold is supplied by the angular artery.
Alar necrosis has been reported following injection to the nasolabial fold, likely due to compression of the angular artery or its branches.
To prevent these serious adverse vascular events, extra caution must be taken when injecting into these areas.
Aspiration prior to injection is recommended to help prevent accidental placement of the filling agent within a vessel.
It is important to watch for the signs of vascular compromise which are severe pain (more than what is expected for a dermal filler injection) and an area of blanching.
If these symptoms occur, swift and aggressive treatment is necessary to prevent tissue necrosis.
In the event of hyaluronic acid-induced vascular compromise and impending necrosis, immediately discontinue the injection.
Next, administer a cutaneous injection of hyaluronidase in the site of filler placement.
Then apply a 2 % nitroglyc- erin paste to the skin.
Nitroglycerin paste has a vasodilatory effect on small-caliber arteri- oles, thus improving flow within the dermal vasculature.
Apply the paste cyclically for 12 h on and 12 h off until clinical improvement.
To further increase vasodilatation to the affected area, apply warm compresses and massage the area.
In addition, aspirin 325 mg daily should be given to prevent clot formation.
Furthermore, methylprednisolone (Medrol dose pack) should be prescribed along with prophylactic antibiotic ther- apy such as levofloxacin.
Along with these measures, application of topical oxygen infusion cream (Dermacyte Oxygen Concentrate, Oxygen Biotherapeutics) twice daily has been reported effective.
Low molecular weight heparin has also been used in the management of patients with filler-induced vascular occlusion.
Factors that increase the possibility of vessel occlusion and resulting vascular compromise include high-pressure injections (anterograde flow more likely), large-volume bolus injections, a stationary rather than moving needle, and a deep plane of injection (larger vessels are found beneath the dermis in the subcutaneous fat).
The glabella is a high-risk anatomic location for ischemic necrosis.
Accidental injection of the supratrochlear or supraorbital arteries in the glabellar region can cause a central retinal artery embolism that impedes blood flow to the retina resulting in visual impairment as a result of retro- grade flow of the filler material into the central retinal artery.
Precautions that can be taken to minimize the risk of central retinal artery embo- lism and iatrogenic blindness include aspirating before injection to detect accidental entry into a vessel; using needles and cannulas of small size as opposed to larger ones, and blunt flexible nee- dles and microcannulas when possible; perform- ing low-pressure injections with the release of the least amount of substance possible rather than bolus injections; and avoiding injection into traumatized tissue.
If visual impairment results after filler injection, an ophthalmologist should be consulted immediately.
First approved in 1989 for the treatment of various neuromuscular disorders, it was not until 2002 that the US Food and Drug Administration (FDA) approved botulinum toxin for its first der- matologic application: enhanced cosmesis of glabellar lines.
By 2004, the FDA extended its approval of onabotulinumtoxin A or Botox?, to the treatment of primary axillary hyperhidrosis refractory to treatment with topical agents.
At present, injection of botulinum toxin is one of the most commonly employed modalities for facial cosmetic enhancement in the United States.
According to the American Society for Aesthetic Plastic Surgery, neurotoxin injection was the most commonly performed nonsurgical cosmetic procedure in the year 2013: of the near 15.1 mil- lion cosmetic procedures performed that year, approximately 42 % (6.3 million) were botulinum toxin injections.
Furthermore, axillary and palmar hyperhidrosis, which affect approximately 1–3 % of the population, had historically proven difficult to treat prior to the approval of botulinum toxin injections.
These findings demonstrate both the clinical and economic impact of botulinum toxin injections in modern medicine, as well as their essential place in the armamentarium of the procedural dermatologist.
While the side effect profile of botulinum toxin formulations is generally favorable, it is important for clinicians to be aware of the com- plications associated with their use.
In this chapter, we explore several of these common and rare adverse effects, with focus on their typical clinical presentation and indications for management.
Furthermore, we briefly discuss the emergence of patients presenting with complications following injection of illicit botulinum toxin-containing compounds in the hands of untrained or nonmedical personnel.
Produced by Clostridium botulinum, an anaerobic, spore-forming bacterium, botulinum toxin is a zinc-containing neurotoxic enzyme that exerts its effect within the synaptic bouton of the neuromuscular junction.
Through the hydrolysis of the proteins synaptobrevin (also referred to as neuronal vesicle-associated membrane protein or VAMP), SNAP25, and syntaxin, botulinum toxin inhibits the release of the neurotransmitter acetyl- choline, thereby inducing flaccid paralysis in affected muscles.
Pathologically, this effect is best demonstrated by the disease manifestations of botulism.
Following ingestion and/or inhalation of clostridial spores, there is reactivation of the bacte- rial life cycle, with resultant production of massive amounts of botulinum toxin.
Ultimately, the systemic release of this toxin load results in a clinical entity characterized by descending flaccid paraly- sis, respiratory arrest, and possibly death.
The strength of botulinum toxin is recorded as a measure of its paralytic activity in mouse species.
The standard unit of injection, the unit (U , is described as the lethal dose for 50 % of mouse models, or LD50, following intraperitoneal injec- tion into the mouse abdomen.
In humans, this dose has been estimated in the range of 3000 U. 
In 1989, the FDA approved the use of botulinum toxin type A – produced from the A subtype of Clostridium botulinum – as a local treatment for disorders ranging from blepharospasm and strabismus to various chronic facial spasm disorders.
It was not until 2002 that botulinum toxin was approved for use in the management of moderate to severe glabellar lines.
As with the neuro- muscular disorders, its therapeutic effect was mediated by the induction of flaccid paralysis in muscles underlying the skin in which rhytides were present.
Following the release of tension within these muscles– which typically takes about 14 days to reach maximal effect– there is a general flattening of the overlying skin that lasts for a period of 3–6 months.
At this point, the recycling and regeneration of new neuromuscular junctions results in the reappearance of the original rhytides.
Despite its effects at the neuromuscular junction, botulinum toxin does not appear to induce any reactive changes within myocytes themselves.
In a clinicopathologic series performed on patients who received botulinum toxin type A injections in doses up to five times greater than those typically used for enhanced cosmesis, histologic examination did not demonstrate any chronic changes in muscle tissue, including scar- ring, fibrosis, or atrophy.
At present, there are three botulinum toxin- containing agents in use in the United States: onabotulinumtoxin A abobotulinumtoxin A and incobotulinumtoxin A All three are derived from Clostridium botulinum serotype A and they each possess their own unique clinical indications.
Among the most commonly used botulinum toxin formulations on the market today, onabotu- linumtoxin A – better known by its trade name, Botox? – is commonly used in cosmetic derma- tology for the release of glabellar lines, hyperki- netic frontal lines, and lines of the lateral canthus (“crow’s feet”).
Marketed under the trade name Dysport?, abob- otulinumtoxin A is also used in clinical practice for facial cosmetic enhancement.
However, it is important for clinicians to note that the relative potency of Dysport? does not equal that of Botox?: several studies have reported conversion factors ranging from 1:3 to 1:5 (Botox? vs. Dysport?). 
While the clinical effects after appropriate dosing are often similar between both agents, these findings are of considerable impor- tance for clinicians or practices in which both toxin formulations are used interchangeably.
Appearing more recently on the market than the other two formulations, incobotulinumtoxin A (trade name Xeomin?) has been approved for the treatment of cervical dystonia, blepharospasm, and glabellar lines.
In comparison to onabotulinum- toxin A and abobotulinumtoxin A containing formulations, Xeomin features a lower total load of protein; therefore, this compound was originally marketed as a potentially safer option due to a theoretically lower chance of inducing host immunologic response.
However, one random- ized, double-blinded trial comparing incobotu- linumtoxin A to onabotulinumtoxin A failed to demonstrate any measurable difference in safety or neutralizing antibody generation between the two arms.?
A myriad of studies have demonstrated the relative safety and low side effect profile of all of the above formulations of botulinum toxin for local injection.
Typically, the common adverse effects experienced by patients are similar for all three agents: these include reactions at the injection site (erythema, pruritus, hematoma formation, or transient rash), focal muscle weakness, and headache.
The risk of complication is related to both the dose administered and the site of injection.
In one meta-analysis on onabotulinumtoxin A's safety in facial injections, it was found that adverse effect rates were much higher in onabotulinumtoxin A groups than in corresponding placebo groups.
Additionally, injections at the glabella carried a higher risk of complications than those at the lateral canthus.
Interestingly, the most commonly reported adverse effect at both sites was transient headache, which may have been an artifact of injection rather than the toxin itself.
While many of the above complications are transient and do not require further management, several rare complications associated with botulinum toxin injection have been reported.
As these manifestations may require further management, it is important for clinicians to be aware of their typical presentations.
The muscles injected during the treatment of glabellar and canthal lines lie in close proximity to key muscles of ocular movement.
Accordingly, it is important for dermatologists to remain cognizant of the ophthalmic complications associated with injection of botulinum toxin.
Among these, the most commonly reported ocular adverse effect is eyelid ptosis.
Typically occurring following injection of the procerus muscle, the proposed mechanism of effect is lateral spreading of injected botulinum toxin through the orbital septum.
This places the levator palpebrae superioris muscle of the upper eye- lid at risk of paralysis, with resultant eyelid ptosis that can manifest within the first 2 weeks following injection.
Clinically, this may manifest as a 1–2 mm depression of the affected eyelid; diag- nosis may be made by comparison of the affected eye with the contralateral lid, as well as an obscuring of the upper pupillary rim on the affected side.
While most cases of ptosis are mild and tend to resolve within 2–4 weeks of injection, evaluation with an ophthalmologist may be indicated in cases of severe visual impairment.
In these cases, the use of mydriatic eyedrops may induce enough upper eyelid contraction to overcome the degree of induced ptosis.
Clinicians may lower the risk of inducing eyelid ptosis by using concentrated solutions of botulinum toxin; this will diminish the migratory potential of a large bolus of dilute solution.
Additionally, while gentle massage is advised to increase in-plane spread of toxin, avoidance of overaggressive horizontal massage will prevent the risk of toxin reaching the medial orbital septum.
Another ocular complication associated with botulinum toxin injection is diplopia, or the visual perception of a doubled image secondary to impaired extraocular muscle function.
These findings are typically due to infiltration of injected botulinum toxin into the nearby extraocular mus- cles and often occur following injection of a large bolus of botulinum toxin or injection at the hands of untrained personnel.
The typical patient presentation is an individual complaining of distorted vision 1–2 weeks following botulinum toxin injection.
Paralysis of the lateral rectus muscle is among the most commonly reported complica- tions; this may occur secondary to the regularity of the lateral canthus as a site of injection for enhanced cosmesis, as well as its close proximity to the lateral rectus muscle.
However, excessive injection of the procerus or nasalis muscles may result in paralysis of the medial rectus muscle.
Depending on the severity of diplopia, referral to ophthalmology may be warranted; however, clini- cians can assure patients that this effect will reverse following regeneration of the neuromus- cular junctions within the affected extraocular muscle.
A more severe manifestation of extraocular dysfunction is strabismus, or unilateral deviation of the affected globe secondary to the loss of function of an extraocular muscle.
If suspected, urgent evaluation by an ophthalmologist is war- ranted: left unmanaged, these patients may experience long-term visual dysfunction.
Ophthalmologists may choose to employ unilateral eye patching or treatment with visual glass prisms throughout the 3–6-month window until the effects of the toxin fade.
Unlike eyelid ptosis, eyebrow ptosis typically occurs following injection of the frontalis muscle for the treatment of hyperkinetic frontal lines.
This scenario often arises secondary to asym- metrical injection of botulinum toxin, injecting a large bolus of dilute solution in the frontal zone, or overaggressive horizontal massage following injection.
It can be avoided by careful preparation in the pre-procedural window: using the smallest amount of concentrated injection material possi- ble, as well as mapping injection sites prior to treatment, may prove helpful for clinicians.
Similar in presentation to eyebrow ptosis is an entity known as pseudoptosis.
In the presence of redundant frontal skin– common in older patients or those with photodamaged skin– injection of the frontalis muscle may result in skin and subcu- taneous tissue folding over the superior aspect of the brow.
Counseling patients on the risks associ- ated with frontalis muscle injection, as well as careful patient selection for injection at this site, may mitigate brow ptosis or pseudoptosis.
Patients with this degree of cutaneous elasticity should also be advised that tissue edema follow- ing injection is common; this tends to resolve 24–48 h following injection.
Exaggerated elevation of the brow tail may occur in the setting of overaggressive treatment of the procerus muscle in comparison to the frontalis muscle.
These patients will develop pronounced elevation of the lateral brow in comparison to the medial brow, which alters resting facial appear- ance and may interfere with normal expressions of emotion.
This complication highlights a clinical pearl for botulinum toxin injection at any site: treatment of a muscle group (i e , elevators) without concomitant injection of its antagonist group (i.e., depressors) may result in unfavorable cosmesis or distortion of resting facial structure.
The superolateral aspect of the bony orbit hosts the lacrimal fossa, within which the lacrimal gland–responsible for tear production – is situated.
When botulinum toxin injectables were first approved for the treatment of lateral canthal lines, there was concern among clinicians that their proximity to this gland could pose a theoretical risk of iatrogenic xerophthalmia.
However, contrasting reports on the effects of injection on tear production exist in the literature: while one prospective cohort of 26 crow's feet areas injected with botulinum toxin type A demonstrated no statistical difference in tear production (as measured by the Schirmer test), one recent study demonstrated that injection of the lateral canthal folds decreased both tear production and tear film stability.
In this latter study, the severity of xerophthalmia was directly related to increasing patient age and increasing dose of botulinum toxin administered.
Despite these findings, numerous case reports have described complications related to tear production following injection for lateral canthal rhytides.
The generally accepted mechanisms of pathogenesis include direct toxin-mediated effects at the lacrimal gland, as well as orbicularis oculi muscle dysfunction secondary to toxin injection.
The typical presentation mirrors that of xerophthalmia: patients report conjunctival injection, a sensation of "sand-like dryness"?or gen- eral eye irritation in the weeks following botulinum toxin injection.
If treatment is indicated, it is generally conservative and limited to management of the adverse effects experienced; patients can also be assured that their symptoms will improve as the effects of the botulinum toxin begin to fade.
However, in cases where there is a significant degree of lagophthalmos (inability to close the eyelids), patients may present with ectropion (eversion of the lower eyelid), which places them at an increased risk of developing chronic keratitis and/or corneal ulcerations.
In cases where this degree of lid dysfunction is suspected, urgent ophthalmological evaluation is warranted.
Avoiding a large bolus of injection at the lateral canthus, as well as avoiding injection within one centimeter of the orbital ridge, can decrease the risk of botulinum toxin-induced xerophthalmia.?
Many patients undergoing botulinum toxin injection may desire treatment of lower facial rhytides.
Treatment in this region poses unique challenges to clinicians: a complex network of eleven separate levator and depressor muscles control lip movement, each with functions rang- ing from speech and eating to subtleties of facial expression.
Therefore, improper treatment in this area may result in notable impairment for patients.
Ptosis of the upper lip may arise following either injection in the infraorbital or perizygo- matic area, as well as injections affecting the superior aspect of the orbicularis oris muscle itself.
For the former, resultant paralysis of lip elevators found in this region–including the zygomaticus major and minor, levator labii superioris, levator labii superioris alaeque nasi, and levator anguli oris–may result in asymmetrical drooping of the upper lip.
Beyond the resultant unfavorable cosmesis, a significant degree of ptosis may interfere with normal speech, chewing, and facial expressions.
Conversely, ptosis of the lower lip may occur with improper injection in the region of the oral depressors, as well as migration of a large bolus into this region.
Ptosis at this site may result in symmetric protrusion of the lower lip or may cause downward bowing of one oral commissure in comparison to the contralateral side.
Beyond unfavorable cosmesis, such drooping of the oral commissures may interfere with drinking, eating, or speaking; if severe, patients may even experience spontaneous dripping of saliva from the affected oral commissure.
Injections in the area surrounding the chin are becoming increasingly popular, especially among male patients.
Typically, patients present for evaluation of "chin furrowing"?or corrugation of the skin overlying the chin secondary to a hypertrophic mentalis muscle, as well as relaxation of a "chin dimple"?or midline cleft overlying the chin.
Chemical denervation with botulinum toxin may ameliorate both conditions, but strict adherence to injections in the midline– as well as injecting at a safe distance from the orbicularis oris muscle – is essential at this site.
Improper injection lateral to the mentalis may result in paralysis of the lower lip depressors, with resultant protrusion of the lower lip or ptosis.
Additionally, migration upward toward the inferior rim of the orbicularis oris may prevent lip pursing and interfere with speech.
Chemodenervation of the platysma provides patients with a safe, nonsurgical method for relaxing vertical neck bands.
Nevertheless, the anterior neck is replete with neurovascular structures at potential risk of disruption, and the large surface area of the platysma often inclines clinicians to inject a high number of units of botulinum toxin (upwards of 100–200U in a single session has been reported by some).
It is advised that clinicians with limited experience in injecting the platysma refer these patients to a procedural dermatologist or someone with greater familiarity of administering botulinum toxin in this area.
Furthermore, the use of no greater than 50U of botulinum toxin is advised when injecting in the anterior neck.
Following injection of the platysma, common adverse effects include those related to the injection process itself: pain, bruising, neck weakness, and generalized anterior neck discomfort are often seen, and patients can be reassured that these symptoms will fade within several days.
Although rarer, more alarming complications may arise following injections of the anterior neck: impaired neck flexion, hoarseness of the voice, and dysphagia have all been reported in the literature.
Their mechanism is likely related to improperly injecting botulinum toxin deeply into the neck, as well as migration of a large bolus toward the deeper musculature of the neck.
To avoid these potential complications, clinicians should use the smallest bolus of concentrated botulinum toxin possible, and they should inject superficially in a horizontal plane.
Having the patient lie supine with their neck slightly flexed during injection may aid in preventing deep injections; additionally, following penetration of the skin, lifting up gently on the syringe to dem- onstrate a superficial location of the needle bevel will aid clinicians in administering the bolus in plane with the platysma.
Historically, hyperhidrotic disorders have posed clinicians with challenges for long-term management.
While the etiology of these disorders ranges from congenital to acquired, they are all believed to result from hyperactive eccrine gland secretion secondary to excessive stimulation by cholinergic sympathetic nerves.
Accordingly, body areas with a high volume of eccrine glands – such as the axillae, palms, and soles– are typically the most affected in these disorders.
In 2004, the FDA approved use of onabotulinum- toxin A for use in the treatment of focal axillary hyperhidrosis; however, both onabotulinumtoxin A and rimabotulinumtoxin B (trade name Myobloc; a botulinum toxin derived from Clostridium botulinum subtype B are often used in clinical practice for the management of focal hyperhidrosis of other sites, including the soles and craniofacial areas.
Several complications following treatment of hyperhidrotic disorders with botulinum toxin have been reported in the literature.
Ona- botulinumtoxin A has been reported as having a radial diffusion capacity of up to 1.5 cm within axillary skin, which makes mapping of the affected axillary skin essential prior to injection.
The starch-iodine test may prove useful in this regard, as it provides clinicians with a demonstrable area of involvement, which can serve as a guide for botulinum toxin injection.
If improperly injected, patients may experience minimal clinical benefit and/or injection site reactions secondary to material migration.
Although exceedingly rare, there is one case report in the literature of a patient who developed superficial thrombophlebitis (Mondor's disease) of the anterior chest veins following injection of botulinum toxin subtype A for treatment of axillary hyperhidrosis.
These findings suggest that while botulinum toxin has proven effective in the management of axillary hyperhidrosis, administration of these injectable formulations is not without associated risks.
The most common complication of botulinum toxin injection for palmar hyperhidrosis is hand weakness: patients may report a general loss of dexterity that improves over the following 3–6 months.
In order to minimize these complications, physicians should first map the injectable area and then administer the injection with a goal of distributing toxin within the superficial dermis.
Many complications following injection of botulinum toxin have been reported in the literature, although cases are sporadic and often contested between studies.
However, two of these entities are worth mentioning: superficial temporal artery pseudoaneurysm and systemic manifestations following local injection.
The superficial temporal artery is one of the terminal branches of the external carotid artery.
In its course through the lateral face, the superficial temporal artery runs along the posterior aspect of the neck of the mandible and ascends ~1–2 cm anterior to the tragus in the preauricular area.
It ultimately splits into two prominent branches – a frontal and parietal branch – both of which can be palpated for pulses or may be visible in certain individuals.
Due to its superficial nature, the superficial temporal artery and its associated branches are at increased risk of trauma during both surgical and nonsurgical procedures of the lateral face.
Several cases of pseudoaneurysm of these vessels have been reported several months following injection of botulinum toxin: patients typically presented with nontender, pulsating, or non-pulsating frontal and/or temporal masses that corresponded with the site of injection.
Occasionally, a bruit may be auscultated over the mass.
Diagnosis can be confirmed with Doppler ultrasound, which demonstrates blood flow with an outpouching mass in connection with the affected vessel.
Depending on the resources available in one's community, prompt evaluation and management by a vascular surgeon or interven- tional radiologist is indicated.
Although exceedingly rare, physicians should remain aware of the risk of systemic manifestations following local botulinum toxin injection.
There are several reports in the literature– occur- ring in both the cosmetic and facial spasmodic disorder settings– of injections of botulinum toxin inducing systemic myasthenic crises.
These findings highlight the importance of obtaining a good clinical history– including a personal or family history of myasthenia gravis or other motor neuron disorders– in all patients before botulinum toxin injection.
Accordingly, clinicians should not administer botulinum toxin injections to any patient with a personal history of disorders involving the motor neuron unit.
At present, administration of botulinum toxin for enhanced facial cosmesis is still the most com- monly performed nonsurgical cosmetic procedure in the United States.
The relatively low adverse effect profile associated with these compounds, coupled with their ubiquitous presence through- out the United States, has resulted in the public's perception of botulinum toxin-containing agents as a safe option for enhancing facial cosmesis.
Although it is strongly suggested that those seeking botulinum toxin injections consult a dermatologist, individuals throughout the medical community– including physicians of all special- ties, nurse practitioners, physician's assistants, dentists, and registered nurses– can pursue certification and provide Botox? injection as a regular part of their clinical practice.
These training certifications, which generally consist of a single-day 8-h course, may not provide healthcare providers with enough time to hone their skills in injecting botulinum toxin; accordingly, the risk of the above complications is generally higher.
Alarmingly, it has been the experience of the authors that there has been an increase in the number of patients presenting for evaluation of complications following botulinum toxin in the nonmedical/illicit setting and/or outside of the United States.
Many of the complications experienced by these patients have been detailed above, with the most common complaint generally being asymmetrical facial tone and resultant lack of cosmetic benefit.
The setting in which these injections are provided also poses a challenge for managing clinicians: as many of these patients are unaware of the type of substance they received as an injection, there is a chance that they have received non- FDA-approved botulinum toxin agents and/or formulations containing many different compounds.
Clues to the latter include induration or prolonged erythema at the injection site, local tissue necrosis, and/or soft tissue hardening as a result of chronic inflammation and fibrosis.
While granuloma formation following injection of onabotulinumtoxin A has been reported in the literature, these cases are the subject of controversy among clinicians; in the presence of a positive his- tory of facial injections performed outside of the medical setting in the United States, the presence of a granuloma strongly suggests injection of a material other than botulinum toxin .
In cases of unclear etiology, pathologic assessment of a biopsy specimen can reveal the presence of foreign bodies, including silicone globules or other foreign injection materials.
While medical management with immunosuppressive agents such as cyclosporine or oral steroids may prove useful in uncomplicated cases of granuloma formation, surgical management– including excision and local tissue debridement – is most likely warranted.
When administered by trained medical professionals, botulinum toxin injections provide patients with a safe, nonsurgical method for both cosmetic and medical conditions alike.
Nevertheless, it is important for clinicians to remain mindful that these agents are not inert: as a neurotoxic compound, botulinum toxin can pose significant morbidity to patients when injected improperly.
Awareness of both the common and rare side effects associated with botulinum toxin injection encourages best practice standards whenever botulinum toxin is injected and also facilitates prompt evaluation and management in the event that a patient experiences any of these described complications (Figs. 13.1, 13.2, and 13.3).
Targeted and innovative techniques and protocols are increasingly used in noninvasive eye and lip rejuvenation with the aim to obtain the best results and reduce side effects.
Understanding the anatomy of the eyelids, lips, and surrounding structures is important to achieve the best results and avoid potential complications.
Palpebral area is very delicate consisting of three layers: cutaneous, muscular, and fibrous layers.
In particular, palpebral skin is thinner com- pared to other skin districts; its hydrolipidic film and skin barrier function are weaker.
The dermis is poorly represented and less rich in collagen and elastic fibers.
The hypodermis is almost absent and blood and lymphatic circulations are slow.
Eyelid skin shows vascular fragility and increased vulnerability to actinic damage.
The use of lasers to treat the eyelids is often limited by longer postoperative wounding, erythema, and the potential risk for hypopigmentation and ectropion.
The upper lip extends from the base of the nose superiorly to the nasolabial folds laterally and to the free edge of the vermilion border inferiorly.
The lower lip extends from the superior free vermilion edge superiorly, to the commissures laterally, and to the mandible inferiorly.
From superficial to deep, the layers of the upper and lower lips include the epidermis, subcutaneous tissue, orbicularis oris muscle fibers, and mucosa.
Fractionated laser technology has allowed physicians to minimize downtime and complica- tions increasing the number of treatments with lower rate of complications than non-fractionated laser treatment.
While ablative fractional devices allow for quicker recovery than traditional fully ablative devices, when compared with their non-ablative counterparts, downtime can be considerably longer, in average 5~7 days.
Unfortunately, adverse effects can still occur even with the best technology and physician care.
Non-ablative fractional lasers (NAFL) are more gentle than the ablative and require a moderate amount of downtime as they induce limited tissue damage and melanocyte stimulation.
In general, NAFR has fewer complications than traditional ablative lasers.
Most complications can be easily managed and are self-limited.
With regard to any side effect, early identification and treatment will improve outcome.
Ablative fractionated lasers (AFL) reduce the tissue trauma decreasing downtime while retaining resurfacing action.
These lasers are significantly safer than their non-fractionated counterpart, but they still maintain high risk of potential damage and complications.
Complication prevention, detection, and treatment are an important part of a physician's ability to provide the best results when treating a patient with fractionated laser.
Fractional lasers perform a pixelated pattern photothermolysis.
This technology makes it possible to obtain microareas of thermal damage surrounded by healthy tissue.
These microcolumns of damage stimulate the healing and skin restruc- turing processes with the production of new collagen and elastin, similar to those achieved with massive treatment of the entire surface, but instead limited to dots of a diameter of 70–150 μm separated by bridges of untouched skin.
It has been estimated that the thermal damage induced by these microcolumns reaches a depth of between 300 and 400 μm in the dermis.
Histological studies by Hantash et al. demonstrated that areas of epidermal and dermal necrosis are visible in the skin immediately after treatment that rapidly heal within 24 h showing keratinocyte migration and elimination of the necrotic epidermal columns through exfoliation of the stratum corneum.
Changes in cell mor-phology have also been observed in the deeper portions of the "columns".?
Specifically, stationary cuboidal phenotypes and even spindle cell migration are visible.
These cells are considered to be responsible for the rapid healing and reepithelialization phenomena after fractional laser treatment.
Fractional CO2 laser combines the"concept"?of fractional photothermolysis with an ablative wavelength of 10,600 mm, successfully treating photoaging, acne scars, and skin flabbiness with minimized postoperative risks and discomfort.
Fractional CO2 laser treatment does not require general anesthesia; however, a cooling system is implemented and topical anesthetics can be applied beforehand.
Erythema may appear and lasts 5–7 days only, with only minimal risks of post-inflammatory hyperpigmentation and superinfections.
The treatment requires more sessions than normal CO2 laser treatment and the results are slower; however, patients prefer fractional laser treatment since it ensures faster heal- ing times without any restrictions to their daily activities.
The non-ablative fractionated lasers combine the gentle and safe aspects of fractionated and non-ablative technologies aiming to improve tex- ture, mild to moderate wrinkles, and acne scarring.
In general, NAFR has fewer complications than traditional ablative lasers.
Most complications can be easily managed and are self-limited.
As with any side effect, early identification and treatment will improve outcome.?
Despite concerns for erythema, it should be kept in mind that erythema is the clinical end point of fractional resurfacing and is an expected, transient side effect.
In the case of non-ablative or ablative fractional resurfacing, redness may persist for 3–7 days.
For NAFR, prolonged erythema is defined as posttreatment redness that persists longer than 4 days.
It has been reported in less than 1 % of patients treated with NAFR.
Ablative fractional resurfacing erythema has a longer duration.
Usually post-resurfacing erythema fades gradually over time.
Prolonged erythema (Fig. 14.1a, b can be caused by inappropriate laser settings, infections, and contact dermatitis.
Patients can be started on a topical steroid (hydrocortisone 2 %) to reduce inflammation.
Transient erythema after non-resurfacing procedures could be covered with cover-up makeup.
After laser resurfacing mild edema could appear together with erythema, remissioning in automatic.
Especially at the level of the eyelids, laser treatment produces marked edema, which can be notable for several days.
The edema of the eye- lids after laser resurfacing can get worse for 1–2 days after the procedure before it starts to reduce because it tends to congregate at eyelid levels.
When needed edema can be treated with oral corticosteroids such as methylprednisolone in a brief course of 5 days (60 mg daily).
Immediate posttreatment urticaria is an expected consequence of fractionated laser skin resurfacing that usually resolves within 3–4 days.
Cold- induced urticaria has been described after fractional carbon dioxide laser resurfacing of the face associated with cooling systems used during the procedure.
A complete medical history before starting treatment could be useful for prevention.
Petechiae or purpura can occur immediately or days after treatment and can take 1–2 weeks to resolve.
Postprocedure bruising can be minimized by avoidance of anticoagulants and other medication that may predispose (e g , aspi- rin, vitamin E ginkgo biloba, etc.).
Intense bruising could resolve leaving post- inflammatory hyperpigmentation, especially in photodamaged individuals and darker skin types.
Focal crusting and erosions may frequently occur during a non-ablative procedure.
Erosions or crusts lasting more than 2–3 days should be treated with a brief course of topical steroids.
Persisting lesions should indicate other causes, such as infections, inappropriate laser settings, or picking behavior.
After AFR larger areas of disepithelialization could be commonly seen and resolve in about a week.
Treatment of the eyelids with AFR in particu- lar can cause erythema, edema, and focal erosions, visible for 3–5 days after treatment.
Posttreatment with abundant emollients can accelerate healing.
Widespread small vesicles may be a reactive phenomenon after fractional laser treatments, especially in eyelid regions.
These lesions resolve within a day or two helped by topical corticosteroid application.
The thin skin of the eyelids is particularly sensitive to irritants and allergens and is thus prone to develop contact dermatitis due to the irritant and/or allergic potential of pre- and posttreatment topical agents (Fig. 14.2).
It is recognized that a wide variety of creams, ointments, cleansers, and other skin care products may cause contact dermatitis after laser resurfacing.
Contact with the same trigger may not lead to a rash on other areas of the skin.
Gentle skin care and topical corticosteroids are recommended if needed.
Acneiform eruption incidence has been reduced by fractional technology comparing to traditional laser resurfacing.
After NAFR treatments the rates of acneiform eruptions range from 2 to 10 %; milia can occur in up to 19 % of treated patients.
AFR treatments also show lower risk of developing acneiform eruptions or acne exacerbation and milia, which may be due to occlusive mois- turizer application in the postoperative period.
Acne and milia often resolve without additional intervention as the healing processes.
Nonocclusive and noncomedogenic moisturizers may help in reducing their incidence.
The most common infection after fractional laser skin resurfacing is related to the herpes simplex virus (HSV), with reported rates ranging from 0.3 to 2.76%.
The incidence of bacterial infection after NAFR appears extremely low with 0.1 % of all treated cases documented to develop impetigo.
The infection rates with traditional ablative laser resurfacing were much higher, with 2–7 % of cases developing HSV reactivation.
Herpes simplex reactivation could be very common without prophylaxis.
Patients may not present with classic herpetiform vesicopustules, but instead may demonstrate only superficial ero- sions that develop during the first week after treatment.
To minimize the risk of HSV reactivation with fractional resurfacing, antiviral prophy- laxis should be administered when a prior his- tory of facial HSV is documented or if full-face ablative laser procedures are performed.
Prophylactic therapy is important even in those without a history of herpetic infections.
All patients should be placed on antiviral prophy- laxis, starting the day before the procedure in those without history of herpetic infections and 3 days before in those with history of herpetic infection.
Antiviral therapy should be continued for a total of 10 days.
The most common causes of skin infections after fractional resurfacing include Staphylococcus aureus (Fig. 14.3), Pseudomonas, Klebsiella, and Enterobacter.
Persistent pruritus and prolonged erythema may be associated with candidiasis.
Atypical mycobacterial infection has also been reported.
For this reason, many practitioners prescribe oral antibiotics and anti- virals before starting the procedure continuing until skin reepithelialization is almost complete.
Even if prophylactic antibiotics and antivirals have been used, in suspicion of skin infection, microbiologic culture testing should be con- ducted to identify the organism and its sensitivity to treatment.
Hyperpigmentation is one of the more common side effects of cutaneous laser resurfacing and may be expected to some degree in all patients with darker skin tones.
Post-inflammatory hyperpigmentation (Fig. 14.4) is much less frequent with fractional laser skin resurfacing than with their non-fractional counterparts.
Even though it is observed in 1–32% of patients depending on the device used, setting parameters, and Fitzpatrick skin phototype.
The reaction is transient, but its resolution may be hastened with the postoperative use of a variety of topi- cal agents, including hydroquinone and retinoic, azelaic, and glycolic acid.
Darker skin phototypes (Fitzpatrick III–VI) have higher susceptibility for developing hyperpigmentation after AFR.
NAFR are associated with very low rates of post-inflamma- tory hyperpigmentation, darker skin phototypes being more prone to develop it.
In general fractional laser treatments of darker skin should use higher fluencies, lower densities, and longer intervals between treatments.
Regular sunscreen use is also important during the healing process to prevent further skin darkening.
Hypopigmentation is not a common complication of AFR.
Postoperative hypopigmentation is often not observed for several months and is particularly difficult because of its tendency to be not responsive to treatment .
When the treatment is performed on a single part of an anatomic site, like perioral regions or eye- lids, it can result in smoothness consistency of the treated side versus the surrounding skin.
In general it resolves spontaneously.
Delayed reepithelialization may occur following the application of resurfacing lasers.
When it doesn't occur in about a week, other causes should be investigated; the most frequent is infection.
It is extremely important to manage this uncommon complication because the longer the skin repairs, the higher is the risk of scarring.
Although the risk of scarring has been significantly reduced with the newer pulsed systems (compared with the continuous wave lasers), 122 inadvertent pulse stacking or scan overlapping, poor technique, as well as incomplete removal of desiccated tissue between laser passes can cause excessive thermal injury that could increase the development of fibrosis.
The most common cause of scarring is postoperative infection.
Focal areas of bright erythema, with pruritus, may signal impending scar formation.
Ultrapotent topical corticosteroid preparations should be applied to decrease the inflammatory response.
A pulsed dye laser (PDL) can also be used to improve the appearance and symptoms of laser-induced burn scars.
The periorbital and mandibular regions are scar-prone anatomic locations that require more conservative treatment protocols.
Eye damages caused by laser procedures are not very common complications secondary to the use of inappropriate safety measures.
Ocular injuries reported during laser use include coloboma and corneal, vitreous, and retinal damage.
Before the laser is turned on, in ready mode patients' eyes should be closed or covered with opaque goggles or eye shields.
The operator and other personnel in the room should wear filter glasses that selec- tively exclude wavelengths emitted by the laser.
Laser-protective eyewear is a well-recognized precaution and includes wraparound glasses and goggles, which are rated by optical density (OD) at various wavelengths.
Ectropion of the lower eyelid after periorbital frational laser is rarely seen.
It is more frequent in patients who have had previous lower blepharoplasty or other surgical manipulations of the periorbital region.
Preoperative clinical evaluation is important to determine eyelid skin laxity and elasticity.
Lower fluences and fewer laser passes should be performed in the periorbital area to decrease the risk of lid eversion.
When ectropion occurs, it usually requires surgical correction.?
Koebnerization Laser-induced trauma may initiate a koebnerizing dermatosis, including diseases such as vitiligo and psoriasis.
Eruptive keratoacanthomas have been reported, most likely secondary to koebnerization.
Laser safety includes the use of protective eye- wear and eye shields, laser signage, control of surgical smoke, tissue splatter and plume, and attention to non-beam and beam hazards.
Treatment setting regulation is important to prevent side effects.
In particular, when treating eyelids laser settings should be lower than those for non-eyelid skin because of the thinness of eye- lid skin.
In particular treatment with fractional lasers should be approached with lower fluence, lower density, and shorter pulse duration settings.
Appropriate precooling, cooling during the procedure, and postcooling should also be con- sidered to provide an extra measure of epidermal protection.
In addition, a detailed disclosure of potential side effects protects not only the patient but also the provider.
In preventing fractional laser complications while treating eyelids, the lips and perioral region are also important to perform correct pre- and post-laser skin care.
Regular use of sunscreens and avoidance of tanning should be started on a preoperative regimen about a full month in advance continuing sun avoidance as skin care practice after the resurfacing.
As regards to post-laser treatment skin care, for patients undergoing NAFL resurfacing, the care is minimal.
The use of a mild, fragrance-free cleanser and moisturizer could be recommended resuming regular skin care regimen after about 1 week.
For patients undergoing AFL, some surgeons recommend cleaning process with only tap water and gentle gauze followed by application of a light lubricating ointment.
Others add the use of local antibiotics and/or antifungal.
When the resurface is complete (between days 4 and 6 after the procedure) but redness has not faded, fragrance-free cleanser and moisturizer should be used.
Makeup is allowed once resurfacing is complete preferring mineral makeup.
It is good news that silicone gel breast implants are returning to the market after an absence of 11 years.
Compared with saline-filled implants, they are easier to use, have no valve or filler mechanism and are prefilled.
Saline-filled implants, as everyone knows, show a ripple effect but there is less foreign material in the body. 
Gel-filled implants feel more natural.
I consider myself a breast implant customer, and there are two things I would like to know when purchasing a breast implant:
1. How thick is the outer membrane of the implant?
I need to know this to make an informed choice about long term rupture rates of the implant.
I would tend to choose thicker rather than thinner walled implants.
2. How thick is the gel inside the implant?
A highly viscous gel might not feel as natural but should be less likely to migrate outside a ruptured capsule surrounding the implant.
Long term follow-up
Because breast implants are inserted for many years, we need long term follow-up.
This should be easy, because women should be highly motivated to be interested in their health; both their breast health and systemic health, but it isn’t that easy.
The new breast shape becomes incorporated into the patient’s body image, and sometimes the powerful defence mechanism of denial takes effect.
Women occasionally do not tell a new partner they have had surgery and the result can be so good that the partner does not suspect.
The implants become a secret from a past life. 
Imagine receiving by mail annual recheck reminder cards for implant and breast re-examinations in those circumstances.
Add to that name changes and moving from city to city, even other provinces, states and countries, and the problem of follow- up assumes new proportions.
Ideally, follow-up for a breast implant patient should be for the rest of a woman’s life.
Who should do this follow-up?
It can be any physician or surgeon.
A national registry for breast implant patients should be set up in Ottawa so that patients can notify the registry of problems such as further operations for pain, scarring, capsule surgery or implant removal or replacement.
This is being done in Alberta and it should be done for the whole country, as it is in Denmark.
In future studies, I think we need to compare apples with oranges.
Not all breast implants are the same.
We need to compare same with same and we need to have considerable technical information from manufacturers so that we can compare implants.
Silicone implants Since 1992, there has been considerable debate as to whether silicone causes or exacerbates immune diseases. 
A number of women have syndromes which are hard to diagnose, in which their biochemical tests are normal for the tests we have available to us now.
As silicone gel implants come back on the market, it might be of value to consider not doing breast augmentations with these implants on women who already have collagen diseases, or syndromes such as chronic fatigue syndrome, fibromyalgia, or those with a strong family history of a collagen disease such as rheumatoid arthritis.
Prospective patients might object, saying they have a right to an operation. 
That might be so, but declining certain patients might be the best thing to do. 
Double lumen implants Consider the double lumen implant. 
It might be one of the best ideas in beast implants. 
This implant, available in the 1980s, was a silicone gel implant, surrounded by a second membrane, forming an outer pocket filled with saline.
It combined the best of both ideas.
If the inner membrane ruptured, gel would be contained in the outer compartment.
If the outer compartment ruptured, it was saline-filled and small volume so there would be little change in implant volume.
But there was a rub.
It was more complicated, and more difficult to make, so it was more expensive.
Sometimes though, it might be best to consider these principles over price when considering a breast implant, even though there is much to be said for simplicity.
Plastic surgeons have sometimes promoted the newest implant with the assumption that the newest idea is the best. 
Those of us who have followed the debate for a longer period have sometimes seen the reverse.
When thin-walled implants replaced thick-walled implants the change, though logical, was not an advance.
Sometimes ideas with alonger track record eventually prove to be better.
Diagnosis of ruptured implants It can be difficult to clinically diagnose a ruptured silicone gel implant.
Scans are good diagnostic tools, but are not accurate in very small ruptures and no one is suggesting we routinely diagnose rupture by surgery.
Perhaps after a certain time period, breast implant patients should have their implants replaced, but who would suggest operating on a happy patient with no complications? 
Long term follow-up will cost something but the expense is worthwhile and necessary.
It will also be disclosed to consumers from time to time as the data is analysed and verified.
This is as it should be and we should contribute to finding out all we can know about these useful devices.
Abstract Purpose – The purpose of this paper is to help understand the extent of regulation of aesthetic medicine in various developed countries and to discuss the current pitfalls and potential strategies in regulating this area of healthcare.
Design/methodology/approach – A range of published articles and press reports from bound and internet sources on aesthetic medicine in the recent five to six years were obtained to allow a better understanding of existing practices and regulatory climate.
Reports from relevant authorities in various countries were also referred to for information on proposed regulatory regimes and future regulatory directions.
Findings – The practice of aesthetic medicine has been marginally regulated, even in more highly developed countries.
The main regulatory concern appears to be the practice of minimally invasive aesthetic surgery by general practitioners.
Professional voluntary self-regulation would probably not be effective in view of the peculiar nature of aesthetic medicine vis-a` -vis conventional medicine.
Practical implications – There is a need for health regulatory bodies across the world to brace themselves for potentially more widespread health and social risks posed by aesthetic medicine.
Statutory governance is needed to maintain safe practice standards and to manage the supply and demand of aesthetic services.
In less developed countries, there is a need for better public education and empowerment to enable patients to make better-informed decisions and assume greater responsibility for the aesthetic services that they seek.
Originality/value – This paper discusses regulatory issues concerning aesthetic medicine which are rarely featured in academic journals. 
It offers some strategies for better regulation of aesthetic medicine which health authorities in certain countries may find useful.
Introduction Aesthetic medicine is a term that has been used by medical professionals to describe surgical procedures (viz. aesthetic/cosmetic surgery) and medical treatments that aim to improve a person’s appearance or subjective well-being.
Indeed, it is a practice of “medicalised” beauty therapy. 
In a society where beauty is increasingly seen as an essential ingredient of health (Moosa, 2002), more doctors are providing aesthetic services as part of their medical practice.
The line dividing between conventional and aesthetic medicine is blurring as more people begin to regard aesthetic medicine as a form of medical science (Peng et al., 1995) and as part of conventional health services.
 In the UK, some hospitals in the National Health Service (NHS) even incorporated beauty therapy in managing certain groups of patients (Sharma and Black, 2001).
Aesthetic surgery should be distinguished from reconstructive surgery as the latter depicts surgery that aims to restore function and form ravaged by disease.
This distinction has been made historically since the mid nineteenth century by the late German facial surgeon, Johann Friedrich Dieffenbach (1792-1847), who is regarded as the “father of plastic surgery” (Gilman, 1999). 
Today, the term “aesthetic surgery” has been widely replaced by “cosmetic surgery”, as evidenced by the greater number of citations using the latter term.
The rise of aesthetic medicine Many modern aesthetic procedures date back to the 1880s and 1890s.
The rise in the number of aesthetic surgery patients and procedures has been remarkable only in the last few decades (BBC, 2006; Cullen, 2002).
For example, between 1997 and 2005, there has been an increase of 444 percent in the total number of cosmetic procedures performed in the USA (ASAPS, 2005).
The rise in the popularity of aesthetic surgery has fostered the expansion of minimally invasive aesthetic procedures such as Botox injections, mesotherapy, laser treatments and intense pulsed light (IPL) therapy (Klatsky, 2001).
These are mainly office-based procedures that require minimal or no local anaesthesia.
The popularity of such aesthetic procedures emanated to neighbouring European countries (Cosmetic design.com, 2005; Bell, 2001) and the UK (Batty, 2005), and later to the USA and South America.
Currently, such procedures are also widely performed in Asian countries like China, South Korea, Thailand and even Cambodia (Weaver, 2003; Bae, 2005; Han, 2005; Choi, 2004; Smith, 1999).
In 2003, nearly 20 million hair removal, skin rejuvenation, tattoo removal, acne reduction and photodynamic therapy treatments were performed.
These earned almost US$6.5 billion for practitioners and US$372 million in revenue for equipment manufacturers (Medical Insight Inc., 2005).
In the same year, four million Botox procedures were performed worldwide, generating over US$2.1 billion in procedure fees.
A new hybrid of services known as “medical spas” also emerged (NCEA, 2005).
These are co-locations of conventional medical services with spa facilities providing minimally invasive aesthetic services, which make up the fastest growing segment of the whole spa industry.
In the USA, a 109 percent rise in the number of such medical spas was noted during the period 2002 to 2004 (ISPA, 2004).
Regulation of aesthetic medicine in the UK, Australia and Canada A brief global scan of health regulatory systems revealed that the practice of aesthetic medicine has been marginally regulated, even in the more developed countries.
However, there are rising concerns that existing health regulations may not be adequate or appropriate to ensure safe practice in aesthetic medicine (BBC, 2005; NSW Health, 2005; Fu, 2004; Enriquez, 2003).
There is less concern over aesthetic procedures performed by registered specialists like dermatologists and plastic surgeons as compared to general practitioners (GPs) because specialists spend more time on training and are generally regarded by the public as more highly competent than GPs.
The need for stricter regulation therefore appears more dire as the number of GPs performing such procedures increases.
UK In the UK, doctors who perform aesthetic (or cosmetic) medicine are primarily those who dropped out of specialist training to work in the private sector.
These doctors are not required to undergo any special training in aesthetic medicine, even though they are free to offer such treatments.
There is no specialist register for aesthetic medicine and doctors from any medical specialty can provide such services.
The Healthcare Commission of the UK, which regulates and inspects all registered establishments carrying out cosmetic surgery, recently estimated that 63 out of 784 aesthetic surgery practitioners were not registered as specialists (Commission for Healthcare Audit and Inspection, 2005).
In 2000, the Care Standard Act was enacted to better regulate private practitioners of aesthetic medicine.
Under the Act, these practitioners were required either to be on the specialist register or to have undertaken specialist training relevant to the procedures they provide if they were already practising prior to 1 April 2002.
Private practitioners were also required to provide the Healthcare Commission with patientssrecords and patient satisfaction surveys.
Australia Cosmetic procedures such as surgical facelifts, chemical peels, botox injections and laser hair removal are highly popular in Australia.
Of the estimated 500 doctors who provide aesthetic procedures in Australia, about 25 per cent are general practitioners (Cornwell, 2000).
The aesthetic practitioners often work in small practices or as employees in specialised clinics.
The industry is highly competitive with very little published research for fear of disclosure of trade secrets.
This probably explains the lack of professional guidance and peer review in aesthetic practice.
Clinics that provide aesthetic services requiring only light sedation do not need to be licensed.
There is no regulation of the quantities or combinations of drugs used, or the qualifications of staff performing the procedures.
Medical practitioners with only basic medical qualifications can proclaim themselves as aesthetic medicine experts, since aesthetic medicine is not a registrable (or legally protected) specialty.
Canada Minimally invasive aesthetic procedures like Botox, aesthetic filler injections, non-surgical facelifts and laser hair removal are highly popular in Canada (Medicard, 2003).
As in Australia, there are no specific regulations in Canada governing the practice of cosmetic procedures, albeit devices such as lasers are regulated under certain legislation, e g the Radiation Emitting Devices Act and the Medical Devices Regulations.
– Amended to O Reg. 
14/95) to regulate medical clinics (CPSO, 2002a).
Nevertheless, this is only limited to clinics that use anaesthesia.
It is noted that under the IHF Act, licensees have to ensure that service providers have qualifications relevant to the services they provide.
The College has also formulated standards on aesthetic surgery to help providers comply with the law.
Despite such regulations, a doctor in Ontario can still delegate aesthetic procedures to non-qualified personnel under his/her supervision (Harvey, 1998).
Even with the Advertising Regulations (CPSO, 2002b), doctors are still falsely proclaiming themselves as aesthetic medicine experts.
Such doctors are also providing patients with misleading information about their qualifications, experience and the aesthetic services they provide.
The need for more effective regulation The gaps in the regulation of aesthetic medicine illustrated in the above countries strongly suggest the need for more effective regulation.
The primary objective of health regulation is to ensure public safety and thereby preserve patients’ trust in the healthcare system and healthcare professionals.
In the presence of regulation, the regulatory body, be it internal (i.e. self) or external, becomes accountable for the safety and quality of the healthcare practices and services rendered to the public. 
Regulatory methods like licensing, certification and accreditation have a common purpose of ensuring that only sufficiently competent practitioners are allowed to practise.
Every procedure in aesthetic medicine is meant to alter some part(s of the body to achieve a more pleasant appearance.
Such alteration would carry a certain risk of harm.
If the principle of health regulation is to prevent harm to patients, then logically aesthetic medicine should be regulated like conventional medicine.
Why then are many countries still hesitant to regulate aesthetic medicine?
Is it a question of cost-effectiveness of regulation?
Or are there political considerations?
One possible reason for the lack of effective regulation is the perception that aesthetic medicine is consumer-driven and therefore the industry should be self-regulated.
Furthermore, many regulatory authorities foresee fiscal and administrative limitations in regulating the industry and are reluctant to be accountable for the quality and safety of aesthetic services.
This reluctance is aggravated by the potential political sensitiveness of disrupting the livelihood of existing aesthetic practitioners by introducing regulation.
Scientific literature has clearly demonstrated the risk of complications from minimally invasive aesthetic procedures, while the efficacy of such procedures remains controversial.
Lasers and IPL have been shown to cause burns and pigmentation problems (Dijkema and Van der Lei, 2005; Roberts et al., 1996) while Botox injections can lead to bruising and blepharoptosis (Caruthers, 2002).
The side effects of aesthetic filler injections range from allergic reactions and permanent lumps to serious complications like blindness and cerebral artery embolism (Medical News Today, 2004; Silva and Curi, 2004; Egido et al., 1993; Andre et al., 2005).
Even simple aesthetic procedures like chemical peeling can lead to bacterial skin infections, herpes simplex reactivations and delayed wound healing (Monheit, 2004).
The most controversial of all aesthetic procedures is probably mesotherapy.
Originally invented in France for treating tinnitus, vascular and lymphatic disorders, mesotherapy has evolved into a body-contouring procedure and a form of therapy for skin ageing and male-pattern baldness (Kalil et al., 2005).
Despite its growing popularity, there is insufficient scientific evidence that establishes its safety and efficacy.
Incidences of urticarial skin reactions and mycobacterium infections have been reported (Bessis et al., 2004; Urbani, 1994; Nagore et al., 2001).
There are currently no standard mesotherapy formulations.
In the USA, no pharmaceutical preparation is licensed or approved by the US Food & Drug Administration (FDA) for use in mesotherapy to achieve anti-aging or adipose tissue reduction purposes.
In fact, phosphatidylcholine (also known as Lipostabil) was prohibited by the Brazilian National Agency of Health in 2003 due to the lack of scientific data supporting its use for the reduction of fat (Hexsel et al., 2003).
The continual rise in the popularity of aesthetic medicine will create unnecessary public demand and may impact negatively on the cultural and moral values of people in the society.
Societal attitudes towards the concept of beauty may become perversed, and people may be encouraged to resort to aesthetic treatments to resist age-related physical changes (Kanter et al., 2001).
This is already seen in certain countries, for example South Korea, where even high school students are placing increasing emphasis on appearances (Park, 2004).
Furthermore, aesthetic medicine may distort the traditional doctor-patient relationship, raise patientssexpectations and increase the risk of medical malpractice litigation (Cullen, 2002).
An unregulated aesthetic medicine industry may also have an adverse impact on professional and ethical standards, as medical professionals may be more likely to sacrifice ethical and moral principles to achieve their profit-driven goals (Ring, 2002).
As aesthetic medicine is a relatively new field, the asymmetry of knowledge between practitioners and patients is more marked and therefore may result in greater likelihood of supply-induced demand.
The latter will create a vicious cycle of escalating public demand, increasing supply and more widespread risks.
Why voluntary self-regulation will not work Health and medical regulation involves a whole range of methods from incentive-based to coercive in nature.
Regulation may be carried out by professionals themselves (internal/self) or by persons outside of the profession (external).
The medical profession is traditionally self-regulated by a representative body of senior doctors.
The regulatory activities are usually backed by legislation specific to registration, practice ethics, discipline and continuous professional development.
This model of regulation, known as statutory self-regulation, is adopted in many countries where governance is by medical councils.
Self-regulation can also be voluntary, which means that professional bodies voluntarily promulgate practice and ethical guidelines for the medical profession.
The activities of such professional bodies are usually not supported by any legislation.
Unlike conventional medical services and providers, there are certain factors inherent in the field of aesthetic medicine that are likely to render voluntary self-regulation ineffective. 
These factors are: Doctors who enter the field of aesthetic medicine do so primarily for its lucrativeness.
General practitioners are turning to aesthetic medicine as an alternative source of income because the intense competition in the private sector and emerging managed care payment schemes have, to a certain extent, reduced the profitability of “bread-and-butter” medical services. 
For livelihood reasons, many aesthetic practitioners would not normally undergo lengthy specialist training and therefore may not be adequately qualified to spearhead self-regulation.
The aesthetic medicine industry is highly competitive and therefore, there is no incentive for any successful practitioner to share his/her experience and skills with others.
This could explain the current lack of published research, clinical guidelines and training courses for providers. 
Such a problem however is not as critical in the US, where professional aesthetic medicine organisations tend to be more highly active in promulgating practice standards and organising relevant training courses (AAAM, 2005).
Voluntary self-regulation often involves quality improvement activities where medical practitioners participate in peer reviews and learn from observed practice deficiencies.
This would probably not happen in the aesthetic industry where practitioners are unlikely to reveal or acknowledge their own shortcomings.
Many medical practitioners are divided on the issue of regulating aesthetic medicine. 
This is because they belong to different stakeholder groups and therefore may perceive regulation in the narrow context of their own agendas. 
It is possible that specialists may adopt a protectionist attitude and favour stricter regulation while GPs who practise aesthetic medicine would prefer minimal regulation and a level-playing field.
Doctors who are not in the aesthetic business or who do not intend to enter the industry may either support regulation or be ambivalent. 
This situation makes voluntary self-regulation difficult.
Voluntary self-regulation often involves the accreditation of training programmes to improve practice standards. 
There are however very few, if any, independent and impartial accrediting bodies that have the expertise to accredit aesthetic medicine training programmes.
Due to the individualistic and non evidence-based nature of the practice, there is little information on the required standards of practice. 
Without such information, it would not be possible to assess the quality of training programmes.
This situation encourages the proliferation of sub-standard, “fly by night” programmes organised by commercial companies.
Voluntary self-regulation may not work in a traditional Asian society that is less litigious than most western societies, and where the socio-cultural concept of “face” prevails (Roth, 2005).
Asian patients are less likely to sue doctors when aesthetic procedures go awry because of the fear of stigmatisation and embarrassment of making public one’s vanity. 
Consequently, there is minimal public pressure on aesthetic practitioners to maintain good practice standards, let alone start voluntary self-regulation.
How should aesthetic medicine be regulated?
Statutory governance of the aesthetic medicine industry may be necessary at the stage where voluntary self-regulation is either not forthcoming or is expected to be ineffective. 
A comprehensive and logical approach to regulating aesthetic medicine should consider the following aspects as outlined below.
Regulating aesthetic medicine facilities In many countries, medical clinics are required to be licensed by health regulatory authorities or accredited by third-party organizations (Teerawattananon et al., 2003; DoH, 2004; AHCA, 2003).
Clinics that house minimally invasive aesthetic procedures may be separately licensed/accredited and monitored if the procedures are deemed to be of higher risk.
In the UK, the Expert Group on the Regulation of Cosmetic Surgery had proposed that all facilities providing aesthetic procedures such as Botox and aesthetic filler injections be licensed with the Healthcare Commission (DoH, 2005).
The aim of licensing/accrediting clinics is to ensure that aesthetic procedures are carried out safely in hygienic and well-equipped premises and by qualified practitioners.
Regular patient record audits and clinic inspections should be conducted to ensure compliance with licensing/accreditation requirements.
Regulating aesthetic equipment, devices and drugs In most countries, the use of medicines and health-related devices (e.g. Therapeutic Goods Administration in Australia and US Food and Drug Administration) are already regulated.
Regulators should continue to keep abreast with new information on emerging products and devices, in particular their safety profile. 
While it may be impossible to test every product or device that enters the market, some audit and quality assurance framework should be put in place to monitor patients who are treated using such products and devices.
A major concern is the use of lasers in aesthetic medicine, which are more likely to cause serious adverse effects than other aesthetic devices.
The Committee of Inquiry in Australia had recommended that Class 3b and 4 lasers be regulated under the Radiation Control Act, which means that users would need to be licensed (HCCC, 1999).
It may not be adequate to just restrict the use of lasers to registered medical practitioners, as most doctors would not be competent enough to operate laser equipment, given that such skills are normally not taught during basic medical training.
Only practitioners who have undergone specialist or formal laser training should be allowed to use laser equipment.
Hence, it had been proposed in NSW that the Radiation Advisory Council issue the user licence only after it had reviewed the quality and appropriateness of the practitioner’s training in lasers.
Where the use of pharmaceutical products in aesthetic medicine is concerned, manufacturers of such products should be required by law to provide detailed product information on the indications, contraindications, possible side effects and constituents of the products. 
This is to ensure accountability from the manufacturers and to prevent harmful products from entering the market.
Regulating practitioners and training The medical practitioner’s level of competency and training in aesthetic procedures has always been a major concern.
Aesthetic medicine is not traditionally taught in medical schools, and is only included in formal specialist training programmes in certain countries like the USA (Pu et al., 1999, 2006).
More commonly, doctors learn aesthetic procedural skills in workshops organised by manufacturers/suppliers of aesthetic pharmaceutical products or devices.
Hence, there is a need for formal structured training in aesthetic procedures to be included in the training curriculum of medical students, general practitioners and specialist trainees.
Learning should be restricted to procedures that are scientifically proven to be effective (e g laser depigmentation, Botox, etc.).
Training programmes should be properly accredited by established and reputable professional organisations.
In Australia, both the Australasian College of Dermatologists and Australasian College of Surgeons have included laser training as part of specialist training in dermatology and plastic surgery respectively (HCCC, 1999).
In addition, laser training and accreditation programmes have been started by a few professional bodies.
Training should be mandated by law (e g the Care Standard Act in UK) otherwise medical practitioners may simply boycott the training programmes.
Continuing aesthetic medicine training and education should be made compulsory and linked to medical registration.
Regulating the actual practice There are two aspects of aesthetic practice that should be regulated: the manner of practice and the technical aspect. 
The manner of practice encompasses advertising, obtaining consent and risk communication, and reflects the professional conduct of the practitioner. 
There should be legal controls to prevent false claims and professional misrepresentation. 
Physicians should not proclaim themselves as specialists in areas that they have not received formal training or which have not been legally recognised as medical specialties. 
Notwithstanding the fact that lay persons may proclaim themselves as experts in dubious areas of aesthetic practice, medical practitioners by virtue of their well-respected profession should ideally not associate themselves with non medical-related practices.
As part of good surgical practice, consent for any aesthetic procedure should be sought from the patient only after s he has been informed of the diagnosis, treatment approaches, expected outcomes, potential side effects and treatment alternatives (McGillis and Stanton-Hicks, 1998).
These essentials in risk communication may be expressed as statutory guidelines to ensure compliance (Peter et al., 1995).
In Australia, it was proposed that a Cosmetic Surgery Credentialing Council be formed to oversee, among other things, media promotions related to the cosmetic surgery industry, including preparing a Code of Conduct for practitioners on advertising, informed consent, communication and patient selection as well as guidelines on patient examination and assessment (Cornwell, 2000).
In France, it was proposed that patient information as part of informed consent be crafted according to guidelines set by the National Agency for Accreditation and Evaluation in Health (ANAES) and endorsed by the French Society of Plastic Reconstructive and Aesthetic Surgery (Flageul et al., 2003).
Educating the public There should be an avenue for the public to obtain information on aesthetic practitioners and services, so that they can make informed decisions concerning aesthetic treatments. 
The information should preferably be provided by a neutral professional body and should include a listing of qualified practitioners as well as indications, effectiveness and potential adverse effects of various treatments based on scientific evidence. 
The mode of delivery of such information may be through the internet or other mass media such as newspapers, magazines, television and radio. 
The setting up of consumer watchdogs like those in Canada (e.g. Health Canada, Canadian Quackery Watch) should also be encouraged to raise public awareness of the aesthetic industry.
Managing the media The media, while useful to regulatory authorities as an avenue to educate the public, may be responsible for creating unnecessary public demand in aesthetic medicine.
It is recognised that media advertising is not just a source of “purchase-related information”, but also a means of social communication (Leiss et al., 1990).
Advertising actually influences how the public behaves (Lysonski and Pollay, 1990).
Past research has demonstrated that advertising can impact on consumersslives by misleading and deceiving consumers (Davis, 1994).
The social risk of over-publicising aesthetic medicine is that it may create perverse public perceptions on the concept of beauty.
The time and money spent on aestheticism may increase at the expense of more important societal obligations such as childhood education, disease prevention and community development.
These arguments support a greater governmental role in regulating the media and moderating the social impact of publicity in aesthetic medicine.
All media material concerning aesthetic medicine should be subject to regulatory scrutiny prior to their public release.
Media messages that might reinforce existing devaluative attitudes of society toward what is considered physically repugnant should be prohibited, since research has shown that the demand for aesthetic medicine arises in response to such societal attitudes (McGregor, 1967).
Regulating the demand and supply In developing or newly-developed countries where the population’s general educational level and spending power are still moderate, consumers may be more price-sensitive and therefore seek cheaper aesthetic services provided by poorly-trained practitioners instead of bona fide specialists.
The less-educated consumer is also less proactive in seeking information about the industry and is more dependent on health authorities to provide such information.
Such deficient “buyers beware” culture should be taken into account when planning a regulatory framework for the industry. 
 In such situations, there is a need to inculcate in the public a greater sense of individual responsibility for aesthetic services used and their clinical outcomes (Fogli, 2003).
Greater control on the supply of aesthetic services may be necessary to keep the demand in check.
A professional register may be set up to limit entry to only well-trained and competent practitioners. 
As the public becomes more mature and knowledgeable, the rules may be gradually relaxed to make way for a more market-based industry.
It may also be necessary to “tame” public demand for aesthetic services by de-emphasising the importance of physical beauty and redefining social values.
This would help avert spurious growth in aesthetic medicine services. 
Overall, it may be easier to regulate aesthetic medicine by controlling supply rather than demand as the latter tends to be more resistant to change or influence, even that of the economy (Duncan et al., 2004).
Regulation versus facilitation Health authorities in most countries are charged with the responsibility for ensuring public safety in the context of healthcare.
Likewise, the role of clinical governance in aesthetic medicine would be to ensure safe practice standards.
However, being a non essential commodity, aesthetic services are distinct from conventional medical services in that the former have higher potential for generating foreign revenue and boosting the economy of the country (Atkinson, 2002; Teh and Chu, 2005).
Although most governments in western countries leave the onus of spearheading sectoral development to the private sector, asian governments are proactive in facilitating medical tourism and developing aesthetic services (Teh and Chu, 2005; SingaporeMedicine, 2004).
The conflicting goals of sector regulation vis-a -vis facilitation thus create further problems in the regulation of aesthetic medicine.
Hence, health authorities need to be clear about their agenda when regulating aesthetic services, and should avoid adopting conflicting roles in governance.
Conclusion While aesthetic medicine may be a booming industry that has promising financial returns, health regulators and policymakers should bear in mind that the physical and socio-psychological well-being of the public may be at stake if the industry grows out of control.
Facilitation of health sector development should never be done at the expense of public safety and social well-being. 
Unlike conventional medicine, voluntary self-regulation is unlikely to be effective in preventing the ethical and social ills of the aesthetic industry.
Depending on the maturity and awareness of the public, greater clinical governance may be needed to better manage the supply and demand of aesthetic services, and ensure that aesthetic practice remains safe and scientifically substantiated.
Continuing public education is necessary to empower patients and consumers to take greater responsibility for their own health and aesthetic care decisions.
Talk about a lunch hour well spent—New Yorkers can now add quick-fix Botox treatments to their list of mid-afternoon errands.
The Upper East Side recently welcomed Smoothmed, an expert Botox on the go retail shop that requires no appointments and promises to banish fine lines in 30 minutes or less.
The walk-in concept, started by two plastic surgeons, takes the battle against aging to a newly accessible level.
The social fabric is changing, Dr Andrew Elkwood, co-owner of the store, said.
Men are more willing to have Botox, and women are more willing to talk about it.
The treatments are administered by physicians who have been trained in the Smoothmed method, and each patient's procedure history is kept on file to ensure the most efficient treatments.
And if a quick trip to New York is not in the future, ELLE.com has found the most effective anti-aging treatments, no needles required.
At 38, Juliet*, a New Yorker whose fashion sensibility falls somewhere distinctly south of the uptown/downtown divide, is simply far too cool—not to mention too young—to be a candidate for the F word.
Or so she thought.
But last year, just before Christmas, the self-described last person on earth anyone would suspect of having cosmetic surgery checked into an exclusive Upper East Side clinic for top-secret eyelid-boosting blepharoplasty, laser skin resurfacing, and the very lift (albeit, she hastens to point out, a minilift) she had previously feared.
For years, you see yourself in pictures and stare at the loose jawline and the tired-looking eyes, and you know that inside, your personality is so much younger and fresher and more joyful than that, Juliet says.
After a while, it's just like, `Screw it!
I m taking care of this.'
Not so long ago, with a tidal wave of miracle shots and high-tech lasers flooding doctors' offices, face-lifts seemed destined to land somewhere between perms and corsets in the dusty annals of beauty history.
But now, the same snip that was once seen as a last resort is back in vogue, thanks to two recent realizations: (a No matter how wash-and-wear they sound, most minor, quick-fix solutions tend to have relatively minor, short-lived results, and (b the dreaded wind tunnel look is all but a thing of the past.
Everyone's face-lift nightmare is the Joker, with those fish lips pulled back into a permanent smile.
It's awful!
Juliet says, letting out a small, smug chuckle.
Honestly, I look like I ve had a three-month vacation.
Wendy Lewis, a New York City cosmetic personal shopper of sorts who charges $350 per hour to help clients navigate the bewildering world of scalpels and injections, says at least 50 percent of her clients are still adamant surgery-phobes who either fear the downtime, price tag, or anesthesia associated with going under the knife, or who simply haven't made that particular mental leap (having a face-lift involves a moment of reckoning, like acknowledging that you're going through menopause, Lewis says).
However, the other half are increasingly warming up to the idea of having lesser surgeries relatively early on so that they won't require a major lift later, Lewis says.
Besides, in an era of $1,200-a pop injections that require regular refills, surgery makes a new kind of sense.
I know women who spend more per year on maintenance than they'd spend on a face-lift, Lewis says.
Sometimes, surgery can get you more bang for your buck.
THE NAME GAME Given the number of catchy-sounding lifts—some of which aren't in fact lifts at all—on the market, it's no wonder Lewis is more overbooked than ever.
There's nothing wrong with the plasma face-lift offered by Beverly Hills cosmetic surgeons Daniel Yamini, MD, and Steven Svehlak, MD, which uses nitrogen plasma energy to resurface the skin—but it's not surgery.
Similarly, the trademarked RestyLift, aka the Volumalift, touted on websites as a 30-minute injectable face-lift, is really just generous shots of the hyaluronic-based filler Restylane.
On the other hand, the one hour, no downtime Lifestyle Lift, which local TV news crews have heralded as a breakthrough in fast-recovery mini-nips, strikes me as a misleading marketing scheme, Lewis says.
As far as I can tell, it's a real face-lift, real surgery, but the terminology makes it sound like nothing.
That said, perusing the surgical menu at A list doctors' offices isn't necessarily any easier.
It practically takes a medical degree to choose between mini-lifts, S lifts, and the L I F T (limited incision face-lift technique).
These are nebulous terms that don't tell you a lot, says Park Avenue plastic surgeon David Hidalgo, MD, a renowned plastic surgery naturalist who was once chief of plastic surgery at New York City's Memorial Sloan Kettering Cancer Center.
Hidalgo simplifies things considerably, explaining that all face-lifts can be classified two ways: by length of incision and by how they manipulate the tissues underneath the skin.
Traditional face-lifts have a full-pattern scar that goes in front of the ear and then extends into the crease behind the ear and into the hairline, he says.
The procedures mentioned above, on the other hand, are variations on the short-scar technique, in which the incision stops before going into the hairline; its popularity grew in the 1990s, after minimizing downtime became a priority and surgeons began to realize they were over operating, removing too much valuable facial fat and pulling too tight.
Hidalgo says a short-scar procedure may sound less invasive, but it can be 90 percent as major as the traditional method.
But plastic surgeon Malcolm Paul, MD, of Newport Beach, California, says that while a short-scar procedure is perfectly adequate for a small amount of looseness in the jowls and cheeks, if a neck needs to be corrected from the jawline down to the clavicle, you need a longer incision to get to it.
Both doctors agree that whether a face-lift is mini or not is primarily determined by the treatment of the SMAS, a fibrous layer that lies between the skin and the muscle and can be tightened in three basic ways.
Least invasive is the SMAS-ectomy, which Hidalgo performs on 90 percent of his patients.
Here, we take a bite out of the SMAS through the incision, tightening the cheeks and pulling up the jowls, he says.
The much more involved Extended-SMAS procedure is like peeling an onion, layer by layer, he says; first the skin is pulled back, and then the entire SMAS is lifted and tightened separately.
The least common SMAS technique is the deep-plane face-lift, in which, he says, you go down to the deepest level and lift everything sandwiched together.
A Belgian surgeon named Patrick Tonnard, MD, came up with the latest way to handle this tricky middle layer: the relatively quick, less-invasive MACS (minimal access cranial suspension lift).
In this version, skin is elevated just a bit, allowing the doctor to weave a stitch through the SMAS and the fat of the cheek, hoisting them up like a purse string.
Manhattan plastic surgeon Lawrence Reed, MD, says the MACS has become his most popular procedure because of its limited undermining (the separation of skin from underlying tissues) and the fact that it leaves just a small scar in front of the ear.
People heal and look good in four to five days, Reed says.
Still, the greatest advance in plastic surgery wasn't technological, it was people realizing they wanted to look natural, Reed says.
We've had the ability to do a natural-looking face-lift for years.
Believe it or not, a lot of people used to like that tight look悠 ve been performing the short-scar lift since I opened my practice in 1976, but it took a long time for anyone to want it.
Lewis agrees.
The technique doesn't matter as much as the amount and direction of the pull, which is a matter of taste that varies from doctor to doctor, she says.
These are the questions you need to ask: How much tissue is being removed?
What areas will be affected - are you going to get my neck?
And where will the scar be?
WATERSHED MOMENT Water—or, more precisely, saline solution—is playing a major role in a new breed of lifts that employ tumescence, a technique borrowed from liposuction, in which large amounts of saline-diluted topical painkillers are injected just under the skin to manage pain with less anesthesia and blood loss during surgery, making it easier to operate.
 A six-year study of 678 face-lifts published in 2004 found that tumescence significantly reduced post-op swelling and bruising, improved scar quality, and minimized other complications such as skin necrosis and hair loss.
Plastic surgeon Zachary Gerut, MD, of Hewlett, New York, is at the deep end of the tumescence pool.
His Rapid Recovery Face-lift begins with the injection of nearly a liter of a diluted Novocaine/adrenaline/saline cocktail into the fatty tissues right under the skin.
Just before I start the surgery, the face becomes taut.
If you tap on it, it sounds like you're tapping a flexed muscle, Gerut says.
Patients look like Jabba the Hut.
It may sound unattractive, not to mention painful, but Gerut says the trick reduces the bruising and swelling associated with anesthesia and eliminates the need for drains and heavy-duty bandages.
(Other surgeons point out that post-op dressings are a matter of personal preference, no matter which technique is practiced.)
Santa Monica's Patrick Abergel, MD—a maverick whose new procedures are often viewed as risky by the competition—has devised a water lift, in which a syringe injector inserts a mixture of saline, lidocaine, and epinephrine that helps liberate the skin from its underlying structures.
He inserts the Abergel Skin Elevator, a custom-made tool not unlike a slim, blunt-ended knitting needle, through a small puncture wound and uses it to elevate the skin further, and then pulls back one to two inches of the loosened skin through a small one-inch incision tucked against the ear.
For those who don't like the idea of all those painkillers being injected, Hidalgo says tumescence doesn't necessarily mean a face-lift will be more hazardous (the drugs are too diluted to risk overdose); its main benefit is making the procedure easier on the surgeon, not producing a better-looking lift.
What I really don't like about it is that all the swelling doesn't go away when you're ready to put things back together, Hidalgo says.
You can't see the elasticity or tone in the skin.
But Paul, who uses what's known as a superwet technique—halfway between the standard amount of local anesthesia and tumescence—in all of his face-lifts, says it makes the SMAS lift off like an orange peel.
If separating the tissues is easier, surgery is less traumatic, there's less risk of nerve damage, and recovery is faster.
HANGING BY A THREAD Cautious optimism is still the prevailing attitude toward what is arguably the biggest development in facial surgery in the past decade: implanted suspension devices, particularly barbed threads—long, thin polypropylene strips that are inserted through small puncture openings near the hairline and swoop down under the skin, grabbing errant fat pads and yanking them back up to their youthful positions.
The most popular, Contour Threads, arrived on the scene two years ago, billed as scar-free, speedy (they take less than an hour to implant), and less pricey than a real lift, with very little anesthesia required.
The technique has proven to be trickier than promised.
While most doctors agree that Contour Threads weren't faulty in the way they originally suspected (they're don't slice through tissue with normal facial movements, and they're not usually difficult to remove), the end result varies widely.
Hidalgo has seen puckering and irregularities and, almost worse—no result at all.
Most of the time, when surgeons who use them show their results at national meetings, everyone looks at each other and says, `Is it me, or do you not see much difference between the before and after, either?' 
he says.
You cannot get anywhere near the results of a traditional, albeit more invasive, face-lift procedure.
Even those who do use the threads say their tensile strength is disappointing; the lift that was originally said to require a total of four threads can actually take up to 12, which means extra swelling and bruising, a downtime of up to 10 days, and, perhaps most disturbing, an increased amount of foreign material lodged permanently under the skin—all for something that might not last long.
Reed's have persisted as little as four months; Lewis tells her clients not to hope for more than two years.
A regular face-lift with cutting, sewing, and suturing is more invasive but has less bruising and swelling and looks normal much sooner than the Contour Threadlift, Reed says, though he finds the sutures useful for patients who are on blood thinners or are undergoing chemotherapy, for whom more invasive procedures are out of the question.
However, nearly every doctor interviewed for this story says future generations of the threads will hold more promise.
First up, an absorbable version of Contour Threads that consist of polydioxanone (the longest lasting absorbable suture to date), which has received FDA approval and is tentatively scheduled to hit the market in the next few months.
Absorbable sutures are said to have substantial tensile strength at six weeks, to have less at three months, and to be completely gone within six months.
What's the point of an absorbable thread if the current ones don't last long enough?
They make sense for a new generation of hybrid techniques, in which threads are getting their best results yet by working in tandem with other procedures.
Facial aging is a combination of gravitational changes and loss of volume, so in many patients, it's not enough to just reposition things.
You have to add volume, too, whether through a cheek implant, fat injections, or other fillers such as Juv?derm, Paul says.
When you take threads and add filler, plus Botox to quiet down the muscles around the brow, one plus one plus one doesn't equal three—it equals 10.
To wit: Paul devised a lift that combines ultrasonic liposuction on the neck and jawline, which emulsifies fat, making it easier to extract, and causes skin to tighten, with just two threads on each side to hold up the remaining lax skin.
Ironically, threads are also proving useful as an adjunct to full-blown surgery.
Tighter skin shouldn't be the only thing holding up a face-lift—you need internal support, says Stephen Bosniak, MD, a plastic surgeon who works in New York City and Rio de Janeiro.
His short-scar face-lift now has the addition of a few deep-reaching Contour Threads, which, he says, tack the SMAS up higher and give extra support to the lower jowls without the aesthetic problems of more superficially placed threads (plus, since the tissues are being undermined, they only need the thread to be in place until they re-adhere post surgery).
Last November, Paul published a paper on using barbed sutures in open mid-facelifts in Aesthetic Surgery Journal.
Part of the problem with a traditional face-lift is that skin, muscle—everything—gets pulled in the same direction.
Barbed sutures give you more control, in that you can pull deeper tissues vertically, and pull the skin in a different direction, he says.
When you put the barbed suture at a deep layer, it works like a shish kebab, catching multiple tissues and stacking them on top of each other to get volume over the cheekbone.
If you did that with a single, normal suture, you'd just catch the tissue in one place, and wherever the needle goes in, that's where you anchor it.
According to Paul, barbed sutures, which he leaves poking out of the surface of the skin for two days after surgery, also provide a revolutionary opportunity for post-op fine-tuning.
When the patient comes in two days later, she looks in the mirror, and I can say, `Okay, I think if your left cheek was up another millimeter, the result would be even more spectacular,' Paul says.
Nothing else has offered that level of precision.
Maria Siemionow, the Cleveland microsurgeon who, last December, led a team of seven male doctors in a 22-hour operation to complete the first facial transplant in the United States, explains how they replaced 80 percent of a patient's face.
"As a hand surgeon, I worked with a lot of children who were burn victims—they'd been holding up their hands to protect their faces from the fire. 
I thought there must be a way to use the techniques in hand surgery to help their faces.
But the skin that was used in facial reconstructive surgery doesn't have the pliability and vascularity that facial tissue demands.
And you also need functional units—a nose, lip, eyelids—we don't tend to have extras.
"When I received approval in 2004, I organized a team of more than 30 specialists to help screen and work with candidates who included patients who had burn injuries or suffered from some kind of congenital errors. 
These are people whose goal isn't to be beautiful, but to have a nose to take a shower—if you don't the water goes in the hole and floods the throat.
"In selecting a donor, we needed someone who had no major diseases, was the same gender—a woman can't worry about shaving her face!
—and matched for approximate age and skin color.
"There were eight surgeons in two teams. 
I was in both the donor and recipient rooms, overseeing the work and assisting surgeons as needed. 
One team did a skin graft to remove all tissues that were damaged.
Then we closed the vessels—you are trying to have a bloodless field. 
hen you are looking at the arteries, veins, and nerves—which will be connected to the arteries, veins, and nerves of the donor.
"The other team removed the donor's face, which took more than nine hours.
First, we lined up the transplant with the patient's face and reconstructed it structure by structure. 
Once you have matched all the vessels, you suture them together.
"You are trying to keep the surgery within the `critical ischemia time,' which means the window that you can cut off blood supply from the graft.
For the skin, this can be about 10 hours, in which time you should connect the arteries and the veins so that blood flow can return and the transplant can `pink up.
I don't remember any nervousness in the room because we were all too busy concentrating.
"Overall, the surgery went even better than expected. 
The patient will participate in physical therapy until she regains control of her jaw and cheeks.
We don't know how long that will take because this has never been done before."
Contrary to what you might assume, face fillers—Botox, Radiesse, Juv?derm, etc.—cost about the same as a face-lift: The pricing doesn't come out to be that different, says dermatologist Doris Day, MD, author of Forget the Facelift: Turn Back the Clock with a Revolutionary Program for Ageless Skin.
With face fillers, you pay less at a time, but since the results aren't lasting, your procedures will add up to about the same cost of a face-lift in the long run.
Yet despite comparable costs, the American Society for Aesthetic Plastic Surgery reports that while plastic surgery rates are dropping, nonsurgical treatments are greatly increasing.
What gives?
Day points to improved technology such as the new MiXto laser treatment and the growing range of face fillers on the market.
Dysport, a Botox competitor, just got FDA approval—and Sculptra, an injectible that lasts for up to two years instead of the usual six to nine months, isn't far behind.
There's really something for everyone—now we have fillers that go deeper, that aren't as superficial, and that come in a variety of consistencies and strengths, she says, adding, Sometimes I ll inject more than one product in the same person—I ll use an off-brand form of Sculptra to create some volume, and then I ll use Radiesse, Juv?derm, Restylane, or Evolence to fill in what I need to fill in afterward.
There are ways to mix them together to get the best results.
Though injectable fillers have made huge strides in the past several years, there are some situations where plastic surgery is the best option.
Face fillers can treat certain lines and wrinkles.
But their results expire and they can't tighten the skin or reposition the deep tissues, says plastic surgeon William Boss, MD.
And in cases where, for example, someone has a tremendous amount of excess skin in the neck area, they're going to need a full face-lift procedure.
For her part, Day agrees: If your neck is really sagging, there's nothing else to be done—it needs to be lifted and to have some skin removed.
Also, if your upper eyelids are drooping over and you can't see, you'll need an eye lift.
Those are the two main things I send people to plastic surgeons for—the neck and eyes.
Age can also determine what route you take.
We take it on a case-by-case basis, but for people in their thirties or early forties, I generally look for noninvasive alternatives such as injectables, says Boss.
And even as you age and become a potential face-lift candidate, you don't necessarily have to go all the way.
Boss, whose practice is based in New Jersey, has developed what he calls the Cool Lift—a procedure that he's been performing for just over two years and which mixes an internal laser treatment with suspension sutures.
Having seen how successful the laser was in shrinking the skin along the inner thighs, stomach, and arms, I incorporated it into a face-lift, says Boss.
The laser is utilized to melt fat, tighten the skin, and recontour.
Then suspension sutures are placed into the deep tissues to lift, and skin is removed.
According to Boss, his procedure differs from a full-fledged face-lift in that minimal skin is elevated, it's done under local anesthesia, and it has a shorter recuperation period—most patients can go out to dinner or back to work within five to seven days afterward.
Even though technology and doctors are making it progressively easier to get a quick fix (note NYC's SmoothMed, a walk-in Botox store owned by plastic surgeons), Day says that preventative steps and topical treatments come first.
She recommends investing in a good SPF 15 or higher sunscreen or makeup, and looking for eye and face creams that contain retinols: Anybody who can tolerate retinoic acid should use it, she says.
Niacinamide is also a good ingredient—it's an anti-inflammatory and antioxidant.
Day's favorites?
For face cream she likes Aveeno Positively Radiant Anti-Wrinkle Cream, Neutrogena Healthy Skin Anti-Wrinkle Cream, and Olay Regenerist Daily Regenerating Serum; for eye cream, she recommends Olay Professional Pro-X Eye Restoration Complex or SkinMedica TNS Illuminating Eye Cream.
Botox has many surprising applications—from disabling sweat glands to preventing migraines—but when you think of major facial contouring, it isn't the first injectable that springs to mind.
However, a recent study by Sydney-based plastic surgeon Steven Liew, MD, published in Dermatology Times showed that the drug can be used to narrow the lower face with, well, jaw-dropping results.
When injected into the masseter (chewing) muscle, botulinum toxin inhibits movement; over time, this causes the muscle to atrophy and shrink.
In Liew's study, which involved 82 female test subjects, all of the patients showed a measurable slimming of the jaw beginning two to four weeks posttreatment, reaching a plateau after three months and lasting up to a year.
The masseter is what we call a `stupid muscle,' meaning it has only one function, which is to chew, Liew says.
It has fewer nerve endings than the areas we inject for frown or smile lines, so the Botox doesn't dissipate as quickly.
Another cosmetic benefit is that diminishing the jaw creates the illusion of a hollowing underneath the cheekbones, which causes them to appear more chiseled.
Many patients say they don't need to wear blush anymore, Liew says.
Enlargement of the muscle may be genetic (in Southeast Asia, where Botox jaw reduction was first done in 1994, 20 percent of the population is affected by masseter hypertrophy, which Liew has dubbed "square-face syndrome"), or it can be caused by chronic teeth grinding and temporomandibular joint disorder (TMJ), issues that Botox also alleviates, along with the attendant pain.
Any notion that the condition can be brought on by an addiction to Bubble Yum, however, is unsubstantiated.
You'd have to chew a lot of gum to build up that muscle, says New York City and Miami dermatologist Fredric Brandt, MD.
That's not something anyone should worry about.
In cases where the breadth of the lower face is due to bone mass, Botox can still be used, but its effects will be less dramatic.
You can check to see what's causing most of the enlargement using a CT scan, Brandt says.
Some people are still very happy to have this done rather than go through jaw reduction surgery, which involves breaking and removing part of the bone.
Liew believes that the uptick in patients asking for this procedure is because an oval jaw is currently considered optimally attractive for women, as opposed to the '80s, when a stronger, more Sigourney Weaver look was in.
But anyone wishing to soften her facial silhouette should proceed with caution.
This procedure is best for younger patients, in their twenties and thirties, without laxity of the skin, Brandt says, because reducing the muscle is likely to cause more jowl formation in the neck.
When you get older, you actually want some of that muscle to hold skin taut.
Studies have also shown a slight decrease in chewing pressure posttreatment (it might be a little harder getting through a steak at first, Liew says), and only experienced derms should be trusted to wield the needle.
If the Botox is injected too far forward on the face, Brandt warns, you might get some muscle weakness in the lip area, which can affect the smile.
Dreading a lifetime of costly Botox injections?
Some eager surgeons are encouraging women to just cut it out (the muscle, that is).
A onetime procedure that costs about the same as two years of Botox will remove the corrugator muscle that creates vertical wrinkles between the brows.
It's usually done in conjunction with upper-eyelid surgery, but Kirkland, Washington–based plastic surgeon Gavin Dry, MD, says more patients are asking for it as an isolated procedure to prevent the brow from wrinkling in the first place.
According to Manhattan plastic surgeon David Hidalgo, MD, though, patients should keep in mind the change is permanent.
I wouldn't say, `Well, you're going to need Botox for the rest of your life, so let's go to the operating table,' Hidalgo notes.
That's not reason enough for surgery.
Besides, he warns that you may end up going back to the needle anyway: Removing the entire corrugator could cause nerve damage, so there's usually residual muscle function.
Rhinoplasty: One Woman's Plastic Surgery Nightmare On a bitter night in February 1992, Hope, a 19-year-old aspiring actor, and her boyfriend, an early Internet entrepreneur, headed out for some sinus-clearing chili dishes and tangy margaritas at a Mexican restaurant on Manhattan's Upper West Side.
It should have been a celebratory occasion: Six weeks earlier, Hope—whose pillowy lips, high, rounded cheekbones, big, bright smile, and wild auburn mane drew comparisons to Julia Roberts in Pretty Woman—had undergone rhinoplasty, commonly known as a nose job.
She had long viewed her olfactory organ as oversize, practically begging for reduction and refinement so as to harmonize with, rather than from, her otherwise comely features.
A month and a half post-op, Hope's nasal anatomy was still in a highly delicate state, but the black-and-blue bruising around her eyes had faded, and the nose itself was finally pain-free.
However, as she entered the restaurant on that dim winter evening, Hope smashed her schnoz smack into a plate-glass door that she failed to see.
Blood spattered everywhere; she lost consciousness for a time and ended up in the emergency room.
She had shattered her septum, twisting her nose to the right, narrowing and raising her right nostril in Picasso-esque fashion, and leaving her with a permanent asymmetry in the middle of her face.
The truth is, Hope already hated her nose job and even wished she had her old honker back.
He gave me a too-thin nose with a pinched tip, she said bitterly about her plastic surgeon.
I looked like I d had a nose job.
It was the Diamond Nose.
The term, once uttered worshipfully but now muttered in denigration, refers to the handiwork of Howard Diamond, MD, a Manhattan plastic surgeon wildly popular in the '60s and '70s who, irrespective of patients' individual features, churned out cookie-cutter conks instantly recognizable by their uniformly scooped-out bridges and turned-up ends.
Beholding her new reflection served only as a cringing reminder to Hope of her adolescent self-loathing and desperate approval-seeking.
It was an impulsive decision, she says.
My mother encouraged it.
A lot of my friends had their noses done.
I wanted to fit in.
At the end of the day, I didn't like me, and that's why I had the surgery.
Now, when I look at pictures taken before, I ask, `Why did I do this?'
There was nothing wrong with me.
Hope learned a classic plastic-surgery lesson the hard way: Cosmetic procedures, especially rhinoplasty, are not to be indulged in lightly.
The operation, surgeons say, may be the most challenging and difficult of all cosmetic surgeries, and yet, according to the most recent statistics from the American Society for Aesthetic Plastic Surgery, we now undergo some 150,000 rhinoplasties per year, and the American Academy of Facial Plastic and Reconstructive Surgery estimates there are around 40,000 do-overs annually.
A certain percentage require revisions, including small tweaking as well as big operations, says Jack Gunter, MD, professor of plastic surgery at University of Texas Southwestern Medical Center in Dallas.
The statistic that's reported is 10 to 15 percent overall.
The nose is a diminutive structure, bely its internal complexity, which includes a valve and several bony structures that control the dynamics and temperature of airflow and 5 million scent receptors that detect odors and transmit the smells to the olfactory bulbs in the brain.
And rhinoplasty is notorious for its vagaries.
Nasal tissues can be wayward, the cartilage refusing to bend to the surgeon's will or the skin too thick to drape smoothly and evenly over the underlying structure.
Furthermore, an alteration such as the removal of a hump from the bridge can change the shape and position of adjacent parts of the nose, prompting a cosmetic domino effect.
But the real wild card, Upper East Side plastic surgeon David Hidalgo, MD, says, is how a patient heals.
It is not unusual for a result that looks great on the table to be less stellar when healing is complete.
This can be due to scar-tissue formation that masks subtle aesthetic nuances in shape or to soft-tissue contraction during healing, which can collapse cartilage that has been weakened as a side effect of improving shape.
Given the fickleness of the nose and the protean nature of the procedure, many plastic surgeons think rhinoplasty is best left to the relatively few who specialize in it.
There are perhaps only a dozen surgeons who do more than 250 rhinoplasties annually, says Rollin Daniel, MD, a nose-job-only surgeon in Newport Beach, California, and cofounder of the Rhinoplasty Society, an elite professional group.
And secondaries, Gunter says, are the most difficult in cosmetic surgery.
With primaries, we have to reshape the nose.
With secondaries, there's very little normal anatomy.
The cartilage is distorted or missing.
You have to rebuild the nose.
There's scar tissue, making the dissection more difficult.
The skin is harder to drape properly.
Mallets and chisels aside, cosmetic surgeons also agree that, emotionally and psychologically, repeat rhinoplasty patients are often emotionally fraught (and justifiably so!)
, ratcheting up the pressure of an already demanding procedure.
Hope certainly fit the profile of a secondary rhinoplasty candidate.
Not only was she unhappy about her nose, but its malfunctioning physiology caused a round-the-clock deluge of mucus that led to countless indignities, from chronic sinus infections to boyfriends' complaints about her snoring.
Yet putting up with such unpleasantries still seemed preferable to another agonizing round of surgery—until 1996, when Hope bumped into a high school classmate she hadn't seen in many years.
The woman stared at her for several unforgiving seconds before blurting, What happened to you?! That was it.
The lash of those words provoked Hope to throw down the gauntlet, or, in her case, the Breathe Right strips.
No longer a self-pitying, scalpel-shy victim, she became a disgruntled cosmetic-surgery consumer entitled to the Rolls-Royce of reconstructive nose jobs.
Jetting between New York and Los Angeles to meet with a who's who of surgeons—15 or so in all—she racked up thousands of frequent-flier miles and shelled out sky-high consultation fees.
Her timing was propitious, coinciding with a revolution in rhinoplasty that transformed and refined the procedure, enabling surgeons to achieve more exacting results.
Its leading practitioners rejected the homogenizing reduction of noses and innovated a radically new technique.
In the old-school closed method, all incisions were made inside the nose, which limited the possibility of making dramatic changes or correcting extreme anomalies.
In the new open method, a single, minimally scarring incision is made across the columella, the strip of skin separating the nostrils, which, like popping the hood of a car, releases the nose's outer covering of skin.
Peeling it back, the surgeon exposes the entire inner hub of nasal organs and can repair, rearrange, and reconstruct any damaged, off-kilter, or missing pieces with precise cartilage grafts.
An open rhinoplasty is like opening your closet door wide to see everything hanging on the rod together, Hidalgo analogizes.
This allows you to select, edit, and rearrange freely.
Closed rhinoplasty only opens the door a crack, so you have to reach in and pull items out one at a time.
It's dark in there, and you never see everything at once.
Open rhinoplasty is especially useful in secondary operations, where often all the clothes have been pulled off the hangers and lie in a crumpled heap inside.
Although this evolution of the procedure should have made it a snap for Hope to land a specialist, remarkably, she found herself out of options in 2002.
No doctor would agree to operate, she says.
They didn't think they could improve on my nose.
They'd say, `You'll never be happy.
You're a pretty girl.
Leave well enough alone.'
But in 2008, long after Hope had forsaken her quest, the possibility of a reprieve presented itself when she came across an article on using injectable fillers to camouflage nasal deformities and finesse flawed rhinoplasty.
Coincidentally, her best friend had just recommended a registered-nurse-cum-aesthetician named Robin Hillary who, working from an examining room at an Upper East Side plastic surgeon's office, could do wonders with such needlework.
Hope quickly became a devotee of Hillary's no-knife nose job, which entailed endless injections of Juv?derm, a hyaluronic-acid-gel formulation that was squirted into Hope's ragged nasal bridge to smooth its surface irregularities.
Though impermanent, the effect was a clear improvement.
However, when Hillary tried to inflate Hope's collapsed right nostril with filler, the treatment backfired.
It further compressed the already squashed nasal opening, almost sealing it shut.
After about six months of giving Hope's nose her best shots, Hillary, recognizing that her syringes had their limitations, suggested that Hope meet with the plastic surgeon working away in the very next room.
Other than the $250 consultation fee, what did Hope have to lose?
So in December 2008, Hope met with plastic surgeon Craig Foster, MD.
You've got the stigmata of a rhinoplasty.
The tip is pinched, Foster noted, ticking off a litany of problems and speculating about their causes and possible solutions.
The goal is to make your nose look less operated-on, straighten it, and open up your airway, he said.
On January 13, 2009, Hope returned to undergo secondary rhinoplasty surgery, a $10,000 operation ($1,000 more than a primary) in Foster's state-of-the-art facility. 
(Many top surgeons outfit their private offices with customized operating rooms.)
In preparation, Hope changed into a burgundy medical gown and matching booties and took a seat in a private waiting area, where I kept her company.
For almost 20 years, I ve lived with a crooked nose, she said, her voice cracking and her eyes welling.
All I ve done is look at other people's noses.
I think my twisted nose is the first thing people see, and they think something really bad happened, like I had a coke problem.
Now I m nervous, but I m excited.
I can't believe I m finally going to do this.
But it was fate.
Those were Hope's parting words as a nurse appeared, escorting her to the operating room as I trailed along.
Climbing on the operating table, Hope lay back, offering up her delicate wrist for the anesthesiologist's fentanyl-laced IV drip and immediately conking out.
Foster daintily sliced across her columella with a small blade and retracted the outer layer of skin, keeping it in place with surgical hooks, his access to the subcutaneous nasal skeleton of bone and cartilage now unfettered.
Foster's first order of business was Hope's septum.
Though crooked, it was surprisingly unmolested, as he put it, and thus was an excellent donor site for grafting.
(In some cases when a nose has already been operated on, there may be no excess septal cartilage to spare for grafting, in which case an ear or a rib provides the source.)
Foster pared and shaped translucent cuttings from it for implanting in the defective areas.
To counter the depression in the cartilage on the left side of Hope's nose, he sewed a spreader graft to her septum, straightening out its contour and widening the middle of her bridge to ease her breathing and stop her unremitting spigot of mucus.
Everybody's nose runs all the time, Foster said while doing so.
The usual problem in an operated nose is that scars inside get in the way of the flow.
It pools and runs out of the nose instead of going back down the throat.
To remarry the tip and the bridge of Hope's nose, as Foster put it, he added a strut to stabilize its pinched end and pre-empt drooping.
And to flesh it out and make it broader and rounder—at Hope's request—he sutured to each side a lateral graft.
Finally, to fix her flattened right nostril, he sliced an opening along its outer edge, into which he inserted a rim graft, much as you might cut open a tiny pita-bread pocket and fill it with your stuffing of choice.
It had been an hour since Foster began.
He had already re-draped the skin, stitching it to the columella.
But then, without looking at his hands but rather keeping his eyes straight ahead, he started running his fingers up and down the length of it, as if playing the piano, relying on touch to determine the symmetry and linearity of forms.
He must have hit a wrong note, because his fingertips hesitated, sensing a deficiency on the left side, which meant he wasn't done yet.
Although he had already stitched the columella closed, Foster cut the suture and lifted the skin once again, adding another small graft to the tip.
Let me just noodle this a bit, he said, focusing on Hope's nostrils before finishing up.
Her rims are in a better position—not perfect.
Five to 7 percent of my rhinoplasties aren't perfect.
I have to futz around with them six to nine months later.
But Hope was immediately over the moon with her new nose.
Right away, despite her post-op condition—which she described as like being hit by a Mack truck, her nose so blocked that it felt as if she'd snorted a brick, the dried blood caked onto the sutures tugging at her tender columella, not to mention her inability to sleep upright as dictated by the aftercare instructions—she was able to pierce through an addling haze of Vicodin to behold, in the blimp of swollen tissue throbbing in the center of her face, an inchoate vision of nasal pulchritude.
All the wrongs that had been plaguing Hope for years had finally been made right.
Not only was her ski-jump bridge gone, but so were the pinched tip and the broken septal bone poking out on her right side.
And—finally!
—she had two open and functional nostrils.
As Foster had counseled Hope to be prepared for extended swelling—nine to 12 months for a secondary rhinoplasty (as compared to six to nine months for a primary)—she took it in stride, her spirits buoyed at every milestone in the healing process.
Among the most memorable was Day 34, the first time she sneezed, the blast shooting out any remaining temporary stitches.
Oh, my God, it felt so good! 
she recounted.
It was better than an orgasm!
As the months passed, her days of snoring and sinus infections became distant memories, and her new nose brought unexpected positive changes, like a newly vibrant sense of smell, as well as livelier taste buds.
And because Hope could now breathe out of both nostrils, her oxygen intake was bolstered and her skin more radiant, eliciting compliments over its healthy glow.
In April, at a follow-up appointment with Foster, Hope reported the reactions that she had been receiving about her nose.
People are saying, `You look great.' 
But they can't figure out what it is.
A good sign of surgery is when you can't pinpoint where the change comes from, the surgeon replied.
I love my new nose, she said, breaking into her Julia Roberts grin.
It's still swollen, but I know it's just right—not too small, not too big, not too wide, and not too skinny.
This is the nose I wish I d gotten from the get-go.
It's a botched job gone good.
DEFINITION OF AESTHETIC PRACTICE There is currently no internationally accepted definition of aesthetic practice.
The UK Cosmetic Surgery Interspecialty Committee has defined cosmetic surgery as an area of practice involving "Operations and other procedures that revise or change the appearance, colour, texture, structure, or position of bodily features, which most would consider otherwise to be within the broad range of 'normal' for that person".
The American Board of Cosmetic Surgery has defined cosmetic surgery as "a subspeciality of medicine and surgery that uniquely restricts itself to the enhancement of appearance through surgical and medical techniques.
It is specifically concerned with maintaining normal appearance, restoring it, or enhancing it beyond the average level toward some aesthetic ideal".
STATISTICS ON COSMETIC SURGERY According to statistics from the American Society for Aesthetic Plastic Surgery (ASAPS) in 2005, there were nearly 11.5 million surgical and nonsurgical procedures performed in the United States.
[2] Surgical procedures accounted for nearly 19% of the total, with nonsurgical procedures making up 81% of the total.
Since 1997, there has been an increase of 444 percent in the total number of cosmetic procedures.
Surgical procedures have increased by 119 percent and nonsurgical procedures by 726 percent.
he top five nonsurgical cosmetic procedures in 2005 were:
5. Chemical peels (556,172) Women had nearly 10,500,000 cosmetic procedures performed in 2005, accounting for 91.4% of the total.
Men had 985,000 procedures, approximately 9% of the total.
People between the ages of 35 and 50 years accounted for the majority of procedures (accounting for 5.3 million (47%) procedures.
Those between 51 and 64 years accounted for 24%, patients aged between 19 and 34 years accounted for 24%, those 65 years and older accounted for 5%, and those aged 18 years and under accounted for 1.5%.
The most common procedures for those aged 18 years and under were laser hair removal, microdermabrasion, rhinoplasty (nose reshaping), otoplasty (cosmetic ear surgery), and chemical peel.
The majority (48%) of the cosmetic procedures were performed in an office facility, 28% in a free-standing surgi-center, and 24% in a hospital.
Americans spent approximately $12.4 billion on cosmetic procedures in 2008.[2]
THE SOCIAL IMPLICATIONS OF AESTHETIC MEDICINE Due to the increasing demand for aesthetic procedures, it is not uncommon for patients to encounter a menu of aesthetic supplies and procedures.
These range from skin care products, skin rejuvenation (tightening, pore reduction, blemish removal, smoothening and tightening the skin), anti-wrinkle treatment, acne scar treatment, pigment removal, stretch mark removal, neck lifting, hair restoration, hair removal, breast firming/enlargement, skin whitening, cellulite removal, lip enhancement, tattoo removal, broken capillary treatment, square jaw treatment, nonsurgical facelift, fat removal, anti-aging medicine, hormonal therapy to mesotherapy.
Numerous skin rejuvenation treatment programs (topical creams, skin care products), skin rejuvenation procedures (such as filler and cosmetic botulinum toxin injections, lasers, light devices, radiofrequency devices, and surgical procedures) have been introduced by dermatologists and plastic surgeons and subsequently, by diverse medical specialities.
Nonmedical practitioners, e g , the beauticians and spa operators, have jumped onto the bandwagon to provide such services.
Many of these aesthetic treatments claim to rejuvenate the skin but are not supported by good scientific evidence.
Services and procedures that are unproven in efficacy by medical practitioners are often provided at significant cost to patients, which is considered by many medical practitioners to be a deviation from the normal practice of modern medicine.
Many medical practitioners have perceived such deviations to be a growing problem that needs to be addressed as it undermines the trust in and professionalism of the medical fraternity.
Concerns have been raised regarding safety issues as well as the quality of such services by the medical profession and the public.
Some patients even sustain injuries and complications from these procedures.
THE MANY CAUSES FOR INCREASED DEMAND FOR AESTHETIC PROCEDURES Several factors can be attributed to the increasing demand for aesthetic dermatology procedures, namely, (1) the secular consumer culture among the population at large to prolong youthfulness and self-image, (2) economic abundance, in particular, among well paid executives during good economic climates and the large proportion of retiring baby boomers who have accumulated sufficient savings as they reach their retirement age, (3) technological and medical advances whereby new cosmeceutics and devices have been invented to treat cosmetic disorders with minimal downtime and complications, (4) media-driven demand and hype promoted by some beauticians, medical practitioners, and the cosmeceutical and medical devices industries, (5) high-pressure advertising by various media, (6), a breakdown of institutions and cultural constraints, philosophy, policies etc and, (7) a lack of regulatory control that would help to differentiate evidence from nonevidence-based aesthetic procedures and appropriate training and accreditation regulations.
 All these factors lead to consumer-driven medicine.
Consumer-driven medicine is often industry-driven medicine with a strong motivation for profit which, in turn, leads to questionable practices and infringement of medical ethics.
It is often media-driven medicine because the media benefits from consumption by serving as the vehicle of advertising.
Advertising encourages needless consumption that may lead to unethical promotions.
EFFECTS OF INCREASED DEMAND FOR AESTHETIC PROCEDURES Increased demand for aesthetic procedures has resulted in an ever-increasing number of beauty parlour and charlatans providing scientifically unproven aesthetic services and making unproven claims.
There is also an increased interest among medical/dental practitioners offering aesthetic procedures for which they were never trained during their medical training, and a confused public who will not be able to distinguish a medically trained aesthetic physician from one who is not.
This confused public is beginning to lose confidence and trust in the medical profession because some practitioners are offering nonevidence-based aesthetic treatments and merge their treatments with those offered by beauticians and participate with media to promote their treatments, thereby trivializing and commercializing medical services.
These commercialized services tend to falsely promote such procedures as having low/no risk, omitting side effects, exaggerating benefits, exaggerating the indications rather than than the limitations of the treatments, overstating good results and hiding complications and poor responses, and tending to make unsubstantiated claims of superiority.
This has been referred to as the invisible hand of the marketing department.
UPHOLDING THE INTEGRITY AND RESPONSIBILITIES OF THE MEDICAL PROFESSION IN AESTHETIC MEDICINE The medical fraternity has been traditionally regarded as a credible and trustworthy profession that has typically abided by the time - honored Hippocratic Oath.
The advice and services offered by medical professionals are often taken seriously with the belief that doctors will always provide scientifically proven and effective procedures. 
Their medical training and government regulations in most countries often ensure that the profession maintains a high standard of practice.
The public generally trusts medical practitioners to carry out aesthetic procedures rather than to leave it to an untrained beautician.
Thus, medical practitioners are attracted by the fairly lucrative and easy way to make a living than to practice conventional medicine.
These factors have inevitably driven medical practitioners of diverse specialities into providing aesthetic services.
We know that aesthetic medicine, as it is promoted today, generally does not have strong evidence-based rigor in many of the procedures offered.
There is a large gap between evidence and practice.
There is a tendency for practitioners of aesthetic medicine to move away from science to quackery.
This has led to loss of objectivity and of the conventional professional pursuit of excellence which is expected in the practice of medicine.
The problem is further compounded by the fact that, at the moment, there are no hard-and-fast rules governing the way aesthetic procedures like botulinum toxin injections are carried out or promoted. 
Patient safety is left to the discretion of individual doctors.
In many countries, there is no proper accreditation process to regulate the practice of aesthetic medicine.
Many aesthetic practitioners are not adequately trained to carry out aesthetic procedures.
This has resulted in patients complaining against medical practitioners.
The practice of aesthetic medicine should not be exempted from the need for structured training and accreditation.
This ultimately serves to protect the public from unproven and unsafe treatments.
Leaving the aesthetic medicine industry to regulate itself is not a feasible solution as professional and ethical standards in an unregulated industry might take a hit in this lucrative business.
In Singapore, the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines require doctors to treat patients according to generally accepted methods.
A doctor shall not offer to patients, management plans or remedies that are not generally accepted by the profession, except in the context of a formal and approved clinical trial.
The guiding principles in any medical treatment must be that it is effective and that due cognizance will be given to patient safety.
In the context of aesthetic practice, it must go beyond the Do No Harm principle and must be seen to benefit the patient positively.
There are many examples to quote to confirm that this principle is often not practiced in aesthetic medicine.
For example, one report on the treatment of cellulite with noninvasive devices including massage, radiofrequency, mesotherapy, carboxy therapy etc concluded that … no treatment is completely successful as none are more than mildly and temporarily effective.
However, despite the lack of evidence to support efficacy, treatment options continue to proliferate for treating cellulite.
Another report on mesotherapy stated …despite the increasing interest in mesotherapy as an alternative method for body contouring, there are few reports of its safety, efficacy, and mechanism of action.
Their study on the efficacy of mesotherapy for body contouring concluded that mesotherapy is not an effective alternative treatment modality for body contouring.
NEED FOR ETHICAL GUIDELINES FOR THE PRACTICE OF AESTHETIC MEDICINE FOR THE MEDICAL PROFESSION Evidence-based medicine/practice There is a need to implement guiding principles on the practice of aesthetic medicine by the medical profession.
Evidence-based practice is probably the best approach.
As per the SMC Ethical Code and Ethical Guidelines, doctors are responsible for ensuring that they are competent and adequately trained before performing any treatment or procedure on a patient.
He or she should keep abreast of medical knowledge relevant to practice and ensure that clinical and technical skills are maintained.
WHAT IS EVIDENCE-BASED MEDICINE?
Evidence-based medicine (EBM) is defined as "the conscientious, explicit and judicious use of current best evidence about the care of individual patients".
The keywords in the definition are conscientious which signifies an active process which requires learning, practice, and reflection; explicit which describes it as a transparent process used to practice EBM; current reflecting being up to date, and best which signifies that one should seek the most reliable evidence source to inform practice.
EBM is a way of thinking and working with the sole objective of ensuring improved health of our patients.
The term, evidence-based practice is often used instead of EBM and is defined as integrating one's clinical expertise with the best external evidence from systematic research.
It should be noted that therapeutic guidelines are not the same as EBM.
Many dermatology guidelines now incorporate a grading system that describes the quality of evidence used to make recommendations and describe their strength.
Searching for relevant information for your patients frequently opens up more rather than fewer treatment options.
It is estimated that to keep up with the best evidence available; a general physician would have to examine many journal articles daily and throughout his/her life.
The trick is to know how to find information efficiently, appraise it critically, and use it well.
The techniques and skills needed to find, critically appraise, and use the best evidence available for the care of individual patients, have been developed over two centuries.
These techniques and skills are currently best known as EBM.
Two filters need to be applied if one is to keep practicing EBM: The first is to discard irrelevant information, and the second is to spend more time looking at a few high-quality papers, as per the concept of hierarchy of evidence.
Suzanne Fletcher and Dave Sackett described "levels of evidence" for ranking the validity of evidence about the value of preventive maneuvers, and then assigned them as "grades of recommendations".
Modifications of the above system have been proposed over the last few years. 
But basically, all utilize levels of evidence and grades of recommendation (www.cebm.net/levels_of_evidence.asp).
Levels of evidence are based on study design and the methodological quality of individual studies. 
Grades of recommendation are based on the strength of supporting evidence, taking into account its overall level and the considered judgment of the guideline developers.
THE COCHRANE SKIN GROUP The Cochrane Collaboration (www.cochrane.org), an international voluntary group of reviewers and researchers from a range of professional backgrounds dedicated to producing systematic reviews, was established in 1992
In December 1997, a Cochrane Skin Group was registered with the Cochrane Collaboration to prepare, maintain, and disseminate reviews on the effects of health care for people with dermatological conditions.
The Group has to produce the best evidence about the effects (good or harm) of health care interventions for dermatological diseases.
The scope of the Group includes any dermatological problem that leads a person to seek help from a health care practitioner.
The Group seeks to find and analyze all evidence on the effectiveness of preventive, medical, and surgical interventions and of different models of health care provision and management of dermatological diseases. 
This includes evidence about dermatological treatments that are sold over-the-counter or are widely available.
The Cochrane review is systematic, structured, and painstakingly assembled; it minimizes bias and ensures quality. 
Whenever possible, Cochrane reviews are based only on RCTs because of the major biases associated with other study designs for assessing treatment effects. 
After approval according to the internal and external refereeing procedures of the Group, the review is published in the Cochrane Library (www.cochranelibrary.com).
A useful source for evidence-based dermatology reports can be found in the Cochrane Skin Group review wherein specific reports on treatment and other studies are collated and analyzed based on the strengths of the reports.
Examples of such Cochrane reports are: Laser and photoepilation for unwanted hair growth reported by M. Haedersdal and P.C. G?tzsche.
The authors' conclusion was, "some treatments lead to temporary short-term hair removal.
High quality research is needed on the effect of laser and photoepilation".
Laser resurfacing for facial acne scars reported by Jordan R.E., Cummins C.L., Burls A.J.E., Seukeran D.C. 
The authors' conclusions were, "the lack of good-quality evidence does not enable any conclusions to be drawn about the effectiveness of lasers for treating atrophic or ice-pick acne scars. 
Well designed, randomized, controlled comparisons of carbon dioxide versus Erbium:YAG laser are urgently needed."
WHAT ARE WE TO DO WHEN THE IRRESISTIBLE FORCE OF THE NEED TO OFFER CLINICAL ADVICE MEETS WITH THE IMMOVABLE OBJECT OF FLAWED EVIDENCE?
All we can do is our best: give the advice, but alert the advisees to the flaws in the evidence on which it is based.
APPLICATION OF EVIDENCE-BASED PRACTICE IN AESTHETIC MEDICINE IN SINGAPORE On 1 November 2008, the SMC introduced its guidelines on the practice of aesthetic procedures for Singapore medical practitioners.
Aesthetic procedures under List B are currently regarded as having low or very low level of evidence and are not considered as being well-established. 
Medical practitioners who wish to perform List B aesthetic procedures should list themselves with the SMC's APOC using a prescribed List B notification form before carrying out any List B aesthetic procedure. 
Doctors may be subject to audit and should comply with requirements set by the SMC's APOC and the Ministry of Health. 
Proper documentation of the indications and outcomes of the treatments and procedures are of utmost importance.
Medical practitioners who wish to perform procedures that fall within the definition of Aesthetic Practice in the guidelines but which are not found in either List A or List B, will also have to list themselves with the SMC's APOC. T
he APOC may then decide on the classification of the procedure or further dictate how the doctor should proceed. 
It is recommended that medical practitioners should not practice such procedures until they have been classified by the SMC's APOC.
List A aesthetic procedures This list reflects the aesthetic treatments and procedures that are supported by moderate to high level of scientific evidence and/or have local medical expert consensus that the procedures are well-established and acceptable. 
They are grouped into noninvasive, minimally invasive, and invasive.
List B aesthetic procedures List B contains aesthetic treatments and procedures that are currently regarded as having low/very low level of evidence and/or being neither well established nor acceptable currently.
Having satisfied all the above circumstances and documentation, it is still required of doctors to practise List B aesthetic procedures only under highly monitored conditions that enable the efficacy, or lack thereof, of such procedures to be objectively demonstrated. 
The objectives, methodology, analysis, and findings obtained through such treatments must be of sufficient scientific validity to establish efficacy or otherwise. 
In addition, patient response should be documented and retained alongside all case records of such treatments. 
In the event that the procedure yields adverse or neutral outcomes, the practice of the procedure(s) must be terminated.
The patients must not be charged highly profitable fees for such procedures of low evidence, but a fair fee representing the cost of the procedures plus the cost of providing and administering them. 
Financial documents relating to these procedures must also be retained for the purpose of audit when required. 
No medical practitioner shall advertise that he or she is performing aesthetic procedures in List B. COMPLIANCE WITH SINGAPORE MEDICAL COUNCIL AESTHETIC PROCEDURE GUIDELINES Any medical practitioner who performs any aesthetic procedure that is not in accordance with these guidelines or with any requirements set by the SMC or MOH will be deemed by the medical profession as being unethical and bringing disrepute to the profession. 
Such a doctor may be liable for disciplinary action by the SMC.
"You would be so pretty if you got your nose fixed," my mother said.
Fixed. 
Like I was damaged.
She introduced me to friends with a disclaimer: "My daughter wasn't supposed to look like this."
 She'd chosen my father for breeding because of his handsome face and long fingers, and she wanted her daughter to be a button-nosed pianist. 
My nose was huge, and I didn't play the piano, and my parents are now divorced. 
Just saying.
My beak was big, without a doubt— lumpy, crooked, and, I dare say, stereotypically Jewish amid the sea of wealthy Protestants in our Illinois town (voted, in 1997, one of the best in the nation in which to raise children).
"Pain for beauty," was my mother's motto, as she warped my long hair into scalp-pinching braids. 
A former actress and model, she appeared in a few episodes of All My Children before I was born. 
When I was growing up, she couldn't leave the house without asking, "Do I look beautiful? 
You're not looking—look. 
Beautiful?"
My mom had convinced her frugal mother to pay for her own nose job when she was a teen; later, she had it tweaked twice to get it right.
 So when a salesclerk or waitress recognized us as mother and daughter, she was insulted. 
Her surgeries were supposed to have saved her from looking like me.
At her best, my mother has always been generous, fun, witty, and deeply concerned about me, and, in her way, she was trying to help. 
To her, a smaller nose would be one less obstacle to a happy future. 
But when she asked again and again if she looked beautiful, I'd burst into tears, desperate for her to tell me I was beautiful too.
And yet, oddly, when I wasn't crying, I was also totally into my nose.
I was convinced that it made me funny, approachable, quirky, Jewish; that my personality, my identity, and my relationship with my mother were all in there. 
Depending on the day, my haircut, the bathroom lighting, or whether a boy had asked me to a dance (and they did), I ping-ponged between feeling exotic and like a total freak. 
Still, I rejected a "happy puberty" nose job at 13 and a "sweet 16" rhinoplasty, too.
Yet by 2006, when I was 24, single, and working in film production in New York City, it became clear that my mother wasn't the only one who reacted negatively to my nose. 
People stopped me on the street to tell me I looked like Barbra Streisand. 
Japanese tourists wanted to take pictures with me. 
Hairstylists told me I needed to play down my nose—"no offense." 
I started writing down the unprovoked remarks in a journal; in one year, I recorded 59.
2006/9/23 Gay man at a party in Williamsburg: "Damn, girl, why you never got that thing taken off?"
A woman overhearing: "I like it, don't get it fixed."
Her friend: "You're Jewish, right?"
The nose hadn't stopped me from dating, getting jobs, or making friends. 
But it was beginning to feel like some silly outfit I'd put on to annoy my mother. 
After years of defiantly building an identity around it, was I finally going to admit that I hated it too?
I went to see a plastic surgeon, who created a digital projection of the nose he could give me: scooped, small, with a slight upturn. 
The picture looked like another girl. 
And she was so pretty.
But I was worried. 
Would changing my nose change my identity? 
Would I lose the thing that gave me character? 
The doctor seemed amused. 
"Do you really think you are your nose?" 
he asked.
Well, yes. 
And this, I realized, was the real problem: My nose overshadowed what I loved about myself. 
After years of struggling not to be my mother's mirror, it was time to be happy with my own reflection.
My surgery was in November 2007. 
My mother flew to New York and booked a hotel for us near the doctor's office, where she drew me baths and read to me for the first few days of my recovery—the kind of mothering I had longed for. 
"Relax," she told me as she replaced the bandages. 
"Soon you'll be prettier than me."
My new nose isn't tiny, but it's smaller, more sculpted. 
As one colleague said, "Now I can see your eyes, cheeks, and smile, too." 
I hate to say it, but my mother is right: It's the nose I was meant to have.
I don't have to make excuses for it or cover it with my hair. 
I can just be.
Asked why she used to be so cruel about my nose, my mother has explained that her own mother made her feel worthless. 
While that sad cycle helps me to understand her, it doesn't excuse our past. 
Now each time she tells me I'm lovely, I feel the full force of its opposite—the stinging comments of my youth. 
But at least I believe her. 
I hate to admit how much that matters to me.
In the post-ski-jump era, the best nose job is one that looks like no nose job at all.
According to NYC plastic surgeon Steven Pearlman, MD, who specializes in revision rhinoplasty (i e , do-overs), spreader grafts—pieces of the patient's own cartilage he inserts into the middle third of the nose—create a smoother curve from the brow to the tip, with no 'drop-off' in the middle.
For patients with very thin skin, who were previously prone to the bony-looking shrink-wrap effect, Pearlman also adds ultrathin grafts of cartilage or tissue taken from the temple to the tip of the nose, a trick he refers to as carpet padding.
Scalpel-phobic?
Injections of Botox and fillers temporarily smooth bumps, lift drooping tips, and add definition, says L A –based cosmetic surgeon Alexander Rivkin, MD.
He perfected the profile below in minutes with two vials of the filler Radiesse, which lasts 10 to 12 months.
For a long-term fix, Rivkin recently began offering the same treatment using ArteFill, a filler made of Lucite spheres suspended in collagen, which is shown to last up to 15 years.
Botox has become synonymous with many things — vanity, self-esteem, the search for eternal youth — but before it became a fixture in high-end dermatologists' offices, it had a lot of non-cosmetic medical applications. 
(Well, after scientists learned how to process Botulinum toxin so that it no longer killed us immediately.)
This past Friday, Botox was approved by the FDA for use in the treatment of chronic migraines. 
In a story in the New York Times, a company spokesperson predicted that Botox sales for medical use would soon surpass sales for cosmetic use.
 Botox, which is produced by Allergan, was first approved for use in 1989 for various eye muscle disorders.
 It wasn't approved for cosmetic use and wrinkle reduction until 2002, after doctors noted the rather fortuitous effects that the injections produced in the skin around the treated areas. 
And, eureka, a "miraculous" and contentious potion was born.
Even more recent studies show that Botox provides a moderate, yet statistically significant decrease in the number of days chronic migraine sufferers experienced headaches. 
The FDA defines "chronic" as more than 15 days per month. 
Ouch. 
If you've ever had a migraine and all the accompanying symptoms — visual disturbances, nausea, sensitivity to light — imagine how debilitating it would be to have them that frequently.
We spoke to Dr. Alexander Mauskop, who is the Director and founder of the New York Headache Center, and is board-certified in Neurology with a sub-specialty in Headache Medicine. 
Dr.Mauskop has been using Botox off-label (it's legal, but not covered by insurance) for chronic migraine treatment for 15 years; he estimates that he's treated about 5000 patients.
ELLE: So will Botox become a first-line therapy for chronic migraines, or is it better suited as an adjunct to other medical treatments?
Alexander Mauskop: If money was not an issue, I would use it as first line preventive therapy in my patients.
Traditional migraine drugs that we use have a lot of side effects. 
I'm also a big advocate of alternative therapies. 
You have to see what works in each individual case.
ELLE: Speaking of side effects, doesn't Botox have some scary ones?
AM: It's very dependent on the experience of the physician. 
I would make sure that your physician has done these types of injections a few hundred times, at least. 
Side effects can include droopy eyelids, neck weakness, headache (it takes about a week for the Botox to take effect), and neck pain. 
And of course — no wrinkles.
ELLE: How many injections and how often?
AM: It requires about 20-30 injections every three months. 
We use a "follow the pain" approach and inject the forehead, jaw muscles, neck muscles, back of the skull, and sometimes even the shoulders.
ELLE: How exactly does it work? 
Don't migraines originate in the brain?
AM: Everyone was skeptical at first, but when we were faced with difficult patients we thought it was worth a try. 
It worked for many patients. 
Then the research finally caught up with clinical observation. 
In migraines you can have some muscle spasm of the cranial muscles; Botox can block those muscle contractions and the neurotransmitters that send pain messages to the brain.
It's all a feedback mechanism.
ELLE: How much does the treatment cost?
AM: It can cost between $1,000 and $2,000 per treatment. 
But now that it's FDA approved for this, insurance companies will have to start picking up some of the cost.
All of which means that this could be a promising treatment for more people with chronic migraines. 
There are obviously a lot of cost-benefit considerations. 
Hate needles? 
Probably not the right therapy. 
Hate taking tons of pills? 
Perhaps Botox would work for you. 
But please, as always, educate yourself and speak to a trusted healthcare provider before undertaking any kind of medical treatment.
Sailing up New York's Sprain Brook Parkway in my father's beige, ocean-liner-size Cadillac, I declared from the backseat: I want a nose job.
A few girls in my ninth-grade class had returned from winter vacation with snazzy new snouts, and I was resolved to do the same.
I had, after all, inherited my father's nose, complete with its protruding bump and long, beakish tip.
A cuter, daintier model, I argued, might soften my boyish face.
Both of my parents wholeheartedly agreed.
I wish I had a recording of the conversation so that I could replay the long sigh of relief that discharged from my mother's mouth.
My father married her later in life; by the time I was born, he was 50. 
Raised in a poor immigrant neighborhood in East New York, Brooklyn, he had cultivated a distinguished look and a self-styled British accent that gave him the enchanting air of Cary Grant. 
In all things, I sought his approval. 
At 10, I toiled alongside him in his workshop in our basement; later I took up his passions of writing and painting. 
He taught me to love Laurel & Hardy. 
Just as Hardy would lock eyes with the camera, expressing his irritation with Laurel's antics, my dad looked to me for understanding.
On a trip to California when I was 16, we left my mother and sister at the hotel; in the rental car, he told me we were on our way to an important meeting in Hollywood to discuss the possibility of producing his screenplay. 
It was a journey that could change his fate, and I was his chosen copilot.
Despite this bond, by the time I hit puberty, it was clear that, unlike my younger sister, Sophia—who was popular, well accessorized, and boy-crazy—I was not living up to his definition of womanhood. 
My father was born in 1928, the same year as Mickey Mouse, and possessed an old-fashioned, Disneyfied view of women: We should be soft, feminine, gentle—and constantly on a quest for our prince. 
Next to the label-conscious, salon-styled girls at my private school, I resembled a prepubescent boy, both aesthetically and spiritually. 
Rail thin, breasts hidden under oversize flannel shirts, I spent weekends wolfing down pizza and playing video games.
And then there was my nose—his nose—which grew more exaggerated at the onset of puberty. 
It became the focus of my self-loathing, a manifestation of all my shortcomings as a girl. 
Altering it was one way, at least, that I could become more feminine.
So, a few days after high school graduation, I finally got my nose job. 
The surgery flattened the bridge of my nose but left it with a lengthy tip and asymmetrical nostrils.
A second procedure shaved down the tip and reshaped the nostrils. 
As promised, it made my face softer. 
Less self-conscious, I began to put more care into the way I dressed and even wore a little makeup.
But the anxious, tugging sensation in my chest was still there. 
Surgery eliminated the one problem that had so preoccupied me, but it forced me to acknowledge another, bigger issue—my sexuality—that would make me a failed woman in my father's eyes.
With time, I was able to crack my former self-perception.
In college, I entered my first relationship with a woman and began to feel attractive and desirable—another first.
I spent a semester in Florence, suspended in what seemed like a whirling dream of bicurious girls trying to bed me. 
Would that have been possible with my old nose?
I had spent my first postcollege year in San Francisco, but my father asked me to return to New York because of his waning health. 
Within a few weeks, I met a woman and one night accidentally fell asleep at her apartment, waking at 5 a.m. to discover 16 messages from my mother on my cell phone.
I rushed home and tearfully came clean. 
My mother lambasted me for deceit and pronounced my sexuality a "phase."
From then on, my father was polite to me at family occasions, but increasingly distant. 
One Father's Day, I had a trophy made for him, which he received with indifference. 
When I bought tickets to "Seeing Debussy, Hearing Monet" at Carnegie Hall for his birthday, he declined, blaming his health.
My mother filled the gap, vilifying me and my "choices" even after I moved in with my girlfriend. 
She told me the news had aggravated my father's health, that he couldn't sleep at night because he was so distraught.
Until age 79, he spent his semiretired days in his Brooklyn law office, curled up with copies of The New Yorker and the New York Post, listening to a crackling radio and trading dirty jokes with the guys down the hall. 
But last November, he was hospitalized after a fall, and it fell to me to pack up the office where he'd worked for more than 50 years. 
I uncovered unsold screenplays and short stories, illegible phone messages, and, at the very bottom of the pile, a stack of pictures. 
I flipped through them, snickering at the '70s sideburns and wide-collar shirts, until one gave me pause. 
It was my father's high school graduation portrait.
Staring out from this glossy black-and-white photo was my own face: my closed-mouth smile; my dark, deep-set eyes. 
And there it was: my old nose. 
Despite everything the surgery did for me—and it did a lot—I wish I could undo it. 
At 31, I've come to appreciate the things I inherited from my father: his humor, his love of ketchup and Mondrian paintings. 
When he is gone, how will I reconcile my decision to erase something we once shared? 
I stared at the image, tears running down my cheeks.
Soon afterward, my father entered hospice care. 
Twice, his lungs filled with fluid, and he narrowly escaped death. 
But while his body hangs on precariously, his mind remains remarkably intact.
I've spent more time with him this year than over the previous 10, our relationship reduced to its purest form: a father and daughter who have a lot in common and care for one another. 
We talk or watch Laurel & Hardy while he keeps the nurses laughing with puns and one-liners. 
It's both a gift and some kind of cosmic joke.
In the end, this is what we're left with: an aging parent wasting away in a hospital room, muscle and fat disappearing from his body. 
When I visit him each week, I scan his face: eyes, cheeks, mouth, chin. 
My gaze stops at the nose, and I bring my right hand to my face and run my index finger along the bridge of my own.
I was a fat kid, born fat to my petite European mother, who had been a fit model in the '60s. 
My chubbiness worked for me. 
I could fall down in front of our apartment building on NYC's ultraskinny Fifth Avenue and bounce right up, unharmed. 
Compared to my older brother, I was treated with kid gloves: I never had to do chores, wash dishes, babysit, because my parents thought I already had enough to deal with, what with my gigantic size. 
Most obsessed of all was my mother. 
When I was 13, she got me my own private aerobics instructor. 
But by 15, at 5'8", I was an adult size 16.
I didn't mind it so much, really. 
I didn't want to deal with boys or sex or going to parties and all that. 
I was really happy playing video games, reading, baking brownies with my best friend, and watching movies. 
The only problems occurred when I was out in public, and then it was the men who were the cruelest, not the girls. 
Grown men. 
Once, on my way to school, two guys walked toward me, and, from about 30 feet away, I could hear their soft, high-pitched singsong: "Fatty! 
Faaaaatty!"
By 16, I'd had enough, and I spent a year and a half weighing every single thing I put in my mouth, eating salads with no dressing, climbing the StairMaster for an hour a day, doing countless sit-ups. 
I hit 155 pounds, and considered myself normal looking—except for my stomach. 
While the rest of my body shrunk down, my waist remained a stubborn inner tube of flesh. 
I felt deformed. 
And I still hadn't kissed a boy. 
The thought of talking to one absolutely terrified me: I was fat; boys made fun of me—that was the way it was.
Senior year of high school, a solution presented itself. 
It was creative and unorthodox, but also totally insane: I fashioned a girdle out of duct tape and old panty hose. 
Yes! 
Sometimes when I pulled the tape off at the end of the day, skin would come with it, leaving scars that stuck to my hips and rib cage for years. 
But at last I could wear a T-shirt in public. 
I had a figure—a nice one.
My mother, terrified that I was going to hurt myself (not an unfounded fear, considering I passed out once or twice), made an appointment with a plastic surgeon. 
I'd been dreaming about liposuction ever since I read about it in Jackie Collins' Hollywood Wives, my favorite book at age 10.
Yep, that's not going anywhere, the doctor said when I lifted my shirt to display the inner tube.
A week later, I was under anesthesia and on the operating table.
This was the '90s, the stone age of lipo; surgeons flooded the area with saline, then sucked out the fat through a large cannula.
Recovery was awful.
I woke up swaddled in my constrictive bodysuit, and in a really bad mood—a common side effect of anesthesia.
But a nurse stared me straight in the face and said, Wow, you're a really good-looking girl.
The way she said it—seriously, almost to herself more than to me—made me think she meant it.
It was the first time anyone had ever complimented my looks.
After three weeks of intense pain and constant fantasies about my new body, I unzipped my bodysuit and got an unpleasant shock. 
My stomach looked almost exactly the same—a little slimmer, maybe—save for one thing: a huge dent, like a dog bite, right beneath my belly button. 
My mother confessed that she had run into the operating room as I was being wheeled in to tell the doctor "not to do too much." 
From the looks of it, the doctor just stuck the cannula in at that one spot and pulled it out. 
I played on my mom's guilt for a full year, and then she allowed me to get a second operation.
My new doctor was French, handsome, and blunt.
I got the exact same Yep, that's not going anywhere line, but in a French accent.
Plus, What a mess he made!
What endearing honesty.
At least he said he could fix it, which was all I cared about.
This time, lipo worked.
(We sucked a lot of fat away, the surgeon said.)
The next day, my face broke out in a violent, lumpy red rash which my derm diagnosed as rosacea: It happens sometimes after the body's had a major trauma to it, like a car crash.
It had never occurred to me to wonder what exactly was actually occurring during surgery, while I lay unconscious.
Later, I d see a video on TV of the same tumescent liposuction procedure.
The violence of it—the cannula shoving violently in and out of a stomach swollen with liquid??—was horrible.
But it didn't stop me from getting my arms done the next year, when I turned 20.
I don't remember much about this one—how I got my mother to agree to it, who the doctor was, what happened before or after.
I do remember the recovery was easier than with my stomach.
Three lipos in three years, all before I had even graduated college.
I felt like I looked okay—not the freak I once thought I was.
But weight was still a constant issue, as was my wonky-looking stomach.
The divet was still very much there, and on top of that, one side of my waist indented more than the other.
Exercise did nothing to balance it out.
And while I might have looked great in clothes, I never wore a bikini, and I never let a boy see me naked with the lights on.
Over the next eight years, I did everything from endermologie (a deep-tissue, machine-based massage) to mesotherapy (a big, painful, $3,000 mess of injections of a so-called fat-dissolving compound, which peppered my stomach with odd, circular bruises and did absolutely nothing to the fat).
I tried seaweed body wraps, a roster of famous diet doctors, trendy detoxes, and celebrity-trainer workouts.
By 29, I was a size 4 and 136 pounds.
But my stomach, that stomach, was still there: a misshapen reminder both of who I had once been, and who I still couldn't be.
A bad breakup triggered the next surgery.
The difference between lipo circa 1998 and lipo circa 2009 was shocking; the procedure was cheaper, faster, better.
And most important I didn't need my mother's permission.
I plonked down my entire savings, $10,000 (a lump sum I got as an advance for a book I was ghostwriting) for Manhattan-based surgeon Bruce Katz, MD.
When I showed him my stomach, he just smiled kindly and said, Yes, I think I can help you with that.
Katz's specialty, laser-assisted lipo uses a cannula with a laser at its tip: The beam of light ruptures fat cells, the contents of which are then easily vacuumed out through the cannula.
Also, I was awake for the entire procedure.
Katz would ask me to get up from the table every so often to see how everything hangs.
Up.
Then down.
Then up.
Then down.
Impulse in check, though, the first appointment I made this time around was with my therapist—not a surgeon—in search of approval or absolution.
Am I crazy for even considering this again?
I think in your case, when you had it done when you were younger, it wasn't in your control, and that must have been so frustrating, she says.
So now that you're older and you can do it the way you want to do it, without any sort of familial repercussions—no guilt or shame—but privately, of course that's tempting.
That's when I mention to her it's my thighs I want done.
But your legs are tiny! 
she says, surprised.
Plastic surgery can become incredibly addictive.
I don't think you're crazy, but I definitely think getting lipo on your thighs is crazy.
I make another appointment with Katz.
He pinches my legs and says, Nope.
Nothing I can do about this.
The fat is under the muscle.
The only way to get rid of it is with cardio.
For a second, I don't understand.
What does he mean, No?
But his refusal—the first I ve heard over the course of four operations in a dozen years—gives me pause.
The surgeries on my waistline solved a problem that had no other clear solution, but it's startling to realize how accustomed I ve become to throwing money and a cannula at my every body issue (an attitude I may have inherited from my mother, who, despite discouraging my own revisions, has a surgery count nearing the double digits).
Now, after a few weeks of daily visits to the gym, my developing muscles remind me that change can be achieved by myself, all on my own?
—on this particular problem area, at least.
Fifteen times a week on average, Robert Schwarcz, MD, a New York City–based cosmetic surgeon, injects patients with Botox.
For certain individuals he also writes down a phone number on a piece of paper and tells them to make an appointment.
It's not for a dermatologist or a colorist with a flair for youthful-looking highlights.
The number is for Angela Kulangi, a facialist at Total Skin, a day spa that specializes in electric facials that deliver, via small wet sponges, low levels of microcurrent—1/1,000,000 of an amp (a light bulb runs on less than one ampere)—to stimulate the muscles of the face and neck.
If the patient has been using neurotoxins for more than three years, and if she has genetically thin skin and slim facial musculature, I ll make a gentle suggestion for her to see Angela, says Schwarcz.
I like the idea of providing a plumpness to a nonactive muscle and generating controlled muscular activity.
This same youthful fullness is what everyone who opens a jar of hyaluronic acid cream or books a filler session is attempting to retain or replicate.
And it's not that the botulinum toxins—Botox, Dysport, and the recently FDA-approved Xeomin—are in direct opposition to that end.
In fact, the toxins do not act directly on muscles—they bind to neurotransmitters, preventing them from signaling muscles to contract.
Initial medical use for the toxins wasn't even related to wrinkles or anti-aging.
In 1980, doctors began using it to quiet uncontrollable blinking and relax muscles that cause eyes to cross.
The cosmetic neurotoxin revolution began in 1987, when two Vancouver-based doctors discovered the neurotoxin's smoothing effect on the elevens, the frown lines between the eyebrows.
Derms and nonderms alike promptly took it one better, using injections to create lift.
When a neurotoxin is shot into a muscle that pulls downward, say, in the brow area, the antagonist muscle that pulls upward is left unopposed to dominate.
Add to that carefully placed injections to relax the frontalis muscle, which creates the worry lines, those horizontal ones across the forehead, and doctors could mimic the effect of a brow lift without picking up a scalpel.
If a muscle is immobilized, even temporarily, it will use less energy and have a tendency to atrophy, says skin physiologist Peter Pugliese, MD, author of the textbook Physiology of the Skin, who notes that researchers soon figured out how to make this atrophy yield short-term aesthetic benefits.
Dermatologist Fredric Brandt, MD, whose New York and Florida–based practice is the largest user of Botox in the world, explains that one can, like a sculptor, dramatically slim the jawline by injecting a large amount of a neurotoxin into the masseter, the primary chewing muscle that runs along the side of the face.
It is reversible, Brandt says.
But one treatment will last for a year.
However, atrophy can have a downside—which is where, for some doctors, electric facials come in.
These doctors believe that, in the wrong hands over time, neurotoxins could cause the face to lose desired fullness, and so they are prescribing microcurrent as a noninvasive companion to neurotoxin injections to diminish any loss in muscle tone.
In fact, dermatologist Nicholas Perricone, MD, steers his patients away from using neurotoxins at all, believing microcurrent, plus the right diet and topicals, to be the best anti?wrinkle strategy.
Electric facials, whether done at home or in a spa, he argues, help build convexities in the face.
Convexities are what make you youthful, he says.
That is critical.
If you look at the cheekbones, the forehead, the temples, the jawline of someone young, they come out in an arc away from the face.
They bulge out.
Around the age of 40 to the midfifties, the convexities go flat.
From 60 up, they can go concave.
Electrostim keeps the muscles plump and active, preventing or correcting loss of the convexities.
The idea of using electric current to stimulate muscles sounds both high-tech and barbaric, but in truth it has been in practice for hundreds of years.
For that we can thank Jean Jallabert, a professor in Geneva, Switzerland, for credibly reporting in 1748 that he alleviated paralysis in a locksmith's right arm by using a 90-minute series of electric shock sessions over the course of several months.
In 1982, researcher Ngok Cheng, MD, at the Catholic University of Leuven, Belgium, led a study that provided hard evidence of microcurrent's role in cellular vitality by proving that microcurrent increased levels of ATP—the fuel a cell needs to function—in lab-rat skin cells by 500 percent.
Orthopedic surgeon Robert Becker, MD, compiled multiple studies in his 1985 tome The Body Electric, citing the role of electricity in cell regeneration.
For decades, microcurrent has been used in different frequencies and waveforms to treat everything from wounds to migraines to chronic pain.
Professional athletes and anyone who has had physical therapy have often experienced an electrostim machine, as orthopedists routinely prescribe microcurrent to aid in the repair of ligaments and muscles.
On a muscular level, the microcurrent acts like a personal trainer to tone and shorten muscle fibers.
On a dermal level, as Pugliese, the skin physiologist, notes, there is serious anti-aging action going on.
Pugliese has spent more than five years analyzing microcurrent's effect on fibroblasts by biopsying skin before and in between microcurrent treatments, and has found a statistically significant increase not only in the production of collagen and elastin, the skin's main structural proteins, which degrade with age, but in that of glycosaminoglycans, or GAGs, the viscous material in which the proteins are embedded.
When you see a nice plump cheek like a baby's and you pinch it and it feels very good and snappy, he says, that's GAGs.
And, according to Perricone, the long-term benefits are more than skin-deep: If you have a microstimulation machine, you don't have to have perfect genes, Perricone says.
When I first started working with celebrities, I assumed they were genetically gifted and had perfect symmetry.
But now he knows that symmetry can be made: Not only can we use electrostim to increase our muscle mass, we can accentuate one side of the face by working it harder than the other to give a more symmetrical appearance.
Electric facials are on the menu everywhere from Perricone's New York flagship spa to Four Seasons hotels to Elizabeth Arden's Red Door salons.
Professional-grade microcurrent machines emit a positive and a negative current via two wands, probes, or sponges.
When the probes are placed a few inches apart on the face, a circuit of current travels from one point to the other and stimulates the tissue in between, Perricone says.
The current is subsensory, which means all one feels is the gliding of the rods and perhaps a slight tingle.
Customers often fall asleep midfacial.
The other option is to DIY with an at-home device.
Suzanne Somers teamed up with engineer Rodger Mohme, who previously led the team at Apple to shrink a desktop computer down to laptop size, to create the FaceMaster, a vanity-table version of a large in-spa machine.
The only handheld microcurrent device with FDA approval is the NuFACE, created by Carol Cole, a SoCal facialist who got tired of lugging her gigantic machine up into the Hollywood Hills.
It emits the same level of current as a pro machine (you can get a 30-minute poolside NuFACE treatment at the Four Seasons Maui for $125), but the micro-amps deliver via two fixed metal probes.
ELLE editors tested both the FaceMaster and NuFACE in our offices and found they instantly increased circulation for that glowy, plump-but-not-puffy look that lasted for a few hours.
But, in our untrained hands, the DIY could not provide microcurrents' more sophisticated, bespoke effects.
With the right expertise, microcurrent can be used to dramatically, if temporarily, shape the face.
It's no wonder celebrities have become insatiable consumers of electric facials, especially during awards season.
The pop lasts for about five hours, says facialist Melanie Simon, whose skin-care company, Circ-Cell, is partially backed by Lynn Harless, aka Justin Timberlake's mom.
Madonna and Kate Winslet are outspoken fans of Tracie Martyn's trademarked Red Carpet Facial, a proprietary treatment that incorporates mild electrical current.
Regular microcurrent sessions were rumored to be Princess Di's beauty secret.
And according to an industry source, J Lo just spent $22,900 on her own professional-grade CACI Ultra (no word on whether she's administering them herself).
Depending on where the probes are placed, either above the origin or insertion point of a muscle, and how many seconds they're held there, users can smooth a furrowed area by stretching the muscle or add lift by shortening the muscle.
If you lift from the cheekbones toward the hairline, it will make your eyes more almond shaped, says makeup artist Kristin Hilton, who travels between New York and L A to work on clients including Uma Thurman and Milla Jovovich.
You can even create an arch in the eyebrows.
Hilton keeps NuFACE in her makeup kit so she can sculpt and lift before she applies a client's makeup.
I m a skeptical person, Hilton says.
For me to like something like this is unusual.
But I use it for five minutes on each side, pulling upward.
Everything's tighter.
You look more awake.
People know something's different, but they don't know what.
Usually they say, `Did you get your hair cut?'
The exact protocol for combining Botox and microcurrent has yet to be written, but most proponents agree to wait a few weeks post-injection before getting a facial.
According to Charles Boyd, MD, a plastic surgeon with practices in Michigan and New York, In the first 24 hours after an injection, you could potentially move the Botox from a muscle where you injected it into a muscle you did not intend, he says.
That doesn't mean it's going to move from your forehead to your neck, but maybe from your eyebrow to your upper eyelid.
Simon's clients wait two weeks post-Botox for an electric facial, then return for monthly follow-ups (per skin's renewal cycle, which is 28 days).
Botox and electric facials are great companions.
I could spend hours smoothing lines out and then my clients will walk out the door and make the expression that caused the wrinkle 1,000 times that night, Simon says.
Botox is very efficient at knocking out expression wrinkles.
Electric current fixes everything else?
—it's the cherry on top.
Designers have been showing Birkenstock- and Teva-inspired shoes on the runway for several seasons now, and certain fashion editors have even vowed to retire their heels completely. 
But some women may not have gotten the memo, if an increasingly popular procedure is any indication.
Plumping fillers—the same kind that doctors inject into the face to add volume back—can help high heel wearers who just can't lay off the stilettos and have chronic foot pain as a result. 
According to Dr. Mitchell Chasin, the founder and medical director of Reflections Center for Skin and Body in New Jersey, requests for a so-called "stiletto lift" have increased over the last year.
Normally when you walk, your weight gets evenly distributed over the entire sole of the foot.
But when you strap on a heel, suddenly that weight all comes down over the ball of the foot.
The ball of the foot has a pad of fat that's a shock absorber between the bone and the outside world, Dr. Chasin said. 
"As people wear high heels, that pad of fat gets pushed out of the way and what happens then is that bone doesn't really have a cushion and it becomes irritated." 
Your 125mm Louboutins then become torture devices as a result.
Dr Chasin offers a procedure in which he injects a filler called Radiesse into the sole of the foot.
Radiesse acts in two different ways to help restore volume and cushioning to the ball of the foot.
In the weeks immediately following the injection, it forms a sort of lattice over the bone, which acts as a cushion.
Then over the longer term, it actually stimulates your own body to create collagen, which further increases the cushioning.
Dr Chasin said that most women experience immediate relief after the injections.
But first, you have to get through the experience of having multiple injections in the bottom of your foot.
A typical patient requires one to two syringes of the filler to treat the feet completely.
Before Dr Chasin injects them, he numbs the bottom of the feet first with a topical numbing cream, then with injectable lidocaine, a stronger numbing agent.
He also mixes lidocaine into the filler syringes.
Still sound horrifying?
People have so much pain there to begin with that sometimes the lidocaine is a relief, Dr Chasin countered.
While the stiletto lift has been around for about five years, Dr Chasin has been seeing an increase in requests for it over the last six to 10 months.
He currently does about 10 of them per month.
The cost varies from $750 to $1,500 depending how many syringes of filler the woman requires, and results generally last for about a year.
Professional women between the ages of 35 and 45 make up the bulk of those requesting the procedure.
We also get people who are going out more, who are dancing, who are more active socially.
They're active professionals, Dr Chasin said.
But getting the injections doesn't mean you should run around in six-inchers everyday.
Use heels in moderation and not all the time, Dr Chasin advised.
That's what got you there in the first place.
He also said that the skinniness of the heel matters as much or more than the height.
So try to opt for chunkier heels and save the pin-thin stilettos for special occasions.
The answer isn't to fill it and continue to abuse it, he said.
But do the women he treats actually take this advice?
Not at all!
They're like, 'Okay!' 
then they come in to see me while wearing their heels, Dr Chasin laughed.
We can only try, right?
Application of Microautologous Fat Transplantation in the Correction of Sunken Upper Eyelid Background: Although fat grafting has been clinically applied by surgeons in esthetic and reconstructive surgery, it has widely evolved in processes such as harvesting, processing, and placement of fat, using the fat-grafting procedure, which dates back over 100 years. 
Surgeons frequently use fat grafting to recontour, augment, or fill soft-tissue defects, facial wrinkles, or skin problems such as depressions or scars. 
However, fat grafting has not been thoroughly understood and has not been conclusively standardized to ensure superior clinical results. 
Methods: This study was intended to determine the role of microautologous fat transplantation (MAFT) under evidence-based medicine, particularly in accurate delivery of small fat parcels. 
The research method involved the conceptualization of MAFT and the development of an innovative surgical instrument for fat placement. 
Clinically, 168 patients with sunken upper eyelids with multiple folds underwent this procedure. 
Results: The major findings suggested that MAFT exhibits promising clinical results and offers a superior guideline for fat placement. 
Details of the technique and theoretical implications are also discussed. 
Conclusions: The therapeutic effects of MAFT and the long-term clinical results of patients with sunken upper eyelids with multiple folds indicated satisfactory outcomes. 
Based on the results, MAFT offers an alternative option to surgeons for performing fat grafting and provides a more favorable option for the benefit and welfare of patients by reducing the potential complications.
In Asian people, the superior sulcus in the upper eyelid frequently becomes visible because of aging or overzealous removal of the orbital fat through blepharoplasty or other unknown etiologies. 
The hollow or sunken appearance is often accompanied by multiple eyelid folds, which result from variable insertion levels of levator palpebrae superioris, with consequent thinning of the skin and orbicularis oculi muscle and/or preaponeurotic fat atrophy. 
The coalescence of both phenomena results in a tired, weary, and even exhausted appearance.
Certain strategies, such as autologous fat grafting, dermal fat grafting, or allogenous dermal grafting, have been described and detailed in the literature for correcting the aforementioned problems.
Currently, numerous soft-tissue fillers are widely used despite their short duration of efficacy.
A reliable strategy with favorable long-term effects that leads to higher patient satisfaction and higher confidence of surgeons has not yet been developed.
Fat grafting was initially addressed over a century ago by Neuber.
Thereafter, fat-grafting techniques, methods, and protocols have been enhanced numerous times to improve the fat survival or fat retention rate.
Numerous surgical mentors in this field have investigated innovative methods for potentially improving fat grafting.
In this article, we advocate a new concept of microautologous fat transplantation (MAFT) and its application in correcting sunken upper eyelids with multiple folds.
The results indicated that MAFT facilitates reduced morbidity, higher patient satisfaction, and favorable long-term follow-up results.
MATERIALS AND METHODS Patient Demography A total of 168 patients (2 men and 166 women) received fat grafting for correction of sunken upper eyelids with multiple folds from September 2007 to September 2010 at the Charming Institute of Aesthetic and Regenerative Surgery, Kaohsiung, Taiwan.
These patients were regularly followed up at the outpatient clinic.
Preoperative and postoperative photographs taken at each visit were compared.
In addition, complications such as calcification, fibrosis, nodulation, uneven skin (irregular surface), and cyst formation were meticulously recorded.
Anesthetization Unless accompanied with other major adjunct procedures, all patients were anesthetized using total intravenous anesthesia for the entire MAFT procedure.
Concurrently, local anesthesia was administered at the incision sites (donor and recipient sites) by infiltrating 2% Xylocaine (Lidocaine Hydrochloride 20mg/ml, Oriental Co., Taiwan) with epinephrine (1:1000).
The fat-harvesting area, primarily the lower abdomen, was preinfiltrated with a tumescent solution prepared at a ratio of 2% Xylocaine:Lactate Ringer solution:epinephrine (1:1000) = 10 mL:30 mL:0.2 mL.
Fat Harvesting The donor area was preinfiltrated with a tumescent solution after the incisional site was anesthetized.
Approximately 10 to 15 min after the tumescent solution was administered, a blunt-tip cannula (diameter, 3 mm) was used to harvest the fat, and the lipoaspirated volume was the same as that of the infiltrated tumescent solution to achieve a high proportion of purified fat after centrifugation.
To ensure minimal damage to the lipoaspirate, the plunger of a 10-mL Luer-Lok syringe was pulled back for 2 to 3 mL and maintained so that, while it was connected to the liposuction cannula, the reactive aspirating negative pressure was maintained between 270 and 330 mm Hg.
Fat Processing and Refinement For fat processing, various methods, such as the sieve method, multiple-layer gauze filtration, and centrifugation, have been proposed in the literature.
The internationally accepted Coleman’s technique was used for processing the lipoaspirate through centrifugation because of its advantages of less environmental exposure and lower manual manipulation in the aseptic procedure.
A standard centrifugation of 3000 rpm, which was approximately 1200g for 3 minutes, was applied to process (purify) the fat.
Fat Transfer The purified fat was carefully transferred into a 1-mL Luer Slip syringe by using a transducer and was prepared for transplantation.
Supplemental Digital Content 1, which displays the microautologous fat transplantation for sunken upper eyelids.
After the purified fat was transferred, the fatfilled syringe was loaded into the MAFT-Gun instrument.
The predetermined volume of the fat parcel to be injected during each triggering was adjusted by rotating the dial with labeled numbers depicting the total injection frequencies per 1 mL of fat graft.
An 18-G blunt cannula was used to inject fat while withdrawing the MAFT-Gun.
Each delivered fat volume was set at 1/240 mL and meticulously transplanted in 3 to 4 layers: a deep layer above the inferior orbital rim; a middle layer, the sub–orbicularis oculi muscle (deep in the muscle); and superficial layer, the supraorbicularis oculi muscle (just beneath the dermis of the eyelid).
Postoperative care was provided regularly and without any special dressings or massage.
Oral antibiotic and nonsteroid anti-inflammatory drugs were administered for 3 days, as required.
All patients were regularly photographed at each follow-up visit, and the preoperative and postoperative photographs of each patient were compared.
RESULTS The average age of the patients was 35.5 years (range, 26–52 years), and the total injection volume of fat was 1.8 mL for the right side (range, 1.2–2.3 mL) and 1.7 mL for the left side (range, 0.8–2.4 mL).
The average operation time was 34 min unless combined with other adjunctive procedures such as upper or lower blepharoplasty or fat grafting of other areas.
No major complications were encountered except 2 cases of prolonged swelling for > 2 weeks.
All patients were satisfied with the results except one who requested secondary fat grafting.
DISCUSSION Literature Review For over a century, surgeons have struggled to apply autologous fat grafting in plastic, reconstructive, and esthetic surgery with variable results.
In 1893, the grand surgeon, Neuber, became the first to reconstruct a facial defect.
Thereafter, several reports have described fat grafting: Kanavel stated that “fat cells are the best friend of the surgeon,” Peer described an approximately 55% fat-graft retention rate, and Bames9 reported convincing results regarding fat grafting for breast augmentation.
In 1977, Illouz10 reported on “liposuction” and developed the related medical instruments.
Subsequently, fat graft ing was fine-tuned and applied in plastic surgery; for example, Fournier used fat grafting to fill involuted facial tissues, and Chajchir and Benzaquen used fat grafting for rejuvenation of facial wrinkles and treatment of hemifacial atrophy.
In addition, various endeavors have been attempted for recipient site preparation; for example, Asken performed subcision to prepare a pocket for fat grafting, and Nguyen et al reported muscle as the optimal recipient site for fat grafting.
In the past 2 decades, prominent surgeons have illustrated numerous principal theories.
Carpaneda and Ribeiro postulated higher fat graft survival, and in 1993 and 1994, they experimentally proved that the graft survival is higher when the grafting is within 1 to 2 mm from the margin.
In 1994, Coleman presented the structure fat graft method and emphasized that in special locations, such as periorbital areas, each fat parcel must be between 1/30 and 1/50 mL.
Based on the review of the aforementioned literature, experts and scientists in the field have demonstrated various fatgrafting techniques; however, no conclusive strategy has yet been developed.
Evidence-based Medicine in Fat Grafting Evidence-based medicine applies the most reliable evidence gained from scientific methods to clinical decision making. 
In autologous fat grafting, 2 theories were proposed by Carpaneda and Coleman, which demonstrate the importance of evidencebased medicine.
Theory by Carpaneda Carpaneda and Ribeiro demonstrated only 40% graft survival at 1.5 ± 0.5 mm peripheral to the graft margin.  
Furthermore, they reported that thickness and geometrical shape are the keys to successful fat transplantation and concluded that the diameter of the fat graft (either spherical or cylindroid shaped) should be < 3 mm to achieve higher graft survival rates.
Coleman’s Theory Coleman proposed the concept of structure fat grafting and emphasized that the fat parcels should be manually arranged in layers with a volume of < 1/10 mL per injection for each parcel; in special sites such as periorbital areas, each fat parcel should be 1/30–1/50 mL. 
Moreover, the complications and morbidities can be minimized by avoiding the central necrosis of a fat graft that can be induced through overinjection when each parcel is placed.
Disadvantages of Commercialized Medical Devices: Ratchet Guns For several years, commercially available ratchet guns have been clinically applied in fat grafting with variable results. 
The advantages of ratchet guns include the accurate control of fat parcels by pulling of the trigger, and the ergonomic design.
However, the disadvantages are the relatively large volume injected per triggering (1/10 mL, 1/2 mL, and up to 1 mL) and the potential exposure of the fat graft inside the syringe to ambient air because of repeated manipulation of the plunger. 
Although some surgeons have reported favorable results, most surgeons are hesitant in using these instruments. 
Accordingly, in addition to accuracy, fat grafting also necessitates delicate, precise, and consistent control of the placement of each fat parcel.
The aforementioned evidence-based medicine indicates the necessity for precise, accurate, and consistent delivery of each parcel, as insisted by Coleman and Carpaneda. 
However, commercial devices have not yet satisfied all the requirements for precise delivery.
Moreover, manual operation is not only physically difficult; it is also scientifically impossible to deliver each fat parcel at minute volumes between 1/30 and 1/50 mL when using this method.
Myths Regarding Overinjection with Massage Previous studies have emphasized the requirements for optimal fat grafting at recipient sites, such as the periorbital area, wherein a fat droplet should be as minute as 1/30 to 1/50 mL. 
The delicate placement of fat graft relies on the surgeon’s manual skills; however, even an experienced surgeon cannot expect to inject each minute fat parcel with accuracy and consistency, particularly in the case of tissue resistance inside the donor area. 
Therefore, instances of overinjection or abrupt placement of fat are frequently observed and unavoidable.
Based on a study conducted by Peer that indicated approximately 55% graft survival after fat grafting, some surgeons prefer to perform fat grafting through overinjection at the recipient site, followed by vigorous manual massage exerted by the operator to even out and flatten the skin surface. 
However, as illustrated in Figure 7, overinjection can eventfully induce several complications as described previously.
Concept of MAFT Similar to the acceptance of skin grafts, a fat graft regains its blood circulation 48 h after implantation (neovascularization formation). 
However, the inflow of nutrients and outflow of metabolites (adipocytes) depend on the initial diffusion and plasmatic imbibition after grafting. 
Carpaneda and Ribeiro demonstrated that the central area eventually necrotizes and only the marginal zone survives at a rate of approximately 40% at 1.5 ± 0.5 mm from the grafted margin, regardless of the shape of the fat graft (spherical or cylindrical).
Previous studies complications associated with the large size of an implanted fat parcel, including absorption, cyst formation, fibrosis, calcification, ossification, and asymmetry. 
This phenomenon of “central necrosis” induces a cascade of aggressive chain reactions, leading to numerous unavoidable complications including unpredictable graft survival and fat retention. 
Therefore, it is highly recommended that the size of the implanted fat droplets be as small as possible.
Based on the theory postulated by Carpaneda, the mathematical formula for determining the optimal volume of fat parcels (here, the fat graft is presumed to be spherical in shape) is calculated as follows: the volume of a globe is (4/3)πr3, where r is the global radius and π is the ratio of any circle’s circumference to its diameter in Euclidean space. 
Table 1 presents the information regarding the volume of each fat parcel at the radii of 1, 1.5, and 2 mm.
We concluded that the injection frequency of 1-mL fat parcels for a spherical graft with a 2-mm radius can be calculated by dividing 1000 mm3 (1 mL) by (4/3) π (2 mm)3. 
Therefore, a minimal injection frequency of 30 was set for each 1 mL fat-graft parcel to achieve superior graft survival rates.
What MAFT Emphasizes and How It Works Precise, Accurate, and Consistent Placement The subcutaneous tissue overlying the skin where fat grafts are primarily placed possesses a strong longitudinal adherence to the fibrous septa, with strong fascia or ligaments. 
For placement of minute parcels, a tunneling maneuver of the injection needle is required by moving it back and forth to loosen the tough subcutaneous tissues and place as small a par cel as possible. 
Such a maneuver in fat placement results in more tissue injury and necessitates a longer healing time. 
Moreover, severe ecchymosis and swelling in the first 2 weeks after grafting embarrassed and frustrated the patients with an unattractive or bruised appearance. 
Some swelling persisted even 16 weeks after grafting.
Alternative to Overinjection with Manual Massage As observed in Figure 7, an irregular depression was observed as a soft-tissue defect (mimicking soft-tissue depression or grooves). 
Surgeons often overinjected the sunken areas, followed by vigorous massage to remold and flatten them evenly.
However, after vigorous massage, the fat parcels formed a confluent mass. 
Although the skin surface appeared smooth and full after operation for days to weeks, the remolding processes including absorption and fibrosis continued and evolved because of central necrosis. 
Eventually, as shown in Figure 7E, irregular skin and uneven surface over the graft area appeared as unavoidable morbidities.
An Instrument to Reflect the Concept of MAFT The innovative transmission system of the MAFTGun was designed to minimize the injecting volume to 1/240 mL per parcel. 
This microdelivery mechanism ensured that the radius of each injected droplet was approximately 1 mm, which has been documented in the literature as essential to decreasing the severity of the inevitable central necrosis of the fat parcel. 
Therefore, the graft survival rate improved when the fat droplet resided in the tissue with no potential central necrosis, which was the primary reason for impairing the transmission of nutrients inside and the metabolites outside the adipocyte (or preadipocyte).
No Excess Swelling and Long Healing Time Compared with Other Traditional Modalities Even when performed by the most experienced surgeons, postoperative swelling and edema are unavoidable, which often frustrates patients. 
Severe bruising and swelling develop in the recipient areas in the first week after fat grafting, and this is primarily attributed to the to-and-fro movements of the injection cannula during the injection procedure. 
However, the strong and tough adherent subcutaneous tissue in some recipient areas needs to be loosened by using such a maneuver to place the fine fat parcel and avoid the dislodgement of huge droplets by abrupt overinjection. 
The patented microcontrolling system of MAFT-Gun ensured that the injection volume of each parcel was predetermined and thus controlled in the procedure. 
A steady and accurate volume was transmitted at each trigger pull, regardless of the strength exerted by surgeons or the tempo of the injection. 
Therefore, by reducing the frequency of the back-and-forth tunneling movements used to loosen the recipient area, postoperative healing time was reduced, and the swelling and edematous appearance was minimal when compared with traditional techniques.
Enhanced Performance of Surgeons Surgeons have to turn their hands often because the fixed pinhole of commercial injection needles requires changing for various grafting sites. 
The inconstant and labor-intensive turning of the surgeons' hands impedes efficacious performance during the grafting procedure. 
A clear marking with 360° multirange adjustability of the MAFT instrument provided precise control of the direction of injection. 
With this innovation, surgeons were able to change the pinhole of the injection needle freely, comfortably, and accurately.
The user-friendly trigger system based on the pulling maneuver enabled a predetermined volume of each parcel to be precisely delivered. 
Right- or left-handed use of the handpiece was set in advance, which is therefore adaptable for use by all surgeons.
Innovation of MAFT-Gun The MAFT-Gun provided an innovative operating system to deliver fat grafts with a flexible volume of 1/60, 1/90, 1/120, 1/150, 1/180, or 1/240 mL per injection (by rotating the adjustable dial to 60, 90, 120, 150, 180, or 240, respectively), which was suitable for the needs of the surgeons performing the grafting procedure at various areas. 
Ease of use and ergonomics in application defined the characteristics of this state-of-the-art device as a preferential assisting device.
Problems with Sunken Upper Eyelids Sunken upper eyelids, particularly in Oriental people, are a common occurrence and often present a weak and tired appearance.
Based on racial and physiognomic considerations, Asian people might wish to enhance the facial appearance caused by sunken upper eyelids, not only for beautification but also for luck.
Several operative strategies, including fascia, dermal grafts, and derma-fat-fascia grafts, have been documented in the literature.
However, no satisfactory long-term results have been reported.
Commercial soft-tissue fillers such as hyaluronic acid, collagen, or other synthetic biocompatible/degradable materials are popular in the cosmetic market.
However, because of the high cost, short duration, and risk of allergies and other complications, an ideal filler is yet to be defined regarding persistency, no allergy reactions, and lower morbidity.
In this study, the sunken upper eyelids were recontoured using the MAFT concept and by employing the MAFTGun, which enabled an accurate and precise transplantation of each fat droplet.
In addition to the recontouring of the hollow-looking eyes, most patients observed that after MAFT, their skin texture and appearance was more youthful and rejuvenated, which implied the existence of stem cells or stromal vascular fractions in the transplanted fat.
Because fat grafts play an essential role as “more than a permanent filler,” as advocated by Coleman, they occupy the future stage in regenerative medicine.
Therefore, the success of completion of a fat grafting procedure has promising applications not only in cosmetic surgery but also in reconstructive surgery.
CONCLUSIONS The evolutionary era of fat grafting is the result of the continuous endeavors of various plastic surgeons.
All the strategies of fat grafting, including harvesting, processing, refinement, and transplantation, exhibit promising progress.
MAFT is introduced as a novel approach in fat grafting, and its execution can be accomplished using the innovative MAFT-Gun instrument.
Using this technique, sunken upper eyelids with multiple folds, which present as hollow eyes, can be reconstructed with favorable long-term follow-up results.
Diffusion and Perfusion: The Keys to Fat Grafting Abstract Background: Fat grafting is now widely used in plastic surgery. 
Long-term graft retention can be unpredictable. 
Fat grafts must obtain oxygen via diffusion until neovascularization occurs, so oxygen delivery may be the overarching variable in graft retention.
Methods: We studied the peer-reviewed literature to determine which aspects of a fat graft and the microenvironment surrounding a fat graft affect oxygen delivery and created 3 models relating distinct variables to oxygen delivery and graft retention.
Results: Our models confirm that thin microribbons of fat maximize oxygen transport when injected into a large, compliant, well-vascularized recipient site. 
The “Microribbon Model” predicts that, in a typical human, fat injections larger than 0.16 cm in radius will have a region of central necrosis. 
Our “Fluid Accommodation Model” predicts that once grafted tissues approach a critical interstitial fluid pressure of 9 mm Hg, any additional fluid will drastically increase interstitial fluid pressure and reduce capillary perfusion and oxygen delivery. 
Our “External Volume Expansion Effect Model” predicts the effect of vascular changes induced by preoperative external volume expansion that allow for greater volumes of fat to be successfully grafted.
Conclusions: These models confirm that initial fat grafting survival is limited by oxygen diffusion. 
Preoperative expansion increases oxygen diffusion capacity allowing for additional graft retention. 
These models provide a scientific framework for testing the current fat grafting theories.
Autologous fat grafting is increasingly used for breast augmentation and reconstruction. 
Fat grafts are easily available, biocompatible, cause low donor-site morbidity, and give grafted sites a natural appearance. 
However, fat grafting is generally considered an unpredictable procedure, with long-term retention commonly varying between 10% and 80%. 
Much work has been done to optimize this procedure; however, the clinical practice has advanced faster than the supporting science. 
Fat grafting can be considered in phases: harvesting, processing, reinjecting, and managing the recipient site. 
To determine the optimal surgical methods for harvesting, processing, and reinjecting, Gametal completed an extensive literature review. 
Their results show the variability of current surgical techniques with current literature only supporting general principles and not any specific technique. 
Furthermore, no experimental or theoretical studies have analyzed how the different surgical methods alter the microenvironment surrounding the graft or how the microenvironment affects graft retention.
In this context, we define a model as a conceptual and mathematical representation of a phenomenon that has occurred in the past in an attempt to predict how it will occur in the future as specific variables change. 
Modeling has been critical for many advances in plastic surgery. 
Our group has modeled both skin expansion and the mechanical forces involved in vacuum-assisted closure devices. 
These models have helped enhance our understanding of the biological effects and medical uses of mechanical forces. 
Modeling provides the theoretical framework for testing theories. 
This study aims to identify the role of the recipient site in fat grafting and create a model to serve as a scientific basis to analyze the variables related to the recipient site and graft retention.
Grafted fat initially lacks vascular support and must receive oxygen and nutrients by diffusion from nearby capillaries until neovascularization occurs.18 Oxygen seems to be the critical molecule required for cell survival.
Low oxygen partial pressures in the center of the graft can lead to cell necrosis.
Attempts to improve graft retention have largely been based on the “cell survival theory,” which states that long-term graft volume consists primarily of grafted adipocytes that have survived the entire procedure.
This theory has generally been accepted and has directed most efforts to maintaining adipocytes viability through improved harvesting, processing, and reinjecting techniques.
Studies supporting the cell survival theory claim that the “viable zone” (40% adipocyte survival) reaches as far down as 0.2 cm from the periphery of the grafted tissue.
These conclusions are based mostly on morphological observations with H E staining.
However, judging adipocyte health by shape or nuclear appearance can be misleading, and histologic sections are too thin to show most nuclei of healthy adipocytes.
Moreover, the “cell survival theory” may fail to get to the complex phenomena occurring in fat grafting.
Fat grafts are not pure aggregates of adipocytes, but a mixture of adipocytes, preadipocytes, endothelial cells, pericytes, stem cells, fibroblasts, inflammatory cells, and matrix.
Using immunostain for perilipin, a method for determining adipocyte viability, Etoetal in the Yoshimura Lab tested the cell survival theory and concluded that a dynamic remodeling of grafted adipose tissue (AT) occurs.
In hypoxic cell cultures, they demonstrated that adipocytes cannot survive more than 1 day of severe ischemia-mimicking conditions (1% O2 with no serum), whereas adipose-derived stromal cells (ASCs) remained viable for up to 72 hours.
In a second experiment, the inguinal fat pad of a mouse was grafted to the scalp.
Only the peripheral area (surviving zone; <0.03 cm from the edge) of the graft had a high survival rate of both adipocytes and ASCs.
In a deeper (regenerating) zone, most adipocytes did not survive more than 1 day, but ASCs survived and eventually provided new adipocytes.
By day 3, the number of proliferating cells increased, and by day 7, they found an increased thickness of the zone with viable adipocytes.
At the center of the graft, no AT survived, and macrophages removed the dead cells; this was named the “necrotic zone.”
Recent studies support this “host replacement theory.”
Rigamonti et al26 suggest that 4.8% of preadipocytes are replicating at any time, and 1–5% of adipocytes are replaced each day.
When mouse AT oxygenation reaches less than 65% of baseline, adipocytes undergo apoptosis in 24 hours; however, ASCs can survive for multiple days in severe hypoxia.
Hypoxia is known to enhance ASC proliferation.
Injured adipocytes release fibroblast growth factor-2, which stimulates ASC proliferation and hepatocyte growth factor, contributing to the regeneration of AT.
The retention of grafted fat largely depends on the distance metabolites must travel to reach the center of the graft and on the depths of the surviving and regenerating zones.
MATERIALS AND METHODS We searched Pubmed for original articles with the term “fat grafting” in the title or abstract to determine which aspects of the microenvironment surrounding fat grafts affect retention. 
We modeled the relationship between oxygen consumption by metabolizing fat tissue and oxygen delivery via diffusion for grafted fat cylinders of varying radii. 
We called this the “Microribbon Model.”
In a steady state, oxygen delivery matches oxygen consumption, and oxygen must diffuse off erythrocytes, through the capillary walls, through the extracellular space, and into the grafted cells. 
To optimize the potential for oxygen delivery, the vascular perfusion must be functioning properly, and several articles propose that an increased interstitial fluid pressure (IFP) during fat grafting might restrict perfusion. 
To determine the physiological plausibility of this hypothesis, we modeled the relationship between fluid accumulation, IFP, and perfusion. 
We called this the “Fluid Accommodation Model.”
To study how the information from the first 2 models can be used to optimize the fat grafting procedure, we explored which existing fat grafting procedures were attempting to optimize the variables in our models. 
Although several articles emphasized a biological approach with cytokines and stem cells, only external volume expansion (EVE) emphasized enhancing oxygen delivery. 
Therefore, we modeled how EVE could prepare the recipient site to allow the critical variables in the first 2 models to be optimized during fat grafting. 
We called this the “EVE Effect Model.” 
The information from these models comes from our calculations derived from established equations, relationships, and constants.
RESULTS The literature to date concludes that oxygen delivery seems to be the most crucial molecule for fat graft survival. 
The thickness of the exterior rim of viable cells in multicell spheroids increases linearly with the theoretical oxygen diffusion distance. 
Oxygen diffusion is the limiting variable in determining cell survival in spheroids. 
Therefore, it seems that the core principle of fat graft survival is that oxygen concentration at any point in a graft is a function of the oxygen concentration of the surrounding capillaries, the diffusion rate of oxygen to reach that point in the tissue, the distance from the oxygen source, and the metabolic rate. 
In other words, at every point within a fat graft, there is a race between the rate at which oxygen is needed by the cells and the rate at which oxygen can be delivered by the capillaries and diffused through the AT.
According to standard principles in physiology, the metabolic rate of a given section of AT is directly proportional to its volume (V). 
However, the diffusion rate of any substance is directly proportional to the surface area (SA) over which diffusion takes place, and the SA:V ratio of any interior section of a cylinder is (2/radius). 
Therefore, as the radius of a cylindrical injection of AT increases, the SA:V ratio decreases, and oxygen’s diffusion rate cannot meet the tissue’s metabolic needs. 
In addition, diffusion is related to the square of the distance between the oxygen source and where it is consumed. 
When the distance is increased by a factor of 2, the delivery of oxygen is decreased by a factor of 4.
Using diffusion and metabolism equations and biological and physical constants,31–37 we modeled the theoretical borders between the surviving, regenerating, and necrotic zones for fat grafts of different radii (Appendix 1). 
According to the Microribbon Model in standard human conditions, the largest fat microribbon with no necrotic zone would have a radius of 0.16 cm. 
Such a graft would have a surviving zone of 0.03 cm and a regenerating zone of 0.13 cm. 
As graft radius increases beyond this point, the necrotic zone grows rapidly.
This Microribbon Model correlates well with experimental data. 
When multicell spheroids were cultured in excess medium, the spheroids ceased to expand at a radius of 0.15 cm. 
Carpaneda and Ribeiro suggest that, in humans, only the region 0.15 cm from the edge of a fat graft retains a significant percent of its volume. 
Current successful method descriptions suggest a 0.13-cm limit for the radius of reinjected fat.
Multiple studies report negative correlation between fat graft particle width and retention percentage. 
Long-term fat graft retention requires small volumes of fat to be diffusely distributed into a well-vascularized recipient site through well-separated tunnels. 
If the microinjections are not diffusely distributed in the recipient site, they will coalesce, forming particles too wide to survive.
Fat graft survival is also largely dependent on the vasculature’s ability to delivery oxygen blood through the capillaries surrounding the graft. 
Several surgeons have suggested that injecting too much fat into a small recipient site can increase IFP enough to constrict capillaries, inducing ischemia in the grafted tissues. 
Guyton demonstrated that, for up to a certain volume, interstitial fluid can accumulate in a tissue without significant IFP increase, but beyond that range, any additional fluid causes drastic IFP increases, quickly reaching levels associated with compartment syndrome. 
Milosevic et al also demonstrated that capillary perfusion decreases with increasing IFP. 
Therefore, it is recognized that fluid accumulation can lead to increased IFP and that increased IFP can lead to decreased capillary perfusion.
Using these relationships, we modeled the change in relative capillary perfusion as a function of IFP and interstitial fluid accumulation to determine if increased IFP during fat graft is enough to limit capillary perfusion and oxygen delivery. 
According to this Fluid Accommodation Model, a given tissue compartment can accommodate about 60% of its weight in interstitial fluid before reaching a critical IFP (IFPC) of 9 mm Hg, beyond which, any additional fluid causes a drastic IFP increase and capillary perfusion decrease. 
It is important to recognize that this 60% accommodation is a generalized estimation, which will change with differences in the compliance of tissues; therefore, the IFP could be monitored intraoperatively if excess fat injections could be a possibility. 
This IFPC closely correlates with recent suggestions of IFP-based fat grafting stop points of 9–10 mm Hg.
Increased IFP may also inhibit retention of grafted cells by mechanical compression, which induces apoptosis and regulates cytokine release.
Therefore, interstitial volume, compliance, and vascularity determine how many microribbons of fat can be dispersed before increasing IFP enough to significantly reduce perfusion and cell survival.
Mechanical forces can induce angiogenesis, adipogenesis, and increased subcutaneous tissue thickness and compliance. 
Our group previously studied the mechanism behind EVE’s effects and found that the macroscopic swelling is likely due to deformation of the extracellular matrix, which induces tension on the cells anchored to extracellular matrix fibers. 
This micromechanical strain is transferred to the cytoskeleton, where it acts as a gate-control signal to induce proliferation.
EVE-induced ischemia activates the hypoxia inducible factor -1α/vascular endothelial growth factor pathway to induce vascular remodeling, angiogenesis, and cell proliferation. 
Adipogenesis can be induced by lymphedema or water-rich empty proteinaceous matrices. 
Inflammation promotes these processes.
Khouri et al developed a suction-based EVE bra (BRAVA) that noninvasively induces long-term breast growth in humans.
It uses cyclical forces, which have a greater effect than continuous forces. 
Daily BRAVA-use induces temporary edema and angiogenesis and sustained increases in subcutaneous tissue thickness and compliance. 
Once fat grafting to the breast was more accepted and understood, BRAVA was proposed for application in preparation for fat grafting. 
Pre-expansion and resultant augmentation had a strong linear correlation (R2=0.87), and pre-expansion allowed significantly more AT to be grafted and retained than what was reported in a meta-analysis of 6 other published reports on fat graft breast augmentation without pre-expansion (P < 0.00001). 
Preoperative expansion also has several clinical applications in breast augmentation and reconstruction (Khouri et al, unpublished data, 2014).
To understand the effectiveness of EVE devices for fat grafting, we must consider the ratio of grafted fat to recipient site volume. 
If the original recipient site is 100 mL and noncompliant, and 30 mL of AT are to be grafted, there is no need for pre-expansion because, with a 30% increase, the AT can be diffusely microinjected. 
If the original recipient site is 100 mL, and the volume of AT to be grafted is 90 mL, this 90% increase cannot be done without overcrowding, which would cause coalescence, increased IFP, reduced perfusion and oxygen delivery, thinner surviving and regenerating zones, and significant volume loss. 
However, our EVE Effect Model predicts that a tight 100-mL recipient site can be transformed into a compliant 300-mL site and, according to the Starling equation, cause edema influx. 
Because the fat microribbons can be diffusely dispersed into the pre-expanded tissue, less coalescence occurs and more AT can be grafted before reaching IFPC. 
As IFP increases, the Starling equation dictates that interstitial fluid is reabsorbed, allowing IFP to quickly return to baseline levels.
Our EVE Effect Model also predicts that the preoperative cyclical negative pressure treatment increases the host vascular density and diameter, increasing total oxygenated blood delivery, decreasing the mean distance each oxygen molecule must diffuse to reach the center of a grafted microribbon, and accelerating graft revascularization: a major determinant of volume retention.
DISCUSSION We have presented 3 models to predict how recipient site vascularity, volume, and compliance determine fat graft retention by regulating oxygen delivery via perfusion and diffusion. 
To the best of our knowledge, this is the first study to mathematically model the essential variables relating to oxygen delivery and graft retention. 
The information from these models comes from our calculations derived from established equations, relationships, and constants. 
Our Microribbon Model suggests that any fat injection with a radius greater than 0.16 cm in standard human conditions will have a zone of central necrosis. 
Our Fluid Accommodation Model suggests that interstitial fluid injections that cause IFP to increase past IFPC will restrict perfusion. 
Our EVE Effect Model explains how the information from the first 2 models can be used to optimize the fat grafting procedure. 
It predicts that preoperative EVE increases recipient site vascularity, volume, and compliance, allowing more AT to be successfully grafted. 
For grafting small volumes of fat into large, compliant, highly vascularized recipient sites, the recipient bed will likely accept the graft even if the surgeon does not specifically consider each of the variables in these models. 
However, for grafting large volumes of fat into small, restricted, poorly vascularized recipient sites for procedures such as total breast reconstruction, or irradiated tissues, surgeons must optimize each of the variables related to graft retention. 
None of these models can predict fat graft retention on their own, but taken together, they enhance our understanding of the biological events occurring during fat grafting and allow us harness this knowledge to enhance surgical outcomes.
Modeling provides the theoretical framework for testing theories, so these models require experimental data to be further accepted. 
To test the Microribbon Model, experiments similar to the ones performed by Eto et al would have to be reproduced, but pO2 would have to be measured at various depths within grafts or cylindrical cell cultures of various radii. 
To test the Fluid Accommodation Model, studies would have to measure IFP, perfusion, and pO2 as fluid is injected into living tissue. 
To test the EVE Effect Model, a complex set of experiments would be required. 
More importantly, to truly test the effects of EVE in fat grafting, a large prospective randomized controlled trial should be performed. 
It is hoped that these studies will lead to long-term prospective studies in humans.
Conclusion Our models predict the following: that fat injections larger than 0.16 cm in radius will have an area of central necrosis; that, in fat grafting, IFPs greater than 9 mmHg will cause decreased capillary perfusion; and that EVE can enhance tissue volume, vascularity, and compliance, allowing more AT to be successfully grafted.
Platelet rich plasma is a promising therapy in dermatology and aesthetic medicine. 
In this article we will discuss the pros and cons of platelet rich plasma (PRP) and the usage of PRP in aesthetics. 
PRP is especially used for conditions like facial and neck rejuvenation, fine lines and wrinkles, abdominal striae and facial scarring.
Usage of platelet rich plasma (PRP) in aesthetic medicine is a new concept.
In dermatology and cosmetic medicine, PRP has been used to treat acne, scarring, and alopecia (especially in women).
It is also effective for skin rejuvenation and tightening around the eyes.
Before injecting PRP to treat hair loss, a tiny scalp roller with spikes is used to stimulate the thinning areas.
The rationale is that this sends a message to the hair follicles to start the healing process.
Then, PRP is injected over the affected area to further stimulate stem cells in the follicle.
Platelet-rich plasma is injected by multiple tiny punctures under the dermis, with or without topical local anesthesia.
The process is painless if sufficient topical anesthesia is applied.
When PRP is injected into the damaged area, it stimulates the tissue, causing mild inflammation that triggers the healing cascade.
As a result, new collagen begins to develop.
As this collagen matures, it begins to shrink and tightens and strengthens the skin.
Improvement in skin texture and tone is noticeable within 3 weeks.
Full collagen regeneration requires 3 months.
The PRP treatments can be used on all skin types and tones.
Minimal swelling, bruising, and redness for the initial 12 to 24 hours are expected.
A bruise at the needlestick site may be visible for 2 to 3 days.
Swelling from the fluid is what the patient will notice first.
During several weeks, the platelets stimulate growth factors, which assists in more collagen stimulation.
Treatment results vary but last up to 18 months in most patients.
In PRP, activated platelets release many other bioactive proteins responsible for attracting macrophages and mesenchymal stem cells.
Inside the platelet are two types of granules, namely, alpha granules and dense bodies.
Alpha granules contain the clotting and growth factors that are released in the healing process.
Normally at the resting state, platelets require a trigger to activate and become a participant in wound healing and hemostasis.
Growth factors and other cytokines in platelets include the following: platelet-derived growth factor, transforming growth factor, fibroblast growth factor, insulinlike growth factor 1, insulin like growth factor 2, vascular endothelial growth factor, epidermal growth factor, interleukin 8, keratinocyte growth factor, and connective tissue growth factor.
The platelets secrete growth factors, including platelet-derived growth factor and vascular endothelial growth factors.
Platelet-derived growth factor is one of numerous growth factors or proteins that regulate cell growth and division.
In particular, it has a significant role in the formation of blood vessels (angiogenesis) and the growth of blood vessels from already existing blood vessel tissue.
Vascular endothelial growth factor is a chemical signal produced by cells that stimulates the growth of new blood vessels.
It is part of the system that restores the oxygen supply to tissues when blood circulation is inadequate.
Advantages of using PRP for aesthetic medicine include the following: tissue regeneration and rejuvenation, induction of cell differentiation, extracellular matrix formation, recruitment of other cells to the site of injury, and an increase in collagen production, which can increase skin thickness and overall skin health. 
In addition, PRP is nonallergenic, is an autologous physiological product, eliminates donor transmissible infections, and is a biological glue for tissue adhesion, especially in skin flaps, bone grafts, and trauma. 
Although PRP is a promising therapy for most patients, the practitioner must take into account some considerations during the initial assessment before suggesting this treatment.
Contraindications include the following: sepsis, cancer, chemotherapy, platelet dysfunction syndrome, critical thrombocytopenia, hypofibrinogenemia, hemodynamic instability, anticoagulation therapy, acute and chronic infections, chronic pathological conditions of the liver, severe metabolic and systemic disorders, and skin disease (systemic lupus erythematosus, porphyria, and allergies), as well as heavy nicotine, drug, and alcohol consumption.
Adverse effects of PRP treatment may occur, some of which are significant.
The most common adverse effects are infection, skin discoloration and bruising, pain in the injected area, allergic reaction (a rare occurrence), and blood clot (because PRP therapy uses a needle, a vein could be damaged).
Certain factors (eg, smoking and alcohol intake) diminish stem cell release.
Avoiding these will increase the success of the PRP procedure.
The platelets work by causing an inflammatory reaction.
If this inflammatory reaction is diminished, the clinical outcome is significantly compromised.
For this reason, the use of anti-inflammatory drugs is not recommended.
This restriction should be in place for about 1 to 2 weeks.
Platelet concentration is a rich source of various cytokines and growth factors, which are activated after its injection into the target tissue.
Platelets are activated endogenously by coagulation factors (in some methods of preparing PRP, the activated PRP is injected to the tissue).
Following their attachment to special receptors on the cell surfaces, some intracellular processes are activated, that facilitate extracellular matrix (ECM) accumulation and improve cell proliferation and differentiation.
Tissue regeneration is resulted from cell proliferation, angiogenesis and cell migration.
Matrix metaloproteinas proteins (MMP) are involved in aging process by degradation of collagen and other extracellular matrix (ECM) proteins, this characteristic can be used to benefit rejuvenation.
They can help regeneration of dermis through omission of collagen fragments that are harmful to the dermal connective tissue, and so, provide an appropriate foundation for new collagen deposition.
In some studies aPRP (activated PRP) increases the expression of MMP-1 and MMP-3 protein.
Thus, aPRP may cause ECM remodeling through stimulating the removal of photo-damaged ECM components and inducing the synthesis of new collagen by fibroblasts, which are in turn proliferated by their stimulation.
Another mechanism of PRP for skin rejuvenization, is through acceleration of hyaluronic acid production.
Hyaluronic acid absorbs water and makes hyaluronic acid matrix swelled which increases skin volume and turgor.
It also promotes cell proliferation, extracellular matrix synthesis and helps to the adjustment of the collagen fibers diameter.
Overall, it could enhance skin elasticity.
All these processes and some other unknown ones contribute to tissue rejuvenation through PRP.
Platelet Rich Plasma (PRP) is used for stimulation of both superficial and deep dermis layers.
For superficial stimulation, the injection must be done in the superficial dermis.
The PRP must be injected into the deep dermis or subdermal tissues when using as filler.
The superficial injection might be done just like mesotherapy technique in order to improve the skin texture, volume and hydration.
The technique is easy to be performed and has no important side-effects.
Side-effects might appear from mild bruising and occasional swelling to rarely infections.
Compared with other skin rejuvenation therapies, the clinical experience using PRP can result in skin rejuvenation and global facial volumisation.
PRP is a form of bio-stimulator that is safe and creates an immediate, long lasting volumetric effect with natural looking results.
To prepare PRP, a small amount of blood is drawn from the patient’s arm.
The blood is then placed in a centrifuge that spins at high speed and separates the platelets from the rest of the blood components.
The typical baseline blood platelet count is approximately 200 000 per microliter; therapeutic PRP centrifuges concentrate the platelets by roughly 5-fold.
However, broad variability exists in the production of PRP by various concentrating equipment and techniques.
The platelets collected in PRP are activated by the addition of thrombin and/or calcium gluconate, which induces the release of these factors from alpha granules.
The entire process takes less than 15 minutes and increases the concentration of platelets and growth factors up to 600%, along with an inherent rise in human stem cell proliferation due to exposure to concentrated platelets up to 10 times above native levels.
The concentrated PRP is then injected into and around the affected area, jump-starting and significantly strengthening the body’s natural healing signals.
Injections of PRP heal the area over time, during 1 to 3 months.
Because the patient’s blood is used, there is no risk of a transmissible infection and a low risk of allergic reaction.
Aging of the skin, dermal components, and cells means that the skin texture and appearance deteriorate and have been damaged.
Aging affects the hands and soft tissue of the face, neck, and decollete.
This is characterized by sagging jowls, thinning of the skin, puffiness, age spots, and wrinkling.
In dermatology and cosmetic medicine, PRP has been used to treat acne, scarring, and alopecia (especially in women).
It is also effective for skin rejuvenation and tightening around the eyes (for thin crepe-like skin and fine lines) and in the following areas: cheeks and midface, thinning skin on the neck, jawline and submalar regions, back of hands, decollete, and others (eg, knees, elbows, and upper arms, as well as for postpregnancy skin laxity).
Platelet-rich plasma is injected by multiple tiny punctures under the dermis, with or without topical local anesthesia.
The process is painless if sufficient topical anesthesia is applied.
When PRP is injected into the damaged area, it stimulates the tissue, causing mild inflammation that triggers the healing cascade.
As a result, new collagen begins to develop.
As this collagen matures, it begins to shrink and tightens and strengthens the skin, as well as the tendons and ligaments of the damaged area when it is injected at that level.
Improvement in skin texture and tone is noticeable within 3 weeks.
Full collagen regeneration requires 3 months.
Topical skin care and light therapies can enhance these results.
Advanced wrinkling cannot be reversed, and severe scarring may not respond to treatment.
In my experience, surgical scars respond well cosmetically.
The PRP treatments can be used on all skin types and tones.
Minimal swelling, bruising, and redness for the initial 12 to 24 hours are expected.
A bruise at the needlestick site may be visible for 2 to 3 days.
Swelling from the fluid is what the patient will notice first.
During several weeks, the platelets stimulate growth factors, which assists in more collagen stimulation.
Treatment results vary but last up to 18 months in most patients.
Biannual touch-up treatments will maintain the results.
As an initial treatment strategy, up to 3 injections may be given within a 6-month time frame.
These are usually performed 2 to 3 weeks apart.
Certain factors (eg, smoking and alcohol intake) diminish stem cell release.
Avoiding these will increase the success of the PRP procedure.
The platelets work by causing an inflammatory reaction.
If this inflammatory reaction is diminished, the clinical outcome is significantly compromised.
For this reason, the use of anti-inflammatory drugs is not recommended.
This restriction should be in place for about 1 to 2 weeks.
Proponents of PRP therapy argue that negative clinical results are associated with poor-quality PRP harvest or concentration by inadequate devices.
The specification that gathering devices capture a percentage of a given thrombocyte count is a marketing bias because significant individual variability exists in the platelet concentration of human plasma.
More is not necessarily better in this case.
Variability in platelet concentrating techniques may alter platelet degranulation characteristics, which could affect clinical results.
PRP has made the most significant progress in the facial area. 
Platelet Rich Plasma (PRP) with fat transfer is the surgical combination of injecting a patient’s own plasma containing growth factors along with their own purified fat to augment areas of lost volume and wrinkles on the face. 
Containing beneficial growth factors, PRP may additionally be used with fat transfer or subcision to re-plump areas of lost volume or depressed scarring from acne or trauma. 
Subcision surgically releases the pulled down portion of the scar from within, inducing the body’s healing response to create blemish free skin cells. 
Combined with fat transfer, PRP softens the appearance of depressed, roling scars. 
The latest facial rejuvenation procedure is the face lift which combines the power of new PRP technology and facial fillers to minimize the signs of facial aging.
This non- surgical procedure promotes new tissue growth to improve overall facial skin tone for a more youthful appearance.
The PRP is combined with a facial filler and then re- injected into areas of concern around the face.
Patients benefit from this procedure as there is minimal downtime and results can last for over a year.
The true “lift” effect is achievable with a combination of fillers, layered with the PRP serum.
The fillers provide an instant fill or volume correction and the PRP – injected above the filler – immediately kick-starts a skin regeneration process.
Patients can see and feel the effects within minutes as their skin becomes tauter and smoother.
The use of PRP with fillers not only enhances the skin tone and texture, but prolongs the effective filler correction for 3 to 6 months longer than when fillers are used alone.
Monthly intradermal injections of PRP in 3 sessions have shown satisfactory results in face and neck rejuvenation and scar attenuation.
A study showed that a combination of fractional non-ablative (erbium glass) laser therapy with topical application of PRP, resulted in objective improvement in skin elasticity, a lower erythema index and an increase in collagen density as well.
Histological examination showed an increase in length of dermoepidermal junction, amount of collagen and fibroblasts in the treated skin.
Patients who don’t want or need fillers can benefit from PRP. 
The activated PRP serum can be injected just under the skin surface to stimulate the body to make a small amount of its own ‘filler’. 
Although this will not approximate the same results as one gets from a gel filler, some improvement in textural changes can be seen.
PRP in combination with fractional ablative lasers (carbon dioxide) for deep wrinkles and severe photodamaged skin, has also been shown to reduce commonly encountered, transient adverse effects and decrease the downtime. 
Fractional laser treatments are known for their ability to retexture skin. 
Adding PRP takes laser resurfacing to a new level by accelerating healing and increasing desired new collagen formation. 
Following your laser treatment, activated PRP serum is applied to skin that is ideally suited to accept the wound-healing platelet serum. 
PRP can also be used as ‘PRP Facial’ which consists of PRP applied to skin that has been prepared by an automatic microneedle. 
These micro-needling makes tiny “wounds” in the skin which accept the PRP serum and begins the process of collagen creation along with the tissue enhancement from growth factors found in the plasma serum. 
The micro needling-based procedure is also producing great results in terms of minimizing the appearance of both scarring and stretch marks.
In scarring, the micro needling is used to break up the fibrous tissues of the scar and the PRP spurs the growth of healthy tissue.
For stretch marks, micro needling creates damage over the thinned skin of the stretch mark. 
PRP then promotes growth of thicker skin.
As with all therapies, adequate training and experience are paramount. 
The beauty of the PRP technique, especially in dermatology and as an adjunctive tool in practice, is that it can be used as part of a multifaceted or layered approach. 
Significant clinical outcomes can be obtained with concomitant use of light therapies, fillers, and mesotherapy. 
Due to limited studies on clinical efficacy and safety, further studies are required to investigate the mechanism of action behind the therapeutic effects of these products and their long-term safety.
Still, the PRP has certain limitations as there is no standardization in PRP preparation and specific quality parameters in PRP preparation are still lacking.
The research reveals the impact of a belief in god and god’s Providence on the happiness and quality of life of patients bene?ting from aesthetic medicine treatments in Poland (country where over 90 % of society declare to be deeply devout). 
The work also examines age and sex of the patients bene?ting from beauty treatments (botulinum toxin, ?
llers, medical peels and needle mesotherapy), their quality of life and also the impact of various factors, including God and Divine Providence on their happiness. 
The research shows the analysis of factors in?uencing the successes or failures in the past year and presents the comparison of patients who have bene?ted from the aesthetic medicine treatments (cosmetic medicine) to the common average Polish citizens.
The concept of God is not an innate one, but it is gradually formed in the psyche of a humankind. 
It is usually being shaped from an early childhood in the process of socialization, and it is modi?ed on the basis of one’s own cognitive and emotional experiences, primarily associated with the structure of one’s family life. 
Providence is in as god’s interest in everything that He has created especially a man, leading him to the full perfection and to the ultimate goal.
There is no speci?c, biblical prohibition of changing the appearance of our face, our bodies. 
The belief is that God gives us the freedom of choice, and our conscience must lead us and guide through the behaviours that are not explicitly prohibited for us. 
For this reason, one cannot ?
nd any justi?cation for believing that aesthetic medicine treatments (cosmetic medicine) are clearly immoral; however, one must be careful not to overuse them. 
People are worthy, as they are made in the image of God. 
A person’s worth does not depend on and does not change with changes in the appearance of one’s face or body because I have rejected him…,because man sees the appearance but the Lord looks into the heart. 
It is not our appearance that makes us worthy, but a belief in God whose image we have been made. 
Regardless of how one looks, this should not be forgotten.
The following work reveals what kind of in?uence of a belief in God and God’s Providence has on the happiness and quality of life of patients bene?ting from aesthetic medicine treatments in Poland (country where over 90 % of society declare to be deeply devout). 
The work examines age and sex of the patients bene?ting from beauty treatments, their quality of life and also the impact of various factors, a belief in God on their happiness.
The research shows the analysis of factors in?uencing the successes or failures in the past year and compares the patients who have bene?ted from the aesthetic medicine treatments to the common average Polish citizens.
In the research, 603 respondents of both sexes took part; they were aged from 21 to 61 years, bene?ting from the cosmetic treatments in aesthetic medicine clinics in Poland (botulinum toxin, ?
llers, medical peels, needle mesotherapy), randomly selected to take part in the test.
Scheffeg’s and Bonferroni’s methods and expert system were used for multiple comparisons. 
In the social studies, an assessment fraction error (1/2 con?dence interval) is possible to be below 4 %, and in this test, it was at 3.99 %. 
The formula for the minimum sample size for dichotomous variables (it is a vast majority in the study) is given by equation: where n—sample size; Z—statistics for the desired level of con?dence; p—an estimate of the expected proportion of the variable of interest in the population; d—half the width of the desired interval.
The sample size n is 603 patients. 
For a 95 % con?dence level, from a standard normal distribution, Z = 1.96. 
The value d is at the level of 3.99 %, assuming that the position of the variables of interest is approaching unity (assumed p = 99 %).
The following issues regarding patients bene?ting from the aesthetic treatments have been examined: age distribution, taking gender into account; evaluation of the factors essential to a happy life, including the in?uence of God and God’s Providence on patients’ happiness; evaluation of the quality of life of patients bene?ting from the aesthetic medicine treatments (cosmetic medicine); causal attribution style, that is, who or what did the successes or failures in the past year depend on.
Age distribution of people bene?ting from aesthetic medicine treatments, taking gender into account. 
The average age of patients bene?ting from the aesthetic medicine treatments (cosmetic medicine) in Poland is 38 years; most often, they are people from 30 to 49 years of age (74 %). 
Women signi?cantly earlier begin to use such treatments. 
In a group of men, the greatest interest in the use of aesthetic medicine treatments begins before 40 years of age (which is probably associated with the midlife crisis); however, from 45 years, it steadily decreases. 
Ageing women much less frequently resign from the treatments. 
Nevertheless, men and women over 55 years of age signi?cantly lose interest in the aesthetic medicine treatments.
Evaluation of factors essential to a happy life of patients bene?ting from aesthetic medicine treatments in Poland. 
People perceive happiness in many different ways.
For some, the condition for happiness will be owning a lot of money, for others enjoying a good health, and for others, family and a successful marriage or appropriate education and work. 
Patients were asked to classify, in the order of importance (1—the least important, 7—the most important), the individual factors that could bring a sense of happiness.
For patients bene?ting from the aesthetic medicine treatments (cosmetic medicine), the most important prerequisite for happiness is health (91 %).
The second is cheerfulness and optimism (86 %). 
Family; children rank also very high (84 %), followed by successful marriage (83 %). 
The least important condition for happiness is the Providence of God that appears in 36 % of evaluations in the lower half of the scale. 
The next is education (18 %), a strong character (16 %) and friends (15 %).
Evaluation of the quality of life of patients bene?ting from the aesthetic medicine treatments. 
Evaluation of the ‘‘level of happiness’’ and joy of life is virtually not possible other than the subjective evaluation and declaration. 
Therefore, respondents were asked how much they enjoy their lives.
It is easy to notice that all aesthetic medicine patients enjoy life to some extent. 
The vast majority of them say that they really enjoy their life (91 %).
Causal attribution style. 
The causal attribution scale used in the study is supposed to provide answers to the question: who or what do the aesthetic medicine patients make responsible for the quality of their own lives: themselves, the authorities, friends, strangers, fate/Providence of God or aesthetic medicine treatments (cosmetic medicine).
Aesthetic medicine patients more often (16 % p.p.) see their impact on whether the past year was successful or not, and 4.5 times more often indicate a signi?cant impact of the authorities on their life than the average Pole does. 
In a much lower degree (14 % p.p.) than average Poles, aesthetic medicine patients recognize the impact of fate and Divine Providence on the past year, similar to the impact of other people (5 % less p.p.).
First of all, it is worth noting that all patients using aesthetic medicine treatments (cosmetic medicine) very highly evaluated their own impact on whether last year was successful or not.
Even in the case of an unsuccessful year, assessment of one’s own impact on this situation has increased.
Strangers have had a limited and permanent in?uence on the aesthetic medicine patients which does not change in respect of whether the year was successful or not.
In case of ‘the average Pole’’, it looks different, the in?uence of strangers on the past year has been indicated, and their impact increases in the situations where the last year was unsuccessful.
However, patients bene?ting from aesthetic medicine treatments, in case of unsuccessful year, are more likely to blame their friends for it.
Unfortunately, the study lacks data from ‘Social Diagnosis’’.
When it comes to fate and God’s Providence then again, aesthetic medicine patients much less often point out that this factor is an indicator of the past year’s success or failure comparing to the average Poles, but in both cases, the frequency of the indications on the fate and Providence of God as the cause increased if the past year was unsuccessful.
Aesthetic medicine patients are much more aware of the impact of the authorities on whether their year was successful or not than the average Pole. 
Also, in case of an unsuccessful year, the tendency to indicate the authorities as the reasons for such state does not increase so dramatically as in case of the average Pole. 
In general, it is possible to notice an increased desire to indicate the individual factors that could, in subjects’ opinion, have an impact on whether the past year was successful or not. 
But there is one exception. 
A lot of patients are more likely to point to the aesthetic medicine treatments (cosmetic medicine) as one of the reasons that the past year was successful.
The study carried out by psychologists has shown that people who consider themselves as attractive rate higher their mental health and are more extraverted and happier. 
Their quality of life is signi?cantly improved. 
Langlois in his research notes similarly that the attractive people, in accordance with the stereotype ‘‘beautiful is good’’, are considered to be (in addition to greater intelligence, more assertiveness, more con?dence) happier than the average ones. 
This is related to the fact that beautiful people, since birth experience more smile, are milder judged by environment and a greater capacity is seen in them. 
Such person becomes more con?dent and enjoys the world and the environment. 
Aesthetic medicine patients are also satis?ed and happy people.
In this work, all the aesthetic medicine patients enjoy the life to some extent; none of the interviewed replied that they do not enjoy the life. 
Up to 91 % of them say that they highly enjoy it. 
This percentage is signi?cant, compared to other social groups, for instance, to patients in the perimenopausal period. 
Here, Polish women evaluate their quality of life as good in 41 %, while Greek women only in 17.6 %. 
It is de?nitely better among American women, as it has been shown that 51 % of them during menopause and after menopause are very satis?ed and experience the happiest period in their life; however, patients after aesthetic medicine treatments (cosmetic medicine) evaluate their quality of life the highest.
For patients bene?ting from the aesthetic medicine treatments (cosmetic medicine), the most important prerequisite for happiness is their health (91 %). 
The second is cheerfulness and optimism (86 %). 
Family; children rank also very high (84 %) and successful marriage (83 %). 
The least important condition of happiness is the Providence of God that appears in 36 % of evaluations in the lower half of the scale. 
The next is education (18 %), a strong character (16 %) and friends (15 %).
The style of the causal attribution is a human tendency to search for reasons for one’s own state of behaviour and effects of the actions or state of behaviours and the effects of other people’s actions in certain factors.
The causal attribution scale used in the study provided an answer to the question whether the past year has been successful or not and who or what do the aesthetic medicine patients make responsible for the quality of their own lives: themselves, the authorities, friends, strangers, fate/ Providence of God or aesthetic medicine treatments.
In many studies, this question is related to a con?rmed attributive inclination in the service of ego (‘‘whatever good—it is me, whatever wrong—it’s not me’’) and the theory of social ingratitude, which says that the social reception of changes at the macro-level is asymmetrical: those who from the beginning are gaining on these changes show little appreciation to their creators, they mainly look for causes of improvement of their own life in themselves, and the change for better, they experience quite poorly.
Those who claim to be harmed as a result of the implementation of reforms blame the authors of the reforms for the deterioration of the conditions of their life and experience changes for worse much stronger.
Therefore, who the responsibility is assigned to depends on the direction of the perceived change in the quality of one’s own life.
It is noticed that in comparison with the results of the "Social Diagnosis", which has an impact on the entire Polish population, the results obtained in the study of aesthetic medicine patients considerably differ from them.
Aesthetic medicine patients can more often (about 16 p p ) see their impact on whether the past year was successful or not.
This is probably the greater awareness and social status of patients bene?ting from such treatments, because the average aesthetic medicine and anti-ageing patient in Poland is a young woman, well established, educated and happy with the life.
This can be seen especially in the impact of authorities on the past yearAesthetic medicine patients 4.5 times more often show a signi?cant impact of the authority on their life than does the average Pole, because the average Pole much more frequently blame fate, Providence and other people for deterioration in the quality of his life, while not recognizing the impact of the authority on such situation.
Even if the year was relatively quiet a calm year in the politics, the aesthetic medicine patients, as a better-situated social group, can detect not only simple political events, but also the less noticeable to the average Pole, such as, tax system affecting the economy.
One can notice that patients bene?ting from aesthetic medicine treatments (cosmetic medicine) are much more aware and feel more responsible for their fate than the average Pole.
Aesthetic medicine patients differ from the average people; this is indicated by the causal attribution style, that is, who will the responsibility for the speci?c changes in the quality of life be assigned to.
In addition, over 90 % of the population declare that is deeply devout and 41.6 % of adults are reported to systematically participate in church services and other religious ceremonie.
In such case, the response in this study should be different, because of the deep faith, but only 36 % of patients responded that their happiness depends on God and Providence.
In addition, according to the "Social Diagnosis", the impact of religious practices on the mental well-being of Poles deteriorates yearly that would explain the low results in this work.
Most likely, such data result from the fact that patients strongly tend to think about God, in the toughest moments of their lives, when they are faced with a disease (oncology, surgery, etc.), while the aesthetic medicine is the only ?
eld of medicine that deals with a healthy patient.
Patients bene?t from treatments to improve their appearance, in the aesthetic sense.
Keep in mind that a typical aesthetic medicine patient in Poland is a young woman, well established and educated, while most of the religious groups in Poland include: women above the age of 60, primarily an inhabitant of the village, with basic education, mostly annuitants and retired, who rarely or never use aesthetic medicine from the ?
nancial reasons and their beliefs.
Therefore, patients after aesthetic medicine treatments (cosmetic medicine) in Poland are a group of people who are highly assessing their quality of life and who are happy; however, to a small extent, they attribute these reasons to God or Divine Providence, even in such a Catholic country as Poland.
The average age of patients bene?ting from the aesthetic medicine treatments (cosmetic medicine) in Poland is 38 years. 
91 % of patients bene?ting from the aesthetic medicine treatments (cosmetic medicine) claim that they strongly enjoy life. 
For patients using the aesthetic medicine treatments (cosmetic medicine) in Poland, God and Divine Providence (36 %) and education (18 %), a strong character (16 %) and friends (15 %) are the least important conditions for happiness. 
The most important prerequisite for happiness for them is health (91 %), cheerfulness and optimism (86 %) and family; children (84 %) and successful marriage (83 %). 
Aesthetic medicine patients much less (about 14 % p.p.) than the average Poles tended to be in?uenced by fate and Providence of God in the past year. 
Aesthetic medicine patients more often (about 16 % p.p.) notice their own impact on whether the past year was successful or not, and 4.5 times more often indicate a signi?cant impact of the authority on their life than does the average Pole.
The Royal College of Surgeons (RCS) has today published information about a new system of certification that will be introduced in cosmetic surgery next year. 
It will help distinguish highly qualified, competent surgeons who perform cosmetic surgery from those who lack experience and training.
Ever since Sir Bruce Keogh’s Review of the Regulation of Cosmetic Interventions in 2013, the RCS has led work to make cosmetic surgery safer for patients. 
This includes developing robust standards of training and practice for surgeons undertaking cosmetic surgery, which have been developed by the Cosmetic Surgery Interspecialty Committee (CSIC) in a number of surgical areas.
I was involved in the development of the cosmetic surgery standards as the deputy lead in aesthetic facial surgery for the British Association of Oral & Maxillofacial Surgery (BAOMS) and have been a SAC RCS Aesthetic Surgery committee member for a number of years. 
Even though I am a trained Consultant Oral and Maxillofacial Surgeon (OMFS), with more than 20 years’ experience of working in the NHS and private sector, I plan to apply for certification.
This is because, at the moment, it can be very difficult for a patient to assess a surgeon’s training and experience. 
Prospective patients are often advised to look for a record of surgical training and for the national surgical association they may belong to. 
I believe we need a more robust system to protect patients and one which they will understand.
Cosmetic facial surgery is very much a part of the surgical role and experience of OMFS. 
In the NHS, I treat patients with cancer of the mouth, head and neck. 
I also perform reconstructive surgery of the face, jaw, skin and mouth.
The patients I treat for cosmetic surgery are predominantly female and they are primarily concerned with the effects of ageing. 
They may come to see me if they are contemplating having a face lift or skin tightened around their eyes, face, neck or jaw line.
I also treat younger patients who may have concerns about the look of their nose, ears, or the size of their chin.  
For my patients, entrusting someone with how their face looks is an enormous and potentially life-changing decision.
I know from treating patients who have come to see me for corrective surgery following treatment elsewhere, how devastating it can be when things go wrong.
One case that springs to mind involved a woman who had travelled to North Africa for a face lift. 
Her wounds had become infected and she had necrosis, or dead skin, around her face, when she returned home. 
I repaired the wounds and treated the infection but the experience was very unpleasant and distressing for her.
Another case involved a patient who had threads inserted from her temple into the middle of her face, to tighten the skin. 
The procedure had been performed by an aesthetic doctor, not a surgeon.
She could feel the stitches through her skin and asked me to remove them and to perform a face lift.
You may ask how a voluntary system of certification would protect these patients. 
Those of us who have studied, trained and worked as surgeons, know how much training and experience is required to perform an operation successfully. 
Informing and educating patients about this is an important part of the process.
Under the proposed new system patients will be able to search for a certified surgeon on a register on the RCS website removing some of the hurdles they have to get through to find an appropriate surgeon.
Surgeons will also only be able to apply for certification in one or more groups of closely related procedures if they are on the GMC specialist register in the area, in which they wish to practice. 
This will improve patient safety - we cannot all be specialists in every region of the body and a surgeon should only practice cosmetic surgery in the field they are trained in. 
But for patients’ protection, it is also important that surgeons only undertake procedures in an area in which they have the appropriate training, qualifications and experience. 
Applicants for certification will have to demonstrate evidence of their personal experience and training, in particular body areas. 
The well trained surgeon should not be concerned by this, and frankly, we should not support complaints from surgeons who are ineligible to apply because they only undertake one or two procedures a year. 
Certification should also help protect patients from unscrupulous ‘fly in and fly out’ surgeons who are not appropriately qualified and do not have proper insurance. 
If these individuals wish to be certified they will have to provide evidence of how they meet all the requirements, including providing evidence of their qualifications, training, experience and that they have insurance to practice cosmetic surgery in the UK.
Collecting information about a patient’s outcome of their cosmetic surgery is also important.
Cosmetic surgery cannot record cure or survival rates, and it is very subjective, but it is important that surgeons are able to show they can deliver the outcomes the patient would hope for. 
This will help the surgeon to establish the importance of understanding the patient’s expectations before they agree to operate.
It is as true in cosmetic surgery as other branches of surgery that a good surgeon is the surgeon who knows when not to operate.
I hope you will join me in preparing and applying for certification. 
Let’s protect patients and help them to identify appropriately qualified and experienced surgeons from individuals who should not be operating.
Mr Tim Mellor is a Consultant and Oral & Maxillofacial Surgeon.
We partnered with Google to find out our beloved country's most-asked beauty questions, and then turned to the nation's top skin, makeup, and hair experts for the answers.
HOW OLD DO I NEED TO BE BEFORE I CAN GET BOTOX? 
(MOST SEARCHED IN SOUTH CAROLINA) According to dermatologist Fredric Brandt, MD, who was one of the first practitioners to use Botox in the '90s, "it's not a chronological age, it's a biological age." 
You'll know you're a candidate "if you have lines and wrinkles around your eyes or on your brow that are caused by expression movements" and that remain visible when your face is at rest.
HOW DO YOU KEEP NECK SKIN TIGHT? 
(MOST SEARCHED IN CALIFORNIA AND MARYLAND) Celeb-beloved Beverly Hills dermatologist Harold Lancer, MD, says that "the neck is one of the most asked-about areas of the body for women.
" It's also notoriously one of the hardest to treat once signs of aging, such as sagging or wrinkling, begin to show. 
In addition to scrupulous use of SPF, Lancer suggests extending your facial skin care regimen—including serums, exfoliating cleansers, and retinoids—down to the bra line. "
Many people make the mistake of using body lotions on the neck and de?collete?
," he says, "but the skin there is thinner and more delicate than the rest of the body." 
To address skin on the neck and chest that has already become lax, derms rely on collagen-stimulating fractionated radio-frequency and ultrasound devices, which typically deliver tightening results within three to six months posttreatment. 
For a quicker fix, a strategic Botox injection technique known as the Nefertiti lift—in which small amounts of the neurotoxin are distributed along the jawline—can relax the muscles that pull the neck downward.
HOW CAN YOU HIDE WRINKLES? 
(MOST SEARCHED IN COLORADO, DELAWARE, AND FLORIDA) Wrinkles provide a coverage challenge because they have a different texture and color from surrounding skin—they appear darker since the valley of the wrinkle doesn't reflect light.
Makeup artist Taylor Chang-Babaian treats unevenness with a hyaluronic acid–based serum that acts as "a filler to plump up the wrinkles." 
She then eliminates darkness with either a sheer foundation or a pigment-rich concealer, depending on the zone of the face.
"The skin on the forehead is really thin, so you need less makeup there," she says. 
For creases around the eyes, "I apply the concealer at a 45-degree upward angle, which will cancel out the wrinkles that point downward, as well as draw the eyes up and change the angles of the face," Chang-Babaian says. 
"You want all the angles to go up."
WHICH FOODS INCREASE SKIN'S ELASTICITY? 
(MOST SEARCHED IN CONNECTICUT) Packed with omega-3 essential fatty acids, cold-water fish—wild salmon, sardines, herring, trout—help boost skin's bounce. 
For the seafood averse, oral supplements or citrus fruits, leafy vegetables, and flaxseed are also proven to keep things tight.
The bee story begins in Asia, with SangMi Han, MD, a research biologist, at the National Academy of Agricultural Science in South Korea.
Following the observation that Korean beekeepers had flawless hands, Han began to investigate the beneficial effects of bee venom on the skin. 
She found that the venom was a potent combination of enzymes, peptides, and amino acids that worked on all levels of the skin to encourage cell regeneration and collagen formation and reverse sun damage by increasing epidermal growth factor (EGF).
EGF repairs the skin, fades freckles, and wrecks wrinkles. 
A beauty triple threat. 
The research also showed the venom to decrease matrix metalloproteinases (MMPs), which are destructive proteins created by ultraviolet light. 
Abundant MMPs equal a one-way ticket to sagsville. 
But the purification process is the pi?ce de r?sistance of this whole tale. 
Han created a purification process that removed any unwanted particles from the venom after it had been collected from the hive, guaranteeing its purity and potency. 
Best of all, the process was safe, ensuring the bee's life-span, well-being, and performance were not affected.
But let's not forget beautifying manuka honey, created by bees who feed on the manuka bush, which is native to New Zealand. 
Honey, an amazing humectant, keeps the skin hydrated, soft, and vibrant. 
It helps in the fight against MMPs as well, helping to preserve a youthful look. 
Oh, and did we mention that in addition to reversing wrinkles, both the honey and the venom have antibacterial properties that can zap zits? 
Pretty damn cool. 
So what happens when you mix purified bee venom and manuka honey? 
You get the closest thing to Botox in a bottle. 
Manuka Doctor, which harnesses the power of natural ingredients from the hive into scientifically enhanced skin-care formulations that are refined, concentrated and 100 percent bee friendly. 
Manuka Doctor is the only skin-care range to combine the potency of patented purified bee venom with the healing benefits of certified manuka honey for authentic solutions that work to combat everything from blemishes to signs of aging. 
The brand is made up of serums, oils, creams, face masks, targeted wrinkle fillers, lip plumpers, and primers so you can easily pick your, er, poison?
Reading the title of this makes me instantly dislike the author. 
Me. 
I sound self-obsessed, superficial and vapid.
I know I'm none of those things, which is why I'm sharing my story. 
Because I am surprisingly comfortable in my own skin.
I started one of the first beauty blogs in the world: Meg's Makeup. 
My job was to test potions and powders. 
I flew around the country and filmed national TV shows talking about serums and creams. 
I was always honest. 
When anyone asked what the best way to get rid of lines were, I would tell them the truth: Botox. 
Plastic surgery isn't for everyone, but I've never been against surgical enhancements. 
The boobs I envisioned myself having never came naturally so I bought some. 
I have thin hair, so my luscious mane is all extensions. 
My top lip is skinny, so I get it injected to appear fuller. 
I also rescue dogs, give money to the less fortunate and hand out sandwiches to the homeless to combat my fear of being judged. 
And the fear of being judged is why every celebrity in Hollywood denies having had work done. 
It's just their "lucky genes" and "eating clean" that has kept them perpetually young and thin. 
I live here. 
I know that is complete B.S. Growing up, I weighed 90 pounds soaking wet. 
My body type isn't apple or pear, it's spider: I have spindly, long chicken legs and arms and a really round stomach. 
I buy my clothes in a size zero, but I can't wear anything that's tight in the middle. 
When I turned 38, I quit smoking and a sad consequence of that is weight gain.
In my case, the weight concentrated even more around my belly and everywhere I went—the nail salon, the dry cleaners—I found myself being congratulated on a baby I was not carrying. 
I followed the typical course of action: I subscribed to a whole foods delivery service, hired a personal trainer and went to the gym four days a week for five months. 
My arms became sculpted.
My butt was toned. 
My legs were great. 
My stomach? 
The same.
I began to get discouraged, so I decided to call in the big guns. 
They say to be successful in life, you should have a good lawyer, mechanic and accountant on speed dial. 
If you live in Los Angeles, you have to replace those with colorist, dermatologist and plastic surgeon. 
Look, I know a lot of plastic surgeons. 
I've seen their before and after photos, I've interviewed them for magazines and TV, I've even been in a relationship with one.
I'm the friend everyone calls when they're looking for a recommendation. 
Dr. Marc Mani is the real deal. 
He's like a nightclub with no sign out front; you have to audition to get him to work on you and he has sent more than a few friends out the door if he didn't approve of their decision to get work done.
(A close girlfriend told me that Dr. Mani matter-of-factly informed her that if her boobs were any larger, she would look ridiculous.) 
Other surgeons are just happy for the business, but I knew he would tell me the truth.
I walked into his office and changed into a gown. 
He stared at my stomach, then he looked me straight in the eye and said, "Go to the gym. 
If it doesn't go away after that, then come back." 
That was that.
I went to back to working out for a few months, but when nothing changed, I made another appointment to see Dr. Mani.
This time, he gave me a different response: "Yes, that stomach is hereditary, part of getting older." 
He paused and then pinched under my chin. 
"This is also fat you can't exercise away. 
I'll remove that as well." 
My God, I hadn't even noticed my chin before!
"The smoking hollowed out your face, so I'm going to take the fat from your stomach and put it into your cheeks to fill your face out," he said. 
Then he touched the area under my eyes. 
"And while you're under, I'm going to give you a lower bleph." 
I nodded my head as though I knew what a "lower bleph" was (turns out, it stands for blephoraplasty—the removal of bags under the eyes). 
I was glad he pointed out these other areas that needed tuning up a mere two days before the stomach surgery because it gave me less time to obsess about it. 
Anyway, there was no question about having him do it—he does the most natural work in town.
Most people keep their plastic surgery a secret. 
Not me. 
I announced it on Facebook and made a YouTube video about it. 
I am in the beauty industry and have always believed in full transparency. 
Plastic surgery is a subject that a lot of women are curious about and I don't think wanting to look better should be a taboo subject. 
Sure, I got a few snotty comments but more than that, I got tons of questions and I replied honestly to all of them.
It's been six weeks since the removal of Gus (what I nicknamed my stomach), and everything else. 
I wore a bandage around my stomach and chin for 24 hours a day for the first week, half that time for the following week. 
It was uncomfortable, but not painful. 
I was up and walking around by the second day but ideally, it takes a week at least to fully recover.
Was my decision extreme? 
Yes, of course it was. 
Could I have lived a perfectly fine life without it? 
Without a doubt. 
Do I feel like a new person? 
No, but I do feel like someone who can go out confidently in a bathing suit. 
Is it expensive? 
Yes, it starts at around 35k, but I don't have children so I won't be paying for college any time soon. 
Was it worth it?
Look at my pictures and decide.
And here's the trailer I made to announce my decision and poke a little fun at myself.
Until recently, surgery with anesthesia was the best option for anyone looking to achieve the Holy Grail of lower-face #goals: a sharper, more chiseled chin. 
Enter a game-changing new injectable solution called Kybella. 
The first injectable substance that the FDA has approved to treat submental fat, Kybella is designed to dissolve stubborn under-the-chin fat. 
Kybella is deoxycholic acid, a fat-absorbing substance found in our bodies naturally. 
When injected, it destroys fat cells under the chin, leaving the skin substantially tighter and the jaw more contoured. 
More than 20 studies, with thousands of patients, have showed that almost 70 percent noted both physical and emotional improvement after treatment.
For best results, patients should commit to about two to six treatments, spaced a month apart, with anywhere from 12 to 20 little injections per visit, says Kavita Mariwalla, MD, a dermatologist in West Islip, New York. 
That might sound like hours of pin-prickly pain, but the treatment is actually quicker than a manicure, at about 20 minutes per session. 
Plus, only a teaspoon of substance is needed to see a difference. 
Unlike Botox, which yields results that last for up to six months in as few as four days, Kybella results are noticeable at four to six weeks and last for years, which means that touch-ups shouldn't be needed. 
As for side effects, expect swelling and bruising that start to fade within three days of treatment. 
So why not inject Kybella all over? 
As of right now, it's indicated only for smaller areas. 
But stay tuned; a similar substance may be in the pipeline for use below the neck. 
Until recently, those wishing to erase a double chin had only one truly effective quick-fix option: surgical liposuction. 
Now, however, streamlining the jaw requires nothing more than a trip to the dermatologist. 
The same molecule used by our digestive system to break down dietary fat is being injected into double chins to melt away neck fat. 
The long-awaited ATX-101, now known as Kybella, has finally been FDA approved.
"It destroys fat cells and increases local collagen production," New York–based dermatologist Francesca Fusco, MD, says in the March 2015 issue of ELLE, making loose flesh—a side effect of some fat-removal methods—less of a worry.
"It's simply an injection, so the ease of use is a great thing," Fusco says of the jawline sculptor. 
Using a synthetic version of the same molecule, deoxycholic acid, that our digestive system uses to process dietary lipids, Kybella shrinks the small pockets of fat that cause double chins. 
In clinical trials, patients experienced significant loss in submental fat as well as an increase in skin firmness following a series of up to six injections spaced four weeks apart.
But the procedure isn't entirely flawless. 
In one clinical study, over 20 percent of patients experienced moderate postshot pain and some experienced bruising and swelling that can last two to five days after each treatment.
About six years ago, a friend looked at my forehead with as much worry as her well-Botoxed brow could muster. 
Her eyebrows endeavored to meet, like the fingers of Adam and God on the ceiling of the Sistine Chapel, sending ever-so-gentle undulations across her forehead. 
What's wrong? 
I asked, frowning and no doubt animating the San Andreas-like fault line between my own brows.
 "You overuse your forehead muscles. 
Your brow is very active," she told me. 
You need Botox.
At 33, this was a first: I had never been accused of hyperactivity. 
While the rest of my body had long demonstrated a gift for leisure, apparently my histrionic brow had been busy in a compensatory frenzy of activity.
Initially, I decided to reject my "friend's" suggestion. 
After all, my frown lines and crow's feet had taken decades of smiling and weeping and laughing and stressing to build. 
We should be proud that we've survived this long in the world, but on the other hand, we don't need to look dejected and angry when we aren't, says Vancouver-based ophthalmologist and cosmetic surgeon Jean Carruthers, MD, aka the mother of Botox.
 In the late '80s, she had been using botulinum toxin to treat ophthalmic issues, such as eye spasms, when she happened upon the injectable's smoothing benefits. 
She's been partaking in her own discovery ever since. 
I haven't frowned since 1987, she tells me cheerily over the phone. 
To Carruthers, the magic of this "penicillin for your self-esteem" is how using it changes people's perceptions of you. 
Think about the Greek masks. 
If you're wearing a sad mask all the time, that's how people read you. 
Are you an energetic, happy person, or are you a frustrated wretch?
 If you get rid of that hostile-looking frown, you're not going to look angry and you're not going to look sad. 
Isn't that better?
I finally experienced this for myself five years ago, when a couple of married plastic-surgeon friends called me.
It was a sunny Sunday afternoon, they had an extra vial of bo' they were hoping to polish off, and they asked me to join them—as if it were an invitation to share a bottle of French ros?. 
It turns out that most of my reservations were financial, because free Botox I did not even try to resist. 
A week later, the skin on my forehead was as taut and smooth as a Gala apple.
Without those fine lines and wrinkles, as Carruthers foretold, I not only looked better, I felt better: As a delightfully unforeseen bonus, the treatment eradicated my tension headaches.
I was also potentially enjoying some long-term antiaging benefits: A 2012 South Korean study concluded that Botox improves the quality of our skin's existing collagen, and peer-reviewed research published in July 2015 by the Journal of the American Medical Association Facial Plastic Surgery revealed that just a single session of Botox improves skin's elasticity in the treated area. 
"It looks like Botox remodels collagen in a more organized fashion and also spurs the production of new collagen and elastin—the fibers that give skin its recoil, its bounce and buoyancy," says NYC-based dermatologist Robert Anolik, who notes that the benefits are cumulative. 
"We're still trying to figure out the how and the why." 
Botox also may improve overall skin texture by impeding oil production.
"It's believed that Botox can trigger a reduction in the size of the oil gland. 
As a consequence, the skin may look smoother and pores should look smaller," Anolik says. 
Another theory gaining traction in academic circles: "Botox might serve as an antioxidant, preventing inflammatory damage on the surrounding collagen and elastin."
I definitely was a return customer, visiting my derm for the occasional top-up. 
Then last year I got pregnant and had to stop cold turkey.
(Allergan, the maker of Botox, recommends that pregnant or breastfeeding mothers avoid the use of neurotoxins.) 
Despite Botox's potential preventative powers, I'm sorry to report that those once-slumbering dynamic lines and wrinkles, the ones not even a natural disaster could have summoned into action, made an aggressive comeback. 
Still nursing, and with time—and REM sleep—in short supply, I decided to look for the next best thing, testing an assortment of topicals, products, and devices, a sort of alt-tox regimen.
To be clear: There isn't anything that can effectively target the dynamic facial lines (those activated by movement) and inhibit facial muscle activity like an injectable neurotoxin. 
But that by no means dissuades skin-care brands from marketing products claiming Botox-like effects. 
(Biopharmaceutical company Revance is busy developing a topical version of Botox, to be administered by derms. 
The cream, purportedly as effective as the injectable but tailored to target crow's feet specifically, is currently in phase three of FDA testing and years away from availability.) 
There's Erasa XEP-30, which contains a patented neuropeptide designed to mimic the paralyzing effects of the venom of the Australian cone snail. 
And you thought a toxin derived from botulism was exotic!
For my needle-less approach, I opt to begin, appropriately, with Dr. Brandt Needles No More. 
Miami-based dermatologist Joely Kaufman, MD, who worked with the late Dr. Brandt in designing the quick-fix wrinkle-relaxing cream, says the key ingredient, "designed to mimic the effects we see with botulinum toxin injections," is a peptide blend that, when absorbed, blocks the signals between nerves and muscle fibers that cause contractions. 
The muscle-relaxing mineral magnesium was added to the cocktail to further enervate muscle movements. 
In an in-house peer-reviewed study, an impressive 100 percent of the test subjects reported that their brow crinkles were significantly visibly smoother in just one hour. 
I apply the light, vaguely minty serum liberally, and identify a satisfying wrinkle-blurring effect. 
Over the next few weeks, I find myself squinting and frowning in my bathroom mirror, strenuously appraising my vitalized new look—probably not the most productive wrinkle-reduction strategy.
While most dermatologists consider Botox the gold-standard short-term wrinkle eraser, there is another school of thought. 
For decades, Connecticut-based dermatologist Nicholas Perricone, MD, has been preaching the doctrine that wrinkles aren't what make us look old. 
"Youthfulness comes from convexities. 
When we get to our forties, those convexities start becoming flat, and then as we get really old, they become concave, Perricone says. "
When I started working with celebrities, I always assumed that they were genetically gifted because they had this beautiful symmetry. 
But I got up close and it wasn't just symmetry." 
Instead, his star clients all had "more convexity in the face than the average person," meaning plump, full cheeks, foreheads and temples, a plush roundness that comes by grace of toned, healthy muscles. 
To him, Botox is counterintuitive: We shouldn't be paralyzing the muscles in our face, we should be pumping them up. "
It's not the muscles that are the problem. 
It's the lack of muscles," says Perricone, who recommends aerobicizing facial muscles with electric stimulation devices.
At the Hotel Bel-Air, I once enjoyed a 90-minute electric facial with a NuFACE device. 
The handheld gizmo stimulates muscle contractions with microcurrent energy delivered via two metal attachments. 
I remember floating out of the spa, my skin feeling as fresh and petal-soft as the peonies blooming in the hotel's gardens.
"Electrostimu-lation promotes the production of glycosaminoglycans, which [bind with] proteins floating around in the extracellular matrix," says Pennsylvania-based skin physiologist Peter Pugliese, MD. 
Dosing the skin with electricity, he says, also works on a cellular level to jump-start the creation of ATP (adenosine triphosphate, a molecule essential for cellular energy) as well as collagen and elastin, and, over time, will reduce visible crinkles while enhancing muscle tone.
I acquire my very own NuFACE, and dutifully, for five minutes a day, sweep the device in an upward motion across my cheek.
It does make my face look a bit fuller, fresher, smoother—brighter, even. 
Though it turns out that performing this in my bathroom while the baby naps does not prove quite as restorative as enjoying a 90-minute spa treatment at the Hotel Bel-Air.
There is one more stop on the anti-wrinkle express, and for that I skip from high tech to low tech—very low—and score a pack of Frownies facial patches. 
The cult product was dreamed up in 1889 by a housewife, Margaret Kroesen, for her daughter, a concert pianist afflicted with frown lines from years of concentrated playing. 
The paper and adhesive patches pull skin into place, smooth and flat, while you sleep. 
Gloria Swanson wore them in Sunset Blvd.; Raquel Welch praised their powers in her book Raquel: Beyond the Cleavage.
Some people wear negligees, I think as I tuck into bed.
Me?
Flesh-toned facial Post-its. 
But the next morning, I wake to find that my brow looks astonishingly well-rested (even if the rest of me is not).
Used in concert, my new arsenal of treatments has made me look somewhat more alert, vaguely less exhausted; my cheeks are more plumped up, maybe even a little more convex. 
I behold my napping nine-month-old, his pillowy cheeks pink from sleep, and marvel at that bounty of collagen and elastin and glycosaminoglycans, that efficient ATP, those energetic fibroblasts not yet lethargic from age. 
But what I marvel at most is that he doesn't know about any of this, doesn't know from wrinkles and lines, and doesn't care—he has other things to laugh, and frown, about.
Living in L.A. for the past two decades, I've become immune to many a visual WTF.
Post-rhinoplasty teens with bandaged noses and bruised eyes cruising $5,000 bags at Barneys no longer shock. 
Prides of taut moms with the exact same shade of buttery highlights and identical plump pouts don't raise a brow. 
Even matrons with pulled-taffy faces and staple scars behind their ears barely move me. 
But lately, I've noticed a phenomenon far subtler than these, and yet more disturbing: young women, sometimes very young, their lips suspiciously full, cheekbones hyper-defined, skin seemingly airbrushed, like filtered selfies come to life.
Now, I'm no crusader against cosmetic fairy dust. 
My inaugural Botox injections, at age 33, erased the two exclamation points between my eyebrows. 
(I noticed them one afternoon in my rearview mirror at a traffic light and actually rubbed at them with a wet thumb as if they were smudges.) 
ut on the day I got those shots, that was all I got; I left the doctor's office with my laugh lines and the faint crinkles around my eyes intact.
"They want these cheekbones. 
They want those lips. 
That chin. 
We're living in a world of immediate gratification" These days, however, a subtle tweak equals a missed opportunity, at least among a certain demographic. 
And dermatological weapons that originated to replace lost facial fat and smooth lined skin—i.e., to address aging—are augmenting faces that haven't had a chance to age at all or, in some cases, even to mature. 
New York City–based dermatologist Dennis Gross, MD, says that women barely past college age have begun to come in with a laundry list. 
"They want these cheekbones. 
They want those lips. 
That chin. 
We're living in a world of immediate gratification," he says. 
"I tell them, 'You don't have to do everything at once.'" 
L.A. derm Jessica Wu, MD, sees a fixation with every line: "It used to be people waited until their thirties, forties, and fifties to treat smile lines or crow's-feet. 
Now it seems like filler is an accessory."
But as I stare (and stare) at these creatures— many of whom have undoubtedly been rendered lusher, more symmetrical, more empirically beautiful by such fixes—I wonder: Are these toxins and fillers actually doing the opposite of what their users hope and making young women look years older? 
What is the long game for a woman who started customizing her features in her twenties?
What will "youthful" look like in her forties and beyond?
"What is the long game for a woman who started customizing her features in her twenties? 
What will 'youthful' look like in her forties and beyond?"
According to the American Society of Plastic Surgeons, use of soft-tissue fillers among 20- to 29-year-olds was up to more than 67,000 procedures in 2015, an almost 33 percent jump from 2010; the same age group had more than 100,000 Botox treatments. 
(To be clear, that's still only a fraction of what 30- to 39-year-olds had done in 2015: 270,054 fillers, 1.2 million Botox sessions.)
On the brutally honest cosmetic enhancement forum RealSelf.com—visited by some 77 million people last year—the demographic most interested in dermal fillers so far this year is 25 to 34, and that interest has risen 37 percent since 2015. 
Among that age group, "there's no more stigma to having fillers or Botox," notes RealSelf spokesperson Jennifer Moses. 
"The mind-set is more like, 'It's my body.
It's my choice. 
It's my money.'"
Amen to that.
But even my five-year-old's devilish grin makes her eyes crinkle.
That's not aging, it's looking human.
When we see a 24-year-old with no discernible demarcations of life—no fissures, nary a freckle—the brain gets addled.
It's hard to process because it looks odd, abnormal, says S Jay Olshansky, PhD, a researcher at the University of Chicago's Center on Aging.
He calls the effect an extreme dissonance: It makes us stare at the face longer, trying to figure out what's wrong with it.
In 2014, Olshansky helped launch the website Face My Age.
It's a fascinating way to bolster or blindside your self-esteem in mere minutes—and, interestingly, two-thirds of its users are between 18 and 34.
Plug in your gender and birth date and upload an unsmiling, no-makeup selfie, and, based on wrinkles, age spots, and hair color, the program will assess your age.
(It rated me six years younger than my actual age—thank you, Botox.)
The algorithm attempts to take plastic surgery into account—it's one of the questions asked—though when Olshansky ran a picture of 81-year-old Joan Rivers, the software clocked her at 56.
Rivers would have loved that.
But as the TV-watching public knows, the human brain is not as easily fooled.
An altered face reads to the eye as ageless, says Olshansky, but not necessarily in a good way.
"They'd rather look like techno-humans with no shadows on their faces than look even slightly aged."
Think about it: What assumptions do you make about women who have had "work done"? 
Even if you can't put your finger on it, even if the work is good, by and large, the brain categorizes them as older. 
Which, according to Gross, would be the fate young patients fear most. 
"They'd rather look like techno-humans with no shadows on their faces" than look even slightly aged, he says. 
He's actually been told, "I'd rather look weird than old."
In 2013, Carolyn Black Becker, PhD, a psychology professor at Trinity University, co-authored a study entitled, I m Not Just Fat, I m Old: Has the Study of Body Image Talk Overlooked 'Old Talk'?
Polling 914 women ages 18 to 87, she found that 66 percent grouse about signs of aging.
What really struck me is that 85 percent of 18- to 29-year-olds are engaging in old talk, Becker says with a sigh.
I heard comments like, 'I use fillers because I m seeing the bare hint of a line.
I wouldn't want to have any wrinkles or any lines on my face.'
Almost every expert I asked about the filler 'er up era name-checked the Kardashian-Jenners.
That big a cultural shift can't, and shouldn't, be blamed on a single family, even a very well-documented one. 
But almost every expert I asked about the filler 'er up era name-checked the Kardashian-Jenners. 
Kylie, whose extraterrestrial beauty could pass for anything from 16 to 34 (actual age: 18), is probably the most influential shape shifter of all, with her 68 million–plus Instagram fans.
In an April interview in Paper, Jenner said the biggest misconception people have about her is, "Probably that I'm just super fake and that at 16/17, I got my full face reconstructed...."I do want to sympathize, but a review of pictures since 2010 shows an incredible transformation, even given the forces of wealth, puberty, and contouring makeup. 
Never mind her much-discussed lips—gone is her cute cinnamon sprinkle of freckles, faint laugh lines, and the normal hollows beneath her eyes.
Simon Ourian, MD, the Beverly Hills cosmetic derm to the whole clan, insists that Kylie "hasn't done as much as people think" but agrees that overfilling and over smoothing is making twentysomethings look "older" and "cartoony." 
As a policy, Ourian won't treat girls younger than 18, but he regularly receives calls from 12- and 14-year-olds looking to inflate their lips. 
"At 18, they can make a decision for themselves without the influence of other people," he says. 
"That doesn't mean that they make the right decision."
"So perhaps it's not a bad idea to wait to change one's looks until the brain, too, has been allowed to mature a bit."
You can't buy a drink until you're 21, or in some cases rent a car until you're 25. 
Research into "emerging adulthood"—roughly ages 18 to 29—has revealed that well into our twenties, the brain is still a work in progress. 
So perhaps it's not a bad idea to wait to change one's looks until the brain, too, has been allowed to mature a bit. (How many of us feel truly great about the tattoo we got at 2 A.M. on our 20th birthday? And chances are it's not on your face.)
(How many of us feel truly great about the tattoo we got at 2 A.M. on our 20th birthday? 
And chances are it's not on your face.)
A few weeks ago, I had dinner with an 18-year-old movie star who told me everyone asks if her plump pout is inflated. 
It's not, she swore, and pictures of her as a child with a big pucker are proof. 
But as we walked through Beverly Hills on a warm night, she went on to tell me she could name three actresses her age who use fillers in their lips and cheeks. 
It's crazy, she said with a shrug. 
"They're already hooked."
Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. 
Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. 
A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers.
The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations.
Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. 
Asians between the third and sixth decades age well compared with age-matched Caucasians. 
Younger Asians’ increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty.
Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. 
Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. 
Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized.
In Asia, the past decade has witnessed a tremendous increase in the number of patients who request and receive facial injectable treatments, non-ablative skin resurfacing and other non-surgical procedures, compared with the number of patients undergoing esthetic facial surgery. 
This is probably because the public has a much greater awareness of the treatment options available to them. 
Reasons for this include technological advances and improved results achievable with injectable treatments such as botulinum toxin and hyaluronic acid (HA) fillers, the increasing social acceptability of enhancing one’s appearance, increasing affordability and accessibility of injectable treatments, and the rise of the middle class in Asia.
Most Asian esthetic patients, whether young or old, prefer to avoid surgery wherever possible, and they seek natural-looking results.
Therefore, Asian physicians have had to respond to their patients’ expectations, study, and then innovate procedures and management strategies to address the Asian esthetic, including facial shape, structure and proportion, and impact of the aging process on Asian faces.
To date, most studies and published recommendations on the use of facial injectable treatments (especially their use in combination) reference Western populations. 
However, ethnic Asians differ from them in both facial appearance and baseline structural facial anatomy. 
The signs and rate of onset of facial aging are also different in Asians. 
Existing published recommendations cannot be applied directly to Asians. 
Furthermore, relatively few published papers cited in PubMed describe the use of botulinum toxin and HA fillers in Asians, and only one paper describes their combined use in the Asian face. 
Unfortunately, data from clinical trials are often not relevant to real-world practice because typically only one standardized treatment intervention is studied in one facial area; however, esthetic treatment is usually multimodal and individualized. 
Therefore, there is a need for expert guidance on facial esthetic treatment of Asians.
To this end, the Asian Facial Aesthetics Expert Consensus Group, which comprised an anatomist, plastic surgeons, and dermatologists from 11 Asia–Pacific countries, met to discuss current practices regarding the use of non-invasive esthetic treatments in Asians. 
As a prelude to developing consensus opinions on the use of botulinum toxin and HA fillers in Asians, the group discussed concepts of facial beauty and attractiveness, as well as key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians. 
The Expert Group’s goal was to identify esthetic treatments and outcomes that Asian patients most commonly require, and to develop consensus opinions on how these can best be provided.
Proceedings of this meeting are intended to offer guidance to physicians who provide surgical and non-invasive facial esthetic treatment to Asian patients, in the absence of published clinical evidence. 
In this, the first of two papers, attitudes to facial beauty in Asia are described. 
Given that a thorough knowledge of the patient’s facial anatomy and aging process is required to inform facial esthetic treatment, those factors specific to Asian population groups are also discussed. 
Asians are defined here as the diverse groups of ethnicities from East Asia (e.g., China, Korea, Japan, Hong Kong, Taiwan) and Southeast Asia (e.g., Thailand, Singapore, Indonesia, Philippines); those from the Indian subcontinent are not included.
To determine the key trends in the type of Asian patients who present for facial esthetic treatment, the patients’ key facial esthetic concerns, and the most commonly used facial esthetic treatments for each age group, 25 members of the Expert Group completed a pre-meeting online survey developed by Dr. Steven Liew. 
Twenty-one Expert Group members then attended a consensus meeting in Seoul, Korea held on June 4 to June 5, 2014.
The members of this Expert Group have a mean 17 years of specialized experience in the field of facial esthetics (range 7–30 years) and treat Asian patients from China, Hong Kong, India, Indonesia, Japan, Korea, the Philippines, Singapore, Taiwan, Thailand, and Australia.
The process used to develop the consensus statements presented here was based on agreed statements created following discussions around survey outcomes, peer-reviewed literature, and clinical experience. 
Final versions of the statements were approved by all authors after being suggested and debated by the experts during the meeting, and modified, if necessary, while drafting the manuscript.
This article does not contain any studies with human participants or animals performed by any of the authors.
The points presented here are a summary of the outcomes of discussions that took place at the Expert Consensus Group meeting and thus reflect the consensus expert opinions of all participants.
Attractive and beautiful people of all races have distinct ethnic features, which reflect harmony, symmetry, and balance. 
However, when comparing the most attractive and beautiful people with their counterparts in other parts of the world, they share remarkable similarity with respect to facial shape.
Facial shape is the essential key to facial beauty, with an oval face considered attractive (and youthful) by people of all racial backgrounds. 
An oval face in this context refers to a smooth egg-shaped curve outlining the perimeter of the face, with a smooth transition from the forehead through the temples, around the outside of the cheeks, preauricular region, angle of the jaw, and jawline through to the chin, without indentations or projections in the line. 
A well-projected nose and chin is also considered attractive. 
Asians of all ethnicities and ages highly prize clear, unblemished, fair, and youthful skin.
Beauty is universal. 
Every ethnic group has its esthetically strong and weak points, but on the whole, the most beautiful and attractive people of each and all races tend to look similar in terms of face shape, and harmonious delicacy of features, balance, and symmetry. 
As faces become less attractive, they display more distinct ethnic features. 
Caucasian faces generally have more pronounced three-dimensionality with larger, more deeply set eyes, greater anterior projection of the brow, nose, maxilla, and chin. 
Caucasians also tend to have narrower faces and greater vertical height. 
Asians tend to have a wider face with shorter vertical height, which is flat or concave in the medial maxilla and has a lack of brow, nasal, and chin projection. 
On the other hand, they possess greater infraorbital volume, fuller lips, and superior skin qualities compared to Caucasians, which enables them to resist environmental insults and delay physiological and anatomical signs of aging.
Mindful of this concept of universal beauty, regardless of race or ethnicity, physicians in Asia seek to enhance “deficient” features and improve esthetic balance. 
In Asians, attractiveness is achieved by aiming to create an oval facial shape, by narrowing the lower face and increasing vertical height of the face. 
The anterior projection of the brow, medial cheek, nose, and chin is increased to improve the three-dimensionality of the face, and the appearance of the eyes is enlarged.
Globalization has enhanced our ability to recognize, study, and create beauty in all ethnic groups. 
In Asians, it is now common to improve anterior projection and three-dimensionality (double eyelid, nose/cheek/forehead augmentation), increase vertical height (chin augmentation), and reduce lower facial width (masseter reduction). 
In the past, these practices may have been perceived as an attempt to “Westernize” the Asian face. 
However, this is now understood to be the optimization of facial esthetic appearance within the individual’s own ethnicity.
Beauty is influenced by customs, traditions, and trends, and the current ideals for the female Asian face include a smooth, convex forehead, large eyes, a petite nose with a raised bridge, full but not prominent lips that are proportionally balanced, and an oval, egg-shaped face with a neat “v-shaped” jawline.
Beautiful people of all races show similarity in facial characteristics while retaining distinct ethnic features. 
Asians are not a homogeneous group but rather comprise many varied ethnic origins, with each group having its own unique facial characteristics. 
Treatment to achieve esthetic changes in Asians should not be viewed as an attempt at Westernization, but rather the optimization of Asian ethnic features, in the same way that Westerners who receive lip enhancement, lateral malar enhancement, or skin tanning are not trying to “Easternize” their appearance as they attempt to make up for their intrinsic ethnicity-associated structural weaknesses.
The desire for facial esthetic improvement has always existed, but uptake was previously limited due to the expense of plastic surgery and the limited number of skilled practitioners.
The results of the Expert Group’s pre-meeting survey showed that most Asian facial esthetics patients are female, but the proportion of males seeking treatment has increased during the last decade, from 12 % in 2005–2009 to 19 % in 2010–2014.
The proportion of younger Asian patients (i e , aged 18–40 years) who present with esthetic concerns has increased slightly in the past 5 years: from 44 % in 2005–2009 to 48 % in 2010–2014.
This may be the result of an increased sense of self identity and pride, and younger patients having more economic power, aspiration, and social independence.
Other reasons for this increase include (i understanding that early use of esthetic treatment may prevent or reduce progress of aging; (ii) increasing awareness of esthetic procedures and treatments received by their peers and “public” figures in social media; (iii) increasing accessibility and affordability of products and treatments; (iv) increasing numbers of trained esthetic physicians; and (v the safety of injectable products that has emerged over the past 5–10 years.
The Expert Group’s pre-meeting survey responses regarding the top three structural esthetic concerns among Asians of different age groups is shown in Table 1—rated according to physicianssopinions of what patients needed to have treated and according to what physicians thought were the patientssopinions regarding their most pressing concerns.
There was generally agreement between the two sets of opinions.
The survey results showed that younger patients (aged ?
40 years) most commonly request the esthetic treatments that improve facial shape and three-dimensionality.
While these patients believe that they are merely seeking esthetic improvements, physicians recognize that requested treatments result from the underlying facial structural features common to Asians that can contribute to a negative esthetic impact.
As patients age, their treatment needs and preferences evolve to address issues associated with aging.
Those aged older than 40 years are more likely to request treatments and procedures that improve volume loss, sagging, and wrinkles.
The available treatment options, as well as awareness of new treatments and procedures, have increased over the past decade.
The proportion of younger patients in Asia who present with esthetic concerns has increased over the past 5 years.
The most common treatment concerns among younger patients (excluding skin concerns) are the result of underlying structural features that can contribute to a negative esthetic impact or relative weakness.
In Asia, patients seek treatment at a relatively young age to address the perceived undesirable facial features that correlate with the underlying characteristic structural anatomical features detailed in Table 2.
A thorough knowledge of the patient’s facial anatomy and age-related processes is required to inform facial esthetic treatment.
The physical features of the Asian face are related to specific skeletal and morphological features that differ from those of Caucasians.
Although there is great diversity due to the ethnic variations that exist among Asian populations, typical facial features can still be identified.
Asians tend to have a wide and short face.
In profile, the face typically appears flat or, in some cases, even concave.
Compared with the Caucasian face, the Asian face is characterized by greater intercanthal width, epicanthal folds, smaller eye fissure length, hooding of the upper eyelid/lateral brow (creating a “puffy” eyelid appearance), smaller oral width, greater mandibular width and a square lower face, and retruded chin.
The nose has a flat dorsum, wider base, and less tip projection The lips of Asians tend to be fuller than those of Caucasians, with the upper lip often being more prominent.
Ethnic Asians have a thicker soft tissue layer next to the most lateral point of the ala nasi, compared with Caucasians. 
These factors, together with retrusion of the pyriform margin of the bony structure in Asians, correspond with the hidden columella, wider alar base, and flatter nose characteristically observed in Asians.
Skin aging differs between Asians and Caucasians in several aspects.
Pigmentary problems such as lentigines and seborrheic keratosis are particularly common among Asians, but wrinkles tend to manifest 1–2 decades later in Asians than in age-matched Caucasians.
A comparison of skin aging in Chinese and French populations living under similar climate conditions indicated that in the Chinese population, wrinkle development followed a biphasic trend, with a slow increase until the ages of 40–50 years, followed by a rapid increase thereafter.
By the age of 60 years, the wrinkle intensity in both French and Chinese populations appeared similar.
This is likely due to the increased melanin in Asian skin affording a sun protection factor (SPF) of approximately 7, compared with a SPF of 3.4 in Caucasians.
In another study that compared facial wrinkles among Japanese, Chinese, and Thai women, the wrinkle intensity was greatest among Thais, followed by Chinese, and then Japanese women.
With Thailand being the most tropical country of the three and having a higher ultraviolet light exposure, photoaging was the most obvious reason for these findings, but other factors, including language and facial expression, also contributed to differences in wrinkle score between Chinese and Japanese women.
Factors other than SPF differences that may also contribute to the reduced skin aging observed between Asians and age-matched Caucasians include skin structure and thickness, diets high in antioxidants (e g , green tea and omega-3 and -6 fatty acids), and smoking rates.
Sociocultural aspects, such as skincare practices and muscle use, during language articulation and facial expressions may also contribute to the differential development of dynamic wrinkles between Asians and Western populations.
In Asians, the physiological facial aging process involves the same dynamic and complex three-dimensional interplay between the overlying soft tissue and its underlying skeletal structures as in Western populations. 
Facial fat and soft tissue volume loss, deflation and descent, and bony remodeling all give rise to the same common signs of aging. 
Retaining ligaments also play a role: as the ligamentous system attenuates, facial fat descends.
Despite the similarities in the physiological processes and characteristics of facial aging among all races, differences in skeletal structural support and in the propensities of facial soft tissue to sag result in slower rates of facial aging in Asians than in Caucasians.
In most Asian patients, the dense fat and fibrous connection between the superficial muscular aponeurotic system and the deep fascia reduce midfacial sagging for longer, and the combination of increased superficial fat and thickened dermis lessen the incidence of superficial rhytids.
Eventually, however, due to the loss of dermal support (despite the initially thicker skin), the heavier malar fat pad and weaker skeletal support in the Asian face contribute to tissue descent that manifests as facial sagging with aging.
Nevertheless, overall, the Asian face retains its youthful appearance for longer due to delayed signs of skin aging and sagging, compared with age-matched Caucasians.
Asians between the third and sixth decades age well compared with age-matched Caucasians.
Even within the population described as “Asian” in this manuscript, significant facial morphological differences are seen, which may underlie the scarcity of published treatment recommendations targeted at “Asians” as a group.
Asians have facial anatomical features that may contribute to what they perceive as an esthetically undesirable appearance.
Increasing numbers of younger patients in Asia are seeking cosmetic treatment specifically to address these structural issues, as evidenced by the types of treatment that are in highest demand by different age groups.
Treatments to achieve esthetic changes in Asians are not aimed at the Westernization, but rather the optimization and beautification of their ethnic features, via the correction of underlying structural characteristics that can contribute to a negative esthetic impact.
In Asians, facial aging manifests differently compared with Caucasians in terms of the time course and observed changes, and Asians who present for anti-aging treatments require different strategies and management techniques from Caucasian patients.
The intrinsic sun protection afforded by the pigment in Asian skin delays photoaging, which appears to be an important factor contributing to the perception that Asians age well.
Although Asians age better extrinsically, in particular those who present for first treatment at a later age require treatment to address not only the underlying structural features that can contribute to a negative esthetic impact but also cumulative age-related changes.
These patients will often require combination treatment and a treatment planning strategy that recognizes the complexity of the interplay between the underlying anatomical state and skin aging.
Background: Direct-to-implant breast reconstruction can be achieved more easily by means of soft-tissue replacement devices such as dermal matrices and synthetic meshes. 
The feasibility of a subcutaneous approach has been recently investigated by some studies with different devices functioning as implant support. 
Aim of this study is to analyze the long-term results, both objective and subjective, of a previous nonrandomized trial comparing prepectoral (subcutaneous) and retropectoral breast reconstructions. 
Methods: Patients enrolled in a nonrandomized prospective trial, comparing the standard retropectoral reconstruction and the prepectoral subcutaneous approach, using a titanium-coated mesh in both techniques, were followed up and evaluated for long-term results. 
Cases were compared in terms of the causes and rate of reinterventions, of the postoperative BREAST-Q questionnaire results, and of an objective surgical evaluation. 
Results: The subcutaneous group had a rate of implant failure and removal of 5.1% when compared with 0% in the retropectoral group. 
Aesthetic outcome was significantly better for the subcutaneous group both at a subjective and at an objective evaluation. 
Capsular contracture rate was 0% in the subcutaneous group. 
Conclusions: A higher rate of implant failure and removal, although not significant, always because of skin flaps and wound problems, should be taken into account for a careful patients selection. 
The subcutaneous breast reconstruction shows good long-term results. 
A coherent subjective and objective cosmetic advantage of this approach emerges. 
Moreover, no capsular contracture is evident, albeit in a relatively limited number of cases.
An implant-based breast reconstruction (IBBR) is by far the preferred way of restoring a female breast after mastectomy and a 2-stage breast reconstruction, by means of a tissue expander, accounts for approximately 70% of all reconstructions according to the American Society of Plastic Surgeons statistics.
Nonetheless, the opportunity of a direct-to-implant breast reconstruction in breast surgical oncology is very fascinating and tempting for surgeons and for women as well.
Whenever surgical conditions, tumor stage and adjuvant treatments allow this option, it is definitely worth considering the avoidance of a temporary tissue expander and its discomfort.
A 1-stage procedure is quite demanding in technical terms.
A full muscular pocket, to cover the prosthesis, allows the use of small to medium size implants and sometimes does not let the surgeon recreate a good lower pole shape and inframammary fold contour.
The introduction of soft-tissue replacement devices in IBBR dramatically expands this field in breast surgery.
Acellular dermal matrices (ADMs) are by far the most frequently used worldwide.
A lot of data are present in literature for ADMs use in breast reconstruction.Synthetic meshes are used as well, as an alternative to ADMs.
A titanium-coated polypropylene mesh (TCPM), TiLoop Bra (pfm medical, Cologne, Germany), is approved for use in breast surgery in Europe since 2008.
There are studies showing its safety and effectiveness in IBBR, with promising results in terms of capsular contracture.
Soft-tissue replacement devices are traditionally used as an inferolateral extension of pectoralis major muscle. 
ADMs or synthetic meshes function as a hammock to adjust an implant after its placement in a retropectoral position and after muscle detachment from its inferior aspect. 
Recently, a novel approach, with a prepectoral, subcutaneous, muscle-sparing implant positioning, has been described. 
In a previous study, we described a prospective nonrandomized clinical trial designed to compare a muscle-sparing method of using TCPM, as a complete coverage for a prepectoral implant, with the standard retropectoral muscular mesh implant coverage. 
Results are limited to a shortterm follow-up, with surgical complications and implant loss showing no difference between the 2 groups.
Aim of this study is to analyze and evaluate longterm results on the same patients enrolled in the aforementioned trial, with 25 months of median follow-up. 
To ascertain reliability and quality of the subcutaneous reconstructions performed in the previous study, the analysis is focused on long-term surgical complications, requiring reintervention, along with objective parameters such as rippling, capsular contracture, and cosmetic outcome. 
Another primary endpoint of present evaluation is women’s quality of life (QOL), analyzing functional and aesthetic subjective parameters.
In 2011, a prospective nonrandomized clinical study was started to compare the use of TCPM in direct-to-implant reconstructions either in the standard muscular mesh implant coverage (group 1, G 1, breast implants in partial retropectoral position, with synthetic TCPM placed as a hammock-like elongation of the muscle over the inferolateral pole) or in a different muscle-sparing technique (group 2, G 2, totally subcutaneous, prepectoral implant adjustment, wrapped in a TCPM bag).
Enrollment ended in January 2014.
Study design and surgical details were previously described.
Briefly, inclusion criteria were age less than 80 years, normal body mass index (BMI; range, 18.5–24.9), small-to-medium size breasts, and ptosis grade of the first and second degree according to the 3-tier Regnault ptosis scale.
Exclusion criteria were previous breast surgery, T4 and metastatic cancers, refusal to sign the consent, comorbidities (diabetes, renal failure, congestive heart failure, pulmonary diseases, hypertension, chronic hepatic diseases, and metabolic diseases), smoking, and previous radiotherapy to the chest wall.
Cases baseline characteristics and oncological data of the 2 groups are shown in Table 1.
In May 2015, with a minimum follow-up of 16 months from the last enrolled case, we proceeded to a surgical, functional, and aesthetic analysis of all cases.
Patients were called and invited to participate in a long-term clinic evaluation.
All patients signed a consent to accept the visit/questionnaire within a standard out-patient clinic scheduled activity.
No ethical committee approval was required.
All further surgical procedures and postoperative radiation therapies, between the first reconstruction and last follow-up, were investigated and registered.
Furthermore, both an objective and a subjective evaluation were conducted.
All the evaluations started and were completed within May 2015.
The subjective evaluation was conducted using the postoperative section of BREAST-Q (Memorial Sloan-Kettering Cancer Center and The University of British Columbia ? 
2006, all rights reserved).
According to a recent study on long-term patient-reported QOL after breast implant reconstruction,26 the BREAST-Q reconstruction module was divided into multiple independent scales: satisfaction with breasts (16 items), satisfaction with outcome (7 items), psychosocial well being (10 items), physical well being (16 items), and sexual well being (6 items).
For each scale, item responses were summed and transformed into a score, ranging from 0 to 100.
Higher scores indicate greater satisfaction or QOL.
On the other hand, the objective evaluation was performed by 2 surgeons simultaneously.
The evaluating surgeons were staff members of the Breast Unit but not those who operated on the patients of the study.
A 5-item form was fulfilled for every reconstruction case.
The form was structured as follows: a capsular contracture evaluation, using the 4-grade Baker classification; b registration of signs of rippling, using a 5-grade Likert scale (score: 1, strongly disagree; 2, disagree; 3, undecided; 4, agree; 5, strongly agree) to judge the statement “this case has no signs at all of rippling”; c registration of signs of implant’s profile visibility, using a 5-grade Likert scale to judge the statement “this case has no signs at all of a visible implant”; d registration of signs of implant borders tangibility at smooth touch, using a 5-grade Likert scale to judge the statement “this case has no signs at all of palpable implant borders”; e aesthetic result, judging the statement “this case has an excellent aesthetic outcome,” still using a 5-grade Likert scale.
This evaluation was conducted by 2 different surgeons at the same time, giving a single agreed score for every item.
Subjective evaluation was conducted by every single patient, whereas the objective evaluation was performed on every single operated breast, therefore, for both reconstructions in bilateral cases.
Statistical Analysis Comparison between muscular mesh pocket and mesh bag pocket patients was made by Wilcoxon’s rank sum test for continuous variables and χ2 test or Fisher’s exact test for categorical variables. 
BREASTQ scores were compared as a continuous variable. 
For each scale, we reported median, range, mean, and standard deviation of the score. 
All statistical analyses were performed by STATA 12.1 (StataCorp. 2011, Stata Statistical Software: Release 12, StataCorp LP, College Station, Tex.)
Twenty-nine patients had been initially enrolled in G 1 and 34 patients in G 2; there were 5 bilateral reconstructions in each group, meaning that an overall number of 34 cases in G 1 and 39 cases in G 2 had been performed.
Cases from the 2 groups were not significantly different in terms of type of intervention (nipple-sparing mastectomy vs skin-sparing mastectomy), concurrent axillary lymph nodes dissection (ALND), preoperative chemotherapy, and postoperative radiation therapy (Table 1).
One patient of G 2 died before this study and was not evaluated.
Therefore, 29 patients from G 1 and 33 patients from G 2 were invited and visited as for the purposes of this analysis.
One patient in G 2 had her implant removed in the early postoperative course because of a large skin-flap necrosis (as reported in the previous study on short-term complications).
Two more patients in G 2 had their implant removed later on because of wound dehiscence during chemotherapy in one case and ipsilateral chest wall local recurrence in the other.
Because all these 3 cases had a different type of reconstruction, with autologous flaps, they were not submitted to present study objective and subjective functional and aesthetic evaluation.
Eventually, 29 (49%) patients, 34 (49%) cases, were evaluated from G 1 and 30 (51%) patients, 35 (51%) cases, from G 2, with 26 and 25 months of median follow-up, respectively.
Early surgical complications from a previous study and long-term results with data analyses from this study are shown in Table 2.
Breast reconstruction is nowadays a goal that can be achieved more easily and with a much greater cosmetic satisfaction for both women and surgeons. 
An implant reconstruction is the preferred way of achieving such a result, and a 2-stage procedure is the commonest solution. 
A single-stage procedure is an interesting option whenever anatomical and oncological characteristics allow it. 
In a recent study, the single-stage and 2-stage procedures are compared in terms of surgical complications and women’s satisfaction. 
Results show no differences in terms of surgical complications, but the singlestage approach is associated with higher sexual well-being satisfaction, even though more than 80% of patients required reinterventions with additional surgical revisions.
Even in terms of costs, a 2013 study shows a slight advantage for the 1-stage procedure, although only during the first 18 months and without statistical significance. 
A 1-stage technique with a direct-toimplant approach is, therefore, more often adapted particularly after the introduction of soft-tissue replacement devices such as ADMs and synthetic meshes. 
The standard use of these entails their placement as an elongation of the pectoralis major muscle, previously detached from its inferior aspect. 
The implant is, hence, covered by the muscle on the medial-upper pole and by such devices on the inferolateral pole to better define the lower profile and inframammary fold contour. 
Based on the rationale that prosthetic devices are actually subcutaneous under the mastectomy flaps in all the inferolateral reconstructed breast, a complete subcutaneous approach can possibly be used in selected cases. 
The direct-to-implant subcutaneous reconstruction with a muscle-sparing technique, wrapping the implant entirely within a TCPM bag, and placing it underneath skin flaps, is described in a previous study, which constitutes the background of this long-term analysis. 
The subcutaneous procedure means shifting the position of the implant from a retropectoral site to a prepectoral one, as schematically shown in Figs. 4, 5.
The subcutaneous approach is described, shortly after our study, also in 2 more papers, although in a smaller number of cases and using ADMs as coverage for the implant.
Results of our previously published prospective nonrandomized clinical study are limited to short-term complications and show that there are no differences in terms of surgical complications between the 2 groups of patients.
Studies on the subcutaneous approach conclude that it is safe and feasible.
Unfortunately, so far, none of them present long-term results.
Moreover, few article deal with the QOL in terms of cosmetic outcomes of breast cancer survivors submitted to any type of reconstruction, as highlighted in a recent study.
This study faces the issue of subjective cosmetic outcome in the restricted sample of breast cancer survivors enrolled in the previous trial comparing the prepectoral and retropectoral breast reconstructions.
In addition to the cosmetic aspect, a subjective functional evaluation (as part of BREAST-Q and an objective assessment, from surgeonssperspective, are considered too.
Results show that in terms of long-term outcomes the musclesparing technique has an encouraging performance.
First, it should be acknowledged that 1 late implant failure and removal, because of poor incision borders healing during chemotherapy, was recorded in G 2.
This, summed with 1 early implant loss from the short-term evaluation, makes a surgical failure rate for the subcutaneous technique of 2 out of 39 cases (5.1%) versus 0% in the standard muscular mesh pocket group.
The other registered implant removal in G 2 was because of a locoregional chest wall recurrence.
Notwithstanding this difference in surgical failure, due in both cases to skin flaps and wound problems, the implant change rate for functional and aesthetic reasons definitely favors the subcutaneous technique with 4 cases (12%) and 0 cases (0%) for G-1 and G-2, respectively. 
A similar number of fat grafts over the implant procedures, to ameliorate the cosmetic outcome, were performed in the 2 groups. 
In terms of subjective QOL parameters, the BREAST-Q evaluation gives a statistically significant difference in the “satisfaction with outcome” group of items, with the subcutaneous technique favored over the retropectoral one. 
In our opinion, this excellent result in the subjective satisfaction with reconstructed breast is because of the more natural appearance that a subcutaneous implant entails. 
This approach, in fact, naturally recreates the innate ptosis of the breast, being the implant in the original anatomical position of the breast gland.
Among the objective evaluation parameters, a significant difference is exhibited for the capsular contracture rate and for the aesthetic outcome.
In both cases, the subcutaneous technique results are superior to the retropectoral standard procedure.
As for the capsular contracture rate, a III–IV grade contracture is recorded in 4 (12%) G 1 cases, compared with 0% in G 2.
A theoretical explanation for such a good result in capsular contracture is that the subcutaneous approach avoids any mechanical stress over the implant and over its capsule as opposed to a retropectoral technique.
This hypothesis is corroborated by a recent article showing a significant difference in capsular thickness between tissue expanders placed subcutaneously and those placed in the standard submuscular position.
Interestingly, no grade III–IV capsular contractures were encountered in G 2 even considering that 9 (26%) cases in this group received a postoperative radiation therapy.
Furthermore, the chemically and biologically inert nature of the titanium-coated mesh might play a role in this as hypothesized in a recent study.
Synthetic mesh constitutes an interface between implant and skin flaps, recreating a new fascia and supporting the implant itself to prevent rotations in the early postoperative course.
The same goal can be achieved by ADMs as described in the aforementioned studies.
A TCPM has a good flexibility, which helps in placement.
Its loose knitwork helps in fluids drainage, avoiding closed space.
Moreover, the new fascia created by mesh integration within tissues appears very thin and soft when exposed.
A formal histologic analysis of TCPM integration within tissues was performed in 1 study, with good results in terms of fibrosis and subsequent capsular contracture.
Besides, costs are definitely lower for TCPM when compared with ADMs overall.
Nonetheless, a subcutaneous reconstruction can be done, as reported in the cited articles from different authors with TCPM or ADMs alternatively and seemingly with good results in both cases.
The surgeons’ aesthetic outcome judgment is deemed excellent in 91% of G-2 cases versus 65% of G-1, and this is coherent with the women subjective evaluation, with a significant advantage of the subcutaneous approach. 
A retropectoral implant has the disadvantage of the muscle presence, which can retract or somehow flatten the implant itself, with high ridden breast appearance and unpleasant “animated” implants. 
A subcutaneous reconstruction, instead, allows a more natural ptosis and appearance of the breast (See video, See Supplemental Digital Content 1, which displays cosmetic long-term result of a bilateral subcutaneous breast reconstruction, bilateral mastectomy with direct-to-implant subcutaneous breast reconstruction in a skinny woman, and appearance at 24 month follow-up, in a patient submitted to systemic adjuvant chemotherapy and postoperative radiation therapy on the right side.
On the other hand, it is important to highlight that a careful patients selection is mandatory for a subcutaneous approach. 
The absence of muscle coverage over the implant can expose the medial aspect of the reconstructed breast to more visible implant borders and signs of rippling. 
These drawbacks can be corrected with a fat graft procedure over the implant capsule, as occurred in 3 cases (9%) in G-2. 
The surgeon choice of the subcutaneous technique over the submuscular one can be made intraoperatively on the basis of skin flaps viability and thickness. 
Also the reconstructed breast medial-upper aspect and sternal border contour is deemed important in the decision of using or sparing the muscle. 
A BMI lower than 18.5 was an exclusion criterion in patients enrollment. 
Nonetheless, even with normal BMI patients, in case of skinny flaps on the upper/medial pole of the reconstructed breast, a submuscular approach might be chosen if implant borders visibility and some ripples are predictable. 
Some oncological aspects are of utmost importance as well, in the surgical planning beforehand. 
In case, if a postoperative radiation, and a chemotherapy as well, is anticipated, which could jeopardize a correct wound and skin flaps healing, then a subcutaneous approach and maybe the entire directto-implant reconstruction strategy would be better changed. 
All results are limited by the number of cases and by the nonrandomization nature of the previous study upon which this long-term analysis was conducted. 
Further analysis and larger numbers should be used to confirm present results. 
Nonetheless, this is, to our knowledge, the first study evaluating the subcutaneous approach with a median follow-up of 25 months. 
In conclusion, subcutaneous breast reconstruction exhibits encouraging results in terms of aesthetic outcome and capsular contracture over a long-term period of evaluation. 
Skin flaps viability and wound healing are of utmost importance for its successful performance. 
Present results might lead to a consideration of the muscle-sparing subcutaneous approach as a valid alternative to the standard retropectoral technique. 
As much as conservative, mastectomies have changed the breast surgical oncology scenario, a “conservative reconstruction” paradigm is worth considering.
Gone are the days when a consistently radiant glow is chalked up to good genes alone. 
In this era of multi skin-care regimens, what everyone really wants to know when they see a lustrous complexion is, "What are you using and who is your dermatologist?" 
Enter Manhattan dermatologist Dennis Gross, MD, and his eponymous skin-care line. 
A favorite of the perfectly complected Naomi Campbell and January Jones, it includes the award-winning Alpha Beta Peel, a must-have in ELLE editors' routines. 
Dedicated to making industry secrets available beyond his Upper East Side offices, Gross is tackling new frontiers in antiaging and developing accessible treatments and products to help smooth and luminize your skin.
WHAT'S THE MOST COMMON QUESTION YOU GET FROM PATIENTS? 
The phrase "tired-looking skin" has grown organically among my patient population. 
Dull, less vibrant, not responding like it used to. 
The skin gets exhausted and runs out of energy.
It can be from stress or pollution or lifestyle. 
Even the amount of heavy metals from hard water alone starts taking its toll on the skin and makes every problem you have look worse.
WHAT'S THE BEST SOLUTION? 
It's a rather quick fix. 
Skin needs an influx of energy from the mitochondria, which is like the battery within skin cells. 
This can come from a topical ingredient like vitamin C, the most powerful and important part of any antiaging routine. 
It's an antioxidant, which means it both increases collagen levels and protects the collagen you already have. 
It also works on uneven skin tones—an incredible combo. 
Vitamin C does lose some potency when exposed to air, so look for products with airtight valves, as well as amber bottles to help protect from light degradation.
WHAT ARE THE BIGGEST CHANGES IN ANTIAGING TECHNOLOGY YOU'VE SEEN IN THE PAST FEW YEARS? 
Now we can do things that don't have a downtime. 
Treatments like Fraxel, with its significant recovery time and pain, are being phased out in favor of noninvasive lasers that smooth and firm without destroying or injuring the skin. 
My 3D laser treatments, for instance, are a combination, a cocktailing, of two lasers that stimulate collagen, remove uneven skin colors, work on redness, and firm skin on the face and neck. 
Another advantage of this approach is its reach: The cells that make collagen lie at multiple levels, but previous lasers have worked on only one skin layer. 
The GentleMax Pro uses dual-wavelength technology to heat skin to 45 degrees Celsius and encourages the fibroblast cells to stimulate collagen; the Vbeam laser follows to eliminate redness and continue stimulation of collagen production. 
Noninvasive lasers can even work preventively, meaning whatever stage you're in—a fine line, a wrinkle, drooping—if you have the budget, you can start doing treatments immediately to stop the clock. 
It's all based on not letting your skin's collagen production diminish. 
In your midthirties, when you start to see the texture of your skin change, you might start thinking about it.
Also, five years ago, no one thought that heat could destroy fat. 
We had the idea of freezing fat, maybe, and trying to break it up with ultrasound, but now there's SculpSure, which is a breakthrough, revolutionary treatment to reduce body fat with noninvasive lasers. 
The laser safely raises the temperature of body fat to destroy fat cells [adipose tissue] beneath the skin, which are then naturally eliminated by the body and don't return.
If there is excess fat in certain pockets that have been resistant to diet and exercise, it's now possible to get rid of them. 
I think SculpSure will replace liposuction.
ARE ANTIAGING SUPPLEMENTS EFFECTIVE? 
Supplements are an important part of healthy living. 
My motto is, anything good for the heart is good for the skin.
I'm a big fan of omega-3 fatty acids, fish oils, resveratrol, and vitamin D. I believe they will slow the aging process to keep skin looking younger. 
WHERE IS THE FUTURE OF ANTIAGING GOING? 
LED light increases energy in fibroblast cells, stimulating collagen production. 
And it's completely nonirritating. 
You want to be sure, with any LED device, to look at the instructions and the claims. 
Government regulations require backup for statements that devices produce collagen; they require photos of people who have gotten results. 
LED light is the next frontier.
1
Dr Dennis Gross Skincare Spectralite Eyecare Pro ($159, drdennisgross.com),which utilizes red light therapy, can result in the reduction of fine lines if used for three minutes daily over eight weeks.
2
Lips have no ability to tan, so be sure to use a hydrating lip product with SPF, like Palmer's Cocoa Butter formula Swivel Stick ultimate moisture ($2.19, target.com).
3
For irritated, dry skin, Gross recommends Aveeno Eczema Therapy Moisturizing Cream ($9.68, amazon.com), rich in soothing collodial oatmeal.
4
His C+ Collagen Brighten + Firm Vitamin C Serum ($78, sephora.com) "is approaching equal popularity" to his coveted peel.
5
 Gross describes the advent of his at-home Alpha Beta Daily Peel pads ($16, sephora.com) as "one of the crowning moments of my career."
Facial lines and wrinkles are strongly influenced by individual differences in anatomy and muscle activity and no single injection protocol will suit all patients. 
However, there is only limited information in the published literature on how to develop a tailored approach to botulinum toxin treatment.
An expert panel of physicians was convened to establish a consensus on developing an individualized approach to treatment of the forehead with incobotulinumtoxinA. 
Separate treatment protocols were developed for men and women and subdivided by background level of muscle activity: kinetic, hyperkinetic, and hypertonic. 
Each muscle tone category was then further subdivided to take account of individual characteristics that can influence treatment.
Consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. 
A tailored treatment protocol is described for men and women with a wide range of forehead presentations. 
For each presentation, units of toxin as well as the precise location of injection points were defined by creating a 12-zone map of the forehead.
These recommendations depart from traditional consensus documents by providing detailed incobotulinumtoxinA injection protocols for the forehead based on the major parameters that differ between patients, including muscular anatomy, size, and tone.
It is expected that the use of this document will lead to more satisfactory, natural, and individualized aesthetic outcomes for patients.
All share the same mode of action, with differences between products occurring because of proprietary manufacturing processes, purification methods, and inactive ingredients in the formulation. 
INCO is the only product free from complexing proteins or neurotoxin-associated proteins. 
These play no role in the neuronal mode of action of the toxin complex and have no effect on product diffusion. 
Stability is unaffected by their absence, with INCO having a shelf-life of 3–4 years at room temperature, compared with 2–3 years for ONA and ABO and a requirement for refrigeration. 
A lack of complexing proteins also reduces the potential antigenicity of a product and thus the risk of developing secondary neutralizing antibodies.
All three toxins are US Food and Drug Administration (FDA)-approved for the treatment of moderate-to-severe glabellar frown lines. 
ONA and INCO are also approved for the treatment of lateral periorbital lines (crow’s feet) in the EU. 
For INCO only, European regulatory authorities reached a consensus in 2016 on approvability for the combined treatment of upper facial lines (glabellar frown lines, lateral periorbital lines, and horizontal forehead lines). 
Results from head-to-head clinical trials have demonstrated that INCO and ONA have similar efficacy and tolerability when used in a 1:1 dose conversion ratio for the treatment of glabellar frown lines and lateral periorbital lines. 
A recent consensus review suggests that a conversion ratio of 1:2.5 (INCO/ONA:ABO) may be assumed in aesthetic indications. 
In addition to the above-mentioned approved indications, all the products are also widely used off-label for a number of other aesthetic indications, including lifting and reshaping the eyebrows, softening perioral lines, treating platysmal bands, and correcting facial asymmetry.
The most important goal of botulinum toxin treatment in aesthetic medicine is to achieve a balance between dynamic wrinkles caused by hyperactive muscles while maintaining natural facial animation. 
This is influenced by a number of factors including individual anatomy, structure, action and mass of the muscles, and personal aesthetic preferences. 
Tailored treatment taking into account all these factors is required for optimal results and consequently patient satisfaction with treatment and their physician.
Why is this expert consensus required in aesthetics? 
Clinical data and consensus articles provide helpful guidance on aesthetic indications, but their consideration of individual patient differences is more limited. 
Patients differ enormously in their facial anatomy both within and between genders, and treating all patients at the same injection points and with the same doses will leave many with less than optimal results. 
The current document was put together to help physicians develop an individualized approach to botulinum toxin treatment of the forehead.
Twelve experts in the fields of aesthetic medicine, dermatology, and plastic surgery convened four times between July 2014 and February 2015 in Madrid, Spain, to develop independent, consensus-based recommendations for the use of INCO for aesthetic indications in patients with varying degrees of muscular activity and wrinkle severity. 
During these meetings, the group developed a series of recommendations covering the clinical history and physical evaluation of the patient as well as a muscular map of each treatment area illustrating the points of injection. 
The following text summarizes the recommendations for the treatment of the forehead. 
The content reflects the opinions of the authors only. 
The recommendations of the group for the treatment of other facial muscles will be published in a separate paper.
A number of patient characteristics and anatomical features help define their suitability for botulinum toxin injection. 
The positions, strength, and insertion points of the facial muscles can be determined by inspecting them at rest, by observing their movements while the patient makes varying facial expressions, and by palpating them. 
Signs for areas of stronger contraction include greater dynamic movement, deeper lines, and larger apparent mass during use.
Consensus members classified patients into three groups based on their facial muscle contractions and line severity prior to treatment: kinetic, hyperkinetic, and hypertonic. 
Kinetic patients are those with regular muscle contraction and wrinkles during active expression but not at rest. 
Hyperkinetic patients have more excessive muscle contraction and may require more frequent treatment and higher doses to achieve the desired effect. 
Finally, hypertonic patients are those with an inability to relax specific muscles and with visible wrinkles at rest. 
They may still be candidates for treatment, but should be advised that while botulinum toxin treatment may result in some improvements, the wrinkles will not completely disappear and additional use of an injectable dermal filler may be necessary. 
Deep static lines due to loss of skin elasticity are not suitable for botulinum toxin injection.
The aim of treatment is to eliminate lines when the patient is at rest, but to leave the ability for some movement and minimal wrinkling when the patient is animated or actively expressing emotion.
The dosing units described in this document are applicable to INCO and ONA and use standard reconstitution volumes. 
The units of ABO are different, but a conversion ratio of INCO/ONA:ABO of 1:2.5 or 1:3 is generally assumed in aesthetic indications.
Horizontal forehead lines are caused by the contraction of the frontalis, a large pair of muscles whose fibers are oriented vertically and whose medial fibers are joined in the glabellar region, where they intersect with the procerus. 
The central and lateral fibers merge with the corrugator supercilii and the inner part of the orbicularis oculi. 
Contraction of the frontalis raises the eyebrows and the upper eyelid, wrinkling the forehead in the process. 
The corrugator supercilii work antagonistically as depressors of the brow, and the forehead should not undergo treatment without treatment of the corrugator. 
The simultaneous treatment of all upper facial lines is an approved indication for INCO and is effective and commonly performed in aesthetic practice.
Before beginning the treatment, the physician should evaluate the patient for expressivity, muscle mass, symmetry, lateral versus medial movement, compensation for brow ptosis, and brow width and height. 
The intensity of contractions along the height of the frontalis can differ substantially from individual to individual, and variations in muscle function should be taken into account when deciding on the dose of botulium toxin and where the injections will be placed. 
This can be detected by light palpation over the area while the patient actively raises and lowers the eyebrows.
Treatment of the frontalis muscles can not only reduce horizontal forehead lines but can also affect eyebrow shape and height. 
Brow shape is influenced by the complex interplay between the frontalis and the lateral (lateral orbicularis oculi) and medial (procerus, corrugator supercilii, medial orbicularis oculi) brow depressors, and the use of botulinum toxin treatments to shape the brow is not considered in this document. 
To precisely define the location of injection points for individual patients, the consensus group divided the forehead into 12 zones positioned 1.5?
2.0 cm above the eyebrow to avoid any risk of brow ptosis.
Injection points and units vary between men and women due to differences in anatomy and patient preferences, and they were considered separately when designing a treatment protocol for the forehead. 
The point of divergence of the two frontalis muscles is generally lower in men than women, which has implications for injection sites. 
Men typically also have greater muscle mass and a larger forehead surface area than women and require higher doses. 
Eyebrows are naturally positioned lower in men, and excessive relaxation of the lower frontalis can result in brow ptosis. 
Men and women were then subdivided by muscle tone prior to treatment (kinetic, hyperkinetic, and hypertonic). 
Each muscle tone category was further subdivided to take account of individual characteristics that can influence treatment. 
In this manner, a tailored treatment protocol was developed for women and men with a wide range of forehead presentations.
In women with an average size forehead and dynamic forehead lines, the group recommends intramuscular injection at four injection points across the midline of the forehead (F5 to F8) with 1?
2 U of botulinum toxin per point depending on the strength of the frontalis. 
The injection points should be ~1.5?
2.0 cm apart and placed on alternating sides of the targeted horizontal lines.
Women with a high forehead and dynamic wrinkles are treated as mentioned previously with 1?
2 U at each of injection points F5 to F8. 
If required, a second line of injections can be placed above the first with the addition of two injection points at F2 and F3, and subcutaneous injection of 1 U of botulinum toxin at each point.
The so-called Mephisto sign occurs in some patients when lateral movement of the frontalis remains after treatment and produces visible wrinkles. 
It is more common when treatment of the forehead is restricted to the area between the midpupillary lines. 
Women with strong lateral frontalis fibers should receive 1 U intramuscularly at F6 and F7 and 1 U subcutaneously at points F9 and F12.
Upper eyelid ptosis may occur when treatment of the frontalis muscle unmasks subtle pre-existing weakness of the levator palpebrae superioris muscle. 
Botulinum toxin product labels recommend evaluation of the upper eyelid, especially in patients with a history of glabellar trauma or surgery, for the presence of levator palpebra muscle separation or weakness. 
These patients are treated by intramuscular injection of 1?
2 U at points F5 to F8, but with the addition of 1 U of botulinum toxin subcutaneously at points F6 and F7.
The frontalis may form either a uniform band across the forehead or be V-shaped with a relative absence of fibers medially. 
Women with the latter presentation are treated by subcutaneous injection of 1 U of botulinum toxin on the midline between F6 and F7 in addition to intramuscular injection of 1?
2 U at points F5 and F8.
Treatment is with the same pattern of intramuscular injection as for women with a kinetic frontalis, but using the higher end of the dose range (2 U) per injection point.
In the first row of injections, treatment is with 2 U intra-muscularly at each of points F5 to F8. 
Women with a high forehead can receive a second line of injections placed above the first. 
However, in those with a hyperkinetic frontalis, the two additional injection points at F2 and F3 are injected intramuscularly rather than subcutaneously with 1 U of botulinum toxin at each point.
Treatment is with 2 U of toxin injected intramuscularly at injection sites F6 and F7. 
Two lateral injections are also placed on each side of the forehead by injecting 1 U of toxin subcutaneously at the lateral limit of zones F1/F5 and F5/F9, and on the other side of the forehead 1 U at the lateral limit of zones F4/F8 and F8/F12.
These women should receive 1 U of botulinum toxin subcutaneously at each of two sites defined as the midline of F5/F6 and F7/F8 in addition to the standard F5–F8 injection points.
Treatment is with intramuscular injection of 2 U of botulinum toxin at each of points F5 to F8 and with 1 U subcutaneously on the midline of F6/F7.
Hypertonic patients are difficult to treat, and the limitations of botulinum toxin treatment should be explained beforehand. 
The recommended treatment protocol is 1 U of botulinum toxin subcutaneously at sites F5 and F8, and 1 U intramuscularly at sites F6 and F7. 
Hypertonic patients are particularly susceptible to brow ptosis, and injection in the lateral limit of the frontalis should be avoided.
Treatment is as for women with an average-size forehead with the recommendation that patients are evaluated after several days at the follow-up appointment to determine if further treatment is necessary.
These are uncommon in women with a hypertonic frontalis, and the details of their treatment are presented in Table 1.
For men with regular frontalis contractions, dynamic forehead wrinkles, and an average size forehead, the group recommends intramuscular injection at four injection points across the midline of the forehead (F5 to F8) with 2 U of botulinum toxin per point. 
As in women, the injection points should be ~1.5–2.0 cm apart and placed on alternating sides of the targeted horizontal lines.
It is important not to accentuate a prominent forehead due to a receding hairline or shaved head. 
Smoothing out the entire forehead or leaving muscle activity above the level of the normal hairline would draw attention to the upper third of the face. 
In addition to intramuscular injection of 2 U at points F5 to F8, these men can also be treated with additional intramuscular injection of 1 U at points F1 and F4 (1 cm below the muscle attachment).
In addition to intramuscular injection of 2 U at points F5 to F8, 1 U of toxin can be injected intramuscularly at each of injection sites F9 and F12 coinciding with the point of maximum contraction.
Men with palpebral weakness should receive intramuscular injection of 2 U at points F5 and F8 plus 3 U at points F6 and F7.
Standard treatment is with intramuscular injection of 2 U at points F5 to F8 plus subcutaneous injection of 1 U of botulinum toxin on the midline of F6/F7.
Treatment should be restricted to 1 U intramuscularly at points F6 and F7 and 1 U subcutaneously at points F9 and F12.
The group recommends the same pattern of intramuscular injection as for men with a kinetic frontalis (F5 to F8) with the addition of two further intramuscular injections of 1U each on the midline of points F1/F2 and F3/F4.
A second line of injections can be placed above the first as in men with a kinetic frontalis, but a higher dose may be used. 
In addition to 2 U intramuscularly in each of points F5 to F8, they are treated with 2 U intramuscularly in the midline of points F1/F2 and 2 U intramuscularly in the midline of points F3/F4.
In addition to intramuscular injection of 2 U at points F5 to F8, 1 U of toxin can be injected intramuscularly at each of injection sites F9 and F12 (coinciding with the point of maximum contraction) plus 1 U intramuscularly on the midline of points F1/F2 and points F3/F4.
The group recommends intramuscular injection of 1 U at points F5 to F8 plus 2 U of botulinum toxin intramuscularly on the midline of points F1/F2 and points F3/F4.
Standard treatment is with intramuscular injection of 2 U at points F5 to F8. 
In addition, these patients can receive intra-muscular injection of 1 U of botulinum toxin on the midline between points F1/F2 and F3/F4 as well as 1 U subcutaneously at each of points F6 and F7.
Men with a short forehead and hyperkinetic frontalis receive the standard treatment of 2 U intramuscularly at each of points F5 to F8.
Prominent lateral superciliary wrinkles will require additional injections in the lateral frontalis. 
In addition to intramuscular injection of 2 U at points F5 to F8, 1 U can be injected intra-muscularly on the midline of points F1/F2 and F3/F4, and 1 U subcutaneously in the lateral limit of points F9 and F12.
The limitations of botulinum toxin treatment in these patients should be explained before starting the treatment to avoid disappointment. 
The recommended treatment protocol is 1 U of botulinum toxin intramuscularly at sites F5 to F8.
Two rows of injection are used. 
In the first row, toxin is administered intramuscularly as 1 U at each of points F5 to F8.
In the second row, 1 U is administered intramuscularly at the midline of points F1/F2 and F3/F4.
One unit of toxin may be injected intramuscularly at the midline of points F1/F5, F2/F6, F3/F7, and F4/F8. 
When performing this treatment, the brow depressor muscles (corrugator supercilii, procerus, depressor supercilii, and superolateral portion of the orbicularis oculi) should be treated at the same time.
Men with a short forehead and hypertonic frontalis should be treated with intramuscular injection of 1 U at each of points F5 to F8.
The Mephisto sign and V-shaped frontalis are rare in men with a hypertonic frontalis, and the details of their treatment are presented in Table 2.
Patient satisfaction with botulinum toxin treatment depends on the physician’s ability to visualize and recommend a treatment plan that meets the patient’s goals and needs. 
A number of consensus documents have been published to assist physicians on the use of botulinum toxin in aesthetic medicine. 
However, to the authors’ knowledge, this is the first document to provide an individualized approach to treatment with detailed injection protocols for the forehead based on the major parameters that differ between patients, including muscular anatomy, size, and tone.
The recommendations were developed on the premise that no single injection protocol can suit all patients. 
However, few studies in the literature account for differences in facial anatomy and muscle tone when evaluating treatment with botulinum toxin. 
For example, a review on the use of botulinum toxin in men found only two studies that accounted for gender in either the study design or subgroup analysis and only one dose-ranging study. 
As the number of male patients seeking treatment has been increasing, physicians need to account for gender when evaluating and treating their cosmetic patients. 
Sexual dimorphism in facial anatomy and cutaneous physiology is well documented, yet these differences are rarely accounted for in clinical practice. 
Men and women also differ in a number of other facial features including the size of the forehead, the position and shape of the eyebrows, and the shape of the jaw. 
Such anatomical variations between genders result in differences in aging and consequently in how individuals should be treated.
For an optimal aesthetic outcome, each patient should undergo a static and dynamic assessment of muscle position, mass, and functional status prior to treatment. 
In the current consensus, muscle tone is divided into kinetic, hyperkinetic, and hypertonic, and each must be treated differently for optimal results. 
Careful observation of the extent of dynamic movement of the skin will identify areas of stronger or weaker muscle contraction. 
In this way, the physician can determine why certain wrinkles are formed and which muscles are creating them. 
This information is needed to balance the effects of opposing muscles and minimize the risk of unwanted outcomes. 
The static and dynamic evaluation may also identify other more subtle variations in facial musculature that should be considered during the planning of an effective botulinum toxin treatment regimen, such as palpebral weakness, compensatory muscle use, and facial asymmetry. 
The dynamic assessment is therefore essential to optimize the dose and injection technique for each patient.
It is hoped that the current consensus document will be of use to a wide range of aesthetic physicians from beginners to experts. 
It departs from the single template of dosing and injection points described in most consensus guidelines by tailoring treatment protocols to individual patients, which will lead to more satisfactory, natural, and individualized aesthetic outcomes.
When people go under the knife, they're focusing more and more on fat, fillers, and facelifts to achieve the perfect selfie. 
The American Society of Plastic Surgeons released data that shows upticks in facelifts, fat transplants, and injectables—and Instagram filters might be the reason.
Doctors performed almost 1.8 million cosmetic surgeries in 2016. 
The five most popular: 1. 
Breast augmentation (290,467 procedures, up 4 percent from 2015) 2. 
Liposuction (235,237 procedures, up 6 percent from 2015) 3. 
Nose reshaping (223,018 procedures, up 2 percent from 2015) 4. 
Eyelid surgery (209,020 procedures, up 2 percent from 2015 )5. 
Facelifts (131,106 procedures, up 4 percent from 2015).
Plus, a whopping 15.5 million minimally invasive cosmetic procedures were performed last year. 
The most popular varieties: 1. 
Botox (7 million procedures, up 4 percent from 2015) 2. 
Soft tissue fillers (2.6 million procedures, up 2 percent from 2015) 3. 
Chemical peel (1.36 million procedures, up 4 percent since 2015) 4. 
Laser hair removal (1.1 million procedures, down 1 percent from 2015) 5. 
Microdermabrasion (775,000 procedures, down 3 percent from 2015).
The study found several fascinating trends in 2016's data. 
First of all, the facelift had previously fallen from the top five (bested by the tummy tuck), but came back in 2016, and surgeons point to Instagram. 
"Patients are captivated by instant improvements to the face," Dr. Debra Johnson, president of the American Society of Plastic Surgeons, said in a statement. 
"It's evident in the popularity of apps and filters that change how we can shape and shade our faces."
Second, patients are getting more procedures that harvest their own fat to deposit elsewhere in the body. 
There were increases in cosmetic fat injections that target specific areas, that "freeze" fat without surgery, and that tighten sagging areas. 
The number of butt and breast augmentations that use fat grafting also increased.
Third, and perhaps most striking, is that the ASPS's data covered labiaplasty for the first time ever. 
The surgery, which lifts or injects fat and fillers into the labia, was performed 12,000 times in 2016, a 39 percent uptick from 2015.
Beyond the ASPS data, surgeons are reporting anecdotally that patients' specific requests have been changing, according to CNN. 
One doctor said his patients are requesting smaller sizes when they get breast implants. 
Another said his patients want fewer procedures that remove extra skin and are opting for fillers instead. 
Fillers are also popular because of the Kylie Jenner effect; the reality star has admitted she uses them to plump her famous lips.
But the Guardian also reports that more people are actually requesting lip reduction procedures than ever before. 
There were 28,430 lip augmentation procedures last year, but there were also 3,547 lip reduction surgeries, with the latter skyrocketing 283 percent.
"A decade ago plastic surgeons might have seen a patient every seven to ten years when they needed a major procedure like a facelift or tummy tuck," Dr. Johnson said in the ASPS statement. 
"Now patients have ongoing relationships with their plastic surgeons and feel more comfortable discussing all areas of their body that they may be interested in rejuvenating."
Hollywood's proclivity for Botox, fillers, and other under-the-needle procedures yielding magically smooth, line-free complexions is at an all time high. 
And I'm not afraid to admit that as a beauty editor, and pop-culture-devouring woman in 2017, it's fed a beautiful dark-twisted fantasy of staying wrinkle-free forever. 
I mean, I have yet to see any semblance of crow's feet on a Kardashian. 
I have nothing against cosmetic surgery. 
In fact, by nature of the job, I'm up on every cutting-edge procedure and toy with the idea of them daily. 
But as of now, I'm looking to topical solutions to ward off the early signs of aging I'm dealing with.
While my regimen used to be comprised of a myriad of different products, lately I've been looking to one: La Prairie's new Line Interception Power Duo. 
Two weeks in, it's worked better than anything else so far and I've got the litmus test to prove it—my very first wrinkle! 
Or rather expression line, which is one of the three types of wrinkles one can have. 
The other two are sun-induced and gravity lines. 
The latter being vertical and the hardest to counter. 
Thankfully, the combination of a day and night cream found in the Power Duo address all three in Botox-like fashion—but *sans* needles.
"The day cream focuses on expression lines," explains Dr. Jacqueline Hill, director of innovation and science at La Prairie.
"The three peptides we use in our day cream work on expression lines by interfering with the signaling process that leads to muscle contraction at three different levels."
To put it in perspective, Botox injections cause muscles to refrain from contracting by inhibiting the signaling pathway a bit later in the game (the second level, as opposed to the first). 
The day cream acts earlier on and in more complementary ways in gentler fashion—i.e. no weird facial expressions.
In addition to collagen-stimulating peptides and moisturizing hyaluronic acid, the formula also contains SPF 30, offering broad spectrum protection with UVA and UVB filters that prevent future damage from sun exposure.
Good News: At night, the skin is in a regenerative mode, meaning skin renewal is accelerated and repair processes take place. 
Bad News: These processes slow down with age. 
The silver lining? 
The night cream helps to compensate for this decline by regenerating the skin at several levels, counteracting the impact of daily aggressions.
"It helps stimulate the production of collagen, elastin, and hyaluronic acid," says Dr. Hill. 
"Thus, helps to optimize skin renewal to fill wrinkles from within and strengthen the extracellular matrix. 
The appearance of wrinkles, even vertical, is visibly reduced."
The biggest claim of the La Prairie's groundbreaking duo is that it can visibly decrease the appearance of wrinkles after 14 days and 14 nights. 
Because I look at my face day in and day out, I knew the only way I'd be able to really tell is with the receipts. 
i.e. photographs of the expression line on my forehead in question. 
So I snapped a photo of myself pre-Line Interception, then after I used the day cream and night cream daily, along with my normal routine of cleansing, toning, and exfoliating for 14 days. 
As you can see in the before and after, my fine line is *technically* still there. 
However, it's far less perceptible in the hi-res shot, let alone with the bare eye. 
To me, that's a win.
A few other notes: Despite being packed with SPF, the day cream is ultra-lightweight and melts into the skin, making it imperceptible beneath my makeup, which cannot be said for most moisturizers with sun protection. 
The night cream is equally lovely to slather on before bed. 
Another thing I love about the duo is that it's two different creams housed in one airless—no oxidation—carry-on-friendly tube that just makes life easy. 
I can take it anywhere.
As far as the price tag, $350 is a precious amount of change, but when you consider that it's a non-invasive alternative to pricey procedures, as well as something that can complement and even prolong the need for cosmetic procedures like Botox, it's a worthwhile AM/PM investment for the woman that doesn't mess around when it comes to skincare.
It goes without saying that no one wants to look done. 
Still, we've all seen it, or maybe it's even happened to us: the brow too high, too low, too frozen; the balloonish lips or Angelina-Jolie-in-Maleficent cheekbones that give the game away. 
Here is a person, these all-too-obvious needle- assisted interventions say, who hoped to look younger, prettier—someone who strove to arrest aging, ? 
la Blake Lively's magical imperviousness to time in The Age of Adaline, or even to reverse it, like Benjamin Button—and overshot the mark.
Thankfully, as dermatologists have grown more sophisticated in their methods and the array of fillers, neurotoxins, and fat dissolvers like Kybella has become more diverse and specialized, patently obvious nonsurgical work is becoming the exception rather than the rule. 
(And surely, if the 9 million-plus injections done in the United States in 2015 had made us a nation of funny- faced freaks, we'd know it.)
The best needle wielders now recognize that the most natural-looking effects are achieved incrementally, with tiny, almost imperceptible adjustments.
"I'm a big believer in 'You don't fill up the gas tank in one try,' " says Los Angeles-based dermatologist Annie Chiu, MD. 
"Softly adjusting gives the most beautiful results, and budget-wise it's more reasonable as well. 
You can always add, but it's harder to take away. 
Hyaluronic acid fillers are reversible, but you obviously don't want to do that unless absolutely necessary."
"Icall them little tweak-bits," says New York-based derm Dendy Engelman, MD. 
"This is the secret behind all the celebrities who the layperson thinks are just genetic phenoms. 
They are able to age beautifully because they're not doing major overhauls. 
They're not changing their faces, adding tons of volume, or erasing their expressions. 
They're just focusing on tiny changes that really fly under the radar. 
They're not so perceptible that it's like, 'Oh, she went and got her eyes done' or 'She's changed her lips.' 
Nobody can tell."
With injectables, small hits can have a big impact—and not necessarily in the places one might expect. 
Engelman, for example, sometimes uses "a tiny bit of Botox at the base of the columella, which is that divider between the nostrils," to lift the tip of the nose. 
"There are a lot of small physiological changes that people don't really notice as signs of aging, which we can address," she says. 
Another trick: making the eyes look bigger by injecting a baby dose of neurotoxin just underneath the eye. 
"If you just put one unit of Botox there," Engelman says, "it drops the lower eyelid about one or two millimeters and opens up the aperture of the eye. 
So you look a little more awake, a little younger or prettier—but not noticeably different."
In more traditionally treated areas, derms tend to stay with standard doses of Botox and fillers—"I believe that if you use too little between the eyebrows, you're not going to prevent those etched lines from getting deeper over time,"says New York–based dermatologist Whitney Bowe, MD.
"And I find that I need to put in .1 to .2 ccs—the more traditional doses of filler—along the cheekbone in order to get the lifting effect I'm after." 
But for the rest of the face, Bowe says, "I've completely changed my injection technique."
To address crow's feet, for example, Bowe "wraps" microdoses of neurotoxin—delivered with an ultrathin tuberculin needle—around the eye, starting from the tail of the eyebrow and finishing under the lower eyelid.
"Instead of hitting that area with just three injections on each side, which is what was studied during FDA trials, I actually do a series of about six or seven injection sites," she says. 
"That way, I get a very gentle, natural, widespread effect that opens up the eye and lightens up heavy lids. 
It also changes the texture of the skin in a way that traditional deeper injections don't, because I'm actually affecting only the very superficial muscle fibers. 
So when people complain that they have crepey or cigarette-paper skin around the eye, it helps to smooth that out."
Similarly, Bowe uses minuscule doses of hyaluronic acid fillers in marionette lines, smile lines, and nasolabial folds, placing them shallowly into the dermis "to gently hydrate the skin from beneath the surface." 
This imparts an immediate dewy glow but also, she says, galvanizes a longer-term benefit: "It triggers your own body to make more collagen.
I'm deliberately wounding the skin in tiny points down and along those lines in order to tell your body to start healing itself. 
I find that by doing this injection technique, I'm able to get a much more powerful preventive effect from the filler, because I'm creating ten- sion on the fibroblast cells, making them create more collagen. 
Again, it's very off-label, but if I see people every three months and I use very low doses distributed in a lot of different areas, I'm able to get healthier-looking skin over time. 
So even after the enzymes in our bodies break down that hyaluronic acid filler, the skin looks tighter and firmer."
"This is the secret behind all the celebrities," Engelman says.
The goal, always, should be natural movement (nothing should "stop you from communicating, emoting, showing sympathy or empathy or interest," Bowe says)—even if that means leaving a few wrinkles unsmoothed and not going full throttle on a particular area, which could create, say, an overlarge lip that's disharmonious with the rest of the face. 
Indeed, with cruel irony, anything too heavy-handed can actually backfire and make someone's face read as being older, rather than younger. 
"It's always that fine line between doing just enough but never teetering over into too much," Engelman says. 
"I think that although Kylie Jenner has had good work, she looks about 15 years older than her real age. 
All these young girls are doing way too much, way too early. 
I always say to my young patients, 'The one thing I can't give you is your actual youth, so you need to ride that out as long as you can. 
When that starts to break down—and it will—we can start to do things. 
But in the meantime, don't go messing with it. 
If you start monkeying with it too early, it knocks you into an older-looking category.'"
When we do see overfilled or disconcertingly immobile faces, there can be several factors to blame, but it nearly always involves either an unskilled injector or an unscrupulous one who will acquiesce to patients who want—and are willing to pay for—something they don't need. 
"Every time I look at celebrities who have crossed over to the dark side of doing too much, it's not that I'm upset with them; I'm upset with the doctor who did it to them," Engelman says. 
"We all know the right aesthetic."
It's important, therefore, to find a board-certified dermatologist or plastic surgeon who will work with you to strike the right balance—and say no to you when necessary. 
When Bowe encounters "millennials who come in with Instagram pictures of enormous lips," she says, "I have to counsel them extensively about how we have to maintain the proper ratios and proportions. 
I can put in only a little bit of product but focus on the pillows of the lips, and give you a beautiful, sexy smirk when you're at rest. 
I can turn up the corners or make the Cupid's bow pop. 
It's not about pump- ing lips full of product and giving you two big sausages." 
Even when a patient does have naturally thin lips and desires a fuller pout, Bowe takes it slow: "I'd rather do a series of treatments using very small injections at a time. 
Someone might need two syringes to get to the point where she's going to be happy, yes, but I'll do one syringe, and then I'll have the patient come back in a month or two to do the second. 
I like to give the tissues a chance to recover, and then evaluate."
In general, derms are breaking away from a one-size-fits-all approach and tackling individual faces with an eye toward modest interventions that preserve idiosyncrasies and asymmetries; the goal is to make us look like better versions of ourselves, not like everyone else. 
"I really believe injectables are an art," Chiu says. 
"Every single face is different, and there are vast differences, even culturally, in how you approach someone. 
It's about enhancing—not changing."
"When I talk to patients, new or established, I'm actually analyzing their expressions and balance and beauty," says New York dermatologist and Mount Sinai Medical Center associate clinical professor Ellen Marmur, MD. 
"By the time we catch up on our news or introductions, I already have an idea of what I might like to offer. 
I draw out a master plan with each patient, even using an iPad painting tool on a photo of the patient. 
We start with baby steps and give touch-ups until we've achieved a uniquely personalized map of what and where to inject."
Although it may seem counterintuitive, or even wasteful, to invest money in something so deliberately invisible, Marmur says, "economic analysis has proven that routine, under-the-radar procedures pay off over time more than the big, dramatic antiaging procedures." 
No one will know how we've managed to sail through time so remarkably unravaged. 
And isn't it better to leave them guessing?
If you thought boob jobs came in just two speeds—big and extra big—think again. 
According to a survey conducted by The Plastic Surgery Group, 30 percent of patients are now requesting smaller nipples with their regular breast augmentation programming.
One hundred thirty-one participants were asked to rate nipples from one to five in order of attractiveness and to appraise the diameter of the areola, Goldilocks style, as "too big," "too small," or "just right."
"We found that patients with smaller nipples rated higher in attractiveness than those with larger nipples," consultant plastic surgeon Mo Akhavani said in a press release. 
The nipples that ranked most attractive and as "just right" in size occupied 25 to 30 percent of the breast when viewed head on.
On the flip side, nips that occupied more than 50 percent of the breast in the same view earned a sweeping "too big" from 92 percent of respondents. 
Small nipples RULE. 
Got it. 
But not too small. 
Seventy-eight percent of respondents rated areolas that occupied less than 15 percent of the breast width "too small."
"Clearly the results of our survey demonstrate that a single nipple size is not appropriate for all women and the nipple diameter should be adjusted so that it is 25 to 30 percent of the breast width. 
There is also a modern trend towards smaller nipples," Akhavani added.
Choose your own proportionately sized nipple adventure.
Aesthetic outcome in patients’ demand for cosmetic treatments have been influenced by some parameters such as clinical improvement after procedures, risk and potential complications, and downtime periods. 
These parameters could validate plasma technology as a new regenerative modality.
A basic understanding of plasma physics and histopathological aspects of plasma is required to understand the impact of plasma technology on aesthetic medicine. 
Plasma is the fourth state of matter, which comprises ionized atoms. 
Almost the entire universe comprises this matter. 
When sufficient energy is delivered to gas atoms, ionization occurs and the atoms acquire a positive charge after the electrons escape.
In terms of pressure, plasma can be categorized into low-pressure, atmospheric-pressure, and high-pressure plasma. 
Furthermore, in terms of relative temperatures, it can be classified into thermal and non-thermal plasma. 
Plasma can also be produced artificially.
For artificial plasma production, using an ultra-high-frequency radiofrequency generator, the energy applied to the gas atoms is emitted in a millisecond pulse to the skin via a handpiece. 
Thermal-air-based electrical discharge plasma is used in cosmetic regeneration.
Plasma action’s mechanism on the skin involves two steps: immediate tissue contraction and thermal disruption. 
Denaturation of collagen and other proteins in the dermis following the thermal effect of plasma induces clinically observed, immediate tissue contraction. 
Cascade of neo-collagenization has been stimulated through thermal disruption of dermal solar elastosis, fibroblasts activation, and migration from the deeper dermis and cytokine release.
Plasma is more uniform than ablative resurfacing lasers, including carbon dioxide (CO2) resurfacing laser, since it does not depend on the interaction with a specific target.
Regarding the level of energy of plasma and tissue shedding, high-energy plasma induces shedding in epidermis and upper dermis, whereas low-energy plasma induces shedding in only the upper part of tum corneum.
An experimental study on comparing the histopathological effect of plasma skin regeneration (PSR) and CO2 laser in terms of tissue and plasma interaction was conducted in 2008. 
The results of this animal study demonstrated that high-fluence CO2 laser generated a greater thickness of thermal damage zone than any energy level of PSR. 
Furthermore, it revealed that plasma produced equal thermal damage zone from the low- and medium-fluence CO2 laser.
Epidermal necrosis using low-energy settings PSR were less than or similar to epidermal changes in the lowest fluence in CO2 laser.
PSR technology helps in the treatment of facial rhytides, solar keratosis, seborrhoeic keratosis, and warts. 
Some studies have considered the clinical effects of PSR technology on periorbital rejuvenation.
More than 90% improvement with conventional blepharoplasty and approximately 20% and 30% improvement using PSR in the tightening of upper eyelid and peri-orbital wrinkles were achieved, respectively. 
Approximately 40% improvement in facial acne scars after six months was achieved after a single treatment of PSR.
PSR has been used in the rejuvenation of non-facial skin, including the chest, neck, and dorsum of hands. 
Furthermore, it can be used to treat traumatic scars, benign familial pemphigus, and porokeratosis.
Although no major side effects in clinical studies have been reported to date, side effects could occur due to the heat delivered to the skin, including erythema, edema, scaling, crusting, scarring, and skin pigmentation.
Plasma application has great potential in dermatology; however, further clinical and histopathological studies are required to support previous findings and to address some issues and questions about safety and efficacy.
Technological advances in medicine have given the sick and the disabled a chance of making a full recovery. 
However, contemporary trends show that medicine goes far beyond its restorative functions. 
The increasing popularity of plastic surgery raises many questions. 
Is medicine beginning a new era of its development as a response to the commercialisation of the human body? 
Does not correcting nature lead to people’s segregation into the better and the worse ones?
The development of medical technologies has accelerated the commercialisation of the body by treating it as a package that one can “redecorate” to be more attractive in the market of social relations. 
Plastic surgery is trying to solve the identity crisis and psychological problems of people. 
New forms of medicalisation are emerging. 
A lack of success is seen as a symptom of a disease that can be cured with a scalpel.
Plastic surgery can be a tool of reconstruction of one’s identity but only under strict circumstances. 
By posturing as a solution to people’s psychological and sociological problems, medicine must reckon with a moral/ethical critique.
The fact that humans have bodies is undeniable. 
However, the answer to the question of where the boundary between the physical and social body lies is not so obvious. 
If it is possible to function with artificial organs, support life with an apparatus or change the appearance through surgery, where does the “pure” or “natural” man end?
The world is becoming increasingly uncertain; during the last two decades expressions such as the culture of fear or the risk society have emerged. 
Uncertainty concerns not only the condition of the natural environment or the state of world security but also what the human body is. 
Being a subject of medical interest for many centuries, it has become one of the most medicalised elements of the contemporary world. 
Technological advances in medicine have created enormous possibilities, giving hope for fitness and recovery to the sick, handicapped and injured in accidents, allowing for early diagnosis that saves lives of millions of people in the world, and enabling us to look inside the human body and remove defects that formerly excluded man from functioning in society.
However, currently observed trends indicate that medicine has gone beyond curative and restorative functions understood as providing help to those in need. 
Today, medical activities often concern “repairing normality”. 
The growing popularity of plastic surgery, compounded by the media, makes us ask whether medicine is entering a new phase associated with the technological progress as a response to the commercialisation of the body. 
Does not correcting nature lead to segregation of people into the better ones and the worse ones? 
And consequently, does aesthetic medicine, whose aim is to eliminate uncertainty about one’s body, not give birth to this uncertainty anew? 
In the author’s opinion, technological advances in medicine have accelerated the commercialisation of the human body, making it into a package that can be modernised and improved, thus increasing an individual’s attractiveness in the labour market. 
The body becomes a product, an investment that determines the position of a human being in the arena of interpersonal relations. 
Aesthetic medicine seeks to solve the identity crisis and psychological problems of contemporary people. 
Further manifestations of medicalisation are emerging. 
A healthy person is a person improved by surgical procedures that change not only his or her appearance but also personality. 
A lack of success and self-confidence or an unsuccessful marital life are symptoms of a disease that can be cured with a scalpel.
The presented considerations draw theoretical inspirations from the sociology of the body and the sociology of health, disease and medicine. 
Within the first of the mentioned sub-disciplines of sociology, three main approaches can be distinguished: issues related to the social regulation of the body, the ontology of the body and the experiencing of the body.
The social regulation of the body. 
This perspective focuses on the influence of social institutions on the regulation, control, monitoring and use of the human body. 
Our bodies are subjected to careful “treatment” from the moment of birth the aim of which is to suppress and channel natural instincts to build the so-called social body. 
The constant conflict between nature and culture, between reason and emotions, resurfaces here. 
Many authors are interested in the way institutions of religion, law or medicine regulate the human body. 
The most evident influence of these three institutions can be seen at the birth and death of the human body, but there is also debate over topics such as abortion, euthanasia or organ transplants. 
It is worth noting here that in this perspective feminist movements, which have made the issue of the regulation of the female body by all kinds of institutions one of their central issues, have found their place. 
The control of the human body, manifested in a variety of forms, is to serve primarily to maintain social order. 
The theorists of this trend indicate that throughout the whole life of man the human body is subject to two types of regulations: the first one consists in “training” the human body to specific behaviours, and the main mechanism in this respect is socialisation whose task is to encourage people to hide their natural instincts and behaviours under the mask of socialised conduct. 
We learn to wear a special type of clothing, how to behave in specific situations, and what should not be done or must not be done. 
The other type of regulations is based on continuous control of the effects obtained in the first stage. 
Institutions established for this purpose have a set of penalties and rewards by means of which they effectively enforce the required behaviour. 
Individuals whose bodies do not follow such regulations are isolated and go to hospitals or prisons.
The lived body. 
According to this trend, the human body determines the way in which one explores and responds to the world. 
The perception and experiencing of the world are rooted in the senses of sight, touch, smell, hearing and taste, i.e. the elements that undoubtedly belong to human corporeality. 
Through this corporeality, the outer world appears to us and our reactions to it are born. 
Usually, we are unaware of this fact, because we are also ignorant of the existence of our own body. 
We feel it only when its dysfunction appears—a cold, fracture, contusion, or haemorrhage. 
A disease often forces us to rebuild our consciousness and how we perceive our body. 
A great deal of considerations is also devoted to new tasks and possibilities that stand before the body and the embodied self of a sick person. 
This perspective has appeared as a response to the dualism of the soul and body, nature and culture, reason and emotions popularised in the literature. 
Proponents of this approach argue that it is impossible to separate these two entities from each other, as there is constant interaction between them. 
The body and the soul are a unity that manifests itself most fully in a situation of illness, suffering and pain. 
Somatic complaints are accompanied by specific emotions—anger, sadness, or a sense of powerlessness.
The ontology of the body. 
This last perspective is the most important here, as it focuses on the dilemmas of aesthetic medicine. 
The growing uncertainty of the surrounding world means that the human body has begun to be perceived as fragile, delicate, unreliable, and therefore requiring constant improvements and enhancements. 
At the same time, people have begun to see that the human body is the seat of the self, the place where the human soul is hidden. 
This has additionally intensified the willingness to care for the packaging of such noble content. 
The human body has started to be perceived as a process, it has become a “project” that is developed and carried out throughout an individual’s life. 
Body projects, as this phenomenon is defined in the discussed perspective, have become the basis for an individual’s self-identification. 
Genetic engineering, a healthy diet, physical activity, cosmetic procedures and plastic surgery are just some examples of such “projects”. 
It turns out, however, that what was to contribute to the rebuilding of self-confidence creates an even greater sense of uncertainty. 
The boundary between the body and its image is becoming blurred. 
Increasingly, the reflection, the image of the body itself—the ECG, X-ray or computed tomography—becomes more reliable than the actual person. 
The image of the body becomes the basis for its transformation. 
Nowadays, aesthetic medicine more often creates the image of a human being than simply eliminates existing defects. 
In many television stations, one can watch programmes in which people, mainly women, undergo painful and risky surgical procedures in the name of beauty, self-confidence and success. 
It would not be possible if it were not for medical technological advances that can form human bodies like the sculptor’s hands create a statue. 
However, this is associated with several threats that will be discussed further on.
The other sub-discipline—the sociology of health, disease and medicine— focuses on the social construction of health and disease concepts, a reflection on medicine itself, its organisation and medical professions as well as the relationship between medical science and social sciences. 
In its context, one can speak about the social consequences of changes in medicine. 
Medical advances and health education have changed the structure of diseases from acute to chronic, have caused the emergence of a holistic model of health and disease as a response to the biomedical model, and have increased health awareness of modern societies as well as the importance of the concept of health and disease as social constructs, not only objective products of evidence-based medicine. 
Especially since health has become a commercialised, commoditised category, it deserves consideration. 
There has been a transition from “being healthy” to “having health”, making it a commodity, changing the definition of the disease, and thus blurring the already fluid boundary between the common understanding of health and disease.
Corporeality is associated mainly with the physical dimension, is proof of our existence, and the permanent absence of the body indicates the end of our biological life. 
Ever since ancient times, however, the human body has also had other dimensions—the psychological one, associated with experiencing one’s organism and its perception by an individual, as well as the social one, whose essence is related to other people and how they perceive the body of an individual. 
Therefore, since the beginning of time, the body has been subjected to rituals, customs and treatments aimed at embellishing, modifying, displaying, decorating or covering its certain parts. 
The most common procedure is to hide the body under layers of clothing. 
Nudity, in the Bible, is associated with the feeling of shame and is inseparable from the original sin. 
Having committed the sin, the first people “realised that they were naked”. 
Nowadays deprived of clothes, we feel naked, exposed, but not only in the physical dimension but above all in the spiritual dimension. 
Clothing conceals the imperfections of our beauty, but also of our conscience. 
In addition, without clothing, we become extremely like each other, ordinary, average. 
Clothes are something that sets us apart in a way, makes us richer or poorer, having better or worse taste, while in the face of nakedness we only differ in terms of sex.
Nowadays, the external appearance has become the most important trademark of a person which determines his or her economic, professional, family and social position. 
The ways of dressing, doing one’s hair and makeup, the complexion, the body shape and body structure promoted in the media show at the same time the ideals of a woman and a man that are desirable and appropriate. 
The external appearance determines inclusion or exclusion from a given social group. 
Newspapers, magazines, television, cinema, and the music industry define patterns of appearance that are fashionable. 
The way these patterns are presented means that they also become desirable. 
As in the past, the advertisement showed that a person could become someone better, more valuable, less frustrated, happier or more attractive thanks to the acquisition of a specific product, today television shows that to achieve it one only needs to undergo plastic surgery.
The human body has ceased to be treated as permanent and immutable. 
This change in perception has an ontological meaning, as it forces us to revisit the answer to the question of what the human body is. 
For centuries, it was treated as permanent, immutable and, among others, because of that fact, it was not an object of interest in social sciences. 
In sociology, it appeared incidentally as the basis for social activities, but not as an object of a separate scientific reflection. 
Anthropology was the first to make the body the centre of study, showing its diversity, dissimilarity of treatment and use. 
In sociology, the body appeared through the sociology of sport, followed by the sociology of the body and medicine. 
The body has ceased to be something that “is”, nowadays one “has”, “possessed”, “modifies”, and “creates” the body. 
The body is treated as a process and as a “project”. 
It has become a long-term investment that is supposed to provide benefits, prestige, and respect. 
Thus, the flexible body is subjected to many modifications throughout the entire human life, depending on the needs or desires of a given individual. 
At the same time, it is perceived as the most important element of human personality. 
Jan Szczepa?ski’s classic concept distinguishes biogenic elements (of which the body is part) as well as psychogenic and sociogenic personalities. 
The body is also an important element of Ralph Turner’s self-image and self-conception. 
The selfimage is a “photograph” of our “self” which we see at a specific moment and which changes from moment to moment. 
The self-conception is a permanent “picture” of our “self”, the concept of who we really are. 
If the body of an individual ceases to be permanent and becomes “fluid”, it also has consequences for such lasting constructs as the self-conception. 
Interest in body makeover programmes, in which ordinary people decide to “remodel” their bodies, shows not only the economic dimensions of the play between demand and supply of commercial medical services but also the social transformation of orientation towards hedonistic and consumerist values. 
According to Wolfgang Welsch, referred to by Agnieszka Maj, today’s man is homo aestheticus, i.e., an “educated hedonist”—a sensitive, conscious person with a sublime taste, ready to shape and stylise his or her soul and body.
As the programmes show, many people deciding to undergo plastic surgery believe that with their new noses or breasts their well-being will improve, their self-confidence will increase and, therefore, the quality of their lives will be enhanced. 
The first programmes on this subject did not take into consideration possible side effects, which might suggest that the procedures were a safe technique for improving one’s appearance. 
Currently, information on side effects appears in the programmes, the convalescence process is also shown, which somewhat balances the optimistic and pleasant image of plastic surgery. 
Moreover, there are also programmes showing the side effects of plastic surgery. 
Many formats also show people for whom aesthetic medicine is the last chance for a normal life and full social activity (victims of accidents, diseases, people with congenital malformations and deformities). 
In this way, two separate types of medicine are presented—restorative medicine and medicine that fulfils desires. 
The former gives a chance for a normal life, restoring a healthy look and self-confidence, counteracting social exclusion and stigmatisation. 
The latter makes life better, easier, more beautiful; pleasant medicine that makes an individual’s life better and an individual him or herself healthier. 
This division is equally unfavourable for patients as well as medicine itself. 
On the one hand, it somewhat alleviates the hedonistic orientation of aesthetic medicine itself, but on the other hand, the confrontation of the healthy and the sick that avail of its offer falls to the disadvantage of the former, accused of vanity.
The contemporary image of the body contradicts somewhat demographic trends. 
On the one hand, we are dealing with the so-called greying population, which is a result of the decline in the number of births and the extension of the length of human life. 
On the other hand, there is no place for old age in modern societies. 
It is associated with illness, suffering, powerlessness and social uselessness, and above all with a deformed body, which becomes unattractive, unsightly, wrinkled, and distorted. 
Technological advances have contributed to a significant extension of human existence, and now attempts are being made to mask this achievement with the help of plastic surgery. 
Medicine has become a cure and a weapon at the same time. 
Old age has been medicalised and is treated like a disease. 
Death begins to be perceived as an “accident at work” made by a doctor which soon can be prevented. 
And elderly people as a social category are marginalised, sidelined, even though in many countries they constitute a huge percentage of the population. 
Old age is unfashionable and unwanted, and modern generations are no different from the main character in The Picture of Dorian Gray who wanted to preserve his youth at all costs. 
According to surveys conducted by the Centre for Public Opinion Research (CBOS) from 2017, as much as 87% of Poles attach great importance to their own appearance. 
According to the same report, the look is of great importance both in personal life and professional career. 
As far as the personal sphere is concerned, as much as 38% of the respondents believe that the appearance has a large impact on the success of a person in life, while for 32% the appearance determines the success of a person in life. 
In the professional sphere, the responses were 37% and 33%, respectively. 
According to the GfK Beauty report from 2016, the external appearance reflects well-being for 35% of the respondents. 
The determinants of beauty in women are now symmetry and proportionality of the figure and face, well-groomed appearance, smooth and radiant skin without discoloration, wrinkles and pimples, unnecessary hair, and the body structure— from a slim figure to anorexic thinness. 
The determinants of male beauty are also proportionality and symmetry, as well as a muscular body structure, clean skin and neat nails, and increasingly often a lack of characteristic male hair. 
Added to this is a radiant smile with white teeth and elegant fashionable attire for both sexes.
Old age has no place in this scenario; if someone wants to age with dignity, they must cover up the signs of entering the golden years. 
Only in this way will they not be excluded from society, the labour market, and the social relations market.
Aesthetic medicine is a branch of medical aesthetics understood as a subdiscipline of medicine dealing with the prevention of skin aging and improving the physical attractiveness of the patient (by restoring or improving the natural appearance).
Treatments aimed at modifying the human body have been known for millennia. 
In the 6th century BC in India, reconstructions of the nose, ears and mouth were carried out, while in China since the 10th century AD women’s feet were bound because the ideal was a woman with small feet. 
In the Turkish literature of the 11th century, descriptions of operations of drooping eyelids and gynecomastia procedures appeared. 
Pioneering facelifts, often ending in patients’ death due to the materials used—a solution of arsenic and lead—were carried out in the 19th century in Great Britain. 
In the 20th century, surgical procedures became even more popular, and at the same time more invasive. 
In the 1920s, women had their ribs removed to give them the slim wasp waist. 
Such a procedure was allegedly performed on Pola Negri. 
Marilyn Monroe also owed her face and image to plastic surgery—to make her face shapelier, a sponge implant was sewn into her chin. 
It was reportedly replaced every five years. 
The first plastic surgery clinic was opened in the United States in 1921 and was founded by a Polish surgeon, Jacek Maliniak.
The 1960s were a period of popularisation of silicone breast implants. 
In 2000, Botox was invented, which became a commonly used means for smoothing wrinkles, and in 2004, operations rejuvenating voice were initiated. 
Michael Jackson and Cher, who since 1988 have underwent numerous plastic surgeries and became the icons of plastic surgery. 
In 2004, 12 million plastic surgeries were performed in the United States.
Currently, plastic surgeries are a fashionable Holy Communion gift in Brazil and are very popular among the Chinese families with adolescent daughters. 
In the 2003 CBOS study, only 1% of the respondents admitted to having undergone a beautifying treatment, in 2009 it was 2%. 
How many people really want to do this is evidenced by the number of applications for the Polish edition of the “Make Me Beautiful” programme. 
As many as 100,000 Polish women are ready to change their body to find a better job, a partner, to repair marital relations, or to get rid of complexes. 
Breast enlargement or liposuction become a remedy for many problems of a psychological or social nature— these treatments are aimed at solving financial problems (finding a job) or even supplementing intellectual deficiencies (a more beautiful and well-groomed person is also a wiser, better-educated person). 
Individuals are becoming increasingly insecure about themselves and their abilities. 
To increase chances in the labour market or social relations, a person undergoes treatments believing that they will contribute to this goal. 
Medicine today meets social expectations. 
Thanks to technological advances, medicine can save lives even in the most hopeless situations. 
However, it is becoming a threat to many spheres of human functioning by medicalising them. 
Work, professional success, social life, sexual life or earnings cease to be dependent on personality traits, intellect, education, and become dependent on the offer of aesthetic medicine.
Progress in medicine has two faces. 
On the one hand, achievements in this field have given hope for health and life to many millions of sick, handicapped and disabled people. 
Organ transplants or artificial organs prolong the lives of many people with dysfunction of specific parts of the body, and restore mobility to handicapped people, artificial insemination gives hope to many married couples who have difficulty with having children, specialist equipment sustains vital functions, monitors body parameters and is used for complicated procedures, while plastic surgery enables the removal of congenital defects and injuries or damage resulting from accidents. 
On the other hand, medicine has contributed to the acceleration of the commercialisation of the body. 
It has become a commodity with a clearly defined price and market value, depending on the investments made. 
This second face of medicine becomes morally ambiguous, for example, because it contributes to the segregation of people into the better and worse ones, more and less valuable. 
Economic disparities are becoming more pronounced as not everyone can afford these aesthetic medical services. 
The cost of liposuction is approx. 
PLN 3,900, abdominoplasty—PLN 4,900, breast enlargement—PLN 3,500, breast reduction—PLN 4,900, cheek lifting—PLN 3,900, and eyelid surgery—PLN 2,900. 
Added to this are dental procedures (one implant costs approx. 
PLN 8,000), dermatological treatments (Botox—PLN 1,000), beautician’s and hairdresser’s services as well as designers’ consultations usually combined with the change of wardrobe. 
The prices vary significantly and depend on the prestige of the clinic, as well as the medical procedure used (equipment, the form of treatment, materials, etc.). 
Nevertheless, these are not cheap procedures. 
Therefore, those who can afford the costs are made more beautiful, becoming even more attractive, desirable or rich. 
Most people are only left frustrated, and this frustration is the cumulative effect of dissatisfaction with one’s own body and economic constraints preventing its change. 
Such people are left only with the possibility of participating in television programmes in which they make an exhibitionist act of having their bodies publicly improved.
Medicine, manipulating the human body, also manipulates the mind and personality of man. 
Plastic surgery carries a huge risk of psychological problems for both patients and their immediate environment. 
For many people, it seems that after the surgery not only their appearance will change, but also their character, personality, and financial, marital as well as social problems will disappear. 
Reality after the surgery verifies this illusion quite quickly, leaving scars on the body and soul. 
Very often, plastic surgery is a threat to the youngest members of the patient’s family, as children do not recognise a new face of their parent or relative after surgery. 
This can have very serious negative consequences in the relationship between the person who has undergone the procedure and the child.
What is the purpose of contemporary aesthetic medicine—repairing what has been damaged, or creating something new, better, based on what was old and good? 
In other words, does the doctor have the right to model the patient’s body according to the preferences of the latter, despite a lack of health reasons, or should medicine help only when the patient’s life and health are in danger? 
This question does not concern only plastic surgery, but also genetic engineering that enables manipulation of the human genome or prosthetics, i.e. implantation of artificial organs. 
The answer should consider the medical, psychological, social and economic aspects, as it is impossible to talk about these issues and not to mention their commercial dimension. 
This question about the purpose of aesthetic medicine can be extended to medicine in general. 
Not only has the body becomes a commodity, health in general has become commoditised, and the state of one’s depends not on the biological conditions but on one’s financial resources.
Aesthetic medicine is commercial medicine, market-oriented, which has little to do with social service or conscience. 
Each doctor has the right to refuse to perform a medical procedure citing the clause of conscience. 
Nobody has heard of such a behaviour among plastic surgeons or dentists, but it is quite common, for example, among gynaecologists. 
Of significance is probably the fact that aesthetic medicine is basically a completely private activity, while gynaecological services are performed both privately and state-run institutions. 
A private practice often has completely different rules and a system of values. 
As it is a commercial activity, it is subject to market regulations, not moral regulations.
Improvement and beautification become more important than medical treatment.
A serious consequence of medicalisation of old age and popularisation of plastic surgery is the commercialisation, and thus the commoditisation, of the human body. 
Medical specialisations have already introduced a significant fragmentation of man into individual organs, treated by many doctors narrowly specialised in the pathology of a specific organ. 
The patient is dehumanised and ceases to be an actor or a partner and is perceived as a sick pancreas or a badly prognostic cancer. 
Aesthetic medicine further deepens this depersonalisation, assigning a material value to the human body, just as the price of a car and its individual parts are established. 
A facelift begins to resemble the straightening of a car’s body after an accident. 
Advice by stylists and make-up artists is comparable to needing a new paint job, and dental implants—a set of new tires. 
This “repaired” man “leaves” the beauty salon and enters the world where the cult of youth and success dictates the rules.
General medicine is currently generating many discussions about its achievements, discoveries and activities, as well as the effects of these activities. 
The definition of health comprises an overall well-being including physical, mental and social dimensions instead of using the absence of illness or disability as the criteria. 
However, ways to achieve this well-being are changing, and technological advances are being widely used. 
On the one hand, medicine is focused on saving human life.
Its basic principle is “do no harm”. 
It should be emphasised, however, that this does not refer only to a purely medical dimension, in the form of iatrogenic errors, but also to mental and social harm that is far more serious in its consequences. 
On the other hand, medicine is increasingly commercialised, becoming one of many service-provided companies. 
Its goal ceases to be the change from the “bad” state to the “good” state, but increasingly often the goal is the change from the “good” to the “better” state. 
This is particularly visible in the field of aesthetic medicine, which is extremely commercialised nowadays. 
This fact has several negative consequences, such as: psychological effects of cosmetic procedures and plastic surgery, not always in line with patients’ expectations; an increase in social inequalities and progressive polarisation between the very rich and very poor, the beautiful and ugly, the improved and damaged; financial consequences associated with the need to repeat some treatments; social consequences related to new fashions and new ideals of beauty and success redefine interpersonal relationships that were once based on knowledge, experience, opinions or interests, and are replaced by the external appearance; making the external appearance a value in the labour market equal to knowledge and skills; the fluidity of “self”, instability of the self-conception, and consequent mental imbalance leading to emotional and personality disorders; moral consequences related to blurring the boundary between what is real and natural, and what is artificial and created.
Aesthetic medicine can be a tool for rebuilding one’s identity, but only in justified cases (genetic defects or personal injuries due to accidents). 
However, by offering its services as a key to solving personal and professional problems, medicine can lead to disturbances in the sphere of self-image and self-conception, and therefore, must reckon with moral objections.
The most hazardous adverse reactions following hyaluronic acid injections in aesthetic medicine involve vascular complications, known as the Nicolau Syndrome. 
This article presents a vascular complication in the area of the upper part of the nasolabial fold following subcutaneous administration of 0.5 ml of hyaluronic acid. 
At the time of the injection, paling occurred, which was followed by livedo racemosa appearing an hour later. 
Upon the lapse of a week, an ulceration appeared. 
It was not until the tenth day after the hyaluronic acid injection that hyaluronidase was administered. 
After 15 hyperbaric oxygen exposures, the ulcer was completely healed.
Currently, aesthetic medicine uses 160 fillers produced by 50 producers to correct wrinkles and furrows. 
The most popular filler is hyaluronic acid, which was first used in September 1996. 
It was a cross-linked derivative of hyaluronic acid obtained from Streptococcus bacteria.
Adverse reactions following the use of hyaluronic acid constitute an important problem in aesthetic medicine. 
A misdiagnosis may involve a longlasting ineffective therapy, whereas proper diagnosis results in a quick healing process. 
Adverse reactions after the injection of hyaluronic acid may be divided into early and delayed reactions.
Early adverse reactions (erythema, oedema, callosity) usually disappear within a few days following an injection of hyaluronic acid and depend mainly on the level of proteins and bacterial endotoxins.
Delayed reactions occur in about 1% of cases in the form of papules, granulomas, ulcers and biofilms. 
They may occur several days, weeks or months, or even years following administration of hyaluronic acid.
However, the most dangerous adverse reactions following the injections with hyaluronic acid are vascular complications, i.e. the Nicolau Syndrome, which typically occurs during the injection or a few hours after its administration.
Below we present a case of an occurrence of vascular complications following the administration of hyaluronic acid.
A beautician administered to a 45-year-old woman a subcutaneous dose of 0.5 ml of hyaluronic acid under the upper part of the nasolabial fold. 
Immediately after the administration of the filler, paling and pain occurred at the injection site. 
One hour after the injection, retinoblastoma (livedo racemosa) occurred as well as pain radiating to the left eye and a watery secretion from the left nasal passage and tearing of the left eye. 
Also, a sore which had developed in the locality of the application of the hyaluronic acid intensified. 
The next day, the beautician diagnosed herpes and recommended local treatment.
Three days later, the woman appeared for consultation at the Emergency Ward in a hospital. 
An antibiotic ointment was prescribed. 
Oedema and pain in the locality in which the filler was administered had increased, and an ulcer appeared within a week of the treatment.
It was not until the tenth day following the injection of hyaluronic acid in the upper part of the nasolabial fold that 100 U of hyaluronidase was administered to the patient for the purpose of dissolving the filler. 
In addition, an antibiotic therapy (ciprofloxacin and clarithromycin) and prednisone were used.
As a result of this, by the next day, the pain subsided and the swelling decreased. 
To accelerate the treatment of the ulcer, the use of hyperbaric oxygen (HBO) was recommended. 
Each HBO session at 2.5 ATA pressure lasted 90 minutes during which the patient breathed oxygen with 5-minute breaks during which she breathed air. 
During HBO treatment, the ulcer was gradually reduced and after 15 exposures the ulcer was completely healed. 
At present, there is mild scarring at the place of ulceration.
In recent years, aesthetic medicine procedures are frequently performed by unqualified persons, e.g. beauticians. 
The patient was not informed by the beautician about the possibility of an occurrence of adverse reactions. 
Already during the administration of the filler, skin paling and pain appeared at the injection site. 
The beautician disregarded the symptom as she was not familiar with the possible adverse reactions following an injection of hyaluronic acid. 
Upon the lapse of just a few hours, livedo racemosa occurred around the apex of the nose and the upper left side of the nasolabial furrow. 
The beautician diagnosed herpes and recommended local treatment. 
On the third day the patient arrived at the emergency ward at a hospital where only a bacterial infection was diagnosed and an antibiotic ointment prescribed. 
On the seventh day following the injection, an ulcer occurred around the upper left nasolabial furrow. 
It was not until the tenth day after the application of the hyaluronic acid that the right treatment was applied. 
Following an intradermal test, 100 U of hyaluronidase was administered to the upper nasolabial furrow region. 
Already a few minutes after the injection of hyaluronidase, the pain subsided and the swelling decreased. 
In order to accelerate the treatment of ulcers, the use of hyperbaric oxygenation was recommended.
Before administering hyaluronidase, an allergic test should be performed – in rare cases, urticaria or angioedema may occur (in 0.1% of patients) following the administration of hyaluronidase. 
Hyaluronidase is of an animal origin (bovine or ovine) and the occurring allergy may be of type I (immediate) and IV (delayed).
In the described case, only a compression of the facial artery by hyaluronic acid occurred. 
The symptoms included paling and pain at the injection site. 
In such an event it is required to interrupt the procedure and immediately administer hyaluronidase for the purpose of dissolving the hyaluronic acid. 
If ulceration occurs, it is necessary to apply hyperbaric oxygenation.
Intravascular injections are much more serious as the administration of as little as 0.05 ml of hyaluronic acid may result in blindness. 
Anatomic changes in the facial vessels make the procedure unpredictable. 
Injections with hyaluronic acid in the nasal region are particularly hazardous. 
The dorsal nasal artery, which constitutes the terminal branch of the ophthalmic artery, may be single or double. 
The size of a single nasal dorsal artery may reach as much as 1 mm.
Another hazardous area is the nasolabial fold through which the facial artery passes and then transfers into the angular artery that connects with the ophthalmic artery. 
In the described case, vascular symptoms occurred as a result of compression on the facial artery with hyaluronic acid.
The augmentation of wrinkles and furrows should only be performed by physicians who know the anatomy and rules of conduct in the case of an occurrence of adverse reactions. 
Vascular complications are among the most serious complications in aesthetic medicine. 
In the event of an occurrence of skin paling and pain while administering hyaluronic acid, it is required to immediately stop the treatment and administer hyaluronidase to dissolve the filler. 
Hyperbaric oxygenation may play an important role in the treatment of vascular complications of aesthetic medicine.
Anyone who’s had a rough week knows the look: puffy eyes, dark circles, the sudden appearance of fine lines. 
“We call it stress aging,” says Manhattan-based dermatologist and psychiatrist Amy Wechsler, MD. 
“Daily stressors such as a demanding job, a lack of sleep, and an unhealthy lifestyle can manifest as pallid patches, pimples, and wrinkles, which can add three to six years to your skin.”
As dermatologist Whitney Bowe, MD, author of The Beauty of Dirty Skin, explains, “Stress slows down digestion, which creates a shift in bacteria that can compromise the integrity of your gut lining. 
This can cause inflammation throughout the body and lead to acne flare-ups as well as premature aging.” 
Furthermore, the stress hormone cortisol is no friend to skin. 
“It’s infamous for breaking down collagen,” Bowe says.
Thankfully, much of this damage can be mitigated by focusing on daily moments of self-care. 
“When you trigger what’s called the relaxation response, it can stop psychological stress from being translated into inflammation,” Bowe says. 
“I have patients download the meditation app Breathe—five minutes a day can make a world of difference to skin.”
Regular exercise (and sex!) 
is also key. 
“Both increase levels of beta-endorphins, which fight the effects of cortisol,” Wechsler says. 
Even if you’re not feeling stressed, your skin may be. 
Environmental aggressors can also make your complexion freak out. 
“Pollutants cause the formation of free radicals, which damage DNA, resulting in skin aging,” explains Miami-based dermatologist Loretta Ciraldo, MD. 
“Irritants like dust mites and airborne allergens activate enzymes that break down collagen to worsen wrinkles.” 
Look for products with skin barrier–protecting ceramides, anti-inflammatory ingredients such as rose, and antioxidants like vitamin C and green tea. 
Topical and oral probiotics “send calming signals to skin,” Bowe says, and cannabidiol (CBD), a non-psychoactive component of cannabis, has shown anti-inflammatory and anti-acne benefits when applied topically.
Ingested in tinctures or gummies (like celeb-favorite brand Lord Jones, which will debut a skin-care line this month), CBD can diminish anxiety and summon a stressbusting snooze.
Can Botox make you happy?
Botox has moved far beyond its primary use as a cosmetic wrinkle reducer to become an FDA-approved wonder drug used to prevent migraines, excessive sweating, and overactivebladder issues. 
Next, it might supplant SSRIs as a treatment for clinical depression. 
The neurotoxin’s effects on mood are well documented—three randomized, double-blind, placebo-controlled trials have shown it can lessen symptoms of depression when injected in the “11 lines” between the brows—and now Botox manufacturer Allergan has begun the tests needed to clear it for widespread use. 
How does it work? 
One hypothesis is that by paralyzing the muscles that are engaged when you frown, Botox interrupts a biofeedback loop to the brain: “Facial expressions can directly influence emotions—smiling may cause people to feel happy, and frowning makes people feel sad,” says New York dermatologist and psychiatrist Evan Rieder, MD. 
But it’s not a balm for all. 
People who weren’t depressed, Rieder points out, “did not experience an elevation in mood in any of the studies.”
So, you're thinking about getting Botox? 
The popular injectible of botulinum toxin eliminates wrinkles by temporarily paralyzing muscles in the face—and if that doesn’t sound terrifying to you then did you even read the words “paralyzing muscles”? 
In spite of that, Botox was still one of the most popular aesthetic procedures in 2018—namely because the results are excellent, the downtime minimal, and the side effects (if done correctly) nearly non-existent. 
Even so, there are undoubtedly a lot of questions swirling in your mind before going under the needle. 
Here's what you need to know before Botox.
1
Be aware of where your injectable came from Make sure your doctor is an official vendor for any substance you're having injected. 
Allergan, Merz, and Galderma are three of the top manufacturers of neurotoxins and fillers—like Botox, Vistabel, Bocouture, Xeoxin, Azzalure, and Dysport—and Allergan also makes the fat-dissolving Kybella. 
To reduce the risk of getting a expired, contaminated, or potentially dangerous product, some manufacturers' websites offer a tool to search by zip code for every licensed physician who's obtained their product legally.
2
Bin the bargains If the price is questionably low for Botox or filler, you may be getting a diluted dosage, says New York–based dermatologist Kavita Mariwalla, MD. 
Another possibility is that your doctor purchased the product from a supplier in a country such as Canada or the United Kingdom, where government price controls keep pharmaceutical prices substantially lower than those in the United States. 
Not only is it illegal (with very few exceptions) for doctors to intentionally purchase medications outside the country for use on patients within the U.S., manufacturers also say that unauthorized suppliers may compromise the effectiveness and safety of injectables by, for example, not storing them at the proper temperature or even offering counterfeit products.
That said, prices for in-office treatments tend to be higher in metropolitan regions, such as New York, Chicago, and Dallas, where there's a greater demand for cosmetic procedures. 
To find out the price range in your area, call around. 
New York-based dermatologist Elizabeth Hale, MD, adds that you're usually better off with a doctor who bases his or her fee on how many units of product are used, rather than how many different zones of the face are injected. 
"All the muscles in the face are intertwined, and even when I treat, say, just the '11' lines between the brows, I always put a tiny bit in the forehead to balance things out—I don't count that as two [separate] zones."
3
Blood-thinning meds aren't the only thing to avoid pre-injection Most Botox and filler veterans know to lay off anticoagulants such as aspirin and ibuprofen before treatment, since those types of drugs hinder blood clotting and increase the risk of bruising should the needle nick a blood vessel. 
But Manhattan dermatologist Patricia Wexler, MD, has a longer list of things to forgo, including some seemingly innocuous pantry staples. 
"No fish oil, multivitamins, green tea, cinnamon, ginger, and red wine a full week before treatment," she says. 
"Antioxidants, though not all of them, can increase the fragility of blood vessels and prevent clotting." 
Ask your MD at least two weeks ahead of time for a full list of what to avoid.
"No fish oil, multi-vitamins, green tea, cinnamon, ginger, and red wine a full week before treatment," Wexler says.
4
A consultation is crucial"The person performing the injection should have you smile and frown and raise your eyebrows," Hale says. 
"An experienced professional is carefully evaluating you that whole time to see how different areas of your face naturally move, so that he or she can keep you looking refreshed instead of expressionless." 
Some derms like to ask patients to talk about something they're passionate about to gauge facial movement. 
You should also be given a thorough health assessment prior to the injection. 
Certain antibiotics, specifically in the aminoglycoside category, like gentamicin (prescribed for bacterial infections), can increase the potency of neurotoxins. 
(To avoid risk, don't receive treatment for the duration of your antibiotic prescription.) 
Worst-case scenario: You end up with a droopy lid, according to Mariwalla.
5
Bruises can be undone Neurotoxins generally require finer needles and are usually placed more superficially than fillers, but any injection could potentially hit a vessel, causing blood to pool beneath the skin and form an unattractive black-and-blue blotch. 
Fortunately, many dermatology practices, including Hale's, offer a next- day complimentary vascular laser treatment, which breaks down pooled blood into smaller particles, thereby greatly diminishing bruises within 24 hours. 
"It's a good idea to ask up front if whoever you're going to offers it," Hale says. 
"Our patients take a lot of comfort in knowing they can come back for that."
6
Not all fillers are created equal "Never get silicone. 
It's the one filler we see the most complications from," says Mariwalla of one injectable that's occasionally used—but not FDA approved—to fill wrinkles in the face. 
Unlike malleable hyaluronic acid–based fillers, which can be absorbed by the body and will eventually break down, silicone is a synthetic material that can't be metabolized and can harden over time, creating unsightly, uneven bulges. 
"It's permanent, and it does not age well with you," Mariwalla says.
7
Be prepared to take a minute For several hours after your shots, be prepared to avoid putting makeup, washing your hair, exercising, lying down, or messing with the injected zones. 
"You do not want to spread the toxin to muscles or weaken the injection," explains Wexler. 
You're also not going to want to fly for several hours after Botox, as there is some concern that change in cabin pressure will affect the spread of the toxin to muscles you do not want affected. 
Stay grounded (literally and figuratively) for a few days.
8
The Botox buzz Botox given between the brows (the 11’s), can give a temporary sensation of dizziness or headache, which Wexler calls a Botox buzz. 
"This is very transient, and is usually from slight swelling in the area from the fluid injected, and resolves within ten to 15 minutes," she says.
9
Early bird gets...the best results Preventative Botox is a term used when treating younger patients—say, those in their late twenties or early thirties—when expression lines are visible at rest and during movement. 
Starting early will not only prevent worsening, but can typically reverse these first blush lines and wrinkles. 
But, proceed with caution. 
"If you start using the toxin when no lines are visible, you will be using it for 50 years!" 
explains Wexler cautions.
I like to grind. 
Work-wise, dance-wise—let’s grind it out. 
But there’s an area I don’t appreciate grinding, and that’s my mouth. 
I remember when I first realized I was mercilessly grinding my teeth at night: I was on a shoot, getting ready to interview celebrity cosmetic dentist Bill Dorfman about teeth whitening. 
Before filming, he inspected my teeth to make sure everything was good to go.
“Your teeth are beautiful, but do you experience jaw pain?”
Thinking about it, yes, I did. 
My face and head felt sore all the time. 
I had more headaches in a month than I recalled having...ever (not related to politics at that point. 
Those were the days.) 
How did he know that? 
Turns out, my masseter muscle—more on this later—and teeth were a dead giveaway, specifically, my top incisors (the middle two teeth) and my cuspids (the canine teeth) of both my upper and lower jaw.
My cuspids had been sanded down from pointy to flat and straight-edged, and my front two teeth were uneven in length. 
These were the visual red flags that I had been getting my grind on. 
The masseter muscle is the muscle that helps you chew—it’s connected to your lower jaw and cheekbone. 
Because of my grinding, it’s like that muscle had been pumping iron: the constant chewing motion caused the muscle to become enlarged, altering the shape of my face. 
Dr. Dorfman cosmetically sanded my front two teeth so they were the same length and suggested I get a mouthguard to prevent future damage, but also suggested I look into the cause of this: TMJ.
What is TMJ? 
“The TMJ is actually an acronym for temporomandibular joint,” said Dr. Lawrence Fung, DDS of Silicon Beach Dental in Culver City, California. 
“The TMJ consists of structures that connect the lower jaw to the upper jaw and are involved in everyday chewing. 
It is within the TMJ structures that make a substantial contribution to the production of maxillofacial—jaw—pain.”
“A lot of times patients will come in having self-diagnosed TMJ issues,” said Dr. Victoria Veytsman, DDS of Cosmetic Dental Studios in New York City. 
“This presents pain in the jaw, headaches, tightness, difficulty chewing, earaches, limited opening, locking and sometimes clicking. 
When you see your dentist, they may choose to do imaging to evaluate any sort of damage to the joint as well. 
It can cause pain anywhere in the face, jaw and neck.”
Sounds about right. 
Aesthetically, wearing down of the teeth is the most common clue that you’re grinding them, and can ultimately speed up the appearance of aging. 
“Teeth shorten in length over time, with grinding giving a more aged appearance to the smile and entire face,” said Dr. Veytsman. 
“Shorter teeth mean reduced lower third of the face proportionately and gives the illusion of an aging face much faster.”
Once I got my teeth to a good place aesthetically, I was desperate to find out how to ease the pain and protect them long-term. 
First and foremost, I got a nightguard moulded to my mouth at the dentist’s office. 
At the very least, I didn’t want to grind my teeth down anymore than I already had. 
Now, I wear mine religiously. 
I don’t see stress as something that will ever totally disappear from my life—unless winning the lottery is in my future—but taking the time for breathing exercises and meditation before bed has helped me relax and prepare myself for a peaceful sleep. 
A CBD pen from Beboe also currently helps.
I’ve also been offered several practical tips to help calm my jaw inflammation, like avoiding chewy foods and keeping Motrin on standby to help with pain. 
I even tested out acupuncture (yes, on my face) and myofacial massage—in which fingers are used to massage the inside of the mouth—but nothing truly alleviated the aching I experienced long-term except for Botox.
How Does Botox Help With Teeth Grinding? 
Botox has several benefits. 
Of course, we know it as an injectable that helps with aging, but it can help lessen the aching of your jaw by stopping you from grinding your teeth.
“Botox correctly administered can be a great tool to help alleviate pain from grinding as it will help relax the muscles that are in pain,” said Dr. Fung. 
Officially, Botox is approved to relax the muscles in the face to prevent wrinkles from forming.
In this case, it relaxes the masseter muscle and prevents it from overworking.
I had noticed that my face was starting to look wider, and it was because I was building up those masseter muscles. 
Botox helps to lessen the appearance of this muscle—almost deflating it—so in addition to alleviating the clenching, it also slims your jawline. 
A great cosmetic bonus, in my humble opinion.
What Can Go Wrong? 
I’ve been getting this done for two years now, and there’s a few things I’ve learned over time. 
First, I should note that getting Botox injections in the masseter muscle are not an on-label usage for the substance, so make sure you find a professional well-versed in the anatomy of the face. 
You can discuss with your cosmetic dermatologist or a preferred ENT physician, neurosurgeon or dentist. 
(On-label uses for Botox include treating “the look of moderate to severe forehead lines, crow’s feet lines, and frown lines between the eyebrows in adults,” according to the brand website.) 
Overall, I get these injections every four to six months, about 30 units in each masseter muscle. 
There is such a thing as getting too much Botox—if you watch Bravo, you’ve probably been exposed to this—so beware. 
Make sure that you consult your injector prior to getting these injections and ask them how long they’ve been administering injectables like Botox specifically for the masseter muscle.
“Ask [your provider] what can go wrong. 
If you ask a lot of questions about the procedure, then you know that that person has an understanding of the right technique and potential complications,” said Dr. Nancy Samolitis of Facile Dermatology and Boutique in Los Angeles. 
“If you ask what could go wrong and they say, ‘nothing!’ 
that’s a little worrisome.”
Like Dr. Samolitis said, research is critical in finding someone to administer these injections, or any injection. 
You want to make sure they have a good history of performing this treatment or else you could end up like I did at one point, with a crooked smile. 
“The masseter muscle is located in close proximity to the muscles that make you smile,” Dr. Samolitis said. 
“The smile muscles are just a little more superficial. 
It’s very important that the person injecting you understands facial anatomy, because if the wrong muscle is injected or the Botox spreads to the smile muscle, you may not be able to smile for three to four months.”
This happened to me.
(I’ll spare you photographic evidence.) 
As someone who works on-camera for a living, this was a costly mistake—we ended up not airing segments I had shot because of my obviously asymmetrical smile. 
Unfortunately, this isn’t an immediately fixable problem. 
“Sometimes it only happens on one side. 
Do you go and paralyze the other side? 
It’s not something you’re able to fix. 
You just have to wait it out,” said Dr. Samolitis.
The beauty industry is rife with over the top claims about "miracle" skincare products and services, but one too-good-to-be-true innovation I can confidently get behind is the microcurrent facial. 
It involves using a low-grade electrical current to "train" your facial muscles to appear more lifted, tightened, and firm. 
In fact, its nickname is the "non-invasive facelift."
You know it actually works because it has been used medically since the 1980s, approved by the FDA as a muscle stimulator to treat Bell's palsy and muscle paralysis. 
After noticing improved results in patients with atrophied, sagging facial muscles, microcurrent was then adopted as an anti-aging tool. 
Top facialists like Joanna Vargas, Ildi Pekar, and Shamara Bondaroff swear by it, while at-home tools like NuFace and Ziip have become increasingly popular in everyday skin routines.
I experienced the magic of a microcurrent facial myself while visiting the Carillon Miami Wellness Resort. 
Feeling extra dry, dull, and puffy from flying and drinking beachside cocktails to my heart's content (how could you not?)
, I was looking for a treatment to contour my face and give it its glow back. 
Before getting into the facial, I gave myself half an hour to indulge in the massive spa's hydrotherapy circuit: I jumped back and forth from massaging waters, saunas, and steam rooms. 
By the end of it, my muscles felt melted like butter and all the steam had my face ready for Carillon esthetician Nerys Rodriguez to start my 80-minute microcurrent facial.
I walked away from the treatment room with visibly plumper-looking skin, major lift around my brows, more of a defined jawline, and more prominent cheekbones. 
I felt so confident that I totally skipped the usual contouring I do when I applied makeup later that day.
Impressed by my results, I chatted with the esthetician about microcurrent facials, how they work, and why people love them so much they're getting them weekly.
Microcurrent facials are like a gym workout for your face.
"The muscles on the face start going south, just like everything else. 
We have to keep it fit. 
So, we use current to stimulate the muscle, starting low then increasing gradually until you have the firmness you would like," Rodriguez explains. 
While Rodriguez says having a microcurrent facial once a month is sufficient, she adds that clients of hers at Carillon—the wellness resort is also residential—come weekly.
She adds that a microcurrent facial also doubles as an lymphatic drainage massage.
"That's why you were less puffy afterward," she tells me.
"We're hitting a lot of the pressure points on the face."
Microcurrent facials keep skin firm.
"Results are the eyes will be lifted, the forehead gets tighter, and you'll see more of an 'awakened' look," Rodriguez says. 
"It also stimulates collagen, so you'll have a fuller look as well. 
Collagen is the main protein the body has to build muscle. 
As we age, we lose collagen." 
As Rodriguez explains, microcurrent has been shown to encourage the production of ATP (Adenosine triphosphate), which leads to the creation of structural proteins like elastin and collagen.
The procedure starts out like a regular facial.
The entire process included cleansing, LED light therapy, exfoliation, serums, and masking. 
Rodriguez applied a thin film of a conductive gel on me (you can use any water-based gel) then used a microcurrent machine, which had two wands that the electrical current ran through.
I didn't feel any discomfort nor pain, just the cool metal wands lifting sections of my face and staying put for a few seconds and repeating before moving to the next section. 
"It's sending a signal for the muscle that this is where it belongs," Rodriguez says of "training" the facial tissue by going over different parts of your face multiple times.
Inside of the Carillon spa’s thermal experience.
Microcurrent is really safe for most people, but there are a few exceptions.
"People with heart issues, like if they have a pace maker, are not advised to get a microcurrent facial because it stimulates the blood," Rodriguez says. 
She also doesn't recommend microcurrent facials for those with severe acne, adding, "If it's a pimple here or there we can do it. 
If it's aggravated, I would not recommend it.
There's a lot of inflammation going on, so we don't really want to stimulate that." 
Pregnant women in their first trimester are also cautioned against doing it.
If you've had fillers or Botox, you should wait two weeks for it to settle before getting a facial. 
"We don't want to alter their results," Rodriguez says. 
After that period, however, "[botox and fillers] actually work better when you get microcurrent, because it'll make your procedure last longer. 
I actually recommend it, and I've seen great results where it lasts even longer, like the fillers and the Botox."
I noticed higher, tighter cheeks and a more defined jawline after my microcurrent facial.
At-home microcurrent tools work, but are not as strong as professional tools.
Rodriguez says younger clients can get away with using at-home microcurrent tools for maintenance. 
"You don't have to be so dedicated to a professional microcurrent service unless you really want to avoid sagging at all times," she says. 
"If someone's 50 and they're seeing signs of aging, you need something stronger." 
She does advise all clients to pair professional microcurrent facials with at-home tools for maximum results. 
"It only takes five minutes. 
And, I swear, I'm 45 and I use it and I see great results. 
I don't always have to use the professional machine from work, but I just use the NuFace and it's great too," Rodriguez adds.
There’s an unspoken rule on dating apps that says if you don’t meet the person you’re talking to within a week, it’s never going to happen. 
Someone’s leaving tomorrow to go solo backpacking for the month but will hit you up when they’re back? 
Forget about it. 
You have to “figure out your work schedule” before confirming Wednesday? 
No, you’re just not that interested. 
These things move quickly, so when you do find a hot filmmaker who lives in your neighborhood and is passionate about climate change, you have to shoot your shot—even if you have a standing lip plumping appointment on the books.
The good news is that the most popular cosmetic procedures of the moment are non-invasive, meaning you can go in on your lunch break and downtime is minimal or even non-existent. 
With a skilled professional and a great concealer, you can have your Botox and your Hinge date all in one night, whereas in other cases, it’s best to give your skin the buffer of a couple days off.
Below, Gabby Garritano, PA, founder of medical aesthetics clinic JECT NYC, and dermatologist Shereene Idriss, MD, of Union Square Laser Dermatology, break down the recovery windows for the most common beauty treatments. 
Because if you can avoid a guy knocking your newly injected cheekbones when he goes in for the kiss, trust me, you should.
What It Is: a fractionated, resurfacing laser with non-ablative (targets the tissue, not the skin’s surface) or ablative (removes the top layer of skin and creates open wounds) devices to address scarring, pigmentation, sun damage, wrinkles, and more.
Book Your Date: 1 week after. 
According to Dr. Idriss, it’ll feel like you have a bad sunburn for up to two days post-treatment, then over the course of the week, you’ll experience changes in pigmentation as the brown spots flake off. 
In addition to moisturizing regularly, the most important thing you can do is not pick.
What It Is: an injectable neurotoxin that smooths fine lines, wrinkles in the forehead, and crow’s feet by temporarily paralyzing muscles.
Book Your Date: the same day. 
Both Garritano and Dr. Idriss agree that bruising from Botox injections is unlikely and since you won’t see results in terms of facial movements for about a week, you are in the clear to go out immediately after your appointment. 
Garritano recommends icing any bumps that may occur at the injection sites, then touching up with concealer before leaving the office.
What It Is: an injectable hyaluronic acid substance that temporarily increases volume and definition in the lips.
Book Your Date: 2-3 days after. 
“The main side effects are bruising, swelling, and soreness, but that will subside several days after injections,” says Garritano.
“Take arnica, avoid drinking and taking aspirin products for 24 hours before and after the procedure, and ice the area.”
What It Is: an injectable hyaluronic acid substance that temporarily increases volume and definition in the cheeks. 
The main difference between injectables for the lips versus cheeks or smile lines is the density of the hyaluronic acid gel particles.
Book Your Date: 1-2 days after. 
The potential side effects are the same for fillers across the board, but less drastic here. 
Chances are, swelling and bruising will be minor, but you will be sore for a couple of days, so plan the date for a time you can smile fully without wincing.
What It Is: PRP facials, also known as “vampire facials,” take platelet rich plasma from the patient’s own blood and deliver it back into the skin via microneedling. 
Platelets contain high levels of growth factors, which stimulate cell turnover.
Book Your Date: 3-5 days after. 
“Immediately after, you’ll be red and may have some soreness similar to a sunburn, but that’ll typically resolve in 72 hours. 
More sensitive patients may have up to a week of a mild sunburn,” says Garritano. 
For the first week, you’ll want to avoid any retinoids or exfoliating products and apply minimal makeup.
What It Is: a skin-rejuvenating procedure that involves puncturing the skin with microneedles ranging in length from .5-2mm. 
It creates controlled injuries to the skin, which puts collagen production into overdrive, resulting in less visible scarring and increased plumpness and radiance.
Book Your Date: It depends on your skin.
Many people walk out of a microneedling procedure with an out-of-this world glow and wake up the next day looking great, while others have redness that lasts up to five days. 
If it’s your first time, the pros say to give yourself three days of downtime to be safe. 
The more you get microneedling (every four to six weeks is recommended), the less reactive your skin will be.
What It Is: a chemical solution applied to the skin that treats sun spots, uneven texture, fine lines, and acne. 
There are varying levels of chemical peels: Light, superficial ones use glycolic, lactic, or alpha hydroxy acids, while the deepest use tricholoracetic acid (TCA) or phenol and often require intensive aftercare practices.
Book Your Date: It depends on the strength of your peel. 
“Light peels have immediate redness with minimal downtime and you can expect to look your best within 24 hours, but stronger peels can have up to a week of heavy peeling and redness,” says Garritano, who notes that days two and three are usually when the dry, flakiness really starts to show. 
If you do go out, make sure your skin is heavily moisturized (Garritano loves Glytone Soothing Lipid Recovery Cream) and you’re using an SPF of 30 or higher.
What It Is: a minimally invasive facial that uses tiny crystals to exfoliate the superficial layer of dull, uneven skin and help stimulate collagen. 
Over time, it can reduce the appearance of dark spots, discoloration, and sun damage.
Book Your Date: 1 day after. 
Dr. Idriss says that even though microdermabrasion is gentle if done correctly and most people walk out with smoother, more radiant skin, there is always a chance you’ll be red post-treatment for a couple of hours to a day.
What It Is: a technique commonly used to remove hair from the root on the brows and upper lip.
Book Your Date: 1-2 days after. 
Redness and reactive acne are possible side effects, which will be made worse if you’re using retinol products (avoid them the week leading up to your appointment). 
Dr. Idriss recommends waiting a couple of days before dating for your skin to calm down post-treatment and keeping the area well-moisturized in the meantime.
What It Is: an injectable synthetic deoxycholic acid product that permanently destroys fat cells in the submental facial area and may require up to a maximum of six treatments.
Book Your Date: 2 weeks after. 
“Swelling and tenderness and numbness in the area is to be expected and lasts anywhere from one to two weeks,” says Dr. Idriss. 
She adds that you feel nodules post-treatment, which will gradually disappear, and you can massage the area if you can tolerate the pain.
Fuzz Buster: Laser Hair Removal What It Is: Laser hair removal isn’t new, but the technology has dramatically improved. 
The theory is simple: Pulses of laser light target the pigment in a hair follicle; the pigment absorbs the light and in the process damages the follicle, which prevents hair from growing back. 
“Someone with dark hair will get the best results,” explains Christian Karavolas, owner of Romeo & Juliette Laser Hair Removal in New York.
Cost: $500 to $700 per session for full legs; six treatments are usually recommended, spaced six to eight weeks apart.
What I Expected: I can certainly take a little pain in the name of vanity, but the idea of a laser systematically zapping the entire surface area of my legs had me in a cold sweat.
What It’s Actually Like: I’d chosen Romeo & Juliette because I had heard the name whispered in fashion circles—particularly in connection to Victoria’s Secret Angels, who I figure must know a thing or two about the subject. 
Lo and behold, the first person I see in the waiting room looks like an off-duty Angel. 
I take that as a good sign. 
I fill out a de- tailed questionnaire about my skin and health history, and then I’m led to a treatment room. 
The technician evaluates my skin, hands me a pair of safety goggles, and uses a red marker to divide my legs into quadrants from thigh to ankle. 
“Are you ready?” 
she asks sweetly before turning on the laser (the Synchro REPLA:Y Excellium 3.4). 
The first zaps feel hot and shocking, but once I realize it isn’t all that bad, I zone out. 
The technician asks me every couple of minutes if I’m okay, and honestly, I am. 
The whole thing is over in 25 minutes. 
When I sit up and look at my legs, though, my stomach drops: They are completely hairless (yay!)
, but they are also covered with bright red splotches. 
The tech assures me this is perfectly normal. 
She’s right: Within the hour, my legs look fine. 
And did I mention hairless?
The Results: Even after one session, I see a significant decrease in hair growth. 
After a few more, I stop shaving altogether. 
To be honest, I feel jubilant about the whole thing. 
Freedom from my razor! 
I can’t believe that I waited this long to do it. 
—Alexandra Parnass.
The Millennial Laser: Clear + Brilliant What It Is: An intro-level skin-resurfacing laser that works on all skin tones. 
Clear + Brilliant uses heat to poke fractional, invisible columns into your face. 
These micro-injuries stimulate new collagen, which treats early signs of aging—including fine lines, sunspots, enlarged pores, and dullness. 
“It emits the same energy as alternative treatments, but in a smaller, more shallow dose, so there’s less recovery time,” says Anne Chapas, MD, the New York City dermatologist who performed my treatment.
Cost: $300 to $500 per session, depending on your provider.
What I Expected: I went in wanting to even out my skin tone and restore the glow I’d lost from age, stress, and polluted Manhattan air. 
I’ve had laser hair removal done, so I was anticipating that familiar rubber band– snap feeling (spoiler alert! 
I was wrong).
What It’s Actually Like: The appointment lasts 30 minutes, but half of that time is spent getting frosted with numbing cream and waiting for the effects to kick in. 
The laser treatment itself takes less than five minutes, as Chapas makes quick passes over each section of my face. 
The sensation is hot, somewhere between getting poked by a tattoo gun and accidentally tapped by a curling iron.
I leave with a face that feels and looks as though I fell asleep on the beach sans SPF. 
It takes about two hours for the intense redness to fade, and 24 for the swelling to go down. 
Over the next few days, my skin has the texture of low-grit sandpaper.
The Results: On day five, the magic hap- pens. 
I wake up as smooth as a baby seal, with a radiance I’ve only ever been able to fake with makeup. 
My pores even look smaller. 
As for my dark spots, I don’t notice any improvement, but I was told that pigmentation issues typically require four to six treatments to resolve. 
—Maddie Aberman.
Boss Brows: Microblading What It Is: A semi-permanent tattooing process that creates the look of full brows. 
The practitioner, wielding a disposable microblade, etches fine, superficial cuts into the skin, then deposits pigment to mimic the appearance of real hairs. 
The effects last between one and three years—a dream for a natural blonde like me, who’s been spending 10 minutes each morning filling in my light, sparse arches.
Cost: Starts at about $700. 
At her New York City studio, Piret Aava (eyebrowdoctor.com) charges $1,500, which includes a touch-up.
What I Expected: I’m ink-experienced—I have 13 tats total, and I’m not too proud to admit that every single one of them hurt. 
But I had no idea what it would feel like to get a tattoo so close to my eyes. 
And I was worried about the possibility of going from patchy brows to boxy, asymmetrical ones.
What It’s Actually Like: The session is a lot like going to the dentist: You’re reclining in a comfortable chair with a bright light shining on your face, and you’re experiencing an entirely tolerable amount of pain. 
First, Aava mixes several samples of taupe pigment—lighter or darker, cooler or warmer—then paints a streak of each above my right brow. 
Mirror in hand, I decide with Aava which hue meshes best with my hair color and skin tone. 
After outlining my brows with pencil to map out the most flattering shape for my face—and dousing the area with numbing cream—Aava picks up her blade. 
And...phew! 
It’s a scratch-like sensation that’s no more uncomfortable than threading. 
For the next 45 minutes, my eyes water only two or three times as she etches tiny incisions along my brows and inserts the pigment.
The Results: Turns out, cutting your face without scabbing isn’t a thing. 
Mine is minimal, though for about a week, my look is more Groucho Marx than Lily Collins. 
But now, thanks to my microblading fairy godmother, I wake up with the full, neat brows of my dreams—no pencils or pomades required. 
—Kate Foster.
Line Limiter: Botox What It Is: An injectable neurotoxin (Botulinum toxin type A) that temporarily paralyzes muscles to reduce the appearance of wrinkles.
Cost: Depends on the doctor and the number of locations treated, but anticipate spending at least $600 for a small area, like crow’s-feet, and around $1,000 for a large one, such as the neck.
What I Expected: When I’m not smiling or laughing, I look like Grumpy Cat. 
I have what are called “11 lines” between my brows and several horizontal fore- head creases. 
I’m hoping a few shots of Botox will make me appear less like a feline meme.
What It’s Actually Like: “You definitely have some forehead lines and 11s,” confirms NYC dermatologist Macrene Alexiades, MD, PhD.
“How do you feel about your crow’s-feet?” 
“Do it all!” 
I tell her. 
The nurse applies some numbing cream. 
Alexiades tells me to hold the nurse’s hand, and prick, prick, prick goes the needle into my eyebrow muscles. 
I feel just a little pinch and drop the hand-holding. 
As Alexiades works, she explains that she administers Botox in two sessions, since it takes about a week for results to fully take effect. 
I’ll be returning a week later for a follow-up, when she can determine the areas that need more attention (which helps results last up to six months, instead of the usual four). 
The nurse tells me not to exercise, bend over, or lie down for the next four hours to help the Botox settle into the treated area. 
I’m so diligent about keeping my head up that I trip on a step while leaving Alexiades’s office.
The Results: I didn’t want an ice-block forehead, so that means I still have some lines, though they’re much more faint. 
I can still move my brows up and down. 
I was expecting my face to feel tight and stiff, but it feels basically the same as before. 
The overall effect is very natural—I look more relaxed, refreshed, and happier. 
Good-bye, Grumpy Cat. 
—Carol Luz.
In the past, when people complimented me on my skin, I would credit my glowing complexion to my relentless commitment to skincare (three steps: cleanse, hydrate, and protect) and sleep (minimum of seven hours per night). 
However, there was another “secret” that I wasn’t so keen to share: my bi-annual Botox appointment. 
As a woman of color, the topic of injectables wasn’t something that came up at brunch on a regular basis. 
I figured that everyone else who looked like me just wasn’t that into it—or not doing it at all.
According to Carlos Charles of Derma di Colore in New York City, he finds that roughly five to 10 percent of his clientele are requesting injectables, but notes they skew older and with lighter complexions.
“This is mainly because of the differences in the pattern of aging in light versus darker skin tones,” he explains.
“In lighter complexions, signs of aging such is fine lines and volume loss can occur earlier, since these are likely due to an increased susceptibility to the damaging effects of ultraviolet light. 
Also, the pattern of aging in darker skin is typically characterized less by fine lines or wrinkles, but more by overall volume loss later in life.”
"Women of color typically start neuromodulators [like Botox] a bit later than Caucasian patients."
As a beauty editor, I have written about injectables in the past, however, it started to feel weird to promote something that I actually never tried. 
After years of avoidance, and now in my early 30s, I finally buckled after seeing a male friend undergo the treatment and come out looking like a new man. 
After two appointments, I found myself loving the results. 
I looked like a better, more well-rested version of myself sans crow's feet or a wrinkled forehead (which happens when my stress level climbs).
So, why aren't more women of color talking about getting injectables? 
Ahead, we hear from dermatologists on the stigma of getting botox or fillers, the procedures themselves, and more answers to burning questions.
Who is the average patient getting injectables? 
Michelle Henry, a dermatologist and dermatologic surgeon based in New York City, estimates that roughly 50 percent of her clients are of color, and of that pool, about 25 to 30 percent of them are requesting injectables. 
“Women of color typically start neuromodulators a bit later than Caucasian patients, because melanin is protective against UV damage that contributes to the formation of fine lines and wrinkles,” she says. 
Henry adds that she most of her patients still fall within the late 20s and early 30s regardless of ethnicity.
What areas are people getting fillers/Botox? 
For those not super familiar with the filler-game, there are a ton of options available, but it can be confusing to understand what they do. 
To brush up, I caught up with Melissa Doft, a New York City-based, board-certified plastic surgeon to give me the run down on which injectable does what. 
Consider this your new cheat sheet the next time you go to the derm—or even plastic surgeon.
“Hyaluronic acid-thicker versions (like Voluma or Restalift) are great for adding volume to the cheeks, jawline or chin. 
Medium thickness injectables like Restylane, Juvederm or Belotero are excellent for around the mouth to fill in the laugh lines and nose for a liquid rhinoplasty,” Doft explains. 
“More common ‘thinner versions’ like Vobella or Refyne, work well for lips, ear lobes or tear trough—the groove between your lower eyelid and the cheek."
Fran E. Cook-Bolden, a New York City-based dermatologist, cosmetic surgeon and assistant clinical professor at Mount Sinai Health Center says that the areas most commonly treated among women of color include: "the forehead, the area between the eyebrows (known as the glabellar area), the area around our eyes (known as crow’s feet), particularly the area beneath our eyes after years of joyful smiles or squinching to read cell phone messages and lastly, the chin to correct dimpling or a cleft in the middle of the chin."
Will people notice that I got fillers or Botox? 
Naturally, when I had my first Botox appointment, I was nervous about what the outcome would be. 
Despite knowing my administer’s background, I was fearful that I’d look like a weird, altered version of myself versus a more, youthful refreshed one. 
And, turns out I wasn’t that far off to wonder if people “knew” what I had done.
According to Harold Lancer, a board-certified dermatologist based in Beverly Hills, who counts clients including Beyonc?
, Kim Kardashian West and Jennifer Lopez as clients (note: Lancer did not confirm any of the women above have undergone cosmetic procedures), there is a chance that the human mind can subconsciously detect irregularities. 
“If you look at someone, any body part, and it doesn’t match the rest of the surrounding environment you know something is wrong,” he explains.
“When using injectables, the anti-aging goal is subtle changes that leave patients looking refreshed and relaxed—as if they have just returned from a relaxing retreat or vacation,” Cook-Bolden adds.
Do women of color need to approach injectables differently from other patients? 
While most fillers are created equal, those with melanin-rich skin do need to be a bit more mindful about how things are administered. 
Women of color are often warned they're prone to hyperpigmentation—is it true? 
“Hyperpigmentation with injections is a function of the artistry and the expertise of the person doing it,” explains Lancer. 
“It’s not the material, it’s the method in which it’s done. 
Hyperpigmentation is a result of bruising causing pigment from the blood flow in the skin. 
Everyone is prone to that; however, it is more difficult to repair in darker skin types because you have competing melanin interfering with treatment protocols,” he explains.
Henry cautions that bruising can also occur on occasion. 
“If a component of blood called hemosiderin is deposited in the skin, it can leave long-term discoloration. 
This is much harder to resolve in darker complexions versus those with lighter skin tones.”
Is there a stigma toward injectables in communities of color? 
Beyond the logistics of fillers—why is everyone so hush-hush about getting them? 
You and I both know many of our faves over 40+ who looks suspiciously amazing. 
Is it their skin care regimen? 
Does black really not crack? 
Or do they have a not-so-secret secret that they simply aren’t disclosing?
“I think there is still a lot of stigma around cosmetic procedures in communities of color,” shares Henry. 
“There is still a sense that in changing one’s appearance, they are rejecting their ethnicity or heritage. 
However, this is starting to change and women of color are starting to benefit from cosmetic procedures with less guilt and stigma.”
“There is still a sense that in changing one’s appearance, they are rejecting their ethnicity or heritage.”
David Shafer, board-certified plastic surgeon and founder of Shafer Plastic Surgery & Laser Center in New York City notes that celebrities are more keen to share who their dermatologist is but not reveal who their plastic surgeon actually is. 
“Injectables are so popular right not that it seems like everyone—young and old—are requesting treatments,” he explains. 
"Social media certainly plays a role as well as the improving economy as people have more discretionary spending. 
Sometimes it can be frustrating as I would love if my celebrity and VIP patients would be more vocal about their treatments and procedures, but I respect their privacy and I think that is why they keep returning for more treatments with me,” he reveals.
What should you be looking for in a practitioner? 
Make sure whoever you're going to for fillers has a very customized approach for each patient. 
Subtle changes versus those that look “over-corrected” is a big concern for all patients, but is often a result of a cookie-cutter approach. 
“To achieve the most natural result, fillers and neurotoxins must be individualized to meet each patients need,” Cook-Bolden explains.
“Just like the practice of medicine is an art and a science, the use of injectables should be defined as a fine art. 
Opposed to just filling in spaces, we focus on the landscape or palette that we’re working with to restore volume and correct hollowing supporting and restoring ones natural, more youthful bony structure.”
Looking for a doctor who understands ethnic variations in beauty is key.
Henry agrees that looking for a doctor who understands ethnic variations in beauty is key. 
“For instance, the ‘perfect’ proportions for a Caucasian lip is 1:1.6, which allows for a slightly larger bottom lip. 
On the other hand, in Black and Asian women, we often see 1:1 ratio of the upper to lower lip, which is more common and considered more desirable in women of color.”
Are injectables worth their high price? 
While Botox and fillers can be costly—anywhere from $400 to over $1,000 in New York City, for example—the age-old saying “you get what you pay for” comes to mind. 
“There are too many cosmetic practitioners—and people—looking for price as the determining factor as to who does what. 
People are looking for a bargain versus a trained professional,” adds Lancer.
Part of what you're paying for are results that visibly flatter, but don't look obvious. 
“Great work should not be apparent in any ethnicity. 
The patient should look more youthful but not ‘worked on’—if it is noticeable, it is not good work, in my opinion,” emphasizes Henry. 
“Most injectors have a consistent aesthetic. 
Viewing their before and after photos will give you a sense of if their aesthetic is more subtle or natural.”
Bottom line: Aim to look like an enhanced-yet-natural version of yourself, prompting people to ask you “where did you vacation?” 
instead of “what did you get done?”
Flaccidity is closely related to age.
Currently, the fight against the passage of time and its impact on the body results in a continuous i d race for products and procedures aimed at mitigating the visible signs of aging.
Cutaneous flaccidity is a complex problem that involves intrinsic and extrinsic factors.
The loss of volume, excess of skin pigmentation and the low or irregular reflectance of light are among the intrinsic factors1.
On the other hand, the most relevant extrinsic factor is sun exposure, also known as photo-aging.
One of the first events in skin aging is flaccidity.
For example in the face, a descent of the middle and lower thirds occur.
Flaccidity can also be seen in other areas of the body, such as the abdomen or brachial area.
In this dynamic process, aging, as well as soft tissue and bone structures are involved1.
Not only is there a decrease in collagen, skin thinning and fat loss lead to flaccidity2,3.
In addition, there is a subtle interaction between bone resorption, fat atrophy, the thinning of collagen and elastic fibers1, and an evident decrease in cell turnover.
All these factors together added to the effect of gravity on the loose tissue, ultimately conduct to the formation of folds, wrinkles and the fine lines4.
Very frequently, the correction of these aging signs has been approached with surgical techniques and other invasive rejuvenation procedures, such as sutures5, or other suspension systems, like threads.
But these invasive procedures are not the desired choice for many patients.
Skin rejuvenation therapies should be oriented towards the mitigation of the damage and the restoration of the original structure of the tissues, in order to recover their mechanical properties.
Procedures should be as minimally invasive, safe and effective as possible, and deliver natural and more lasting, focusing on the needs of each patient individually4.
The objective of this study was to evaluate the safety and efficacy of AFLAX MLT?, a new multilevel, minimally invasive treatment to recover the elasticity and firmness of the skin.
Study design Prospective, non-randomized, single-center study, carried out on women, at the GMC Clinic center in Buenos Aires (Argentina), during February 2018.
The study was conducted in accordance with the principles established in the current revised version of the Declaration of Helsinki, with Good Clinical Practice (BPC).
Inclusion criteria: Women from 29 to 62 years old, with signs of abdominal flaccidity.
Exclusion criteria: i systemic pathologies, ii) under daily medication, and iii) have received any aesthetic treatment one month before or less of the first session.
Patients were consecutively recruited.
Patients received 3 treatment sessions with AFLAX MLT? in the abdomen, over a month, according to the product specifications.
A follow-up visit was made 30 days after the third treatment.
The treatment consisted of the administration of three products, two of them injectable and a third topical:  Vial 1: injectable for subcutaneous action.
Assets specially designed to act in depth, nourish and protect the tissues that offer trophic support and provide structural basis for the upper layers.
Active principles: glycine, proline, lysine, leucine, alanin, hialuronic acid, decapeptide-4, oligopeptide-24, lipoic acid, thiamin, cyanocobalamin, adenine.  Vial 2: intradermal injectable product specifically designed to act where proteins such as collagen, fibrin or elastin are synthesized.
Improves skin mechanical properties.
Active principles: centroxifenoxine, ascorbic acid, sodium lactate, copper gluconate, zinc gluconate, condroitin sulphate, tripeptide-6.  Vial 3: cosmetic topical product.
This cream on the most superficial layers of the skin (epidermis) producing a tensor effect, immediate and lasting.
Active principles: glutapeptide, cafesilane C2, celutrat, raffermine, sesaflash, lecithin.
Aflax MLT? protocol must be administered by a physician.
Before starting the treatment, skin mechanical properties were evaluated with a cutometer /MPA 580, Courage + Khazaka Electronic GmbH, Cologne, Germany).
The Cutometer? measures the elasticity of the skin by means of pressure (suction) that deforms the skin.
The resistance of the skin to the negative pressure is related to the firmness and its ability to return to the initial position.
All parameters are shown as curves in real time during the measurement.
This device allows the obtainment of information about the elastic and mechanical properties of the skin and to quantify objectively its efficiency.
Measurements were taken at a pressure of 450 mbar, through a 2 mm probe hole.
Cutometry parameters were: suction 2 seconds (on), 10 repetitions and 2 seconds between suction (off).
The treatment protocol included 3 sessions of AFLAX MLT? multilevel therapy in the abdomen, in a period of 1 month.
Each session lasted approximately 20 minutes and was performed by the same physician and in the same facilities.
Every session, included the application of the 3 AFLAX MLT? products (vial 1, vial 2 and cream): i vial 1 was injected at a depth of 5-6 mm through a slow, retrograde, fan technique, with a 27G / 40mm needle; ii) vial 2 was injected intradermally (3 mm), with a 30G1/2 needle: iii) and vial 3 was applied topically in the consultation.
The patient was given the tube of cream for a home-based application during the following 10 days, in the same area and once a day, until the next session.
After each treatment, pain was assessed with a visual analog scale (VAS), classifying it from 0 to 10 (0: no pain and 10: maximum pain that the patient was able to imagine). 30 days after the third therapeutic session, patient and physician satisfaction was evaluated, using a subjective 1 to 5 scale (1: not satisfied, 2: I am not sure, 3: a little bit satisfied, 4: satisfied and 5: very satisfied). 30 days after the third therapeutic session cutometry was performed again.
R0, R2, R5 and R7 variables were re-evaluated with the Cutometer?MPA 580.
At each treatment and follow-up visit, any adverse effects and its characteristics were recorded.
Analyzed variables were: age, patient and researcher satisfaction (outcome), pain and cutometry variables (R0, R2, R5 and R7).
R0: Parameter that shows the maximum amplitude of the curve and represents the passive response of the skin to force (firmness).
R2: represents the gross elasticity, which is the resistance versus return capacity
R5: represents the net elasticity: elastic portion of the curve.
R7: Assesses the portion of the elastic curve compared to the complete curve.
The closer is to 1 (100%), the more elastic the curve.
Side effects were recorded at every visit.
Unless otherwise indicated, quantitative variables are described as the mean followed by the standard deviation (SD) between brackets, while categorical variables are described as a percentage.
Statistical analysis included appropriate measures for statistical significance (Student?€?s paired two-sample t test) using the standard cutoff for significance of P 0.05 via Microsoft Excel.
he study included 39 female patients, with an average age of 45.80 (10.09).
Before treatment, the mean results of skin cutometry were: R0 = 0.28 (0.05) mm, R2 = 0.65 (0.09) mm, R5 = 0.42 (0.07) mm and R7 = 0.33 (0.04) mm.
After 30 days of the third treatment, the results were: R0 = 0.34 (0.05) mm, R2 = 0.76 (0.07) mm, R5 = 0.48 (0.07) mm and R7 = 0.33 (0.04) mm.
The differences between the pre- and post-treatment values were statistically significant for all variables R0 p <0.0001, R2 p <0.0001, R5 p = 0.0003 and R7 p <0.0001 (Figure 1).
The percentages of improvement of the characteristics of the skin at 30 days after the third treatment were: 22.91% for R0, 16.82% for R2, 14.40% for R5 and 20.73% for R7.
R0: Parameter that shows the maximum amplitude of the curve and represents the passive response of the skin to force (firmness).
R2: represents the gross elasticity, which is the resistance versus return capacity.
R5: represents the net elasticity: elastic portion of the curve.
R7: Assesses the portion of the elastic curve compared to the complete curve.
The closer is to 1 (100%), the more elastic the curve.
The subjective evaluation of the treatment by the patients, 30 days after the third treatment with AFLAX MLT? was: 35.90%  5 points “very satisfied”, 53.85%    4points “satisfied”, 10.26% 3 points “a little satisfied”, 0% 2 “I’m not sure”, 0% 1 “not satisfied”.
The subjective evaluation of the treatment by the researcher, 30 days after the third treatment with AFLAX MLT? was: 28.21%  5 “very satisfied”, 53.85%    4“satisfied”, 12.82% 3 “a little satisfied”, 5.13% 2 “I’m not sure”, 0% 1 “not satisfied”.
The average of the subjective assessment by the patients included in the study was 4.26 ± 0.64 and 4.05± 0.79 by the researcher. The differences between the two assessments were not statistically significant (p = 0.2010).
The average value of pain assessment by the patients after the application of each product of AFLAX MLT? treatment, by a VAS  scale: was: 2.33 ± 1.44 for  vial   1;2.77 ± 1.51 for vial 2 and 0.03 ± 0.16 for cream. The differences between vial 1 and vial 2, both administered by injection with 27G and 30G1/2 needle respectively, were not statistically significant (Table 1).
The only adverse effects observed were the usual mild inflammatory signs after a puncture. All resolved within few days.
The results of the study show that AFLAX MLT?? multilevel therapy improves the mechanical properties of the skin, significantly increasing firmness and elasticity.
Both the patients and the researcher evaluated positively the results.
The treatment was well tolerated by the patients, without observing adverse effects.
AFLAX MLT?? multi-level treatment is designed for each product to act at the proper level and help replenish the original structure of the tissue that has deteriorated over time.
Each product contains different actives and its action targets a specific depth of the skin.
This approach is based on the multi-factorial physiopathology of flaccidity.
The results obtained are good and patients?? appearance is natural.
This treatment is indicated when the first symptoms of skin aging appear, so that it could delay the onset of the visible signs of flaccidity and restore the damage.
These statements can be made after reviewing the results of the cutometry, a validated technique that analyzes the mechanical behavior of the skin and thus, the repercussion of age-related changes and photo- aging.
R parameters recorded an important increment in skin firmness compared to the basal values.
Other treatments, such as injected conditioned autologous serum, have also reported an improvement in skin characteristics, but the results have not been as good as the ones reported in this study, with AFLAX MLT??.
Increments of 10.38% in R0, 16.59% in R2, 11.21% in R5 and 16.16% in R7 were reported.
Other techniques such as non-invasive treatment with ultrasound, have also reported the amelioration of the mechanical properties of the skin.
A study assessed the improvement of normal skin after the application of ultrasound, obtaining an improvement in firmness (R = 0) of 15.95%, and 5.52% in the elastic component (R2).
The multi-level treatment AFLAX MLT? offers a minimally invasive option, with no important side effects and with significant results that improve the mechanical characteristics of the skin in a natural way.
However, more studies would be needed with a greater number of patients, in which men were included and with longer follow-up.
Likewise, the duration of the treatment effect should be evaluated and assessed to see if it is possible to improve the result by administering a greater number of sessions and analyze whether it offers the same benefits in other areas of the body.
As it is known the leading and prompting role of involutionary skin changes genesis is caused by abnormal microcirculation based on endothelial and immune dysfunction as well as structural and functional alterations in intercellular matrix (ICM), represented by the consequences of mainly quantitative and functional interruptions in systemic interaction of connective tissue and immune cells 1-4.
Along with that, objective characteristics of involutionary skin changes with well-known clinical signs can be achieved using instrumental skin assessment to make it more specific.
Nowadays, autofibroblasts have proven their efficiency in correcting facial contour, various folds, wrinkles, and atrophic scarring.
Satisfactory clinical effect was observed after three transplantation procedures and lasted for some months5-6.
It is convenient that the biopsy can be repeated many times, cells can be obtained at early passages with the possibility of cryobanking until the next time application.
Safety and efficiency of dermal fibroblasts autotransplantation have been proven by the results of many multi-central randomized placebo-controlled double-blind clinical studies7.
Until now, the most well-known and officially recognized technology of dermal autofibroblasts application was developed in the USA, LAVIV (azficel-T by Fibrocell Science company.
In 2011, FDA (Food and Drug Administration) authorized Fibrocell Science with the right to use LAVIV (azficel-T for nasolabial folds correction7.
However, despite the quite convincing results of fibroblasts autotransplantation, the obtained effect is not always satisfactory neither regarding the clinical manifestations nor the duration of action.
Therefore, currently, new approaches are being developed to the method, sometimes combining it with transplantation of cells with different tissue origin.
A new way of using platelets properties in the course of their co-transplantation with fibroblasts is currently being developed.
However, there has yet to be presented convincing evidence of such an approach's effectiveness in cosmetology at this point.
Nowadays platelet functions have demonstrated a fundamentally new, unexpected side.
As it turned out, the platelets actively participate in inducing inflammation, necessary to prompt the immune reflex, renewal, and formation of immunological response via the cells of native and adaptive immunity (containing TLR-2, TLR-4, TLR-7 ?– TLR-9)8.
They produce lots of growth factors as well as other biologically active substances.
According to the available data, platelet granules contain 827 proteins and their secretion provides cross-coupling of platelets, immune and stromal cells.
It has been shown that fibroblasts stimulated by cytokines respond with the synthesis of collagen and non-collagen proteins10.
Administration of platelets or their products prior to dermal fibroblasts leads to the limited, moderate inflammation.
It may create the conditions for adequate influence upon the transplanted fibroblasts of inflammatory cytokines which in their turn, provide a positive selection of young cells and stimulate their activity.
In this way an increase of cellular efficiency of autofibroblasts can be achieved, transplanted following the platelets, and therefore, we can expect an increased number of young skin fibroblasts because of their high remodeling activity.
In the view of the above said and considering the main function of fibroblasts, at the heart of the method of involutionary changes correction development called neofibrolifting lies the idea of autotransplantation of exactly these cells.
Based on the information regarding the fibroblasts properties in ex vivo cultures as well as currently known powerful stimulatory action, we designed the method which implies prearrangement of moderate and positive inflammation using the platelet- based product.
As a result we influence fibroblasts and inflammatory immune system cells with the following transplantation of autofibroblasts in the initially prepared area.
Throughout this article we would like to present the results of practical use of neofibroblifting method, which is based on stimulation of connective tissue and immune cells by means of growth factors and cytokines followed by administration of autologous dermal fibroblasts.
The study involved female patients who turned to the Institute of Plastic Surgery “Virtus” for cosmetological assistance, with concerns regarding the process of involutionary skin changes.
They were divided into 4 age groups: 25-35 y.o. (n=13), 36-45 y.o. (n=16), 46-55 y.o. (n=18), 56 and older (n=13).
Prior to participation in the research program all patients were examined by a dermatologist, physician, surgeon, endocrinologist and clinical immunologist.
In cases of existing pathology that required treatment, patients received necessary recommendations  and were excluded from the program of involutionary skin changes correction.
The material for obtaining and culturing dermal fibroblasts was obtained from the postauricular area punch-bioptate using the 3.5 mm punch-needles.
Following the mechanical morcellization, the achieved tissue fragments were transferred to the Petri dish into the warm (37,0±0,5°?) growth medium DMEM/F12 with L-glutamin (CTS? GlutaMAX?-I Supplement, Gibco), 1% non-essential aminoacids (MEM Non-Essential Amino Acids Solution, 100×, Gibco), 9 nmol main fibroblasts growth factor (FGF-Basic (AA 1-155) Recombinant Human Protein, Gibco), 15%  fetal bovine  serum  (Fetal Bovine Serum, Gibco) and 0.5% antibiotics (Penicillin- Streptomycin, Gibco). Then the dishes with the material were placed into CO2-incubator.
The culture medium was changed every 3-4 days.
Plasma rich platelets (PRP) were extracted out of 20 ml of the patients' whole venous blood.
For that purpose, a Harvest Smart PReP2 centrifuge (USA) was used.
For structural skin changes evaluation an Ultrasound dermal scanning method by means of mobile high-frequency US device ?DUB - Digital Ultraschall Bildsystem-tpm? with Software DUB-SkinScan ver.3.2 (Germany) was used.
Epidermal hydration level was evaluated using corneometry, based on the measurement of electric capacity of dielectric medium.
Examination of the epidermal barrier function was carried out by measuring skin surface moisture evaporation, transepidermal water loss (TEWL).
The studies employed the diagnostic system Multi Skin Test Center? MC 1000 (Courage+Khazaka electronic GmbH, Germany).
For blood flow testing an ultrasound Doppler scanning (device Minnimax-Dopler-K? St.Pete, Russia) was used.
Blood flow rate in microcirculatory bloodstream was measured using the sensor with emission frequency of 25 mHz.
Additionally, volumetric blood flow rate skin control, forehead and mental area was performed (Qas in ml/sec/cm).
For the interpretation of the results the critical value of significance level was considered 0.05.
The obtained results were processed using the variational statistics methods and Excell (MS Office XP).
As a means of descriptive statistics for quantitative measure, the mean (M value with standard deviation (±SD) was used as well as the Student parametric statistics (t .
Neofibrolifting technique was performed the following way: PRP was administered intradermally at the amount of 14 ml.
After 2 weeks, the same area was treated with intradermal transplantation of 60 mln autofibroblasts.
Bioptates harvesting for the research was performed prior to the treatment, 2 weeks after PRP administration and then 2 weeks afterwards, on the 6th and 12 months after the fibroblasts autotransplantation.
On certain dates, clinical lab and instrumental exams were performed.
As shown in tables 1-7, neofibrolifting resulted in the essential improvement of structural and functional skin parameters (Table 1).
Table 2 shows that the dermal thickness essentially increased in the youngest group as a result of PRP action and remained thick up to six months after the administration of fibroblasts, having normalized after twelve months.
Such an easy enhancement might be the evidence of the so-called reserve of regeneration mechanisms at a relatively young age.
In three other older groups, a considerable increase of dermal thickness took place just six months after autotransplantation and continued increasing up to the twelfth month following the treatment.
Table 3, shows the acoustic skin density also increases as a result of neofibrolifting.
In two young groups this result took place after six and twelve months following the fibroblasts administration, while in other older groups the skin acoustic density increased already after the PRP administration and remained increased up to the end of the studies and even grew thicker in the 2nd and 3rd groups after twelve months.
Analyzing the changes of corneometric anova parametric values in female patients’ skin of different age groups in the dynamics of fibrolifting treatment (Tables 4 and 5), it was discovered that the level of skin hydration in all studied groups increased following the treatment, while TEWL gradually decreased.
We can observe pronounced tendency of increasing corneometric indicators after PRP administration in all the studied groups, while considerable increase was shown only in group 3.
After fibroblasts administration skin hydration became considerably high in all groups, however the high and level in 12 months was recorded only in the 2nd and 3rd groups.
TEWL indicators influenced by neofibrolifting dropped considerably after 6-12 months following autofibroblasts implantation, except for the older group of patients, where the changes after 12 months period seemed uncertain (Tables 6 and 7).
In patients of 56 years of age and older, the increased VBF in the forehead area was observed just after PRP administration; proved stimulation in the cheek area was registered after fibroblasts autotransplantation.
Involutionary skin changes process was determined by progressively decreased epidermal, dermal thickness, acoustic skin density, its hydration, increased transepidermal loss of water (TWEL) and slow blood flow rate, in the forehead and cheek area that possibly is a proving evidence of the influence of microcirculation disorder that leads to structural and functional skin disorganization.
Our studies proved that after the administration of the fibroblasts the epidermal thickness clearly increased in all age groups, while in group 46-55 y o , it had a demonstratively positive and considerable reaction to the PRP administration (Table 1).
In the 1st, 2nd and 4th groups the effect was achieved following autofibroblast administration.
Positive effect of the procedure related to the epidermal thickness was observed after six and twelve months only in the 46- 55 y o age group.
Increased skin acoustic density as a result of neofibrolifting influence can be explained by the enhanced synthesis of collagen fibers, which represents the key elements, that reflect ultrasound waves in the organized state [Jasaitiene D et al, 2011].
Therefore, according to the structural and functional indicators skin conditions were substantially improved based on such indicators as epidermal and dermal thickness, acoustic density, corneometric and evaporimetric data practically in all age groups, most frequently following the fibroblast administration.
The achieved effect lasted for 6-12 months in most cases after autotransplantation It can be assumed that positive skin changes in the process of neofibrolifting treatment can basically be explained by the considerable stimulating therapeutic effect on the volumetric blood flow rate (Tables 6 and 7).
As it is demonstrated in the presented tables, the volumetric blood flow (VBF) in the course of neofibrolifting increased in the forehead and cheek area.
However, in the 1st and the youngest group of patients (25-35 y o ) the increase in the forehead area was observed only in terms of pronounced tendency and it was only in the cheek area that the increased blood flow was real at the end of observation period.
In the group of patients of 36-45 y o , VBF increased considerably in the forehead area for six months following the fibroblasts treatment and lasted for twelve months.
Increased VBF in the cheek area in this group took place immediately after fibroblasts administration and as well lasted until the end of observation.
In the group of 46-55 y o , the real increase of VBF in both areas took place immediately after autotransplantation and lasted for twelve months of observation, however in the forehead area the increased indicators during the observation period had only pronounced tendency nature.
It is important to note that VBF stimulation at the level of pronounced tendency in both areas in all groups of patients was registered just after PRP administration.
Such an obvious consistency even despite the large range of measured values, allows one to assume that PRP administration practically always promotes those necessary fundamental changes that provide further development of transplanted autofibroblasts effect.
Therefore, as a result of the neofibrolifting treatment we can observe pronounced stimulation of age-related structural and functional skin indicators such as: epidermal and dermal thickness, acoustic density, hydration of epidermis and TEWL, as well as VBF in forehead and cheek areas.
The obtained results indicate that aging skin goes through serious structural and functional changes that involve both epidermis and dermis.
They have complex and complicated nature and result in the abnormalities of different levels of regulatory mechanisms.
That is why dermal fibroblasts stop receiving enough metabolic microcirculatory support, and are negatively influenced by endothelial dysfunction, which is largely developed by immunologic mechanisms.
Apparently, understanding the immunopathology process of skin aging mechanism and its influence over the development of involutionary changes has become the key issue in the aging skin regeneration approaches.
As a result of neofibrolifting, VBF rate essentially increases under the influence of fibroblast autotransplantation.
PRP administration can strongly influence indicators mainly in the forehead area and only in the group of patients at the age of 56 and older.
However, in all cases, obvious regenerative tendency can be observed. 2.
All structural and functional aging skin indicators can be largely normalized by using neofibrolifting.
PRP administration in some cases could lead to positive results, however, the "complete"?neofibrolifting, that is PRP combined with autofibroblasts led to the promotion of regeneration and normalization of functional and structural indicators.
Most studies which demonstrated a regeneration of aging skin were observed over the whole period following the treatment of twelve months.
Cellulite is a very common syndrome, universally characterized by the accumulation of localized adiposity and increased body weight1,2.
The condition is so prevalent (especially in women) that many studies have sought to determine whether it is a pathologic occurrence or should even be considered a chronic disease precisely because it is so common.
Although it is very difficult to define a condition that is not considered pathologic, if a condition affects quality of life, it becomes pathologic.
Scientific research tells us that although the genesis of so-called cellulitis is linked to causal, hormonal, genetic, circulatory, and lymphatic factors, it also depends on the subjec's lifestyle.
In the last few years, different modalities have become available for the noninvasive reduction of adipose tissue, including radiofrequency and low-energy laser procedures, high intensity focused ultrasonography, and cryolipolysis3.
In March 2018, an American Society of Plastic Surgeons Report showed a rise in body shaping and non-invasive procedures; the statistics also reveal Americans are turning to new and innovative ways to shape their bodies, as minimally invasive cosmetic procedures have increased nearly 200% since 2000.
More people are choosing to shape different parts of their bodies using ultrasound, radio frequency, infrared light, vacuum massage and injectable medication to reduce fat cells.
Non-invasive procedures to eliminate fat and tighten the skin are gaining popularity, with the fastest growing procedure - cellulite treatments - up nearly 20% over last year 2017.
The term cryolipolysis refers to the gradual and noninvasive cooling of adipose tissue to induce a process called lipolysis, or the breakdown of lipids.
Among these technologies, cryolipolysis has been studied most often, both in in vitro animal models and in randomized controlled trials involving humans.
Scientific studies have shown that under conditions of prolonged exposure to temperatures close to freezing, fat cells are more vulnerable to the effects of cold than surrounding tissues are7.
Other scientific articles have demonstrated that exposure to cold induces the apoptosis of fat cells and the production of cytokines and other mediators of inflammation that gradually eliminate the cells involved8.
In the weeks after treatment, macrophages steadily digest the fat cells exposed to cooling, thus reducing the thickness of the treated adipose layer.
The lipids derived from the cells are slowly released and transported by the lymphatic system for processing and elimination, as happens with fats derived from food.
Although inflammatory reactions and the in situ recall of cells responsible for the elimination of particles are triggered by cryolipolysis, the therapy does not alter blood chemistry values.
This finding indicates that the technology is noninvasive compared with other techniques.
The low rate of adverse effects associated with cryolipolysis is, in fact, the main reason doctorsand patients prefer this technology over others.
The first target of a body remodeling treatment is certainly to guarantee the best result, one that is tangible, lasting, and maximally safe in terms of collateral risks10 and ineffective outcomes.
In this study, we combined the destruction of adipose cells with the simultaneous emission of modulated currents (50-Hz pulses) to sculpt the dermal-epidermal profile (cutaneous), while improving the elasticity of the skin and preserving uninvolved tissues.
The use of cold temperatures combined with a vacuum exploits the principles of cryogenesis and cryocyanogenesis, which act on areas with excess fat, facilitating its disposal.
As stated previously, after treatment, an apoptotic process is triggered in the adipocytes, which leads to a natural, physiological death.
The cells of the immune system determine the natural disposal of damaged adipocytes.
Our approach to this retrospective study was to demonstrate the irrefutable and certain validity of cryoliposculpt treatment through the analysis of data and presentation of the results.
A total of 40 patients were involved in our retrospective study, divided into two cohorts.
Inclusion criteria included an age between 20 and 66 years, presence of localized adiposity and so-called Cellulite (PEFS - Edematofibrosclerotic Panniculopathy), in diet treatment by weight loss with personalized diet.
Exclusion criteria: patients in pregnancy / lactation, renal / hepatic insufficiency, previous cardiac pathologies and / or in pharmacological treatment.
For this study, recruitment of patients was ultimately based on choice of anatomic area and thickness of the fat layer and recognition that cryolipolysis is not recommended for everyone (ie, it is indicated for localized adiposity rather than for obese patients and is most suitable for"body sculpture"?.
All subjects were evaluated after undergoing a medical examination, an anthropoplicometric examination, ultrasonography of the panniculus adiposus, and blood tests.
Patients were assigned to one of two groups: patients who followed a balanced low-calorie diet only or patients who followed a balanced low-calorie diet and underwent a body rehabilitation protocol with cryolipolysis combined with bioactive currents in different areas (Cryoliposculpt).
Every 15 days the weight was checked and the measures of waist, hip, abdominal line, buttocks circumference, thigh root and thigh median were evaluated.
Photographs were taken before and after the evaluation period because it has been shown that cryoliposculpt also induces action on fibroblasts over time11.
The evaluations of our retrospective and observational study were conducted at T0 (baseline) and at T1 (ie at 8 weeks from the beginning of the therapeutic program) as inspected by other studies in the literature.
All the raw data collected, of the anthropometric measurements already specified, have been elaborated and produced using statistically relevant graphs.
The cryolipolysis device used in this study is called Cryoliposculpt.
It has unique technical characteristics that guarantee the efficacy and safety of the treatment while preserving cellular structures and their functionality.
The applicator generates aspiration through an active vacuum, which sucks the treated area inside a cavity, where it comes into contact with two cooling elements.
These cooling elements reduce the temperature by 8°C to 10°C A contact sensor constantly monitors the surface temperature of the skin to ensure safety and efficacy throughout the treatment (Figure 1).
The active non-inertial vacuum, which is continuous and customizable (with respect to the mechanical resistance of the tissues), preserves local microcirculation.
In addition to an inertial vacuum, the device allows delivery of a cycle of modulated microcurrents emitted in succession (spikes of current at 50 Hz) in a random way that does not induce adaptation in the cells.
The microcurrents act on the extracellular interstitium, the microcirculation, and the remodeling and orientation of the collagen fibers without inducing a joule heating in contact with the tissues12.
During treatment, the applicators were positioned on the area of the body where the patient hoped to reduce fat.
An inverse thermal shock was applied to the underlying adipose tissue, cooling it to freezing, while avoiding other tissues.
Although the tissues were under a negative pressure of about 30 mm Hg for 50 minutes during standard treatment, the constant mobilization of the tissue ensured there was no vascular damage or atrophy of the microcirculation; thus, no post-treatment massage was necessary13.
The other Cryolipolysis machines on the market cause the formation of the “stick of butter” and, therefore, to avoid problems are matched as a result of the treatment or manual massages14 or shock  waves  to  accelerate the process of ‘restitutio ad integrum’ of the treated tissues.
We enrolled a total of 40 patients with localized fat and cellulite (average age, 43 years).
Of these, 20 patients were treated with a personalized balanced low-calorie diet and cryoliposculpt and 20 patients followed only a personalized balanced diet.
After measuring the previously indicated areas (waist, hips, abdominal line, buttocks, thigh root and thigh median) at T0 and T1, in this retrospective study we observed in the cohort that performed both the diet and the cryoliposculpt, better results compared to the cohort that only performed the diet.
All 40 patients performed a similar personalized diet.
We observed that the cohort patients who did both thedietandthecryoliposculpt, weremuchmoreadherent and precise in following the dietary indications achieving better weight loss results.
From the measurements measured at T0 and T1, in the areas already specified, we observed a quantitative improvement in localized fat deposits and treated cellulite (Figure 3).
In patients treated with cryoliposculpt, we observed a marked improvement in the dermoepidermal tonicity of the treated areas.
We verified with these patients the results, using a verbal questionnaire concerning the result obtained on a scale from 0 to 3 (0 = null result, 1 = discrete, 2 = good, 3 = excellent), which confirmed our observation.
These observations were also confirmed by the photographic documentation carried out at T0 and T1, with frontal, rear, right lateral and left lateral views, using a standardized grid for the position of the feet.
The evaluation of the photos was made by us doctors and by the patients themselves.
Figure 3 shows the average measurements reported between T0 and T1 (ie, 8 weeks from the beginning of the therapeutic path), the period necessary to determine real results of the treatment7.
We managed to reduce the average waist circumference by 3.65 cm with combined cryolipolysis and diet versus a 1.65-cm reduction with diet alone, a greater than twofold difference between the groups.
The most striking and significant result was evident in the side area, with an average reduction of 4.55 cm in the combined cryolipolysis and diet group compared with 0.275 cm with diet alone, an approximately 16- fold difference between the groups.
In the abdominal area, average reductions were approximately 6 cm and 1.7 cm, respectively.
In the buttocks, average reductions were 7.9 cm and 1.4 cm, respectively.
In the thighs, reductions of 3.35 and 2.625 cm were observed in the cryoliposculpt and diet group compared with reductions of 1.05 cm and 1.275 cm in the diet only group (Figure 4 and Figure 5).
We therefore deduce that a therapeutic treatment program that includes cryoliposculpt and a balanced and controlled diet facilitated reductions in circumference in different areas of the body that were approximately 4 times greater than those produced by diet alone.
The results of the present study suggest an important role of cryoliposculpt in the so-called cellulite, as association of cryolipolysis and active microcurrents for the improvement of the tone and texture of the treated tissue.
This new technique was shown to be a good and safe alternative to invasive treatments of adipose tissue16, even if it remains the gold standard.
Overall, the study demonstrated a reduction in different anatomic areas that was approximately four times greater than that obtained with diet alone.
The safety of all results obtained and efficacy of treatments, inaprotocoltestedworldwide, letsconvalited non-invasive alternatives to body remodeling.
No adverse collateral effects were shown.
Damage to and destruction of adipose cells was achieved without adverse effects to nearby tissues and vascular vessels while preserving all cellular functions of the treated tissues that were under mechanical stress and thermal shock inverted.
Nerves and bones were also unaffected, and no changes were observed in the main organs of the body17.
Gradual improvements over time in the thickness of adipose tissues, illustrating the concept of systemic body remodeling, induced physiological - but nontraumatic - reactions in the body.
Overall, we observed greater improvements in areas with a large quantity of adipose tissue; in addition, the biological inflammatory process removed adipocytes over time and reduced the adipose layer.
Thus, adipose tissue freezing offers a potential new option for many people by remodeling the body without any invasive side effects.
Adiposis dolorosa (AD) was first described in 1892 by the physician, philosopher, neurologist, scientist, Francis Xavier Dercum1-4, from a case in the Philadelphia Hospital.
In this original paper, Dercum described 3 cases of the disease with the gross pathological findings of 2 cases, both of which showed abnormal thyroid glands, thus leading the neurologist to believe that the disease was a clinical entity on the basis of a"disthiroydia"?
This article was preceded by a case report by Dercum himself in 18886, as a 51 year-old woman of Irish heritage with severe pain and enlarged subcutaneous adipose tissue on her arms and back.
He wrote: "Evidently the disease is not simple obesity.
If so, how are we to dispose of the nervous elements present?
Equally plain is it that we have not myxoedema to deal with.
All of these cases lack the peculiar physiognomy, the spade-like hands, the infiltrated skin, the peculiar slowing of speech, and the host of other symptoms found in myxoedema.
It would seem then, that we have here to deal with a connective tissue dystrophy, a fatty metamorphosis of various stages of completeness, occurring in separate regions, or at best unevenly distributed and associated with symptoms suggestive of an irregular and fugitive irritation of nerve-trunks - possibly a neuritis...
Inasmuch as fatty swelling and pain are the most prominent features of the disease, I propose for it the name Adiposis Dolorosa"?
Dercum regarded the disease as a clinical entity and named it adiposis dolorosa (AD) because of its most characteristic symptom, painful fat.
In 1899 White7 described an interesting case of AD as follows: "My patient shrieks when she is gripped...my patient can hardly walk,...My patient goes out of her mind temporarily.
Headache is a common symptom.
Herpes, hematemesis, epistaxis, early menopause, slight pigmentation of the skin, atrophy of the muscles of the hand, and reaction of degeneration of them have all been described as occasional symptoms. ...In my case administration of thyroid did no good....She has been in several hospitals but all with no benefit"?
The first clinical classification system for AD (also named Dercum's Disease, DD) was developed in 1900 by Giudiceandrea as follows: I Nodular type.
A form with painful lipomas, most commonly on the arms or the legs or on the back or thorax.
Sometimes the lipomas occur on multiple locations and occasionally the lipomas form a confluent mass.
The nodules are variable in size and painful on palpation.
A form with diffusely painful adipose tissue.
The pain is symmetric.
A form with diffusely painful adipose tissue and with painful nodular masses.
This classification was then revised in 1901 by Roux and Vitaut9 which proposed four cardinal symptoms of DD, used as diagnostic criteria for several years.
What was reported by Burr in 1900, was then confirmed in 1902 by Dercum19 who described two other cases of AD and considered the most interesting histological finding to be interstitial inflammation of the nerves in the adipose tissue of the painful sites.
In the same year, Dercum and MacCarthy20 published a case of AD with complete autopsy findings, the main pathological lesion being an"adenocarcinoma"?of the pituitary body, while the thyroid appeared regular.
Next, several cases were described, many of which showed abnormalities of the pituitary gland.
DD was also defined as a disorder of the "?haemolymph"?system by Dercum and McCarthy themselves20 and "a general disease of the lymphatic system"?by Mills, suggesting that dysfunction in the hemovascular and/or lymphatic systems may contribute to the development of lipomas.
As early as 1910, Stern noted that neuropsychiatric disturbances and asthenia did not accompany every case.
Cushing in 191227 first questioned the rationale of calling the disease a clinical entity, stating that, in his opinion, many cases reported as AD, "are actually examples of disturbed metabolism secondary to disease of the ductless glands"?
In his later articles, Dercum appeared to be of the same opinion.
In sections from DD adipose tissue increased levels of connective tissue were described by Myers in 1923.
In 1924 Purves-Stewart29 classified the disease among the thropho-neuroses, probably due to disturbed activity of the thyroid and the posterior lobe of the pituitary body.
Winkelman and Eckel in 1925 reported that the disease could be considered as a polyglandular disorder with a consequent altered fat metabolism.
In the first decades of the 1900s several further cases of AD were described.
Moreover, Foot et al in 1926 described a case of AD with necropsy: "The body is that of an extraordinarily adipose negress. "The necropsy findings coincide very accurately with those in undoubted cases of AD.
The very definite lesions in practically all the endocrine glands are striking: pituitary sclerosis and hyperplasia, with a tumor; sclerosis and changes in the colloid content of the thyroid; persistent and well preserved thymic rests; adenoma of both suprarenals, with hyperplasia; ovarian sclerosis and atrophy; and definite, though slight, changes in the pancreas.
Besides these, we see changes in the cranial bones, with exostoses and definite cerebral atrophy, with some generalized thickening of the dura."?.
It is justifiable, however, to ascribe the pathologic findings in this case to a profound disturbance in the endocrine system, probably arising as a result of one of the lesions found in the hypophysis cerebri"?
At the same time, Labb? and Boulin40 reported a case of AD with psychic and nervous disorders which they could not attribute to any one thing which could at the same time cause obesity.
These Authors questioned whether the weakness and susceptibility to fatigue and psychiatric manifestations should be classified as cardinal symptoms.
They argued that obesity per se can induce asthenia, and that it is unclear whether mental disturbances should be included as cardinal symptoms.
Gram in 1930 described a high incidence of obesity with tender subcutaneous infiltrations,"?deforming arthritis"?of the knee, and arterial hypertension in women around and after the climacteric age.
Newburgh in 1931 pointed out that painful areas of fat could disappear just by regulating diet.
According to Wilson43 the disease could be considered as"really a syndrome of symptoms in obese people"?and "AD could not be a clinical entity since there have been no findings consistent in all the cases reported in literature"?
He considered more reasonable to assume that the condition is one of either simple obesity or lipomatosis associated with neurosis or neurasthenia, and that the pathological conditions that had been found in these cases that have come to autopsy were incidental.
A report by Boller in 1934 showed that intralesional injections of procaine relieved pain in six cases.
Kling in 1937 reported on 112 cases of juxta- articular AD, their significance and relation to DD and osteoarthritis.
Since then, four cases of juxta-articular DD in association with seropositive rheumatoid arthritis were reported.
Furthermore, Kling came up with the theory that adipose tissue deposits around the knees might interfere by pressure on the joint with the blood supply and resulted in the development of painful osteoarthritis.
In 1952 Steiger et al expressed their doubts on the pluriglandular involvement in DD.
Hovesen in 1953 reported the inflammatory signs in the DD adipose tissue, i e infiltration of leukocytes and plasma cells.
The painful lipomas could appear in any location and, even if several adipose tissue diseases may present similarly, the pain of DD is specifically associated with fatty nodules.
The absence of pain of the adipose masses should indeed distinguish DD from Cushing syndrome, multiple symmetric lipomatosis, familiar multiple lipomatosis and lipedema as well as cutaneous malignant metastases.
In 2005 DD was unrelated with malignancy by Wortham and Tomlinson.
Gastrointestinal symptoms were also found to be associated in some DD patients as well as metabolic complications including obesity, diabetes, hypertension, dyslipidemia, and nonalcoholic fatty liver disease.
Hereditary factors in DD have been reported by some Authors; however, most reported cases of familiar occurrence of the condition was considered to be sporadic.
DD has been suggested to be an expression of familial multiple lipomas, which is an autosomal dominant disease characterized by multiple asymptomatic lipomas63.
This observation was derived by studying the family patterns of 2 siblings with DD; findings suggested that the disease segregates in an autosomal dominant fashion with variable phenotypic expressivity, ranging from totally asymptomatic to extremely painful lipomas.
Mutational analysis excluded the 8344A→G mitochondrial mutation seen in other patients with multiple lipomas.
The A→G transition at position 8344 in the tRNAlys gene of mitochondrial DNA has been described in the syndrome myoclonic epilepsy and ragged-red fibers (MERRF).
The presence of multiple lipomas resembling those of multiple symmetrical lipomatosis had been described in some members of pedigrees with MERRF harboring the 8344 tRNA mutation64.
An inflammatory etiology has been proposed for DD.
However, laboratory markers for inflammation markers, such as erythrocyte sedimentation rate (ESR) and C reactive protein (CRP), were reported by some authors as normal in most patients.
On the other hand, a few studies revealed elevated levels of CRP and ESR, even if some patients were also affected by an autoimmune disease.
Commonly, markers for autoimmune disease, such as autoantibodies, are negative in DD.
A review of the histopathologic findings of DD showed no consistent histologic abnormality in the adipose tissue that might distinguish these tumors from common sporadic lipomas.
The involvement of hormones and neuropeptides as well as a low level chronic inflammation and vascular factors was discussed by Hansson et al in 2011.
In theory, the sudden appearance of the disease together with the incidence of a slight increase in the number of inflammatory cells in the fat pointed toward the disease being, in part, an immune defense reaction.
Herbst et al in 2009 reported that inflammation and excess collagen may contribute to lower relative resting energy expenditure in patients with AD.
The authors observed significantly higher IL-6 as well as mononuclear giant cell levels in AD compared with control adipose tissue.
The study on adipokines indicated that there was no difference in the levels of tumor necrosis factor (TNF)-±, leptin, adiponectin, plasminogen activator inhibitor-1, interleukin (IL)-1, IL-8, IL-10, macrophage inflammatory protein (MIP)-1±, and monocyte chemotactic protein (MCP) compared to controls.
Nonetheless,  significantly  lower  MIP- 1β  expression and a trend toward higher levels of    IL-13 (interleukin-13) were reported.
In addition, lower levels of fractalkine, also known as chemokine (C X3-C motif) ligand 1, were seen.
The authors concluded that the lowered fractalkine levels were logical, since with prolonged release of fractalkine as seen in neuropathic pain, the receptors to which fractalkine binds are upregulated.
This suggests that there is shift from fractalkine release to receptor-bound fractalkine.
The lower levels of fractalkine found in DD could thus suggest that the substance is receptor-bound.
When receptors are occupied by fractalkine, pain and resistance to opioid analgesia are promoted.
Rasmusssen et al discovered an abnormal lymphatic phenotype in three patients with the disease compared with four female controls using near-infrared fluorescence (NIRF) lymphatic imaging.
The lymphatics in the participants with DD were intact and dilated but could not readily clear lymph when compared with lymphatics in four control patients.
Further NIRF imaging revealed masses of fluorescent tissue within the painful nodules, suggesting a lymphovascular etiology.
Kawale et al85 presented a DD patient with painful thickening of the scalp in bilateral parieto- occipital areas and vertex for more than a year.
The pain in the scalp caused headaches and disturbed sleep and daily activities.
CT and MRI revealed diffuse thickening of the scalp tissue, but no evidence for other anomalies.
Tsang et al noted a case of DD that caused weight loss failure after Roux-en-Y gastric bypass.
Eighteen months after the operation the patient was unable to lose weight, despite adherence to behavioral and dietary guidance.
Endoscopy performed 15 months after the operation excluded that any complications had occurred.
Dercum patients often report that their obesity is refractory to diet and exercise intervention.
Nonetheless, this has never been studied.
Hao et al (2018)87 have recently described an interesting case of a 39-year old man with trauma induced DD.
The authors in their report highlighted the rare nature of painful adipose deposits and the diagnostic challenges.
On histopathology, the fat deposition in DD was notable for mature adult fatty tissue and sometimes, a number of blood vessels suggesting an angiolipoma.
According to some reports, ultrasonography and magnetic resonance imaging (MRI) may aid in the diagnosis of DD74,88,89.
In the study by Tins et al88 on 13 patients with DD, lesions of the condition were found to be markedly hyperechoic on ultrasound, superficial in location, and distinct from characteristic lipomas.
Further, when validated on more than 6000 MRIs, they appeared as ill-defined, nodular, "blush-like"?subcutaneous fat on unenhanced MRI with a decreased T1-weighted signal.
No case of DD was without these features in the study, and the authors concluded that these findings, along with multiple subcutaneous fatty lesions, is ?€?very suggestive and possibly pathognomonic?€?for the condition.
In regards to the pain treatment in DD, some improvement was reported after systemic or intralesional treatment with corticosteroids47,80,90,91, whereas others experienced worsening of the pain92.
According to Taniguchi et al93, the alterations of fat metabolism induced by corticosteroid excess could play a role in the development of this syndrome.
An earlier study suggested that a defect in the synthesis of monounsaturated fatty acids may play a role in its development.
Further studies are needed to support this hypothesis and to identify a specific biochemical defect.
Dalziel94 suggested that the autonomous nervous system mediates pain in DD.
Vasoconstrictor response could be normalized by lidocaine infusion that is thought to decrease the local or central sympathetic vasoconstrictor tone.
Nonetheless, any substantial evidence of nervous system dysfunction has never been found in DD and is hence merely a theory.
Gonciarz et al95 reported in 1997 that interferon (INF)- alfa-2b induced long-term relief of pain in 2 patients with AD and chronic hepatitis C The analgesic effect of IFN therapy occurred 3 weeks after treatment for 6 months.
Whether the mechanism of pain relief with IFN is related to its antiviral effect, to the production of endogenous substances, or to the interference of INF with cytokines involved in cutaneous hyperalgesias, i e interleukin 1 and tumor necrosis factor-alpha, remains still undefined.
Two DD case reports have described pain relief with daily intake of mexiletine, an antiarrhythmic.
Traditional analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), had been thought to have a poor effect, with the pain in DD often refractory to analgesics and to non-steroidal anti- inflammatory drugs (NSAIDs)44,46,68,77-79,91-100.
However, in their extensive article published in 2007, Herbst and Asare-Bediako concluded that 89% achieved relief when treated with an NSAID, as did 97% when treated with an opiate58.
In the same year, Singal et al101 reported improvement of a DD patient on infliximab, with and without methotrexate.
In 2008, Desai et al102 reported on successful treatment with a lidocaine (5%) patch, and Lange et al69 on one with pregabalin associated to manual lymphatic drainage.
Metformin was used with success for AD associated pain by Labuzek et al.
It was hypothesized that the drug could favorably alter the cytokine profile, impacting on tumor necrosis factor, interleukin“1, and leptin104,105.
The pilot study of Herbst and Rutledge105 suggested that rapid cycling hypobaric pressure might reduce pain in patients with DD.
Nonpharmacological approaches for DD may be used as adjuncts to pharmacologic treatments.
Some of these include acupuncture, cognitive behavioral therapy, hypnosis, and biofeedback.
Several liposuction treated patients were reported by Hansson et al in 2011.
According to Dalziel the mechanism behind pain relief following liposuction was nerve plexus destruction within the adipose tissue94.
However, Hansson et al retained unlikely that direct nerve destruction alone explained the pain reduction seen following liposuction.
Liposuction is regarded as a supportive treatment for DD.
Any skeletal pain is not affected.
A significant initial reduction of pain and an improved quality of life is seen but these effects decrease over time.
In an extensive review published in 2012 based on literature data and studies concerning 111 DD patients, Hansson et al described the classification, symptoms and diagnosis, as well as, the epidemiology, etiology, genetic counselling, treatment and prognosis of the disease.
They discussed which symptoms were cardinal and which were associated and promoted a “minimal definition” of AD which including the following signs:
Most often generalized overweight or obesity
 Chronically painful adipose tissue (>3 months)
These authors also suggested the following classification system:
Type I: Generalized diffuse form; generalized, widespread painful adipose tissue in the absence of discreet lipomas 
Type II: Generalized nodular form; widespread painful  adipose tissue with concomitant intense pain in and around multiple discreet lipomas.
Type III: Localized nodular form; pain in and  around ? multiple discreet lipomas
Type IV: Juxta-articular form; discreet deposits of excess fat in specific locations, including the medial aspect of the knee, the hips, and, rarely, the upper arm.
Hanssen et al, by retracing many cases described in the literature, analyzed the consistency between the clinical signs reported and the minimum criteria for the diagnosis of DD.
With the exception of a few cases, according to the authors most of the analyzed literature cases, were not fully consistent with the minimal diagnostic criteria.
Since the original description of DD, in addition to the painful nodular fatty deposits (which are often unaffected by weight loss), the clinical spectrum has changed to include to various degrees other components of DD58 i e general obesity, easy fatigability and weakness (asthenia), and a wide variety of unexplained emotional disturbances, such as depression, confusion, and dementia.
This observation is why DD has been proposed to be relabeled as "Dercum syndrome".
DD has been classified by the World Health Organization (WHO) as a distinct entity and listed as a rare disease by the Orphanet115 and by the National Organization for Rare Disorders (NORD)116.
According to the latter "Dercum Disease is a rare disorder in which there are fatty deposits which apply pressure to the nerves, resulting in weakness and pain.
Various areas of the body may swell for no apparent reason.
The swelling may disappear without treatment, leaving hardened tissue or pendulous skin folds"?
Steiner et al70 referred to DD as a frequently overlooked disease and considered its assignment to the neuropathic pain syndromes to be justified.
Traditional management of DD relying on weight reduction and surgical excision of particularly troublesome lesions has been largely unsatisfactory.
Even at the present time, no known drug can change the course of the disease, and available treatments are only symptomatic.
Originally, Dercum5 attributed the disease to an endocrine dysfunction, as he found atrophy of the thyroid gland.
Similarly, Waldorp proposed that the disease is caused by hypophyseal dysfunction.
However, endocrine involvement was ruled out as early as in 1952.
In addition, more actual approaches have not revealed any endocrine abnormalities.
So, an endocrine dysfunction as the etiology of DD has little support in the modern literature.
Moreover, there are no uniform findings pointing to an inflammatory etiology in DD.
In conclusion, the findings on DD pathophysiology are still inconclusive and the clinical significance of some reports is unclear.
Based on literature data and personal experience, the perception is that this complex condition, which often takes on the contours of a real syndrome, is much more frequent than one might think.
Specific research aimed at defining its pathophysiological aspects could undoubtedly allow better clinical results and therefore a strong effort by the scientific community is warranted to make the diagnosis more accurate and develop targeted therapies against such complex pathological condition which, despite being devastating for patients, is not always recognized and, too often, either underestimated or even neglected.
?Basal Cell Carcinoma (BCC) is the most common skin cancer worldwide, with an incidence of 146-422 cases/ year/100,000 persons in the US, depending on latitude1.
It is more frequent in men and in elderly, but its incidence amongst people younger than 40 is increasing, particularly in women1.
The main cause is the exposure to UV rays of the sun (intermittent intense, rather than cumulative)1,2,3, which is why it is more common in of therapy, a monthly follow-up was performed for the first six months; then quarterly, in the next six months; subsequent monitoring was done every six months. equatorial regions, in the most sun-exposed areas of skin and in fair skin types (tendency to burn, rather than tan)1,3.
The sites most affected are the photo- exposed areas and in 90% of cases it is localized to the head, preferring cheeks, nasolabial folds, forehead and eyelids1.
The periocular region is interested in 20% of cases.
Regarding the clinical features of BCC, six overall subtypes have been identified, of which three are more frequent and three are quite rare, but more aggressive (high risk).
Nodular Basal Cell Carcinoma is the most common subtype (50-79%) of all basal cell carcinomas1 (Table 1).
Basal Cell Carcinoma may be treated with different therapeutic procedures, even with high rates of healing1, but the surgical removal of the tumor remains the preferred method, due to its greater therapeutic efficacy1,5.
Despite surgical treatment being the best method, there are cases in which surgery is not feasible and alternative methods must be used.
Over time, several alternative topical therapies have been utilized, some of which are now obsolete, others are rarely used, and others, more recent, appear promising.
Imiquimod (IMQ), an immune-modulator recently introduced, was effective in the medical treatment of certain skin diseases of viral and neoplastic origin7.
Currently, many studies are underway in order to evaluate its effectiveness in several skin diseases and neoplasms, while the preliminary results are already very promising1,7,8.
Objectives of this study are: first, to evaluate Imiquimod effectiveness in the treatment of subeyelid Nodular Basal Cell Carcinoma; second, to evaluate its ease and safety in delicate areas of the face; third, to evaluate the aesthetic and functional results, in an area of the face where surgery is not always indicated, because of possible permanent sequelae.
A 95 year old woman, with fair skin, light brown hair and blue eyes (Fitzpatrick skin-type 3), for two years had a Nodular Basal Cell Carcinoma in the left subeyelid region.
From six months the lesion ulcerated (rodent ulcer), with a crater-like appearance and hardened edges (Figure 1).
The patient was treated with topical application of 5% Imiquimod cream with the following protocol: 3 applications a week (Mon- Wed-Fri) for a duration of 7 weeks.
The cream was applied in the morning, by covering with a thin layer across the neoplasm, including an annular area of healthy skin around the lesion, for a width of 2 mm.
The cream was left to act for 8 hours, and then it was washed with warm water and mild detergent.
Care was taken to anamnestic and clinical evaluation, also with photographic documentation, at the start of each week,before applying the cream.
After finishing the course.
In the first two weeks, the treatment produced a progressive erythema, which affected the tumor, the upper portion of the cheek and the lower eyelid.
In the next week, it established a growing edema, with a mild serous oozing and some crusts.
Meanwhile, in the upper cheek, growing itching appeared, and sometimes burning with desquamation.
From the fourth week a progressive regression of the tumor was observed, while intense erythema persisted associated with edema.
At the end of treatment the tumor had disappeared; the residual edema resolved within two weeks, while the erythema showed a progressive reduction and disappeared altogether during the third month (Figure 2).
In the following controls we never observed redness or swelling, discolored or atrophic outcomes, and we did not find any other sign of aesthetic damage.
At 36 months, there was no evidence of tumor recurrence and no functional impairment of the involved eyelid; cheeks and eyelids were perfectly symmetrical, with excellent aesthetic results and high satisfaction of the patient (Figure 3).
Surgical removal is the best treatment method for all Basal Cell Carcinoma, due to its greater therapeutic efficacy.
Currently, three main surgical techniques may be used, all of which are effective in high percentage of cases.
Electrodesiccation and Curettage is effective in 95.1% of cases, but it may exit in discolored scar1; Standard Surgical Excision is effective in 95.2% of cases, but it may give unacceptable aesthetic and functional outcomes1,3,10.
Mohs Micrographic Surgery, a tissue sparing method, gives the best results, with efficacy in 98.6% of cases1,3,4; however, this technique is not always feasible, for the frequent lack of specific infrastructures3.
Despite surgical removal remaining the best therapeutic method for Basal Cell Carcinoma, there are cases in which surgery is not possible2,4.
There is no indication for surgery in cases of large or multiple lesions, in difficult anatomical sites, and in high surgical risk patients (elderly, comorbidity, anticoagulants); in other cases there is a consistent risk of unacceptable aesthetic and functional outcome or the patient refuses surgery4,5,8.
Moreover, as in the case we observed, the tumor also may involve a part of the lower eyelid, exposing to the risk of functional damage in case of surgical removal, with possible ectropion, as well as unpredictable cosmetic damage.
When surgery is not feasible, there are several alternative topical therapies(Table 2), of which Imiquimod 5% topic cream, is the most recent and the most promising, because it was effective in the medical treatment of several skin diseases of viral and neoplastic origin.
At present, Imiquimod is approved by the FDA only for the treatment of Anogenital Warts, Actinic Keratosis and Superficial-BCC.
Consequently, the use of IMQ in the Nodular subtype of BCC, currently, must be considered off label.
However, as some recent studies show, it may also be effective in the Nodular-BCC4,5,9, as in other skin tumors.
Imiquimod acts as a potent immune response modifier: it has, firstly, a direct action, with induction of apoptosis in tumor cell lines, by up-regulating pro-apoptotic proteins8; secondly, an indirect action, by release of modulatory cytokines (ILs, IFNa-g which increase the cytotoxic T cells and natural Killer-cells7,8,11.
The main advantages are: high effectiveness with low costs, easy home use, and useful alternative for subjects who cannot be treated surgically7,10.
The local side effects of IMQ are, generally, modest and tolerable, consisting of: erythema, edema, itching, burning, erosion, scabbing, crusting1,2,3.
The systemic adverse effects are very rare and may consist of: flu-like symptoms, nausea, headache, myalgia, fatigue and fever5.
For the use of Imiquimod, a standardized protocol does not exist3.
The most used application is provided 5 times a week, for 6 weeks3,5,8,9; but there are other protocols with application 2-7 times a week, for 4-12 weeks2,4,5,10,11,12.
The effectiveness of the treatment varies from 78,4 to 93,4%, in relation to different variables, and in some works success rates up to 100% have been reported4,5,10,11.
The method we used, with topical application of 5% Imiquimod cream, 3 times a week for 7 weeks, was fully effective, leading to the complete disappearance of the tumor, with no evidence of recurrence at 36 months (Figure 3).
Also from a functional point of view, there were good results, as no static or dynamic alteration of the eyelid function was observed, which can happen with surgical treatment4.
Technically, the method was easy to play; the procedure was done at home, without the need for hospitalization.
The treatment was well tolerated, with erythema, edema, crusting, and only a mild itching or, sometimes, a burning sensation.
In addition, the method did not require anesthesia, removal of tissue, suture, reconstruction or other surgical traumatism.
With regard to aesthetic aspects, there was no scar, no discoloration, no atrophy or fibrosis, and no other type of cosmetic damage.
Cheeks and eyelids appeared perfectly symmetrical, without any anatomical alteration to the lower left eyelid.
The hypo-pigmented area, under the medial canthus, appearing in figure 3, was not caused by this treatment, because it was pre- existing, as seen in figure 1, and was due to photo- chrono-aging, like other discolorations of the face.
Effectiveness: Imiquimod shows full effectiveness also in the Nodular-BCC, with complete disappearance of the tumor and no recurrence at 36 months.
Easy and safe: home treatment may be done, without need for hospitalization; IMQ use is easy and safe in difficult sites and in certain patients, without need for anesthesia, tissue removal, sutures or reconstruction.
Aesthetic results: IMQ gives excellent aesthetic results, as well as functional, without scar, discoloration or atrophy, and without functional damage.
This recent therapeutic method appears fully effective and easily achievable.
The procedure could become the first choice for this particular site and could also find broad indication in other delicate areas of the face.
Age-related facial changes recognize several etiologic factors involving changes of the skin, attrition of the facial septa, and craniofacial resorption, with the significant contribution of external factors, such as body mass index, hormones, alcohol consumption, cigarette smoking, and unprotected sun exposure.
In developed countries, improving the quality of aging has become a major target, also involving aesthetic dermatology.
Over the last decade, minimally invasive procedures have expanded exponentially due to the increasing availability of suitable products and the growing preference of patients for non-surgical methods, with consequent increase in the development of injectable materials for soft-tissue augmentation.
Nasolabial folds may become very marked with aging and can be corrected through dermal filler injections which fill the skin from the inside, restoring the lost facial volume and reducing the depth of these creases.
Multiple injectable materials are available, such as various hyaluronic acid products, calcium hydroxyapatite, and a few others.
For deep facial wrinkles, dermal fillers, compared to botulinum toxin, have the unique property of augmenting tissue volume.
Hyaluronic acid (HA) is commonly used in aesthetic medicine as a filling material (filler), to reduce both superficial and medium-deep wrinkles, or as a bio-revitalizing product to slow down the skin aging process; in fact, thanks to its natural hydrating and stimulating properties, HA reduces the signs of aging while improving skin turgor and elasticity.
HA dermal fillers vary widely in their physical and chemical characteristics and many variables contribute to their overall performance; however, they overall fulfill the request for a safe, quick, and effective procedure, and have a lower risk of allergic reactions compared to previously used collagen fillers.
The main disadvantage to overcome remains the procedure-associated pain and a limited duration of action.
In order to reduce the discomfort/pain sensation perceived by the subject during and after the injection procedure, lidocaine is often mixed with injectable dermal fillers.
Several experiences have been reported on the addition of lidocaine to HA products within the clinical settings with positive outcomes in terms of pain reduction.
However, this technique still raises some concerns relating to the possible impairment of quality and efficacy, as well as the volume and flow characteristics of the injections.
Products containing pre-incorporated, preservative- free lidocaine, which generally preserve volume, concentration, consistency and flow characteristics may seem safer, and associated with less procedural pain.
There are only a few studies directly comparing pure HA fillers and fillers containing HA and lidocaine, whose results reveal in general no significant differences in the safety, efficacy, and longevity of the two treatments, with less procedural pain associated with lidocaine addition.
However, the possibility of a true lidocaine allergy should always be considered since cases, though rare, have been reported, including type I –“ immediate hypersensitivity reactions and severe angioedema, or type IV –“ delayed reactions.
Aliaxin EV Essential Volume (IBSA Farmaceutici Italia SrL) is a resorbable medical device, consisting of a physiological, non-pyrogenic sterile gel that contains cross-linked HA (CLHA) of non-animal origin, produced by bacterial fermentation, used as a filler to correct deep facial cutaneous sagging and to increase facial volume.
It is known that chemico-physical and biological characterization of HA-based dermal fillers is of key importance to differentiate between the numerous available products and to optimize their use.
The different Aliaxin formulations have been tested for their content in soluble HA, water uptake capacity, rheological behavior, stability to enzymatic degradation, and in vitro capacity to stimulate the production of extracellular matrix components, and the different formulations were found to be equivalent to each other regarding insoluble hydrogel concentration.
The results obtained support the product claims of different clinical indications, and its classification regarding hydro-, lift- action.
Furthermore, the biological outcomes also support the efficacy of the product in restoring skin structure.
In the clinical setting, Aliaxin? showed that it can be safely and effectively used, either alone or in combination with a non-cross-linked HA complexed with vitamins, antioxidants, amino acids and minerals, to improve nasolabial fold hydration, trans-epidermal water loss and wrinkle aesthetic appearance.
This study was aimed at comparing, in women aged 40-65 years, Aliaxin EV without and with the addition of lidocaine 0.3% (extemporaneous mixture) in terms of filler on nasolabial folds and of discomfort/pain sensation perceived by the subject during and after the injection procedure.
The investigational product, Aliaxin EV, was compared within subjects with Aliaxin EV with lidocaine 0.3% (split-face method); the two injective products were assigned to the right or left face side of each subject according to a previously defined randomization list.
This study was performed in agreement with the Declaration of Helsinki.
Before the screening, all subjects gave written informed consent.
A final version of the study protocol and appendices were submitted to an Independent Ethic Committee (I E C at DERMING S r l , Clinical Research and Bioengineering Institute.
The President of I.E.C. was Prof. Demetrio Neri.
On 10th March 2017, the clinical trial obtained the I E C approval with protocol number E0817.
The study was registered on ClinicalTrials.gov public registry with the ID NCT03273556.
This was a comparative, randomized, single blind (subjects did not know on which hemiface lidocaine was used), single-center investigator-initiated trial of 4-week duration.
The investigator was an experienced dermatologist.
The study was conducted on 27 female volunteers, aged 40-65 years, who met the inclusion/exclusion criteria detailed below.
Inclusion criteria were: a Wrinkle Severity Rating Scale (WSRS) score between 2-4; asking for nasolabial folds correction; having received lidocaine, at least once before, as local anesthetic; agreeing to maintain their normal habits regarding food, physical activity, make- up use, facial cosmetic and cleansing products, and to arrive at each study visit without make-up; accepting to avoid facial exposure to strong UV irradiation (UV sessions, or sun baths) during the study.
Main exclusion criteria were: pregnant or lactating women, smokers, alcohol or drug abusers, women having received skin treatments for aesthetic correction, such as biomaterials implants, face lifting, botox injections, laser, chemical peeling, in the 6 months prior to the study start, or any permanent filler in the past, women with dermatitis, or other clinically relevant skin conditions or any skin lesions in the treated area, women affected with systemic diseases.
Use of anticoagulants and antiplatelet drugs, anti-histamines, topical and systemic corticosteroids, narcotics, antidepressants, immunosuppressive drugs (with the exception of contraceptive or hormonal treatments starting more than 1 year ago), or of any drugs able to influence the test results in the investigator's opinion was not permitted during the study period. 3 hours before the visit the volunteers were asked not to drink coffee or alcohol, and no cosmetic product to be applied on the skin test areas in the 2 hours preceding each visit.
Study procedures included 2 visits: one baseline visit (T0), when clinical and instrumental evaluations were performed, followed by the injection procedure and thereafter by skin discomfort/pain subjects' self-assessment (immediately and 2 hours after the procedure); and one final visit after 4 weeks (T4) for clinical and instrumental evaluations.
The investigational aesthetic procedure consisted in injecting a maximum of 0.5 mL of Aliaxin EV per hemiface with and without lidocaine 0.3%.
Two injection techniques were used in combination: (I a single-bolus injection with a 27G x 19 mm needle in the periosteal level of the nasal base; (II) linear retrograde injection with a 27G x 13 mm needle in the deep dermis; the needle was inserted along the length of the skin depression and the product was slowly deposited in the fold during needle extraction.
Efficacy evaluation included qualitative (clinical) and quantitative (instrumental) assessments performed at both study visits.
Filling activity on the nasolabial folds was rated by the investigator by means of the WSRS (Table 1)31, while the aesthetic performance was assessed by the Global Aesthetic Improvement Scale (GAIS, Table 2).
At the end of the study (T4), each volunteer was asked to express a self-assessment on the perceived efficacy of the study treatments on the nasolabial folds in terms of filler results (very marked; marked; medium; slight; absent).
Non-invasive instrumental evaluations included 3D nasolabial fold pictures taken with a Primos compact portable device (GFMesstechnik).
The Primos software is able to elaborate 3D representations of skin wrinkles as well as measure the main skin profilometric parameters in vivo or on skin replicas, according to the law DIN EN ISO 4228; moreover, the software directly compares the different images obtained at the study visits before and after treatment.
As a measuring method, Primos compact uses a digital stripe projection based on micro-mirrors which allows for fast and highly precise measuring data acquisition (the speed <70 ms for measuring data admission provides perfect results).
An assortment of different measuring fields, realized by means of different precise recording optics, was used to ensure a wide spectrum of measuring possibilities with ranges up to micrometers.
Following the injection procedure, the investigator assessed product tolerability noting any immediate local events/reactions (swelling, pain, erythema, bruising) and asking for any other adverse event, local or systemic, occurred during the study.
Sensations of stinging, itching, tightening, burning, discomfort and pain were scored by each study subject separately for each hemiface immediately and 2 hours after the injection procedure on a 10 unit visual analogue scale (VAS), where 0 means no sensation and 10 very strong sensation.
The VAS scores were expressed separately for each of the two treated sides.
The volunteers were also asked to express an overall tolerability self-assessment at the end of the study, as bad, poor, good or excellent.
Efficacy variables expressed in absolute values were compared versus baseline and between the two study products.
The data processing was performed by descriptive and inferential analysis: clinical data, VAS and GAIS score by non-parametric test (Wilcoxon test); instrumental data by non- parametric test (Wilcoxon test), when the normality hypothesis was rejected by the Shapiro-Wilk normality test (threshold at 5%), or by parametric test (paired t test), when the normality hypothesis was confirmed.
Twenty-seven women were included in the study: mean age was 55 years, mean body weight 62.5 kg and mean BMI 27.7.
One woman dropped out from the study without a final assessment visit for personal reasons.
The statistical analysis was thus performed on the 26 cases who completed the study as per protocol.
Both study products induced a very significant reduction in wrinkles severity (mean reduction 33.3%, Wilcoxon test p<0.001 T4 vs T0 for both products) with a decrease ?1 grade of the WSRS photographic reference scale observed in 100% of the included subjects.
 The GAIS scores in terms of aesthetic performance, in all 52 hemifaces of the 26 subjects were rated as improved compared to baseline; in particular the investigator rated 8 hemifaces (15% of the subjects) as “improved” (5 with Aliaxin EV alone and 3 with Aliaxin EV plus lidocaine);  26  (50%)  as  “much  improved”  (12  and 14 respectively); 18 (35%) (9 and 9 respectively) as “very much improved”.
There was no significant difference between the two products. The final (T4) GAIS mean value was 1.8 for both treatments. The results of the self-assessment questionnaire on  treatment  efficacy at T4 are summarized in Table 3.
The results of the self-assessment questionnaire on treatment efficacy at T4 are summarized in Table 3.
All but one volunteer expressed a positive judgment on the global aesthetic performance of the products: 3 reported a slight improvement, 2 a medium improvement and the remaining 21 judged their improvement from marked to very marked; none perceived a difference in overall aesthetic performance between the two treatments.
Skin profilometry data showed statistically significant reductions versus baseline in average roughness of the analyzed profile (Ra: -36% with Aliaxin EV alone and -32% with the lidocaine combination; Wilcoxon test p 0.001 T4 vs T0 for both products), in wrinkles total height (Rt: -83% and -69% respectively; Wilcoxon test p 0.001 T4 vs T0 for both products), and in wrinkle maximum depth (Figure 1; Rv: -41% and -31% respectively; Wilcoxon/ paired t test p 0.001 T4 vs T0 for both products).
No statistically significant difference between the 2 treatments was detectable (Paired t test T4 Aliaxin vs T4 Aliaxin + lidocaine p 0.05); however, a trend in favor of Aliaxin alone was observed for all parameters.
Primos photographic documentation of both hemifaces of subject 21, each treated with a different study product is reported in Figure 2.
Slight bruising occurred in 10 volunteers at one injection site, which was attributed to the injection procedure and had disappeared at T4; the women reported that the bruises had actually disappeared within 5-10 days.
At the volunteers' self-assessment of pain/discomfort sensations, the differences between products were statistically significant immediately after the injection procedure (T0A), losing statistical significance at the 2-hour assessment (T02h).
Overall only 3 subjects (12%) scored a VAS magnitude >5.
The investigator judged both products overall tolerability good or excellent in 100% of subjects, as did all volunteers.
The injection procedure with addition of lidocaine was judged more comfortable by 85% of women, while 15% preferred the procedure with Aliaxin EV alone.
An optimal dermal filler should be safe, effective, durable and fully satisfy the patient’s aesthetic demand.
HA-based injectable products are the most extensively used fillers and may vary greatly in terms of HA concentration, particle size, cross-linking agent used, cross-linking degree, percentage of cross-linked and free unmodified HA.
A reliable tool to assess the efficacy of HA-based compounds is the analysis of elastic fibers and collagen in the skin.
Indeed, injection of cross-linked HA (CLHA) into dermal-equivalent cultures was shown to induce elongation of fibroblasts and type I collagen synthesis due to up regulation of the transforming growth factor beta (TGF-β) pathway.
HA injections also increase the synthesis of neo-collagen I and pro-collagen I and III mRNA compared to baseline.
Aliaxin is a recently developed line of HA-based gel medical devices for intradermal treatment, available in prefilled syringes for local injection.
All Aliaxin products contain a highly purified cross-linked HA sodium salt, with a mix of molecular weight ranging from 500 to 2000 kDa, and the addition of sodium phosphate and water for injectable preparations.
Aliaxin products have a good safety and quality profile, as documented by in vitro and in vivo tests, and clinical studies.
Aliaxin EV - Essential Volume is a well-characterized resorbable medical device that, compared to other dermal fillers, showed a particularly high hydro-action with a prolonged aesthetic effect, as well as an easier deliverability due to lower rigidity and viscosit.
Its ability to promote restoration of skin structures was demonstrated in vitro.
The addition of lidocaine to HA products is rather common in clinical practice, with the aim of reducing pain and discomfort associated with the injection procedure, although questions about quality, efficacy, injection characteristics, and safety of the combination have not been fully answered.
This is why this study was aimed at comparing Aliaxin EV with and without lidocaine addition in terms of efficacy, safety and tolerability.
In this randomized, split-face study, Aliaxin EV with and without lidocaine showed to be effective in reducing wrinkle depth as measured by the investigator with specific grading scales, by skin profilometry and as judged by volunteers' self-assessment.
The two injection techniques used were chosen because the first allows a better performance of the injected product, contributing to the volumetric correction of the compartment without useless dispersion in other anatomical areas, and the second, because it allows a better filling effect of nasolabial folds.
The addition of lidocaine to Aliaxin EV reduced pain and stinging and made the injection more comfortable in the judgment of the majority of study subjects, though it has to be remarked that the intensity of such symptoms was rated by very few women higher than half the VAS scale for both products.
The overall tolerability of both treatments was judged from good to excellent by the investigator and by all the study subjects.
This seems to indicate that the injection procedure was not considered really painful or distressing by the volunteers, even without the addition of lidocaine.
Indeed, only 12% of patients scored a significant pain sensation.
In our opinion, this suggests refraining from a systematic use of lidocaine, but rather consulting with the patient about his/her pain threshold and evaluate on an individual basis the best anesthetic procedure, also taking into consideration the opportunity of performing a local anesthesia before the procedure instead of using a lidocaine-containing product or an extemporaneous mixture.
Though the efficacy of the two products, in terms of nasolabial fold reduction, showed no statistical difference, we think it is worth commenting that the instrumental measurements demonstrated a slight but consistent trend toward a superiority of Aliaxin EV alone for all parameters.
Once again, these results do not convince us that the addition of lidocaine to HA dermal fillers impairs their effectiveness.
Previous papers published in the literature and a recent metanalysis by Wang generally report that the addition of lidocaine to HA dermal fillers is safe and inert, and associated with procedural pain reduction.
Our results are not in contrast, however, Aliaxin alone showed a somewhat greater efficacy and seemed to not induce clinically significant pain.
Moreover, most of the previous studies compared different products, and only relatively few studies, including a limited number of subjects, directly compared the same product with and without lidocaine.
We feel that the availability of a minimally invasive procedure not conceived as overly painful by women could save the use of an anesthetic with its potential to increase the risk for adverse events, and to impact on product administration and aesthetic outcome.
In conclusion, Aliaxin EV proved to be effective in reducing nasolabial folds, giving a satisfying aesthetic performance and resulting very well tolerated, both with and without the addition of lidocaine.
Injection correction of tear trough and palpebromalar groove with hyaluronic acid-based fillers has become part of a practice of aesthetic medicine doctor.
This procedure can be carried out by a needle or blunt cannula1.The lower eyelid zone is the most challenging area to treat with hyaluronic acid\1.
Kane described the correction of the tear trough as a difficult problem with multiple causes.
He showed the technique of correction of the tear trough and lower lid using injection of the filler by a needle.
Lambros stressed that when correcting tear trough, it is important to evaluate the following factors: skin quality, definition of the hollow, the orbital fat, and the color of the overlying skin.
Lambros described the microbolus supraperiostal injection technique of the hyaluronic acid by a needle.
He noted that the best patients for the treatment are those with young, thick skin and a definite hollow.
In some cases, after correcting tear trough with a good immediate aesthetic result, adverse effects may appear after a while.
Such delayed adverse effects include: accumulation of the filler below the tear trough (Figure 1), enlargement in the hernia of lower eyelids, and periorbital puffiness.
To prevent these adverse effects, it is very important to consider the anatomical features of each patient.
Hirmand proposed a classification system of the tear trough deformity based on clinical evaluation.
Sadick et al. developed the tear trough rating scale by objectively and subjectively evaluating the clinical appearance of the tear trough with regard to depth of the trough, hyperpigmentation, volume of prolapsed fat, and skin rhytidosis.
Zhivokova and Krasnoselskikh described the principles of the selection of patients for correction of the periorbital zone by fillers depending on eye prominence, presence and prominence of orbital fat, and location and strength of the orbital ligament.
Classification of prominent orbital fat of the lower eyelids is difficult, since the aging of the lower eyelid zone is associated not so much with the increase in fat, but also with the aging of the entire middle third of the face as a whole.
However, to facilitate the selection of patients for correction of the periorbital zone by fillers, I apply my original classification of the lower eyelid zone11.
I identified 3 clinical types of the lower eyelid zone, depending on the presence and prominence of orbital fat: Type I no prominent orbital fat (Figure 2.1) Type II: prominent orbital fat in the medial part of the orbit and visualization of the bony orbital margin in the lateral part (Figure 2.2) Type III: prominent orbital fat visible in both medial and lateral parts of the orbit (Figure 2.3).
For patients with the second and especially the third clinical type of the lower eyelid area, I recommend surgical treatment of hernia of the lower eyelid.
However, in the presence of contraindications to the operation, injection camouflage of hernias is possible.
It should be borne in mind that the target area where the filler will be injected depends on the anatomical features of the periorbital zone, that is, the clinical type of the lower eyelid zone.
To reduce the risk of adverse effects, the filler should be injected precisely into the target space, regardless of the instrument used (needle or cannula).
In all cases of augmentation of the periorbital zone by the filler, submuscular (supraperiosteal) level of product placement is used.
Before the procedure, the marking of dangerous areas is necessary to prevent their traumatization: the zone of angular vessels (the inner corner of the eye and the centimeter lateral to it) and a zone of an infraorbital neurovascular fascicle13.
I recommend to avoid injections into the marked dangerous areas.
From February 2016 to January 2018 118 female patients were treated, aged between 28 and 56 years old.
Patients were divided into 3 groups, depending on the presence and prominence of orbital fat.
Treatment was carried out on: 47 type I (37 by needle 10 by blunt cannula), 66 type II (53 by needle 13 by blunt cannula), 5 type III (4 by needle, 1 by blunt cannula).
In all cases, a monophasic hyaluronic acid-based filler of average reticulation was used for treatment.
Correction of the lower eyelid zone was carried out according to the principles outlined below.
The result was determined by the patient through a visual assessment of photographs based on the criteria for the presence of tear trough and palpebromalar groove.
Patients noted good satisfaction with the results of the correction of the lower eyelid zone.
Most of the patients in this study were able to resume their normal activities after 1 to 2 days with makeup.
In all patients, the aesthetic result lasted for more than one year.
Only six patients were dissatisfied with their results because of hypercorrection.
For the treatment of this effect, hyaluronidase was used (Table 1).
The first clinical type is associated with a loss of volume throughout the lower eyelid area.
More often these are young patients complaining of dark circles under the eyes.
When correcting this type, the filler should be injected under the orbicularis oculi muscle into the space bounded from the top (cranial) by septum and from below (caudally) by the orbital ligament (ORL)14 (Figure 3.1).
Injection of the filler below the ORL ligament can lead to the accumulation of the filler below the tear trough in the deferred perspective.
The marking points between which the injections will be made are: the projection of the bony orbital margin (upper border) and the eyelid-cheek junction (lower border).
When correcting with a needle, the filler is injected bolus or microbolus between the upper and lower boundaries under the orbicularis oculi muscle with a preliminary marking of the dangerous zones.
When correcting with cannula, the filler is also injected under the orbicularis oculi muscle between the boundaries described above.
The preferred entry point for the cannula at the level of lateral canthus is between the projection of the bony orbital margin and the eyelid- cheek junction (lateral lid entry point).
When using the cheek entry point in some cases, the cannula does not pass through the ORL, but pushes it away.
As a result, augmentation tear trough using the cannula from the cheek entry point gives a good immediate aesthetic effect, but delayed may result in the accumulation of the filler below the tear trough.
This type is manifested by hernia of the lower eyelid, visible in the medial part of the orbit.
And simultaneous visualization of the bony orbital margin of the lateral part.
Thus, in the medial part of the lower eyelid the excess volume in the form of a hernia, and in the lateral, loss of volume.
The injection of a filler into a prominent orbital fat is dangerous because of the risk of infection complications and adverse effects in the form of long edema of the periorbital zone and increase in the hernia volume; it should be avoided.
When correcting this type, the filler should be injected submuscular (Figure 3.2), but in the medial part below (caudal) of the tear trough to prevent the filler from getting into the hernia.
And in the lateral part - between the projections of the bony orbital margin and the eyelid- cheek junction.
When using the cannula, the medial part is augmented from the cheek entry point, and the lateral one from the lateral lid entry point.
In this type hernias are visible in the medial and lateral part of the orbit.
As I mentioned above, the injection of the filler into the prominent orbital fat is unacceptable.
Therefore, when correcting this type, the filler is injected only below (caudal) of the tear trough and palpebromal groove9,11 (Figure 3.3).
For the injection, you can use both the needle and the cannula: cheek entry point (Figure 4.3).
An incomplete correction is recommended to avoid a "pillow face" (Figure 5.3).
Observance of the anatomical features of each patient, including the existence and expression of prominent orbital fat, is necessary to obtain the optimal result of injection correction of the periorbital zone.
Correction of the lower eyelid zone, taking into account the principles outlined in this article, gives a good aesthetic result with a low risk of adverse effects.
If the level and target zone of augmentation are observed, post-procedure puffiness is minimal or absent, and a good aesthetic result lasts more than a year.
Androgenetic alopecia is a common form of scalp hair loss that affects up to 50% of males between 18 and 40 years old.
It is a disorder that also affects the female sex and is characterized by a polymorphic clinical presentation.
Even though this condition is a paraphysiological condition, the loss of hair leads to stressful events for the patients with considerable psychosocial consequences.
Genetic and hormone factors play a major role in the pathogenesis of the disease but, given the variety of phenotypes, other etiological factors could divide the disorder into different subgroups.
Hair follicle is a skin appendage and exhibits hair cycle that is divided into three phases: anagen, catagen and telogen4.
The relative duration of these phases varies with a lot of physiologic and pathologic factors as well as hormone factors, body site, age and nutritional status.
Many biochemical substances have been investigated pathologically for studying hair growth and its cycle8,9, but the regulatory mechanism of the hair cycle has not yet been fully understood.
Two leukocyte populations reside in the epidermal compartment of normal skin in adult mice: Langerhans cells, which are a skin-specific member of the dendritic cell family of antigen- presenting cells10, and dendritic epidermal T cells, which are tissue resident γδ T cells11.
The dermal compartment also contains several resident leukocyte populations, including dermal dendritic cells, macrophages, and mast cells.
Keratinocytes are the major cellular component forming the interfollicular epidermis and the intrafollicular epidermis known as the outer root sheath.
Interestingly, Langerhans cells and dendritic epidermal T cells are frequently identified in the outer root sheath of hair follicles, and macrophages and mast cells often show perifollicular distributions in the dermal extracellular matrix.
Mast cells release a number of important signalling molecules, among which histamine has particularly potent pro-inflammatory activities.
Many authors have observed that both the mast cell population and the total histamine content reveal quantitative fluctuations during each cycle.
Botchkarev et al. for example, have reported pathologically that the number and granulation status of the mast cells change dramatically during the murine hair cycle and the mast cells product antagonists and the mast cell secretagogues significantly alter hair cycling in mice.
Moretti et al. demonstrated the fluctuations of the skin mast cell population and histamine content which occur during the hair cycles of rats.
The mast cell population revealed a rise during each telogen, to reach a peak within the first days of anagen, followed by a decline.
Histamine fluctuations were also fairly regular, hence the amine content steadily increased over, approximately, the first 7-11 days of each anagen, continuously decreased during telogen and then increased again.
There was a steep rise of histamine in the first month, already observed by Hardwick25 and Parratt26 and referred by the last author to a temporary influence on the skin of unknown factors, perhaps extracutaneous and "related to the stress involved in weaning"?
During subsequent cycles, the pattern of each fluctuation was remarkably similar and the mast cells and the amine's quantitative changes, instead, probably depended on the hair cycle.
With the aging of the animals, both mast cell and histamine fluctuations manifested a progressive tendency to level out and disappear.
On this ground the continuous decline of the amine while the rats are growing older could indicate a progressive hair's mantle involution.
A close relationship between hair's mantle involution and aging has been noted, in fact, by some authors.
There is no doubt, on the other hand, that the flattening out of all observed fluctuations is a function of aging.
This is in agreement with the fall of skin histamine typical of that process in many species.
Thus, the follicle would produce the histamine which would cause the involution of the follicle itself.
Kumamoto et al. stated that hair follicles might also serve as local reservoirs of precursors for one or more of the skin resident leukocyte populations.
To test this concept, they isolated vibrissal follicles from adult mice and cultured them in the presence of stem cell factor, interleukin 3, interleukin 7, granulocyte-macrophage colony-stimulating factor and Flt3 ligand, which are known to promote the growth and differentiation of Langerhans cells, dendritic epidermal T cells, macrophages, and mast cells.
They reported that relatively large numbers of CD45+/lineage- negative (Lin- )/c kit+/ Fc??RI+ leukocytes with characteristic features of mast cells emerge from the hair follicles under these culture conditions.
Unfractionated hair follicle cultures (containing 40%-70% CD45+ cells) released significant amounts of histamine on ligation of surface IgE receptors, as well as in response to substance P or compound 48/80.
They have demonstrated in this study that relatively large numbers of CD45+/Lin-/c kit+ leukocytes can be readily propagated ex vivo from hair follicle specimens in the presence of 5 added growth factors (stem cell factor, interleukin 3, interleukin 7, granulocyte-macrophage colony-stimulating factor and Flt3 ligand).
These hair follicle derived leukocytes exhibited characteristic features of mast cells, including inclusion of metachromatic granules, surface expression of Fc??RI, proliferative responsiveness to stem cell factor, and histamine release on ligation of surface IgE.
Mast cells are present in normal skin, and increased numbers of mast cells are regularly observed in the skin of patients with atopic dermatitis even before the onset of inflammation.
Unfortunately, in literature, there are no studies that show the histamine activity on follicular keratinocytes but, although with proper precautions and expanding the search area, we can introduce the topic referring to studies conducted on patients with atopic dermatitis.
Mast cells release a number of important signaling molecules, among which histamine has particularly potent pro-inflammatory activities.
After mast cell degranulation, histamine concentrations within the tissue can rise to 10– 1000 μM, and his tamine levels have been reported for lesioned and nonlesioned skin of patients with atopic dermatitis.
A role of endogenous histamine in the modulation of keratinocyte maturation has been suggested by Ashida et al.48 based on the observation that antihistamines have a beneficial effect on skin barrier recovery after tape striping in normal mouse skin.
Gschwandtner et al.49 addressed the impact of histamine on the differentiation of human keratinocytes and their findings show that histamine prevents the expression of late differentiation antigens in keratinocytes and strongly decreases the expression of tight junction and desmosomal proteins, leading to the formation of a defective skin barrier.
To investigate which of the four known histamine receptors (H1R–H4R) is targeted by histamine to induce its effect on keratinocytes, selective agonists and antagonists for the different receptors were applied to keratinocytes in the presence or absence of histamine.
The expression of differentiation proteins was inhibited by the histamine receptor-1 (H1R) agonist 2-pyridylethylamine, while agonists of the other three histamine receptors did not change the expression of keratinocyte differentiation markers.
Accordingly, preincubation of keratinocytes with the H1R antagonist, cetirizine, suppressed the histamine effect.
Cetirizine is a safe and selective, second-generation histamine H1 receptor antagonist, widely used in daily practice.
Charlesworth et al.50 showed that cetirizine causes a significant reduction in both the inflammatory cell infiltrate and PGD2 production and these effects are not related to its anti-H1 activity.
Studies on H1 receptor binding have demonstrated that compared with many other commonly used second-generation H1 antihistamines, cetirizine has a relatively higher and more favorable affinity and selectivity for H1 receptors, which confers a more potent, faster onset and longer duration of action.
Studies investigating the anti-inflammatory/ anti-allergic effects of cetirizine have indicated that it may exhibit anti-inflammatory properties independent of its H1 effects.
Rossi et al.3 carried out a pilot study to evaluate the efficacy of topical cetirizine in patients with AGA.
This study arises from the assumption that prostaglandins would have an important role in the hair growth.
Their action is variable depending on the class they belong to: PGE and PGF2?± play a generally positive role on the hair growth, while PGD2 an inhibitory role on the hair growth.
In this report the efficacy and tolerability of a galenic lotion based on cetirizine 1% once a day on the scalp in a sample of 85 patients was evaluated.
On the basis of hypertrichosis observed in patients treated with analogues of prostaglandin PGF2?±, the supposed mechanism of action concerns the probable ability of Cetirizine to influence the prostaglandin activity.
Nevertheless, it is undeniable that cetirizine is an antihistamine drug.
The data available in literature, therefore, lead us to think that histamine can play a central role in the regulation of the hair cycle.
Histamine can be responsible for the onset of some pathological models that we now call “androgenetic” but which may actually have different etiology.
These disorders could be managed differently from classical androgenetic alopecia, for example using an oral antihistamine drug, such as cetirizine, at an early stage.
Thus, in order to prevent thinning.
They are well known: - The perifollicular inflammation that accompanies hair miniaturization in androgenetic alopecia; - The active phases of the disease in which the patient reports scalp pain and itching, accompanied by an intense hair fall; - And the "fibrous streamers"?located below the follicles in advanced miniaturization, along which it is possible to observe the "Arao-Perkins bodies"? a small residue of anagen follicles of previous cycles.
All these considerations would seem to suggest the presence of a chronic inflammatory disease that presents episodes of remission and exacerbation and that it should be treated as such.
Our knowledge is still very limited and further studies are required to explore the topic.
In the literature, different articles show that several leukocyte populations normally reside in mouse skin and they are frequently identified within or around hair follicles.
These hair follicle derived leukocytes exhibited characteristic features of mast cells.
Mast cells release a number of important signaling molecules, among which histamine has particularly potent pro-inflammatory activities.
Both the mast cell population and the total histamine content revealed quantitative fluctuations during each cycle.
Histamine prevents the expression of late differentiation antigens in keratinocytes and strongly decreases the expression of tight junction and desmosomal proteins, leading to the formation of a defective skin barrier thus, the follicle would produce the histamine which would cause the involution of the follicle itself.
Preincubation of keratinocytes with the H1R antagonist, cetirizine, infact, suppressed the histamine effect.
Cetirizine is a safe and selective, second-generation histamine H1 receptor antagonist, widely used in daily practice.
Studies investigating the anti-inflammatory/ anti-allergic effects of cetirizine have indicated that it may exhibit anti-inflammatory properties independent of its H1 effects.
The data available, therefore, leads us to think that histamine can play a central role in the regulation of the hair cycle.
Histamine can be responsible for the onset of some pathological models that we now call "androgenetic"?but which may actually have a different etiology.
These disorders could be managed differently from classical androgenetic alopecia, for example using an oral antihistamine drug, such as cetirizine, at an early stage in order to prevent thinning.
Three major pitfalls of this review must be noted.
Firstly, there are currently no studies that refer to the influence of histamine on follicular keratinocytes.
The author was inspired by work on patients suffering from other diseases, trying to broaden the field of research.
Secondly, to date, histamine has been considered as a factor that positively influences hair growth.
According to the author, the opposite is true.
Lastly, most of the studies in the literature refer to experiments on mice.
The data available are still too few.
Perhaps in the future, we will be able to talk about "histaminergic alopecia"?but further studies are needed to clarify this important issue.
Cryolipolysis was first described by Rox Anderson and Dieter Manstein in 2008.
It is a unique non invasive method for the selective reduction of fat cells with controlled, localized cooling.
It can selectively damage subcutaneous fat without causing damage to the overlying skin.
Three days after a cryolipolysis session, histological analysis reveals an apoptosis of the adipocytes and a phagocytosis of fat by macrophages, that is present 14-30-days post- treatment.
Histopathologic evidence of inflammation becomes apparent at 10 days and declines 90 days after treatment.
Clinically, cryolipolysis results in localized panniculitis and modulation of fat.
The decrease of fat thickness occurs gradually over the first 3 months following the treatment, and is most pronounced in patients with limited, discrete fat bulges.
Erythema of the skin, bruising, and temporary numbness at the treatment site are commonly observed.
Paradoxical adipose hyperplasia4 and skin necrosis are rare side effects of cryolipolysis.
The aim of this case report is to share CT-scan pictures of a patient revealing subcutaneous fat hyperdensity 3 months after a cryolipolysis session.
Report A 58-year-old woman with no known medical or surgical history came to our clinic with complaints of abdominal fat.
After reviewing available options, we decided to perform a cryolipolysis session.
The cryolipolysis device was a Cristal? (Deleo, France).
An aspirated and refrigerated handpiece set named Ruby by the Deleo company was used at -7C and with a vacuum level 4 on the sub-umbilical area.
A non aspirated and refrigerated handpiece set named Ametysth was used at -7°C without vacuum on the supra-umbilical area.
The session was performed in August 2017 lasting 60 minutes by a French plastic surgeon (L L ).
The 2 areas (sub and supra- umbilical) were treated simultaneously.
The size of the treated area was around 450cm2.
No issues were noted during or immediately after the procedure.
Three months after treatment, the patient visited a gastroenterologist for belly pain without any other symptoms.
The blood test was normal (CBC, ALT, AST, GGT, and PROTEIN C .
An abdominal CT-scan was performed as suggested by the gastroenterologist and discovered a hyperdensity of the subcutaneous fat limited to the cryolipolysis treated areas (Figure 1A - 1B).
No organic cause was noticed and the belly pain disappeared spontaneously without any treatment within a month.
Four months after the procedure, the patient had a 1kg weight loss (66kg to 65kg), a sub- umbilical circumference loss of 4cm (105cm to 101cm) and a supra- umbilical circumference loss of 3cm (77cm to 74cm) (Figure 2A - 2B).
The pinch test decreased from 52mm to 40mm on the sub-umbilical area and from 52mm to 48mm on the supra-umbilical area.
Cryolipolysis is a safe and effective procedure for the reduction of fat in isolated pockets of excess adipose tissue.
Biologically, no changes in lipid levels or liver function tests have been linked.
In our case, the CT- scan was performed 3 months after treatment.
To date, no case describes the radiological signs of cryolipolysis on CT-scan.
The hyperdensity of the subcutaneous fat found in imaging confirms the inflammatory reaction of cryolipolysis but also proves its safety on the overlying tissues.
It has been shown histologically in previous studies that inflammation and loss of adipose tissue are well correlated, and the maximum lobular panniculitis is approximately 4 weeks after cold exposure and resolves about 3 months after.
About this patient, this would seem to support the conclusion that the sequelae of cryolipolysis was responsible for the pain.
The inflammatory reaction is still present even after 3 months, suggesting that some people are more sensitive than others.
The reaction of cold exposure seems to be more important and having a prolonged effect in time.
The CT- scan had also shown that the tissue's inflammation was deeper on the area treated with a handpiece using vacuum compared to a no-vacuum handpiece (maximum supra-umbilical fat hypersignal depth: 0.8cm versus maximum sub-umbilical fat hypersignal depth: 1.6cm).
This suggests that, when the skin laxity allows it, the handpieces with vacuum are more efficient than the handpieces without.
Cryolipolysis induces inflammation related to cold exposure.
At the time of maximum effectiveness, the subcutaneous fat becomes a panniculitis.
This phenomenon is observed on CT scan by a hyperdensity area.
The physiology and efficacy of cryolipolysis have been largely described in the literature.
But for the first time, a case report correlates known clinical and histological data with radiological evidence of inflammation related to the destruction of adipocytes.
Currently, the demand for cosmetic procedures has grown exponentially.
Dental procedures, as well as medical ones, besides working to obtain the principle of health promotion, accompany this trend by the search for aesthetics and welfare.
Facial aesthetic harmony correlates directly with the smile which, in turn, is formed by the union of three components: teeth, gum and lips.
The smile becomes aesthetically pleasing when these elements are disposed in suitable proportion, and exposure of the gingival tissue is limited to 3 mm.
When the gingival exposure is greater than 3 mm, it is characterized the non-aesthetic condition called gummy smile, which affects some patients psychologically.
The gummy smile is often found in women.
The predominance of females can be explained by the fact that male patients present a lower smile line.
Several therapeutic modalities have been proposed for the correction of gummy smile, among them: gingivectomy or gingivoplasty, myectomy and orthognathic surgery; and the last two procedures are more invasive and associated with high morbidity.
In contrast, the use of botulinum toxin can be considered as a therapeutic option to surgery, because it is a more conservative method, more effective, faster and safer.
Currently, botulinum toxin has been shown effective in the treatment of gummy smile in patients with hyperfunction of the muscles involved in smiling, as well as in patients with other stomatological disorders such as bruxism, clenching and orofacial pain.
The purpose of this article is to present the therapeutic association between gingivoplasty and the application of botulinum toxin in managing gummy smile.
Caucasian female, 26-years-old, attended the private clinic with complaints of gummy smile (Figure 1).
Clinically, the patient had an anatomic discrepancy between the length of the upper anterior teeth, and evident gingival exposure greater than 3 mm, featuring the gummy smile (Figure 2).
Initially, gingivoplasty was proposed.
Subsequently, after the clinical results, the application of botulinum toxin was suggested for the correction of gummy smile.
However, the patient was oriented about the recurrence of gingival smile after 6 months of application, because of temporary results.
Under local infiltrative anesthesia, the gingivoplasty was performed with the electrocautery (BE 3000TM, KVN, S?o Paulo, Brazil).
The length of the teeth was increased, characterizing the dental zenith.
The patient reported no complaints or complications after surgery.
After 30 days, satisfactory tissue repair (Figure 4) and the persistence of complaint of gummy smile reported by the patient (Figure 5) were observed.
In the same consultation, botulinum toxin was applied.
Prior to application of botulinum toxin, the surface of the skin was disinfected with ethyl alcohol 70% and the oils from the area were removed, in order to avoid local infection.
The points of application were marked, beside each nostril.
Then, local anesthetic (EmlaTM, Astra, S??o Paulo, Brazil) was applied with the aim of promoting comfort during the procedure.
Botulinum toxin type A (BotoxTM 200 units, Allergan Pharmaceuticals, Westport, Ireland) was diluted in 2 ml of saline, according to the manufacturer's instructions, and injected 2 units in the recommended site, laterally to each nostril.
After application, the patient was advised not to bow their head during the first four hours and not to engage in physical activity during the first 24 hours after the procedure.
After 10 days, the patient was examined.
She presented a uniform dehiscence of the upper lip (Figure 6).
Side effects or complaints were not reported.
Several etiologies have been suggested to gummy smile, as vertical maxillary exces, delayed passive eruption, hyperfunction of the muscles involved in smiling and reduced length of the clinical crown of the teeth, which can occur separately or together, and determine the type of treatment to be used.
In gummy smile caused by overactive muscle, botulinum toxin was indicated.
It is the first treatment of choice for the ease and security of applications, fast effect, besides being a more conservative approach when compared to surgical procedures (myectomy or Le Fort I osteotomy).
The activity of the smile is determined by several facial muscles, such as the elevator of the upper lip and wing of the nose, the zygomatic major and minor, the angle of the mouth, orbicularis oris and risorius.
Among them, the first three ones play higher function and determine the amount of lip elevation and, therefore, should be the muscles affected by the injection of the toxin.
The fibers of these muscles converge to the same area, and they form a triangle, which suggests that the point of adequate election comprehend the three muscles in a single injection.
The toxin, when injected, can spread in an area of 10 to 30 mm, which allows the effective extent.
The proposed site of injection was laterally to the wing of the nose.
After being injected into predetermined locations, the toxin decreases the contraction of the muscles responsible for the elevation of the upper lip, and this reduces gum exposure.
In this report, the result was satisfactory to the harmony of the smile of the patient by association of treatments - gingivoplasty and application of botulinum toxin type A The institution of isolated treatments could not culminate in the excellence of the earned results.
Initially, the creation of the new dental zenith during the course of gingivoplasty promoted the new dental architecture (Figures 2 and 4), favoring harmony gingival-dental- facial for the patient (Figures 1 and 5).
Subsequently, the application of botulinum toxin type A softened the gummy smile, by the uniform dehiscence itself of the upper lip, still promoting smoothness to facial lines of the smile, as can be seen in the nasolabial folds, adjacent to the nostrils, comparing Figures 1 and 6.
The application of botulinum toxin is an alternative; it is less invasive, faster, safer, more effective and it produces harmonics and pleasing results when applied in target muscles, respecting the appropriate dose and type of smile.
It is therefore, a useful adjunct in the aesthetic improvement of the smile and provides better results when combined with gingivoplasty.
Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder with prevalence rates ranging from 5% to 13.9% in women of reproductive age.
PCOS is mainly characterized by chronic anovulation, polycystic ovary morphology, and hyperandrogenism1,2,3.
PCOS is frequently associated with obesity, insulin resistance (IR), diabetes, hypertension and dyslipidemia, conditions conducive to increased cardiovascular disease (CVD) risk.
The percentage of insulin resistance in PCOS has been reported at between 44 to 70%7,8 using surrogate markers.
There is a general agreement that obese women with PCOS are insulin resistant, but IR should be assessed in all PCOS women, both lean and overweight subjects.
Weight reduction in PCOS improves metabolic health10, although, the optimal diet composition is unclear.
High-protein diets cause11 greater satiation and have a greater thermogenic effect.
They are recommended for the reduction of the loss of lean tissue mass during weight loss, for the decrease of serum lipid profile, and for postprandial insulin sensitivity.
Data from several recent studies has promoted also high-fat16, low carbohydrate diets, up to ketogenic diets for their beneficial effects on glucose homeostasis and reduction of body weight and hyperinsulinemia.
Dietary omega-3 polyunsaturated fatty acids (PUFAs) are known to reduce triglyceride and cholesterol levels, and to ameliorate hyperinsulinemia in PCOS patients18.
However, their impact on reduction in androgens is controversial.
The concept of reducing dietary glycemic index (GI) or glycemic load (GL) in the treatment of PCOS has also received considerable interest.
In the general population, this approach can optimally improve the metabolic profile.
At present, data on the effect of modulation of GI or GL on insulin sensitivity, acute satiety, and long-term weight loss and weight-loss maintenance are conflicting.
A low glycemic load diet contains carbohydrates that minimize changes in post prandial glucose levels and leads to a sustained reduction in hyperinsulinemia, in fasting glucose levels and in serum lipids in PCOS.
However, the realization of any long term benefits requires compliance to the low glycemic load diet.
Currently, few studies evidence the beneficial effects of a low glycemic load diet on metabolic profiles of PCOS, regardless of weight reduction.
The aim of this study was to evaluate the effects of two isocaloric and isoenergetic diets differing in glycemic load (GL) on metabolic patterns PCOS syndrome: diet A with a moderately low glycemic load (GL=79-105) versus diet B with a moderately high glycemic load (GL=123- 134) in order to broaden the results of our previous preliminary study.
PCOS patients were selected at the Department of Clinical Medicine and Surgery, University “Federico II”, Naples (Italy) and they all met the Rotterdam criteria of ESHRE/ASRM PCOS Consensus Workshop Group (presence of two out of the following three features: menstrual irregularity; clinical or biochemical hyperandrogenism; positive  ultrasound  presentation of polycystic ovaries by scan).
Only 15 patients, age- matched, with a similar socio-economic background (age: 24.2±3.1 y; BMI: 28.9±5.1 kg/m2) duly completed the protocol.
Exclusion criteria were the following: pregnancy, endocrine disorders, and the use of oral contraceptive or insulin-sensitizing agents.
Patients participating to regular physical activity were also excluded.
Patients were randomly provided with, according to a cross“over design, an isocaloric and isoenergetic diet with either a moderately low glycemic load or a moderately high glycemic load for 3 months, respectively.
The Glycemic Index (GI) is a quantitative assessment of foods based on postprandial blood glucose response, which is often expressedasapercentageoftheresponsetoanequivalent carbohydrate portion of a reference food (white bread or glucose)23.
The glycemic load, which assesses the total glycemic effect of the diet and has proved very useful in epidemiologic studies, is the product of the dietary GI and total dietary carbohydrate: GL= [GI x CHO(g ] /100.
The GI was determined by using the Brand-Miller tables23,24; such tables adopt glucose as a parameter for carbohydrate.
Average daily GI was calculated as [(grams of carbohydrate from food item/total daily grams of carbohydrate) — GI value of the food item].
 Low GI foods are defined as having a value < 56; medium GI foods a value of 56-69, and high GI foods a value ? 70.
Dietary GL was calculated by multiplying the daily GI of each food by the amount of carbohydrate consumed and dividing the product into 100.
To determine energy requirement and consequentially the prescription of the relative diet, the Harris Benedict equation was used so to predict basal metabolic rate adjusted for physical activity level; Table 1 reports composition of 1500-1800 kcal diets with low or moderately high Glycemic Load.
The nutrition education protocol was developed by dietitians.
A dietitian initially instructed the subjects on quantification and recording of their daily food intakes.
Follow-up counseling occurred every 6 days until the end of the study.
At this visit, diet prescription and nutrition goals were reviewed.
The calculation of the Homa index was performed on the parameters of fasting plasma glucose and insulin concentrations, using the following formula: HOMA index = fasting glucose (mmol/L * fasting insulin (mU/L /22.5.
The cut- off point was set to more than 2.5.
A complete physical examination was performed on each patient, at baseline and after 3 and 6 months, including a hirsutism exam using the Ferriman and Gallwey score.
Each body area was visually scored on a scale of zero to four; a score of zero indicated no terminal hair growth, while a score of four indicated full male pattern terminal hair growth.
The evaluation of acne included clinical examination, grading and lesion counting.
Additionally, height, weight, and age, were noted, and body mass index (BMI) was calculated for each patient.
At baseline and after 3 and 6 months, all subjects underwent pelvic ultrasonography and venous blood sampling to evaluate metabolic parameters (total cholesterol, HDL cholesterol, triglycerides, fibrinogen, serum glucose, C peptide, and insulin levels, fasting and two hours after breakfast).
All participants provided data with written health questionnaires and menstrual cycle calendars.
Patients were advised not to perform additional physical exercise compared to the standard physical activity recommendations (150-minute per week of moderate exercise regimen), to avoid interference or bias with the prescribed dietary program.
Data is expressed as mean ± SD and was log transformed before analysis when skewed. Two-tailed analysis was performed by using SPSS13 for Windows (SPSS, Inc., Chicago, IL, USA).
Statistical significance was set at p< 0.05.
Two-tailed analysis was performed by using SPSS13 for Windows (SPSS, Inc., Chicago, IL, USA).
Statistical significance was set at p 0.05.
Baseline parametric data was assessed by using a one- way ANOVA.
For comparison between time points, a repeated measure of ANOVA was used for parametric data.
Bonferroni adjustments were performed on multiple comparisons.
Both diets were well tolerated.
There was an improvement in menstrual cycle in 9 out of the 15 subjects (60%) during the low glycemic load diet (diet A and in 3 patients (20%) during the high glycemic load diet (diet B (p 0.032).
Examination findings reveal no improvement of hirsutism and acne after both diets.
Change of metabolic variables after Diet A and B in the 15 PCOS patients are shown in Table 2.
The mean body weight and BMI changes from baseline to 3 months after both diets were not statistically significant (p 0.784 after diet A vs p 0,914 after diet B (Table 2).
Mean fasting HOMA-R changes from baseline to 3 months after both diets were not statistically significant (p 0.204 after diet A vs p 0,089 after diet B .
As compared with baseline values, three  months  after diet A, there were statistically significant reductions of 2h-after  breakfast  serum  glucose  (from  89.4±8.4 to 78.1±4.2, p<0.011) and 2h-after breakfast-insulin (from 47.2±25.3 to 21.3±7.9, p=<0.001) (Figures 1 and 2). 
Hyperinsulinemia contributes to the hyperandrogenism of PCOS by stimulating ovarian androgen production and decreasing serum sex hormone-binding globulin (SHBG) concentrations.
Following three months of diet B a trend towards a reduction in circulating in serum glucose and 2h-after breakfast-insulin levels was observed, but in none of the cases had it reached statistical significance (Table 2).
It is thought that patients affected by PCOS have a genetic predisposition to insulin resistance of skeletal muscle leading to an elevation in insulin secretion that stimulates testosterone production from the ovaries, which remain sensitive to insulin action.
Infertility, hirsutism, and obesity are characteristics of the disorder.
In addition, women with PCOS are at an elevated risk of developing both T2D and cardiovascular disease, presumably due to their insulin resistance and hyperinsulinism.
Although treatment with oral contraceptives and other drugs that alter the reproductive-endocrine axis can alleviate symptoms, there is a need for nonpharmacological treatment options.
That diet modification through carbohydrate restriction could alleviate symptoms by lowering insulin secretion is a possibility worth pursuing.
Weight reduction through energy restriction has been shown to exert positive influences on both metabolic and hormonal aspects of this condition.
To date, nutritional studies in PCOS patients have focused on the effects of energy restriction and weight loss.
The effects of dietary composition, alterations in carbohydrate amount and type have also been investigated, and more recently, dietary fatty acids, with a particular emphasis on PUFA, have been shown to decrease insulin resistance, prevent excess insulin secretion, and, consequently, decrease the androgen excess and improve gonadal function in PCOS11-15.
Previous studies have reported that women on high protein diets experienced a significant weight loss and a decrease in their serum glucose level.
Some studies have shown that protein-enriched diets can lead to greater weight loss and improvements in biomarkers of metabolic syndrome than standard protein diets.
On the contrary, some high protein diets do not produce significant weight loss, causing a high percentage of adults to stop the diet after a short period of time and return to their original weight.
Other findings have reported that a low-GI hypocaloric diet enhanced insulin sensitivity in a range of subjects, including individuals with type 2 diabetes and PCOS patients.
Interestingly, some authors have reported a significant interaction between diet and metformin use such that the combination of a low-GI diet + metformin use was associated with the greatest improvements in insulin sensitivity32.
In diabetic patients, evidence from studies has suggested that a low-GI hypocaloric diet improved glycemic control reduced waist circumference and reduced weight by increasing satiety and by promoting fat oxidation at the expense of carbohydrate oxidation33,34.
The metabolic profile well known in women with PCOS is equivalent to the insulin resistance syndrome, a clustering within an individual with hyperinsulinemia, mild glucose intolerance, dyslipidemia, and hypertension.
The insulin resistance syndrome has been recognized as a risk factor for developing type 2 diabetes and CVD not only in obese and overweight patients, but also in normal weight women with PCOS where weight loss is not a choice for their management.
Moreover, recent studies have suggested that compared with either aerobic or resistance training alone, combined aerobic-resistance training is more efficacious for improving insulin sensitivity and reducing abdominal fat in a range of obese patient groups.
The improvement of insulin resistance and the decrease of insulin concentration and action can be achieved in different ways: if overweight or if obesity is present, by reducing body weight with lifestyle modifications; by using insulin- sensitizing agents, or by using antiandrogens.
In fact, it has been demonstrated that long-term treatment with antiandrogens may improve insulin sensitivity in both normal weight and obese PCOS women presenting an insulin-resistant state, even without changes in body weight.
This updated study confirms the potential benefits of an isocaloric and isoenergetic diet with a low GI, also related to a relatively high content of unsaturated lipids (see table 1), for the treatment of PCOS, regardless of weight loss and physical activity.
Our sample is low due to the high difficulties in carrying out all the steps contemplated by the protocol.
In summary, our study has shown that an isocaloric and isoenergetic diet with a low GI and a moderately high content of unsaturated lipids leads to a significant reduction in serum glucose and insulin levels two hours after breakfast and improved menstrual regularity in PCOS women over a three-month period, compared with a conventional, relatively high GI, isocaloric diet.
In our hypothesis improved insulin resistance per se, independent of weight loss, may positively affect menstrual cycle in PCOS, as suggested by the higher prevalence of improved menstrual cycles after diet A versus diet B In recent years, there has been an increased focus on the potential beneficial effects of specific dietary fatty acids for chronic diseases including insulin resistance and cardiovascular disease.
It has been shown that replacement of dietary carbohydrate with PUFA in a reduced energy diet may offer additional health benefits in the management of PCOS.
The adoption of healthy dietary patterns should be encouraged among women with PCOS, as they are rich in dietary fiber, antioxidants and anti-inflammatory nutrients, leading to greater satiety, and anti-hyperlipidemic, antihypertensive and antidiabetic properties16.
Some authors have proposed that n-3 PUFAs may improve insulin sensitivity by decreasing the production of inflammatory cytokines including tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6) and increasing secretion of the anti- inflammatory hormone adiponectin. 
Fatty acids and their derivatives also have a role to play in various aspects of reproduction, and are involved in oocyte fertilization, as well as fetal and infant development.
Ongoing work within our research group has suggested that supplementing the diet of women with PCOS with LC n-3 PUFA may have an anti-androgenic effect, mediated by a decrease in the plasma n-6:n-3 ratio rather than a direct functional effect of n-3 PUFA.
In addition to the antiandrogen effect of PUFAs, lifestyle modification, such as diet re-calibration and increased physical activity, is considered as the first- line treatment for PCOS women: a modest weight loss in obese PCOS women of only 5% of initial body weight can result in pregnancy, while a weight loss of 5–10% can reduce hyperandrogenism and insulin levels, mostly in obese PCOS women.
To date, the composition of the optimal diet for women with PCOS is not yet known, but such a diet must not only assist short term with weight management, symptoms and fertility, but also specifically target the long-term risks of type 2 diabetes and CVD.
With insulin resistance and compensatory hyperinsulinemia now recognized as a key factor in the pathogenesis of PCOS, it has become clear that reducing insulin levels and improving insulin sensitivity are an essential part of management.
Diet plays a significant role in the regulation of blood glucose and insulin levels, yet research into the dietary management of PCOS is lacking and most studies have focused on energy restriction rather than dietary composition per se.
Our data has shown that a moderately low glycemic load is recommended for managing PCOS.
This diet is sufficient to significantly improve hyperinsulinemia, restore ovulation and improve menstrual regularity.
The metabolic effects of this dietary program resulted independent of pharmacological therapy, weight loss and exercise and this represents an important tool, considering the chronic nature of PCOS and its high prevalence in young age.
Realization of any long term benefits such as metabolic syndrome and CVD prevention in PCOS would require compliance to the dietary program.
This study suggests that compliance to a moderately low glycemic load diet is possible over a three month period.
The benefits of lifestyle intervention in people with PCOS show that it is possible for dietary modification to ameliorate metabolic parameters and the risk of long term health problems linked with insulin resistance and it is important that this data has been confirmed on a larger number of patients with PCOS in this updated study.
In recent years there has been a growing interest in non-surgical procedures for facial rejuvenation.
Hyaluronic acid (HA) and calciumhydroxyapatite (CHA) are currently the most widely used dermal filler for full facial treatments1.
These provide a high level of comfort in the treatment (both for the practitioner and for the patient) and a long-lasting effect.
In addition, these are safe substances with regard to their compatibility and local resistance.
In addition, the proven safety of Agarose gel has also been a factor in their increased use.
Although only rarely complications are reported.
Agarose is in principle not a completely new material in medicine.
It has been used in the dental field for more than a decade.
The substance class is a neutral polysaccharide, it is completely biocompatible and thus degradable6.
The aim of this article is to show agarose gel as at least equivalent to those for full-facial treatment.
The following overview describes the possibilities of this treatment method.
Detailed knowledge of the facial anatomy with the knowledge of changes in the age are necessary to achieve balanced and natural results after the injection.
It is also essential to be familiar with the character of the dermal filler to be used.
Each face region has its own perfect dermal filler for its purpose.
Complete biodegradability, local resistance and good tolerability as well as perfect biocompatibility are indispensable properties of a suitable dermal filler.
The results of the filler injection are extremely technically and material dependent.
It is necessary to place a 3-dimensional lattice of injected material below the surface of the skin to add volume, alter surface area and thicken skin or subcutaneous tissue.
The degree of correction and the result depends heavily on the injection technique used and the material used hence the required volume.
In the past, surgical techniques dominated the field of facial rejuvenation.
However, the importance of a three- dimensional volume restoration using dermal fillers has become increasingly recognized in recent years and has increasingly gained precedence over a two-dimensional lift by the scalpel.
Hyaluronic acid is very hydrophilic, therefore a change in the treated region after injection is expected.
That makes the substance perfect for a more superficial correction.
It also hydrates the skin, so that wrinkled skin is better glazed.
However, to correct for bone resorption at depth, a substance with less hydrophilic property is needed.
No part of the human organism reflects aging like the facial area.
The face consists of skin, subcutaneous fat, muscle and bone structure.
These individual components age independently, they have their own laws of aging.
In old age, not only changes in the surface of the skin are noted.
Aging processes also occur in various deep structures of the human face especially in the area of the maxillary and mandibular; most notably fat loss and bone resorption.
Striking is the sinking of soft tissue such as eyebrows and cheeks.
Nasal manifestations of the nose result from degradation of the bony and cartilaginous framework.
Therefore, the sinking of the tip of the nose and a shortening of the columella arise.
Through this downward movement, the nose appears longer and larger.
The nose is now larger and the nasolabial angle can be sharpened.
In addition, the elderly patient usually has excessively inelastic skin, which makes an injection more difficult.
However, there are differences, especially depending on race, genetic factors and individual aspects (some earlier, later).
The upper third of the face consists mainly of the forehead.
Here, dominates the glabella and horizontal folds.
These are usually dynamic wrinkles.
Here, a treatment with botulinum toxin is recommended.
Therapeutically significant is the midface, especially with respect to the following changes e g slackening, sinking of the cheek fat, reduction of hypodermic fat, strengthening nasolabial folds, slackening of the lower eyelids with optical extension.
In addition, there is an aging of the nose (extension of the nose, rarification of the nasal skeleton, loss of hypodermic fat in the nasal area, broadening of the nose and convex nose bridge).
Overall, the midface in old age tends to change to hollow-cheeked, flat, empty, and narrow.
The nose as the central area in the middle face of the human being is one of the first visible structures for the opposite and the mirror image.
It is a complex, three- dimensional, trapezoidal organ protruding from the face.
Due to its three-dimensionality, however, the nose causes many people an increased aesthetic distress12.
While wrinkles are often only perceived as two- dimensional disturbing strokes, the cosmetic problems and desires of the patients with regard to the appearance of the nose are much more complex.
Surgical rhinoplasty is therefore one of the most common aesthetic surgical procedures.
As with all surgical interventions, there is a certain amount of rhinoplasty risk of complications with corresponding convalescence time and downtime.
In addition, the operation is associated with high costs.
Increasingly, therefore, many patients develop the desire to avoid surgical intervention.
Still, most have never heard of a nonsurgical nose job.
The lower third of the face extends from the subnasal area to the chin seat.
Displacement of the cheek fat caudally.
This also applies to the mimic muscles, the zygomatic muscle, major and minor, and the m risorius.
Bone atrophy of the maxilla in anterior-posterior direction and congenital low-grade retrognathia.
Due to the sinking cheek fat, the impression of a deepened nasolabial fold is intensified.
By increasing the cheek fat above the nasolabial fold this impression is emphasized.
The cutaneous and subcutaneous shrinkage of fat or bone resorption can be temporarily compensated by appropriate injections of collagen, autologous fat, hyaluronic acid or even agarose gel6,16,17.
Agarose is in principle not a completely new material in medicine.
It has been used in the dental field for more than ten years6.
The substance class is a polysaccharide of D galactose and 3,6-anhydro L galactose, which are glycosidically linked.
Thus it represents a main component of the agar7. 100% based on natural polysaccharides, it is completely biocompatible and thus degradable.
Agarose gel is a sterile, biodegradable, viscoelastic, isotonic, transparent injectable gel implant16,18.
Agarose is broken down in the human organism.
For this purpose, agarose is first transported by the action of macrophages from the site of application and then degraded enzymatically by means of galactosidase.
Agarose is metabolized in the pentose cycle at macrophage, platelet and endothelial reticulum levels6,16.
Because of its biocompatibility, agarose is widely used in clinical trials.
Therefore, the substrate is used in biocompatible tests, for example with regard to cytotoxicity, genotoxicity, mutagenesis, sensitivity, and subcutaneous implants.
In addition, the gel is used in biotechnology for three- dimensional tissue growth and as a controlled release substrate for pharmacological substances.
For the preparation of the treatment a superficial anesthesia with a topical anesthetic is recommended.
In some cases, a local anesthetic injection should also be considered.
Treatment should be as painless as possible.
In addition to topical anesthesia, the use of very thin cannulas also serves this purpose.
It can also be mixed local anesthetic with the gel.
Agarose itself is because of its isotonic properties, as mentioned above, an almost painless injectable.
The injection should be done very slowly.
Only when stretching out of the tissue does it burn.
It is essential to have an extended massage of the injected area to disperse the imported substance with the surrounding tissue.
Agarose gel transforms into a hydrocolloid after injection into the tissue.
This creates a natural and harmonious look.
According to the principle “What you see is what you get”, the result visible immediately after the injection is also the final result.
An additional advantage is the use in patients who have demonstrated intolerances to hyaluronic acid or other ingredients in previous treatments.
In our practical everyday life we inject a variety of facial areas.
The agarose gel used in this study contained 2.5% agarose and 97.5% saline solution for nasolabial fold (Figure. 1) and 3,5% agarose and 96,5% saline solution for rhinoplasty and jaw angle (Figure. 2 & 3).
Patients with acute or chronic skin pathologies or direct involvement in or around the area to be treated were excluded.
Pregnancy, lactation and hyaluronic acid treatment less than 3 months earlier were also excluded criteria.
After discussing patient in-depth information and written consent, discussing the risks and benefits of the procedure, the risks and benefits of alternatives, and answering all questions, the written consent form outlined possible complications such as bruising, swelling and hematoma or pain.
To reduce bruising, patients were asked not to take salicylates in the last 2 weeks before treatment.
In total 27 patients were treated (14 non-surgical nose jobs, four augmentation of jaw angle and nine nasolabial folds).
The patients were between 32 and 68 years old.
All patients were female.
Nobody had a treatment with permanent fillers before. 5 previously had an injection with hyaluronic acid in the area of the nasolabial fold.
For a better comfort, a superficial anesthetic cream was applied.
The agarose was mixed with 0.1 mL of lidocaine 0.1% to be as painless as possible during the injection.
For the injection of the nose and nasolabial fold 30 gauge needles should be used with a length of 13 mm, for the jaw angle 27 gauge needles.
The esthetic evaluation was done after 14 days, and 1, 3 and 6 months after the injection.
While a volume of 1.4 mL agarose gel 2.5% was sufficient for the nasolabial fold (Figure. 1), 2.8 mL were necessary for the jaw angle of agarose gel 3.5% (Figure. 2).
However, for the rhinoplasty, only 0.3 mL of 3.5% agarose gel was sufficient (Figure. 3).
Direct finger compression with cotton gauze and mild cooling were used to reduce bruising and swelling.
Further, no special instructions were required and the patients immediately returned to work.
The only adverse events described were hematoma, redness, bruising and swelling.
All adverse events lasted for a maximum of 4 days.
Patients were asked to re-present 14 days and one month after injection for follow-up and possible reinjection to correct for asymmetry or lack of desired fullness.
These repairs were usually made after 14 or 30 days, with 0.1 mL agarose in the area of the nose (by only three patients), 0.2-0.3 mL at the nasolabial folds (six patients), and a maximum of 0.4 mL at the jaw angle area (two patients).
Such improvements were not necessary in these three patients (see below in Figures 1-3).
Therefore, we asked for an additional follow-up after 3 and 6 months.
All results remained after 6 months.
The agarose-based filler is a great new option for modeling and aesthetic correction in nonsurgical rhinoplasty and complete face treatment.
Especially for patients who want to avoid surgery.
But even for the practitioner, it offers a low-complication possibility of a nose correction with relatively little effort compared to an operative procedure.
So far we have had several very good substances (such as hyaluron and calcium hydroxyapatite) available.
Now, with agarose gel, another substance enriches the dermal filler range with an interesting option.
This popularity of a substance such as agarose will continue to increase in the future as the aging population seeks viable options to correct the signs of aging without surgery.
The utilization of these fillers by trained professionals provides an effective and safe therapy for the management of the aging face.
Polylactic acid (PLLA) is used since long time to achieve the indirect volume augmentation of soft tissues.
This substance was approved in Europe in 1999 and in 2004 FDA has also approved the use of this substance in the treatment of facial lipoatrophy in HIV-positive patients.
In 2009 FDA has also approved the use of this substance in the treatment of facial wrinkles in Aesthetic Medicine.
Polylactic acid has an indirect effect: the volume augmentation is not due to the space occupied by the substance.
It is due to the local reaction caused by polylactic acid and subsequent collagen production by fibroblasts.
It is a completely resorbable filler.
It decomposes into H2O and CO2 in a year.
Some publications show that the stimulation in collagen production could help in the treatment of skin laxity in inner arm region, above all in post menopause women.
Authors will show their experience in the treatment of skin laxity in inner arm region with superficial infiltration of hyper-diluited polylactic acid.
30 female patients were treated, aged between 37 and 64 years old.
Dismorfism was classifyed according to Eric A Appelt and staff new classification system.
Polylactic acid was diluted with 9cc of sterile distilled water plus 1cc of lidocaine 20mg/10ml 12 hours before treatment.
The area of the arms was infiltrated with 1 fl of polylactic acid for a total of 10 cc of solution per side.
The PLLA was injected into the deep dermis, in retrograde direction, in opposite and intersecting fan micropunctures, using 2.5 cc for each injection and a vigorous massage was performed after each infiltration.
The Result was defined by the patients through a visual assessment of the photographs based on criteria of skin colour, presence of wrinkles, shape and volume.
In order to provide objective validation of the result, we performed patients' satisfaction test with the help of photographs as well as ultrasound examination.
After the third application (from 12 to 24 weeks), one was able to observe an improvement in the treated area with good and very food results in groups IIa and IIb and unexpected results from very good to excellent in type IIIa patients at T120.
The skin of the medial region of the arms is extremely thin and delicate, which is why filler hyper-dilution has been employed, associated to vigorous massage which has led to brilliant results where the right therapeutic indication has been considered.
The upper third region of the arms is the one most subject to the modifications arising from weight loss and skin ageing processes: particularly the skin of the medial arm region, which is described by Avelar as the thinnest and most delicate of the whole body.
Glanz and Gonzales-Ulloa have shown that, with age, the lower curvature of the arms' soft tissues increases and a there is a loss of connective support structures with consequent onset of increasingly worsening ptosis up to the occurrence of what is referred to as the ?€?bat wings?€?deformity8.
From the histological point of view the skin of this region features skin about 0.1mm thick, whose appearance is always sinuous and, in some cases, with scarce papillae.
The collagen of young skin is dense and even in the papillary dermis, arranged in parallel bands in the reticular dermis.
In aged skin collagen decreases and its appearance is heterogeneous and disordered.
Although the corrective approach to arm imperfections is very often surgical and depends on the severity of the dysmorphic feature that mainly affects the skin and the subcutaneous adipose component, many patients reject the procedure and seek less invasive methods.
A number of aesthetic medicine techniques have been employed in recent years, including fillers, in order to restore volume to the arm contour and improve the signs of skin ageing in this region.
Among the contemplated fillers, the rationale for using polylactic acid especially lies with its stimulating action for the production of dermal neocollagen.
The use of polylactic acid has gained extensive recognition and commendations: in 1999 in Europe for the correction of scars and wrinkles, in 2004 the FDA approved for treatment of HIV-related lipoatrophy and in 2009 for filling nasolabial folds for aesthetic purposes.
Polylactic acid (PLLA) belongs to the family of alpha hydroxy acids, is biodegradable and bio-compatible.
The injection form consists of a biodegradable synthetic polymer consisting of PLLA micro-particles and associated to sodium carboxymethyl cellulose and apyrogenic mannitol, the latter having an emulsifying effect increasing the moisturising effect of carboxymethyl cellulose.
After injecting, polylactic acid is hydrolysed into lactic acid monomers, which induce a local inflammatory response by drawing in monocytes, macrophages and fibroblasts.
After fibroblasts appear, neocollagenesis occurs of type I and type III collagen fibres with thickening of the dermis.
For the aim of seeking the best corrective approach for this anatomical region, a number of classification systems regarding its aesthetic modifications have been described.
The exact therapeutic indication is therefore related to the degree of dysmorphism of this anatomical region.
Specifically, Eric A. Appelt and staff put forth a new classification system - modifying the one described by Rohrich and Kenkel - entailing seven clinical groups and taking into account the degree of cutaneous excess relating to ptosis, the amount of fat in the subcutaneous tissue and their anatomical distribution area. 
Classification according to Rohrich  R.J., Kenkel J.M.: “Back and arms”. 
In“Ultrasound-assisted liposuction”, 1st Ed. St. Louis, Mo: Quality Medical Publishing, 1998. Pp 231-252. Modified by Appelt et al. in “An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006; 118(1):237-46. 
Taking into account this classification and some patients’ wish not to undergo surgery, we have selected the cases to be treated with PLLA infiltration. The results obtained were assessed with photos and ultrasound examination with 22 MHZ transducer.
?From January 2015 to December 2016, 30 patients were treated, aged between 37 and 64 years old (average age: 48.43).
Treatment was carried out on: 12 type IIa, 10 type IIb and 8 type IIIa patients.
The patients were all female, average age 48.4 but with high variability (9 years), due to the fact that, apart from a peak around the age of 40, patients are almost evenly distributed between 40 and 65 years of age.
No significant age differences are observed among classes IIa, IIb and IIIc (p 0.598, NS) Table 2b.
The following exclusion criteria were considered: pregnancy; breastfeeding; a history of allergy with episodes of anaphylactic reactions and/or hypersensitivity to local anaesthetics, latex and silicon; coagulation disorders; cardiological and metabolic diseases; keloid diathesis9.
Polylactic acid was diluted with 9cc of sterile distilled water plus 1cc of lidocaine 20mg/10ml 12 hours before treatment12.
The area of the arms to be treated was identified with the patients?€? arms hanging down naturally.
The medial area of the arms was considered from the axillary column to the medial condyle of the humerus.
Each area was infiltrated with 1 fl of polylactic acid for a total of 10 cc of solution per side.
A 25G x 15 cm spinal needle was used for the infiltration.
The PLLA was injected into the deep dermis, in retrograde direction, in opposite and intersecting fan micropunctures, using 2.5 cc for each injection.
The patients signed an informed treatment consent form.
Three treatments were performed, with thirty-day intervals: T30, T60, T905.
Vigorous massage was performed after each infiltration.
Patients were then prescribed to massage the treated areas five times a day for five minutes for the five days following infiltration6.
Photos were taken of the patients, and ultrasound examination with 22 MHZ transducer was carried out at: T0, T30 (4 weeks), T60 (8 weeks), T90 (12 weeks) and T120 (16 weeks).
The patients were asked to view the photographs at T30, T60 and T120 and to assess the result according to the Global Aesthetic Improvement Scale (Gais), in an assessment scale taking into consideration five categories (poor; absent; good; very good; excellent) on the basis of some features such as: colour changes of the skin surface, the presence of wrinkles, the shape of the arm contour and the subcutaneous volume change.
After the first session (T30: four weeks) it was not possible to observe any improvement upon clinical examination, except a slight improvement of the skin texture, while the sonogram already showed a slight thickening of the deep dermis.
After the second treatment (T60: eight weeks), both the patients and the operator observed an improvement of the cutaneous surface with greater superficial tension and brighter colour, especially in the type IIa and IIb group of patients (Figures 1a,1b and Figures 2a, 2b).
With the third application (from 12 to 24 weeks), one was able to observe an improvement in the treated area with good and very food results in groups IIa and IIb and unexpected results from very good to excellent in type IIIa patients at T120 (Table 4, Figures 3a, 3b, 3c and Figures 4a, 4b).
As regards the ultrasound analysis of the treated areas, it was possible to observe greater thickening and greater echogenicity at deep dermis level already from time T30.
Echogenicity and thickness continued increasing slowly and progressively up to time T120, although it was not possible to assess the numerical extent (Figures 5a, 5b and Figures 6a, 6b).
No clinically significant adverse events occurred. 20 cases presented with widespread ecchymosis after treatment and 8 cases experienced pain in the injection area.
When comparing progress among the initial classes, a significant difference is observed between the initially most severe group (IIIa) and the others.
The difference is due to the fact that at first intermediate assessment (T60) the score improvement in group IIIa is lower than the other two classes (p=0.006), at the second intermediate assessment group IIIa achieves a good level of satisfaction by the patients, with no difference from the other groups (p=0.896) and at final assessment group IIIa reports an even higher level of satisfaction (p=0.003), achieving a very high level (4.6, considering that 5 corresponds to the statement “Excellent result consistent with the patient’s expectations”), while the other two groups on average stop at a lower level (3.6).
Although treatment of the dysmorphism and skin ageing of the arms is often surgical, for those patients who do not wish to undergo surgery, and in whom the aesthetic changes are not excessively significant, an aesthetic me- dical approach may be taken into consideration in order to improve the clinical situation.
The use of polylactic acid has been recently put forth in order to address the loss of skin density and thickness due to ageing proces- ses3,4.
The dermis thickening action of this filler has been pro- ven in the literature, thanks to its ability to trigger a lo- cal inflammatory response that results in neocollagene- sis11,14,15.
Through histological observations on biopsies, Lemperle and staff have observed the presence of a thin extrace- llular matrix around the hydrolysed PLLA microspheres and infiltrate of macrophages and lymphocytes already three months after the polylactic acid infiltration.
Six months later, biopsy examinations have shown the per- sistence of macrophages and giant cells around the PLLA microspheres, whereas nine months later there was no longer any trace, signifying complete degradation of the injected product and neocollagenesis in the dermis.
Vle- ggaar and Bauer have conducted biopsies in a 55-year- old patient treated with PLLA infiltration to correct the nasolabial folds, showing collagen thickening after 30 months7,13,24.
Philip Stein et al. report that the increase in thickness induced by PLLA is due to the formation of the capsule induced by macrophages, myofibroblasts and neo-for- mation of type I and II collagen fibres22.
With regards to dilution, in our experience we have em- ployed 10cc hyper-dilution, 9 cc of which of sterile dis- tilled water and 1 cc of 20mg/10ml lidocaine, in order to obtain a more fluid, hence easier to handle solution that would spread more easily.
This dilution has allowed us to prevent the possible formation of subcutaneous lumps that often represent a complication for this filler and which might have occurred easily in this anatomical area, also in connection to the thinness of the skin19.
In order to prevent possible complications, for each in- filtration, 10ml of PLLA were injected per side into the deep dermis (preferable) or subcutaneously and vigorous massage was performed on the whole area, followed by massage at home according to the 5-5-5 scheme21.
In order to provide objective validation of the result, we performed patients?€? satisfaction test with the help of photographs as well as ultrasound examination.
The latter showed a thickening effect, although minimal, of the deep dermis, especially in the cases where clinical improvement was most conspicuous, particularly in type IIIa patients.
Specifically, these patients had a better represented subcutaneous adipose tissue compared to the other two classes considered.
This likely further affected the patients?€? opinion of an improvement.
However, the pro- blem of the control group remains, as it was not carried out and would have further validated the results of per- sonal experience.
Our experience did not point to complications.
Side effects such as stinging and pain were reported, which spontaneously subsided in few hours and benefited from the vigorous massage.
?Treatment of ageing in the medial region of the arms may represent a challenge for the aesthetic doctor, espe- cially in patients who reject surgery.
Among the various methods, the use of fillers has a rationale due to their sti- mulating effect for collagen production and thickening of the deep dermis.
Polylactic acid has recently been approved by the FDA for aesthetic use, particularly for correcting the nasola- bial folds.
In view of its ease of handling and scarcity of side effects, when used properly, it has started being used off-label in other body regions as well.
The skin of the medial region of the arms is extremely thin and delicate, which is why filler hyper-dilution has been employed, associated to vigorous massage which has led to brilliant results where the right therapeutic indication has been considered.
Restructuring treatment to reverse aging of the periorbital region is one of the challenges faced by plastic surgeons.
Although there is no single treatment for different skin types, it is nonetheless important to evaluate which treatments are most suitable.
Our study compares amino acids injection treatments with treatments combining percutaneously injected dermaroller and amino acids.
We considered parameters like patient's discomfort during treatment and post- treatment satisfaction.
Such data were analyzed with the Students' t-test.
Infiltration with amino acids proved to be more effective in the long term than the combined approach.
The periorbital region includes lower and upper eyelid and the external area formed by zygomatic and frontal bone structures.
This region is frequently affected by early signs of aging, often requiring intervention in order to improve wrinkles, abnormal pigmentation, skin relaxation, and brow ptosis, albeit, without altering the facial expression1.
In order to determine the best treatment, it is necessary to define a global approach to the affected area, since most aesthetic defects are often associated.
There are two approaches; on the one hand, the surgical route (lower blepharoplasty, upper blepharoplasty, eyebrow lifting and cantopexy, cheeckbone lift and lipofilling)2-4; on the other, the medical-aesthetic solution, which presents the most used and standardized options, like botulinum or hyaluronic acid injections, peeling treatments and the use dermarollers5.
Both approaches are often integrated with each other in order to obtain comprehensive results to the subcutaneous-muscular structure, as well as to the skin proper (Figure 1).
Our study was performed on 10 patients who were treated at our office in 2015.
Our aim was to verify the effectiveness of the bio-revitalizing treatment by comparing it with the use of dermapen and bio- revitalizing products.
Our female patients had a mean age of 53 years (39-73) and no relevant associated diseases.
All patients present a light to moderate facial aging (0-2 Lemperle scale).
Each patient was treated in one eye contour area with bio-revitalizing micro-particles (amino acids + noncross-linked hyaluronic acid).
The injected mix was 1 cc of noncross-linked hyaluronic acid + 100 mg of freeze dried amino acid (50 mg of Glycine, 37.6 mg of L Proline, 5.4 mg of L Lysine, 7 mg of L leucine).
The other eye contour was treated with a 1.5 mmdermapen with controlled mechanical and biorevitalizing damage seeping through small incisions (Figure 4).
Patients were visited 1 day and 7 days after treatment, respectively.
Lastly, we assessed patient's satisfaction with the results of treatment, as well as mild-moderate complications, if any, and the discomfort of both treatments, which we determined on the VAS scale and compared with the Students' t-test to define the statistical significance of averages.
During follow-up, we identified a standard trend, both in terms of satisfaction and the onset of complications; on the other hand, we also took account of non- uniformity of assessment, with regard to the pain of both treatments.
In terms of the onset of complications, on the first day, 8 in 10 patients had greater swelling in the area treated with bio-revitalizing concentrate injection, whilst 2 out of 10 women did not present any difference with the area treated with dermapen. 2 out of 10 patients had bruising in the area treated with bio-revitalizing concentrate injection.Notwithstanding initial swelling-related discomfort, 7 days after treatment, patients reported greater satisfaction about the area treated with bio-revitalizing concentrate injection, with an average VAS score of 8.1, compared with a 6.7 scored by the area treated with dermapen (Tables 1 and 2).
A comparison between our data with Students?€? t test yielded a statistically significant average variance (p <0.012).
Finally, we evaluated patient discomfort.
This datum did not demonstrate uniformity in the sample.
Patients evaluated discomfort at the time of treatment with bio-revitalizing concentrate injection with a mean of 5.4, while the average VAS score was 5.5. in the area treated with dermapen.
The difference between the two data is not statistically significant (p <0.87).
?Proper treatment of the periorbital area continues to be challenging for plastic surgeons.
For a better approach to treatment, it is necessary to fully understand the structures involved in this area's aging process and leverage or counteract their features in order to improve aesthetic results.
Starting from the deepest structure, it is important to identify the bone surface that can function as support and be used for anchors, suspensions or the implantation of prostheses7-8.
Next, we reach the orbicular muscle, whose sphincter movement leads, over the years, to the formation of so-called "crow's feet"? the action of this muscle can be countered in a simple and effective way with the use of botulinum toxin.
However, although the intent is to counteract the muscle movement and to prevent the formation of additional wrinkles, existing wrinkles must also be treated.
The eyelid skin adheres loosely to the orbicular muscle and becomes more evident with age, when subcutaneous tissue and collagen component (which are already very scarce in this area) tend to disappear.
What is enhanced, therefore, is thin skin, which is often loose, non-elastic and with dark spots caused by sun damage.
This is, in our experience, the most difficult area to treat.
The use of long-chain hyaluronic acid is to be discouraged, since it is often perceptible to the touch in areas where the skin is so thin, and because it will likely migrate due to the action of the underlying muscle9-10.
The combined use of botulinum toxin, bio-revitalizing concentrate injection and chemical peeling acts at different levels, starting from the muscle up to the horny layer, and considerably improves skin elasticity, texture and brightness.
The addition of dermaroller with its controlled mechanical action on the dermis creates a further action of a different type.
Our patient sample showed greater satisfaction with the side treated only with bio-revitalizing concentrate.
This result means for us that, although non-crosslinked hyaluronic acid and amino acids have a relatively low molecular weight, percutaneous penetration, even if facilitated, of the dermaroller, is not satisfactory.
Conversely, direct injection of bio-revitalizing concentrate, though at first produces greater trauma and greater liquid retention (swelling), eventually minimizes complications and becomes more effecting within one week from treatment.
Amino acids in the bio-revitalizing concentrate, indeed, stimulate collagen synthesis and growth factors.
Ultimately, the action is to recreate the normal structure of the dermis, improve tissue nourishment and activate metabolic processes, while also slowing down catabolic reactions.
In our experience, therefore, the best non- surgical treatment against aging of the periorbital area is bio-revitalizing concentrate infiltration following botulinum toxin treatment, to be completed with appropriate peeling.
Treatment of the periocular area with a combined approach including surgery and aesthetic medicine is always advisable.
In our experience, in fact, this area has strong aesthetic and emotional relevance for patients, and effective remedy to aging leads to great satisfaction.
Although it requires excellent knowledge in both fields, the dual approach is essential and useful even in cases of small surgical complications, which can be improved through cosmetic medicine measures.
Nowadays, the non-surgical treatment of loose skin on body contours is one of the main requests from our patients.
The decline in demand for major surgery worldwide has stimulated research into a technique that could allow an effective result, on an outpatient basis, without the need for any convalescence period.
The experience we have gained of implanting polylactic acid suspension wires in the face was the starting point for developing a new technique, aimed exclusively at correcting slackness in body skin.
We have reconsidered the anatomical know-how in our possession and, by making the necessary changes, have created a much more suitable implant model, particularly for the abdomen, inner arm and inner thigh areas.
Between May 2013 and May 2016, we treated the following patients: 32 on the abdomen, 22 on the arms and 16 on the thighs.
The patients were all female, and 37 to 62 years of age.
The procedure was found to last 30-40 minutes and was well-tolerated, with daily activities being resumed as soon as the procedure ended.
We found no major or minor complications either during or after the treatment.
Even immediately post-treatment, it was possible to note a marked improvement in the tautness of the skin.
After about 60-90 days there was a stable improvement in skin tone and the tissue laxity induced. 6 months later, the results had remained stable, whilst after 1 year an initial decline was observed.
This technique can therefore be considered a safe and effective method.
Experience, respect for anatomy and patient selection are fundamental aspects in obtaining the best results in each individual case.
Over recent years, there has been an increase in requests for the correction of skin slackness in different areas of the body.
Next to the face, which remains the main request, the demand for treatment of slack skin on the front abdominal wall and the inner arms has increased.
Major surgery (surgical facelift) has undergone a decline over recent years, in favour of less invasive techniques that ensure a much shorter post-operative decursus with the immediate recovery of daily activities1,2.
For example, new non-invasive instrument technologies, such as radio-frequency and micro-focalised ultrasound, have been introduced in order to activate neo-collagenesis and the production of new elastic fibres, thereby reducing skin slackness3-8.
Re-absorbable suspension threads were introduced, which, in addition to creating an immediate lifting effect, stimulate the fibroblasts over time to produce fibroblasts, collagen (types I and III) and elastic fibres6-13.
These new techniques are vastly different from a surgical facelift, which remains a more definitive, but far more invasive intervention, since these activate more tissue stimulation and regeneration, which allows a ?€?softer?€?lifting effect, which is less immediate, structurally different, less long lasting, but which is repeatable, less invasive and less expensive.
Based on our accumulated experience of using resorbable threads for facial slackness, we have dealt with treating skin slackness in other areas of the body, in particular, the anterior abdominal wall, the inner arms and the inner thigh regions, using wires fitted with bi-directional cones.
After some initial experiences which were characterised by poor results, we reconsidered our own anatomical ideas and, by making the necessary changes, created a model implant that is far more suitable for the abdomen, inner arms and inner thighs.
The presence in the skin of lines that correspond to the orientation of natural tension vectors in the skin with a lower tension was first described by Langer in 1861.
In 1942 Cox, and later Stark in 1977 demonstrated that the direction of Langer's lines remains, even after skin is removed from the body and the tension to which has been subjected is resolved, and concluded that these lines had an anatomical basis14-16.
By analysing the direction of the collagen fibres in the dermis, Cox and Stark showed that there was a correlation between the direction of the collagen fibres in the dermis and the direction of Langer lines.
Therefore, the presence and orientation of Langer lines (Figure 1), in our opinion, should always be considered when suspension sutures are used to reduce skin slackness in the various areas of the body.
The sutures we use are made of a resorbable material (polylactic acid) and are fitted with re-absorbable cones (made from polylactic acid and glycolic acid).
Each suture has two sets of cones: these two series have the same number of cones, and are oriented in opposite directions towards the two ends of the suture.
The cones are inserted into the suture and held between two nodes which are placed 0.5 cm or 0.8 cm from one another.
The central part of the suture measures 2 cm and is devoid of cones.
Three different lengths are available for this type of sutures: 30 cm (8 cones), 27.5 cm (12 cones) and 26.7 (16 cones).
The suture material (polylactic acid) is completely re-absorbed in 18-24 months: it acts in the subcutis, stimulating the fibroblasts to produce fibres and collagen, which helps to gradually increase the volume of the area.
The cone material (82% L lactic acid and 18% glycolic copolymer) is reabsorbed entirely in 8-12 months17.
The cones have a (smooth) 360° surface anchorage to the subcutaneous tissue, which allows an instant and solid fixation.
As foreign bodies stimulate the inflammatory reaction, they slowly degrades them, and a fibrous capsule is formed around them: this fibrous reaction consolidates support of the adipose tissue, and prevents the risks of migration or extrusion13.
The technique provides for the insertion of 2 polylactic acid wires with 12 or 16 cones, longitudinally in correspondence with the alba line, using a narrow V technique (with an opening oriented towards the navel), both above and below the position of the umbilicus, put in place with a moderate tension (to prevent the wires sliding, which could tear the subcutaneous tissue).
This allows the right abdominal quadrants to be divided from the left, due to stiffening of the tissue at the midline.
These are the lines of Langer, with their various orientations and directions between the supra-umbilical and sub-umbilical regions, which allow the abdomen to be divided into four separate quadrants.
Hence this technique is defined as the'4-Technique' (Figure 2).
At this point, following the direction of the Langer Lines, for each quadrant, a 12 or 16 cones wire is implanted (depending on the size of the patient), using a U shaped technique, with a tension direction distributed from the medial area to the side area.
Own maximum expression precisely corresponding to its medial area, 1-2 wires are implanted with 12 or 16 cones using the C technique, on the axis of the Langer lines, with traction vectors from the medial region to the lateral region.
The shape that the implant of these wires takes, which resembles a Tau cross, dictated the name of this as the Tau-Technique.
The surface of the inner thigh region is separated into an anterior to a posterior area, again taking the distribution of the Langer lines into account.
To avoid cancelling the opposing tensile forces that the suspension wires can generate, we decided to separate the surface of the arm in an anterior and a posterior area, taking the distribution of the Langer lines into account at all times.
The technique therefore provides for an initial implantation of 1 or 2 wires with 16 cones by a linear technique in correspondence to the medial region of the arm.
This allows resistance to the opposed sliding of the wires to be created, simulating separation of the circular surface of the arm into two semi-circular areas.
The technique therefore provides for the initial implantation of 1 or 2 wires with 16 cones using a linear technique, in correspondence to the medial region of the thigh.
This allows a resistance to the opposed sliding of the wires to be created, simulating the separation of the circular surface of the thigh into two semi-circular areas.
At this point, 1-2 wires are implanted with 12 or 16 cones using a C technique, in axis with the Langer lines, with traction vectors from the medial region towards the lateral one.
It is important to identify (using a Doppler or echo- colour-Doppler device) and mark the path of the great saphenous vein before starting the procedure to position the threads, in order to avoid an accidental puncture and to create a safe area during the implantation.
Between May 2013 and May 2016, we treated the following patients: 32 abdominal patients, 22 inner arm patients and 16 inner thigh patients.
The patients were all female, and from 37 to 62 years of age.
The patients selected had a slackness measured by the pinch-test of between 1 and 2 cm; lower values were excluded due to the risk the cones would be visible on the surface; higher values were excluded because the adipose tissue present could have compromised the result.
The patients were all monitored at 15 days, 2 months, 3 months, 6 months and 12 months.
In choosing the type of wires to be used, measurements taken of the surface to be treated on the patient played a fundamental role.
As a rule, 16-cone threads were used for all areas of the body; when the morphological characteristics demanded it (limited surfaces in the regions being treated), 12-cone wires were used.
Depending on the size of the various body areas, 12 or 16 cones were implanted. 8-cone wires were never been used because they have a tensile strength that is too low for the body districts in question.
Normally, 6 threads are used to treat the abdomen; where there is a limited treated surface, 4 wires are used (2 vertically positioned with the linear technique and 2 positioned laterally with the低”  technique) .
Normally, 3 wires are used for the arm; where there is an increase in the dimensions of the treated area, up to 6 wires (2 longitudinally positioned with the linear technique and 4 positioned transversely with the “C” ?technique) are used .
For the inner thigh, 4 wires were normally used, with a maximum of 6 wires for large surfaces (2 positioned longitudinally with the linear technique and 4 positioned transversely with the “C” ?technique).
All of the treatments were performed with the patient correctly positioned on an operating table.
The treatments lasted 30-40 years and were well tolerated by the patients, who were able to resume their daily activities immediately after the procedure (apart from suspending sporting activities for 15 days).
We did not detect any major complications; the only minor complications were bruising and some irregularities of the skin surface.
In rare cases, bruising may occur (especially after treating the arms) which resolves spontaneously in about 15 days.
Immediately post-treatment, it is very common to have irregularities of the skin surface, which resolve spontaneously within 7-10 days.
Approximately 60-90 days after implantation, a stable improvement in skin tone and tissue firmness can be observed, probably induced by the neo-collagenesis process due to the initial polylactic acid resorption process.
At the check-up 6 months after implantation, the results were still stable, whilst after 1 year, the beginning of a descent was observable.
The use of polylactic acid suspension wires for treating slackness of the abdominal wall, the inner arms and inner thigh regions arose from the experiences gained from using them on the face.
However, the anatomical differences between the various body districts demands a careful assessment of Langer?€?s lines and the adoption of implantation techniques that are specifically designed to successfully treat large flat areas of skin (such as the anterior abdominal wall) or semi-circumferential areas (such as the inside of the arms and thighs).
One needs to be well-acquainted with the techniques for implanting the suspension wires, and above all, to use the correct anatomical plane for inserting the threads themselves.
To facilitate wire implantation, we recommend the use of an operating bed and correctly positioning the patient.
During implantation, the fact that the patient complains of intense pain can be attributed to the needle reaching a layer that is too deep and puncturing the muscle fascia.
This should be assiduously avoided to prevent complications in the post-treatment period.
Careful selection of patients is also important for avoiding those in which the results will be poor, i e those with excess adipose tissue (in which the threads will not be able to reduce the slackness) and those with skin and subcutaneous tissue that is too thin (in which the cones will be excessively visible on the surface for several months).
We believe this method offers considerable advantages.
First of all, the correction of skin laxity of the body with this method is carried out in a surgical outpatient's clinic, without any patient admission, under local anaesthesia.
The implant usually takes only 30-40 minutes and allows almost immediate recovery of daily activities, even if with some limitations on sporting activities in the first 15 days.
This method has also proved to be easily repeatable over time, with results that improve with subsequent implants.
Sub-dividing the areas to be treated into quadrants also means that interventions can be performed in several steps, both to consolidate the result over time, and in response to the patien's requirements (dividing the treatment into several phases also spreads out the cost).
Last but not least, this method is considerably less expensive, and does not require any period of convalescence post- treatment, compared to a surgical face lift, even if the results are less long-lasting.
The use of polylactic acid suspension wires in the treatment of slackness of the abdominal wall, and the inner regions of the arms and thighs can be considered to be a safe and effective method.
Experience, respect for anatomy and patient selection are fundamental aspects in obtaining the best results in each individual case.
Only recently have we come to a freedom in terms of our body management; one that finally gets a new role that is no longer a docile body but a flexible one, which changes through personal choice and action.
It is up to each individual to take responsibility for their own body design because, through the body, we define ourselves and our identity making the body become a visible and personal identity.
It is a thoughtful project, in which the lifestyle, guided by the regimes, is essential: "the appearance of the body, its behaviour, its own sensuality, the ways of undoing basic needs, food, and clothing"?
New body management techniques, the ones called reflexive, are also very important: their main task is to work on the body to modify it; trying to keep it or adapt it in the most appropriate and responsive ways depends on the individual.
Amongst all of these techniques, there is also the aesthetic surgery.
The purpose of this work is to deeply study the motivations that induce people to undergo cosmetic medicine treatments.
With this type of research I want to show all the reasons behind something that can be seen as an apparent aesthetic need.
There was a research that focused on the evaluation of the relationship that links sexuality to beauty and the motivations that push a woman to undergo to aesthetic medicine treatments.
The aim of this work is to analyze the reasons that lead people to undergo aesthetic medicine treatments.
This kind of research shows what can be hidden behind an illusory purely aesthetic necessity.
Underlying this work was a research that focused on the analysis of the relationship between sexuality and beauty, and the reasons that lead women to undergo aesthetic medicine treatments.
Furthermore, the research has examined in depth how the necessity of changing something about themselves, for real problems or for aesthetic wishes, grows and becomes real.
The method that has been used to gather the declarations about this kind of research is a qualitative method, because this method allows the achievement of the predetermined goals through the collection of both stories and in-depth interviews.
Because, as Patton asserts ?qualitative methods are highly personal and interpersonal, because naturalistic inquiry takes the researcher into the real world where people live and work, and because in-depth interviewing opens up what is inside people.
More specifically, it is a biographical type of interview, a research technique that focuses on the biographic study and the reconstruction of the past of the person interviewed, thanks to the confidentiality and the freedom of expression given to the subject.
The biographical interview is a specific application of in- depth interview; it involves unstructured interviews and open-ended questions.
The peculiarity of the unstructured interview, also known as depth interview, resides in the individuality of the topics and in the itinerary of the interview.
The interviewer has only one job: to speak about the topics he wants to speak about; then, the interviewer will let the interviewee develop his way; keeping the initiative of the conversation, stimulating him or leading him to in-depth analysis when there is a connection with interesting topics.
The interviewer has to encourage and stimulate the interviewee and he also has to control the conversation, containing the digression and avoiding off topic comments2-4.
Furthermore, I have chosen to use the qualitative interview because the actions of listening and mediation of the interviewer carry out a function of care towards the interviewed5-8.
In qualitative research, without listening to the other one, there cannot be the comprehension of his point of view, through that process of identification, from the interviewer to the interviewed, essential for the collection of data9.
In-depth interviews were 15, pointed towards women exclusively, and aged between 30 and 60, integrated with phone interviews.
Each interview has been anonymous and confidential.
Indeed, each person who joined this research required anonymity and the names used are fictitious names.
As the interviewer, I have always respected these tasks.
I have always kept the feedback with the interviewee under control after the primary question because, as Rogers says: ?An essential part of the interviewer’s job is the use of techniques in order to focus on and to control the interaction after the primary question, in this way the aims will be achieved properly?.
A typical intervention is represented by the use of the probing questions: these are not proper questions, these are neutral stimuli that have the function to encourage the interviewed to move forward, to lower his defensive barriers, to examine in depth the topic, to give more details11-12.
This is useful to fix the common problem: to receive incomplete, inaccurate and unsuitable answers.
I have tried to keep the topic unchanged, avoiding the use of sentences like “cut to the chase”, “summarize”, etc… therefore, I have tried to accept, respectfully, the interviewed point of view without judgement, neither positive or negative.
Sometimes, it was hard to keep an impartial attitude, because of the sensitivity of the topics13.
Furthermore, during the interviews, I always tried to take advantage of the moments of silence of the interviewed, using them to encourage her to examine in depth a specific topic and I forced myself to focus on that topic without thinking about the next question to ask.
The social and physical place in which the interviews have been realized, has been chosen by the interviewed themselves, so they could feel comfortable and free to express themselves in the most spontaneous way.
This work is developed on an investigation about"the beauty's world"?which focuses on the necessity of a detailed study about the sexual dimension inside itself.
The theoretical propositions and the conceptual tools that I chose for the interpretation of “the beauty’s world”? have concerned many authors that approached those concepts in different ways.
More specifically, Bourdieu sees the human being as a thinking body and he asserts: I am the body that I have.
We learn through our body.
The social order enrolls inside the bodies through this enduring comparison, more or less dramatic, but that always leaves space to the affectivity and, more specifically, to the affective transactions with the social place.
Indeed, Remaury, regarding the relationship between health and beauty, thinks that the body fulfillment is based on the youth-beauty-health triad: beauty corresponds with youth, gained by health.
Therefore, health shows the beauty, the biggest expectation about the present body's cult and the first duty about the self- care.
The pluralization of the current social context highlights how much, nowadays, there is a freedom of managing our own body that accepts a new role, not more a docile body but a flexible one, target of choices and actions that are personal: each one, then, has the responsibility of his own design because, through it, his identity can be determined, the body becomes a visible messenger of identity itself19.
Furthermore, new techniques for the management of the body, called reflexive, should be considered important: their main aim is to work on the body in order to alter it, preserve it or adapt it in the most suitable way, depending on the subject?€?s necessity.
Aesthetic surgery is one of these techniques.
The body-project includes another innovation: the privatization of the body, or better, the privatization of the agencies of social production of the body, the demonstration of the ruling uncertainty in modernity20.
Current societies are, just like yesterday, somatic societies: inside of them, body becomes political and a cultural field of battles21.
According to Juvin, the body becomes bank and market, it is a standard of truth, because it is the only one that remains, as a constant, in our past.
The body is the center of the power, object of all the expectations.
According to Juvin’s theory, if in the past the soul reigned, in this wellness civilization, the body is the ruler.
Therefore, in a society like the current one, where the communication, being multimedia, is able to reach a lot of interlocutors instantaneously (normally, women are more involved than men), it is easy to impose beauty’s models and ideals and so Remuary asserts that ?This augmentation of the beauty’s models is caused by the media (journalists and advertisers): their aim is to sell female beauty’s models repeated a lot of times, whose intensity - despite the attacks of which women are victims - not only doesn’t reduce but it continues to grow during the years.
Today, the image of the realized body goes with a higher and higher number of moments of our lives – from the grains we eat at breakfast, to the time we spend at the cinema?.
One of the reasons that convinces women to resort to aesthetic medicine is the desire of an improvement in order to like themselves more and to be liked by the others.
Indeed, social desirability influences the choices of the social actors.
Giovanna, 31, explains how her problem influenced herself in her social relationships: ?This problem affected my self-esteem and my relationship with others.
It affected me so much it limited my routine.
In the morning, for example, I rarely put my make-up on… because I don’t have time, desire, because in the past I didn’t need to do it; now it became a complex, to show myself to the others, without my make-up on is awful… it leads me to bend, to walk with my head down… I would rather appear rude not saying hi to someone than to show myself with no make-up on.
Basically, I organize it: if I have to pop in to the Garden [a famous meeting place in the city of Catanzaro] to buy cigarettes, I put my make-up on or I?€?d rather not stop by, there is no other option.
I care about the judgement of the people who know me… of course, if I go in a new place it is normal that I feel more sorry if a guy, maybe a nice one, sees me in that way… in the places that I already know it is the same… man or woman, it is the same! […] The idea that the others have about you influences you anyway.
Everyone's opinion.
All that we are is the result of what the others want (us to be)?.
Maria, 40, regarding how the social conditioning can bring a woman to do aesthetic medicine treatments, says:
?Some women decide to have a makeover because they are influenced by what surrounds them, they look for the way to find themselves, they want to find self-confidence in an outward change.
There are also women that seem like fools to me, that do it only because they are influenced by a stereotype to which they want to conform to?.
Lucia, 60, married and mother of three, resorted to aesthetic medicine after a family crisis which involved the relationship with her husband.
About the way in which sexuality changes during the years, so she says: ?Now it is important for me to like myself, before pleasure was important for me.
Unfortunately, sexuality with my husband has changed, he has got a problem, a prostate cancer, for this reason we no longer have sex, but before his operation sex was different, it has changed over time because it is normal… when you are self-confident you have a different attitude, you dare more?.
Francesca, 55, says that she resorted to aesthetic medicine because she needed to be “re-born” after a difficult period and after an abortion.
Regarding the relationship between sexuality and beauty she says that:
?It is true that, when you like yourself, you are more liked by the others… even when you have sex but most of all in what precedes sex… you are more self-confident and, as a consequence of that, you transmit your self-confidence to your partner. I always liked myself, but it is obvious that, with a little help, everything becomes easier?.
Laura, 50, wife and mother, had breast surgery twice and speaking about the relationship with sex, she says:
?The first time I had breast augmentation I did it not for myself, because I could have worn a push-up bra, the problem is with the other sex, if you have to take off your clothes in front of a man and you don’t like yourself, you feel uncomfortable.
You can have toned legs but if you have two awful boobs, what does it matter?
I live only for my job, I don’t care about anything else… it sounds bad but also my friends, my family, my daughter, everything is subsequent to my gym… my life is my job so it is normal that my job has influenced and will always influence my life choices.
During the years, I noticed physical changes but also a very strong change about sex, I used to be a panther… I trained as much as I wanted to have sex… now it is not the same, after the pregnancy everything has changed… my lust is equal to zero.
I don’t have arousal.
I don’t have the desire to make love, even though my husband is five years younger than me and he goes through everything.
Honestly, my relationship with him is less passionate than before, but we grew up a lot.
The rhythm and the frequency decrease because we both have chaotic lives and, honestly, when I come back home I set up, I reorganize and then I just want to rest, holding my husband but I want to relax?.
And then, about this topic, she asserts that: ?Even in sex… come on, you know that a man doesn’t notice your foot’s nail, but we… do!
We must be perfect… light turned off or suffused in order to hide as much as possible our flaws… but the thing is… in that moment a man just wants to reach the orgasm, he doesn’t care about your nail, he doesn’t care about your extra pound!?.
After the declarations of the interviewed it is clear that an essential role in the decisional process, which moved these women to undergo aesthetic medicine treatments, has been played by Doctor Catizzone.
Her way to approach her patients, the comprehension and the reassurances she gave to them, can be considered as shared and decisive factors for all the women interviewed.
Giovanna, 31, says that: ?Of course, if I hadn’t known about the Doctor’s “reputation”, I would have relied on no one else… if I hadn’t had the certainty that the Doctor had the right competences, I would have entrusted my face to her care… because an arm is an arm, but a face is a face?.
Barbara, a 50 years old interviewee, says that for a long time she had the desire to undergo aesthetic operations but only the meeting with the Doctor gave her the right confidence, so she declares: ?I have been thinking of doing them for a long time but I made my decision only when I met the Doctor.
 I was scared, you never know who you can find… then I met the Doctor and my experience started.
I rely on her entirely. This plan is good for now, then we’ll see… when I get old we will decide what to do?.
Lucia, 60, asserts that in the figure of the Doctor she found, first of all, a person inclined to listen, so she says: ?I was wasted, my weight was 48 kgs, my face was marked… I would have changed everything about me… luckily, I met Rosanna who didn’t permit it and she proceeded step by step… I’ve been using botulin and hyaluronic acid for a year… once a year, but then I continue with a vitamin cycle.
The doctor, who is a very honest person, has suggested to me to proceed slowly and to start with the face revitalization.
Since then, I never come here saying “do this to me” but I say to her: “Rosanna, how do I look to you?
What can we do?”.
I totally trust her.
I want to say it again, when I came here for the first time I would have done everything, I would have spent millions!?.
Serena, 40, says that she does annual mesotherapy treatments and, as a consequence of a brutal accident, she had to do a facial plastic, 20 years earlier and, regarding the relationship between doctor and patient, she asserts: ?I went to the Doctor and I trusted her because she doesn’t want to take advantage of her activity; if you go to her, asking her to do lips augmentation, she says no…and before doing something she examines the reasons, she is a kind of psychologist!?.
Giovanna, 31, resorted to aesthetic medicine after a true problem, more than an aesthetic one, so she speaks about what for a  woman should be considered  the strength of her own body: ?In my opinion, a woman is beautiful if she has a beautiful face, her weight can also be 200 kgs but she should have a beautiful face… perfection is hard to be reached, everyone has her own flaws (and women are very good at finding them!) but for me the most important thing is to have a not big enough nose, expressive eyes, whatever color, plump lips… and teeth… teeth are always important… I watch everyone’s teeth.
The body impresses me less, both in women and men. The more a man is toned, the less I like him?.
Lucia, 60, about what captures the attention of a man regarding a woman, says: ?We should understand which is the most important thing also for men… I mean, a young lady could have the will to do breast augmentation in order to be more attractive.
For a man, for example, the breasts, the buttocks, the lips are more important.
I think that for a woman the face is more important… also the breasts, but the buttocks less, I think! I mean, b-side is the first thing a man looks at?.
Bianca, 38, who had some problems on her face because of a violent cystic acne, about her idea of beauty asserts: ?I am an aesthete, I like beauty! I know that I am not beautiful, I can be appreciated or not, I know which are my strengths and my weaknesses. 
Beauty, even though it could be a superficial concept, is aesthetic. There are well - defined aesthetic standards: a tall, slim, wiry woman with a beautiful breast, not a 4th size or a 5th size of bra, but that fits with her body… that a woman is “curvy” is not a problem for me but she also has to have a beautiful face.
The thing is: if you have a beautiful body, the face (which is important anyway), can be less important than the body; if you have a curved body, you should have a beautiful face inevitably… I find beauty there and for this reason it overshadows the body.
The man, indeed, has totally different standards of beauty.
It depends on the man, if he is a man with capital “M”, he would agree with me, but it is not a common situation, I have a very bad consideration about men and I feel more sorry because I have a son… but I will do my best to help him grow up also with a female point of view, so he can see everything from every perspective.
Anyway, I think that there are men, not a lot, that appreciate women beyond their aesthetic beauty?.
Marta, 40, regarding her idea about a beautiful woman and how a man considers a beautiful woman, expresses her point of view:
?In  my  opinion,  a  beautiful  woman  should have a beautiful face, that’s all
A man looks at a beautiful bottom, beautiful boobs and he no longer understands.
A man, honestly, thinks with everything but his head.
I am sure that, no man likes a too plumped lip.
He could be more attracted by the body.
I think that, if a woman has a toned body and beautiful breasts, she is ok with that and it is normal that a man likes her, but a deformed face, because of surgery, no, I think that nobody likes it?.
Laura, 50, admits that she lives the research of beauty as an extreme love for her own body, so she asserts, regarding her idea of aesthetic beauty: ?In my opinion, the physique is more important than the face… I mean physique in all senses. I don’t agree with medicine, I don’t agree with something that could hurt our body.
I don’t agree with medicine, I don’t agree with something that could hurt our body.
I always say to my daughter “you don’t have the right to use drugs, not because drugs are illegal, but because you are in good health and you don’t have the right to take off your health when there are people that are born and live in a wheelchair.
If you have life and beauty you can’t ruin them, you don’t have the right to do that, on the contrary, you have to defend them”.
In my opinion, beauty and health are on the same road.
As for beauty, I think that women and men have different standards.
Women do everything for being thin, toned, we do a lot of sacrifices and then, maybe, men look at the one with a big bottom, a shapely woman.
I like when a woman is not too shapely.
I don’t like too slim women and neither do men… they can’t stimulate a sexual desire, they can make men feel tenderness and we can envy them for the way in which they can wear a dress.
We actually create a lot of problems… we personally let men notice our own flaws because otherwise it is not clear how some women, objectively ugly, could be liked by men?.
This research has put in evidence the strong collaboration between two disciplines very different between them, sociology and medicine.
This research focused on the evaluation of the relationship that links sexuality to beauty and the motivations that push a woman to undergo aesthetic medicine treatments.
Techniques of skin rejuvenation most commonly remain the ablative and exfoliative types of treatments such as peelings, lasers and micro-dermabrasions.
In contrast, the revitalizing treatments focus on replenishment and nourishment to reverse the cutaneous aging signs.
This concept, unique to the technique of skin rejuvenation mesotherapy or revitalization, focuses on replacement and nourishment of the vital components of the skin with mostly poly-vitamin solutions and especially non- cross-linked hyaluronic acid.
Also, soft tissue filler injections have evolved to unique formulations adapted to various depths of injections by altering the rheology of the hyaluronic acid (HA) fillers with various concentrations, cross-linking degree and chain lengths to adapt product injection to unique depths and indications.
HA fillers are being used for skin rejuvenation purposes by utilizing the low density, low cross-linked HA products suited for dermal injections and not purely sub-dermal as with past and traditional HA fillers used mostly for contouring and volumizing.
Many doctors will perform skin rejuvenation with either fine line filler products (minimal cross-linked HA) placed dermally or just sub-dermal by manual or device injection or some may prefer to treat with poly-vitamin products with mesotherapy techniques of injection.
Only recently have we realized the importance of combining both techniques for optimal results.
The technique, which I have named "Bio-skin-gineering"? focuses on treating each individual layer of the skin, with knowledge of exact depths and angle of injection with various products according to the suitability of the product for the specific layer.
The rationale behind this concept is that each layer from epidermal, DEJ, dermal to subdermal needs to be treated individually in order to reduce aging changes in the layers individually and to optimize results.
This protocol is a natural, safe and effective therapeutic intervention to improve the external cutaneous signs  of solar elastosis and photo-aging of the face, neck, d?collet? region and for the hands.
The protocol is especially suitable for patients with:-?? Thin or dehydrated skin -?? Fine wrinkling (crepe paper appearance) -?? Superficial lines or skin coarseness -?? Textural skin aging (due to solar elastosis or poor lifestyle habits) -Need for preventative intervention.
The specific indications that can benefit from this treatment includes: Peri-orbital loose skin and wrinkling  Peri-oral wrinkles Cheek wrinkles Forehead lines Neck and d?collet? skin aging Skin aging on hands.
The  proposed  protocol  focuses  on  replenishment of the decrease in HA (free HA) within the layers; supplementation of the necessary anti-oxidants, vitamins, minerals and agents that will stimulate cell renewal and reduce oxidative aging process; and lastly to replace lost volume within the deep dermal and sub-dermal layers with minimally cross-linked HA to obtain a cushioning effect.
The bio-skin-gineering technique opinion aims to emphasize the importance of knowledge of the precise depths of each layer of the skin and how to accurately reach each layer to optimize treatment outcomes.
The technique is performed in 4 steps, all done in the same treatment session.
Epidermal rejuvenation (0.05 - 0.1mm thick on face to d?collet?) .
The epidermic technique, as described in mesotherapy practice, is performed with a 30G needle of 12mm length at an angle of 10° or less to the skin, with only the bevel entering this superficial layer9-13 (Figures 1A and B .
The movement is rapid and almost"tremor - like" to ensure that the needle does not enter too deep.
Soft pressure on the syringe plunger will ensure droplets of the product are deposited on the surface and reach the epidermis.
Alternatively, the technique of epidermal skin needling with a device containing short 0.5mm - 1.0mm needles and very slight pressure (minimal bleeding) can be used to rejuvenate the epidermis.
The product is applied to the skin before and during the rolling technique on the skin (Figures 1C and D .
Rejuvenation of the epidermis is performed using a sterile injectable poly-vitamin solution with only free hyaluronic acid (not cross-linked at all) that is suitable for epidermal level of injection or needling.
An example of a suitable product for this technique is NCTF135HA?, due to its optimal suitability within the epidermis and dermis, and due to the numerous scientific safety and efficacy data.
Role of epidermal technique: enhance cell turnover, improve moisture balance, nourishment of the avascular epidermis and intense cutaneous stimulation.
The epidermic technique contributes greatly to the radiance that patients notice from the 1st session.
This technique has been described in mesotherapy practice as the papule technique.
This layer can only be reached with a manual injection with a 30G - 32G needle of about 4mm length.
Separating the epidermis from the dermis, with a papule forming, is the aim of the technique.
A typical wheel or papule has to be visible during injection, avoiding too deep injection as this will reach deeper dermis or subdermal level.
The technique is focused on problem areas such as inside wrinkles, scars, eyelid skin or areas where maximal lifting is required.
The same product as mentioned in epidermal technique and not at all with a cross-linked HA, as the papule will remain.
Product choice is essential and should be water soluble, neutral pH and sterile for injection purposes to minimize pain and complications.
Role of papule technique in DEJ: optimizes transfer of nutrients, enhanced microcirculation and improvement of the upper part of the papillary dermis (DEJ).
The dermis is most often treated with aesthetic treatments.
Low viscosity and minimal  cross-linked  HA fillers have become popular for dermal injection to enhance collagen quality and quantity.
Non cross-linked HA solutions are often used for intra- dermal injection. 
The purpose of dermal injections: enhancing collagen content and quality, extracellular matrix enhancement and also improvement of fibroblast and elastin quality.
The objective is to nourish the dermis and the fibroblasts with essential vitamins and minerals, to replace free HA within the dermis and to create multiple punctures into the dermis for microcirculatory improvement, growth factor release and to create a favorable environment for dermal fibroblast cell function.
A quality product containing an ideal combination of essential nutrients, vitamins, minerals, anti-oxidants and free HA will further ensure the bio-revitalising effect of the treatment.
The technique used is referred to as a multi-puncture technique (Figures 3A, B and C .
Ideally performed with a 30G or 32G needle of 4 - 6mm length at an angle of 45° to the skin.
Multiple, fast and repetitive punctures into the dermis is used.
Free (non cross-linked) HA integrates in the dermis and will not cause any complications of long-term nodules or "Tyndell effect".
This will replenish the ECM, induce deep hydration and stimulate fibroblast activity to increase production of the scaffolding components within the ECM.
Dermal rejuvenation with cross-linked HA fillers (low degree cross-linking) are done with a different technique to avoid nodules and other possible complications.
Very small amounts of product should be injected per point.
The techniques that I have found to cause the least amount of side effects for the patients are not papules, but rather very fine ‘worms’ or lines of product in a mesh/ grid pattern.
Alternatively a micro-cannula (25 - 27G) can be used intradermal or immediately sub-dermal which is associated with more resistance due to the density of the dermis and more pain compared to sub-dermal.
Role of cross-linked HA in dermis: maximizes collagen stimulation, support and enhancement of a thin and dehydrated dermis.
The deepest injection of this protocol could either be performed last or one could also start with this layer, especially when using a product that has lidocaine incorporated within the product.
This would minimize the discomfort of the previous techniques in a sensitive patient.
The sub-dermal layer, which is the superficial fat pad directly below the dermis, forms a"cushioning" effect to plump a thin and fragile skin.
The depth ranges from 1 - 1.5 mm in facial skin and is reached with at least 45° angle of injection.
Use a product containing low degree cross-linked HA and also with free HA that is suitable for superficial injection and should not leave nodule formation or uneven lumps or bumps.
The use of low viscosity hyaluronic acid fillers as a cushioning effect and enhancement of the superficial fat pads under the dermis have increased in popularity over the past few years (Figure 4A).
In high-risk regions such as peri-orbital and forehead region, the use of a 25G cannula is vital to reduce the risk of intravascular placement.
When using a needle technique, it is recommended to perform aspiration on the syringe before injection of a cross-linked HA filler.
Most side effects are transient, mild and technique dependent.
These may include mild erythema, bruising and swelling.
Using exclusively HA soft tissue fillers for this directly subdermal level will ensure safety, reversibility and reduced lumpiness, especially with a very low viscosity product.
This technique is ideal to use in patients with loss of sub-dermal fat pads and a skinny or skeletal face.
The loss of superficial as well as deep fat pads leads to more excessive wrinkling and dehydration of the skin and dermis.
Subdermal cross-linked HA injections will give an instant plumping of wrinkling, as well as continued stimulation of collagen and elastin production.
Though, the revitalizing, hydrating and long-term improvement of the dermis and epidermis is only seen when combined with the prior techniques.
The technique used can be either with a micro-cannula (27G or 30G) with a fanned technique (less bruising and reduced risk for vascular placement) or with sub-dermal multipuncture technique with needles (Figures 5A, B and C .
The technique choice varies according to the physician's comfort in skills and according to the product used (Figure 6).
Prior treatment with anaesthetic cream improves patient comfort
In practice, I sometimes start from the deepest technique and end with the most superficial technique.
This reduces pain for sensitive patients because the fine line filler contains lidocaine, which then makes the following techniques almost pain free.
Finish the treatment with an intensive massage with a suitable post procedure product.
The bio-skin-gineering technique can be scheduled in   a course of treatments ranging from 2 - 3 treatments depending on the severity of cutaneous aging of the patient.
The treatments can be spaced apart from 4 - 6 weeks apart with ideally 3 sessions per year.
Clinical results are visible from the first session, which includes improved hydration, smoothness and plumpness (Figures 7A and B .
Continued improvement from 6 weeks to 6 months includes wrinkle reduction and firmness, this can be explained by understanding the wound healing phases of neocollagenesis starting from 4 to 6 weeks only (Figures 8A, B and C .
In a clinical practice it is not possible for physicians to confirm histological improvement on each of our patients following procedures, but we can rely on the studies performed by the manufacturers for efficacy and safety.
In general we understand from clinical data that HA soft tissue fillers have a good safety profile, especially when performed with quality products and meticulously safe and sterile techniques.
Various manufacturers of HA fillers have further shown the improvement of collagen quality and quantity following sub- and intra-dermal placement.
Gathering from these studies, we understand that this protocol will therefore improve collagen quantity and quality.
Injectable polyrevitalizing solutions used with good mesotherapy techniques have also clinically proven the benefits of treatment with quality products on skin hydration, glow, evenness and further collagen stimulation.
Therefore, we could assume that the combined technique would give us the combined the histological improvement within the skin.
Results are most visible in patients with dehydrated, wrinkled or dull skin requiring an intensive boost.
Results are specifically evident on areas with thinner skin such as peri-orbital, neck and d?collet? regions.
Each layer has specific purposes of functionality and contributing towards the skin’s external appearance (Tables 1 and 2).
Histological Changes seen in Skin Photoaging or solar elastosis.
The use of injectable HA to rejuvenate the skin, rehydrate the dermis and reduce wrinkles are based of the role it plays within the human skin.
Some of the functions of HA within human skin :Cushioning and plumping effect (anti-wrinkle) Hydrating (retaining water) Keeps collagen and elastin moist – youthful skinOptimizing wound healingImmune functionUV radiation protectionImproves collagen synthesis and normal skin functionIndispensable for the visco-elastic balance of epidermis and dermisRole player in keratinization in epidermis.
The BIO-SKIN-GINEERING protocol is a combination of techniques to ensure rejuvenation from the deepest layer to the most superficial layer to improve the total rejuvenation of the skin and long-term patient satisfaction.
Ideal for wrinkled, dehydrated or dull skin requiring an intensive boost.
The protocol is most suitable for peri- orbital, peri-oral, neck and d?collet?, or other areas.
Side effects may include some small bruises depending on technique, but other than this no significant risks are involved when using high quality products.
The benefits for the patients include instant radiance and hydration with textural improvement from 4 weeks following the treatment is visible, especially when using high quality products with supporting data.
This technique aims to improve the total rejuvenation of the skin and long-term patient satisfaction.
Physicians should be familiar with the techniques to reach each layer separately and have knowledge of the average depth of the layers in facial skin especially.
High quality polyrevitalising solution with non-crosslinked hyaluronic acid is used for the epidermal, DEJ and dermal layers.
Low degree crosslinking HA fillers are used for the deep dermal injections and sub-dermal placement.
Ensure that products used for this technique has sufficient safety and efficacy data.
The combined techniques and products ensure combined histological benefits and combined clinically evident benefits for both the patient and the physician.
Although scientific data exists for the use of low viscosity HA fillers and also for the use of certain mesotherapy or revitalizing solutions, this combined technique shows promising results and more research in the combination of these techniques and products would be beneficial.
In recent years, the increasing demand for minimally aggressive techniques for body contouring, using noninvasive devices have been developed.
The improvement of body contouring using non-invasive liposuction approaches in place of surgical liposuction, is associated with safer procedures, quicker recovery, fewer side effects, and less discomfort, representing one of the most stimulating areas of plastic and aesthetic surgery today.
In order to improve the efficacy of liposuction method, several technical updates have been introduced, such as ultrasound-assisted or laser- assisted liposuction.
These improvements have increased the selectivity of instruments for adipose tissue, enlarging the total amount of lipoaspirate and reducing total blood loss.
In the literature, several papers have been reported on these surgical techniques, analyzing, in particular, how they work as well as the aesthetic outcome, but no one has given an evidence-based comparison of them.
It is known that the advantages of laser treatment include a less bleeding, dermal shrinking and an earlier recovery time5 and, also, that it does not adversely affect the platelet levels6 but a limitation of these external laser devices is that they cannot use high energy because it causes thermal burns.
The advantages of ultrasound methods are the selective rupture of adipocytes membranes, leaving the blood vessels, connective tissue or nerves undamaged showing no effects on surrounding tissues as damage is restricted to a small point, the tip of the cannula.
As known, the ultrasonic waves can penetrate through tissue and during the way they lose energy for reflecting, scattering, or absorbing by tissues.
It is also reported that ultrasound energy produces molecular vibrations causing a temperature increase above 56° C and the subsequent disruption of the cell membrane and collagen denaturation.
Our group has previously investigated the ex vivo effect of both external and surgical ultrasound-irradiation on human adipose tissue specimens by evaluating the weight change and lipid release over time, the histological architecture as well as adipocytolysis and apoptotic cell death induced by treatment.
In particular, after both external and surgical ultrasound treatment, we observed a significant weight loss, a triglycerides and cholesterol release, a clear alteration of adipose tissue architecture, collagen fiber damaged and a down- modulation of procaspase-9 and an increased level of caspase-310.
In the present work, we report the results of an experimental comparative study between two surgical devices, one based on a low frequency high intensity ultrasound supplied with a harmonic cannula and the second equipped with a Nd:YAG laser cannula, performing ex vivo surgical procedures on samples of human adipose tissue.
Sample weight variation as well as amounts of oily fractions released after treatment as well as the relative neutral lipid profile were evaluated at different time intervals.
The effect of both treatments on the histology of adipose tissue was also analyzed.
Neutral lipids: cholesterol (C), oleic acid (OA), 1,3-dipalmitoyl-2-oleoylglycerol(POP),phosphomolybdic acid hydrate (Cat. 221856) and haematoxylin/eosin, solvents for TLC assay (hexane, diethyleter, acetic acid) were purchased from Sigma Chemical Co. (St. Louis, MO, USA).
Aluminium silica plates were acquired from Merck, Darmstadt, Germany.
Formaldehyde was purchased from J T Baker (Phillipsburg NJ, USA).
Sterile catheter tip syringes were acquired from BD Plastipak (Franklin Lakes, NJ USA 07417). 10% neutral buffered formalin ready to use, dehyol absolute, dehyole 95, and paraffin were purchased from Bio-Optica (Milan, Italy).
Advanced smart processor (ASP300), automatic stainer (5010 Autostainer XL), and rotative microtome (RM2135) were purchased from Leica Microsystems (Nussloch, Germany).
Direct light microscopy (Eclipse 50i, Nikon Corporation, Japan) and inverted optical microscope (Nikon Eclipse TS100, Nikon Corporation, Japan) were from Zeiss (Jena, Germany).
The ultrasound device “Micro lipocavitation” was purchased by Lain Electronic S.r.l., Milan, Italy (Technosinergye Medical Technology, Pomezia - Rome - Italy), composed of a high frequency generator, a radiofrequency transmission cable, and probe with piezoelectric crystal.
The device uses modern microprocessors, able to monitor the session peak cavitation, to manage the enormous amount of energy produced by low frequency ultrasound (US) (37.2-42.2 kHz).
The pulsed 1,064 nm Nd:YAG laser “SmartLipo” (DEKA MELA, Calenzano, Florence, Italy), was composed by a  laser  generator that works in ultra-pulsed mode (pulse time 150 microseconds; frequency 10-40Hz), a transmission cable made in optical fibers (300 micron) and a handpiece equipped with cannula (diameter 1mm) to introduce the optical fiber in tissue thickness.
Subcutaneous tissue specimens of white human fat were obtained from one patient, a 44 year old woman with massive weight loss  history (BMI at  operation=29 kg/m2) referred to the Plastic and Reconstructive Surgery Unit (Director: Prof. Maurizio Giuliani), Casa di Cura Di Lorenzo, Avezzano,  L’Aquila  - Italy,  requiring  a body contouring and undergoing abdominoplasty.
Before treatment, the patient, who gave written informed consent, had an accurate clinical examination to evaluate the general health condition.
Patient was normal.
In order to obtain a good quality of ex vivo adipose tissue sample, reducing the tissue injury, no adrenaline-based solution was administered before skin incision, and the flap was raised with blade; small vessels were coagulated using a bipolar forceps whereas larger perforators were tied with absorbable braided suture.
Immediately after surgery, the sample was kept sterile in saline buffer (NaCl 0,9%) (SB) and sent to the laboratory for ex vivo laser and ultrasound treatment.
Fresh human adipose tissue explant was divided into 6 portions of the same size and weight as far as possible (range: 232-235 g taking care to preserve the integrity of the structural continuity and the junction between the skin layer and subcutaneous fat.
Two tissue portions were used as control (untreated), two were treated with the US device and two were treated with the Nd:YAG laser, as described below.
In order to faithfully reproduce the surgical procedure, adipose tissue specimens were infiltrated by syringe with a volume of saline solution equal to sample weight.
The amount of SB spontaneously released by the specimens was evaluated.
Samples were further weighed at 20 minutes and 2 hours from the end of treatment with US or Nd:YAG laser device for 10 minutes.
Control samples (untreated) were also weighed at the same time intervals.
As previously described10, US treatment was carried out by a surgeon in our group, with a surgical probe equipped with a harmonic cannula (diameter: 2mm; length: 15cm).
The default setting of the ultrasound generator for surgical procedure was chosen to perform the treatment: power 100% (??19-21 W cm2); frequency 37.2-42.2 kHz; the single exposure time was 10 minutes.
To find the optimal resonance frequency, prior to the procedure, the auto-best frequency test was performed according to the manufacturer's instructions.
The treatment was implemented by introducing the cannula directly into fat thickness without skin incision.
The single Nd:YAG laser treatment was performed in parallel by a second surgeon of our group on ex vivo adipose tissue samples in the same environmental conditions of US treatment described above.
The default setting of the laser generator chosen to execute the treatment was: power 10 Watt, 40 Hz and 10 minutes of exposure time.
In order to achieve a uniform energy supply, the optical fiber tip was perpendicularly cut before treatment.
The trocar cannula was introduced into fat thickness without skin incision and then the optical fiber was driven 2 mm beyond the trocar cannula tip.
Both procedures were performed within the standards of clinical practice on ex vivo adipose tissue, administering the energy with slow fan-shape movements from the subcutaneous layer moving to the deeper one (Figure 1).
In the control group, samples were processed in the same manner without US or Nd:YAG laser irradiation.
The experiments were performed at room temperature (~20°C .
Lipids were extracted from the fluid portions released and collected at 2 hours after US and Nd:YAG laser treatments by the sequential addition of 200 μl methanol/HCl, 500 μl chloroform, and 200 μl methanol.
The extraction and centrifugation steps were repeated twice.
The organic phases, obtained from different extraction steps, were collected, dried under nitrogen, and then applied to TLC silica gel plates (20x20 cm).
Neutral lipids were then resolved using the mixture of hexane/diethyleter/acetic acid (70:25:3 v/v) as solvent.
The solvent was allowed to ascend to 1 cm from the top of the plate, and then the plate was removed, air-dried and stained.
Cholesterol (C , oleic acid (OA), 1,3-dipalmitoyl-2-oleoyl glycerol (POP), the latter representative of triacylglycerols (TAG), were used as standard lipids.
TLC staining was obtained by vaporizing 10% phosphomolybdic acid solution on plates.
To perform the plates staining a phosphomolybdic acid solution was prepared by dissolving 10 g in 100 ml ethanol.
Dried silica plates were put in the preheated oven for 10 minutes at 80?°C and acquired by densitometer (UVItec Limited BTS -20M, Cambridge UK).
The densitometric analysis was performed using ImageJ software.
The data obtained from control, US- and laser- treated specimens were compared.
Untreated, US- and laser-treated human adipose tissue samples were fixed in 10% neutral buffered formalin at room temperature for 3 days.
The samples were washed under running water for 2 hours, and dehydrated in the ethanol ascendant series with an automatic processor (Leica ASP 300) and then manually embedded in paraffin.
Tick sections of 4μm were gained with a rotative microtome and stained with haematoxylin and eosin with an automatic stainer (Leica 5010 Autostainer XL).
Glasses were analyzed independently by two pathologists with an Axioskop optical microscope purchased from Zeiss, Germany at 4X magnification.
Statistical analysis of data was performed using two- way ANOVA followed by Bonferroni post-hoc test (Prism 5.0 GraphPad Software, San Diego,  Ca).  Data was expressed as mean ± SD. P<0.05 was considered statistically significant.
The study looked at comparing the ability of low frequency high intensity US and Nd:YAG laser devices to reduce the subcutaneous adipose tissue stores, ex vivo adipose tissue samples, previously infiltrated with SB, and treated for 10 minutes with a single US (Figure 1 upper panel) or laser exposure (Figure 1 lower panel).
The sample weight was evaluated immediately after treatment (T0) and at different time points (20 minutes and 2 hours) from the end of treatment and the relative results are shown in Figure 2.
The spontaneously released fluid from untreated samples (control) was collected and measured at each time points, generating a relative basic sample weight loss (~3% at T0, ~5% at 20 minutes, ~9% at 2 hours).
Both US and laser treatment, either at 20 minutes or 2 hours, led to a significant sample weight loss when compared to untreated samples, with US treatment more relevant than laser exposure in particular at 2 hours.
Of note, US treatment caused a sample weight loss significantly greater than the Nd:YAG laser-induced effect already at 20 minutes post-exposure (P< 0.001) (Figure 2).
All fluid portions released from untreated, US- or Nd:YAG laser-treated specimens were collected and measured either at 20 minutes or 2 hours from the end of treatment (Table 1).
In accordance with the results on weight loss, both US and Nd:YAG laser exposures induced a release of fluid significantly greater than observed in untreated samples either at 20 minutes or 2 hours following treatment (P 0.001).
On the other hand, US treatment induced release of a higher fluid volume as compared to laser exposure (P 0.05) (Table 1).
Moreover, the fluid released by US-treated samples appeared also visually thicker when compared to those collected from the laser-treated samples.
In particular, the amount of the oily fraction in the fluid portions released after US treatment at 2 hours appeared objectively greater in comparison to laser treatment at the same time interval.
The representative images of fluid portions collected after 20 minutes or 2 hours from treatments are shown in Figure 3.
To evaluate the effectiveness of low frequency high intensity US treatment and Nd:YAG laser to injure the adipocyte membranes of ex vivo adipose tissue samples, the analysis of neutral lipids?€? levels in the fluid portions released from US- or laser-treated or untreated samples at both 20 minutes or 2 hours was performed by TLC.
In particular, the levels of cholesterol (CO), oleic acid (OA) and triacylglycerols (TAG) were analyzed after 2 hours from the end of treatment (Figure 4).
Both US and Nd:YAG laser treatments were able to cause an increase of lipid released when compared to untreated samples (control) with different levels of statistical significance, and the effect of US irradiation was more relevant.
Indeed, the treatment with US caused a release of lipid fraction significantly higher when compared to Nd:YAG laser exposure (P 0.001 for all analyzed lipids) (Figures 4 A C .
A representative TLC of neutral lipids released in untreated sample (control) and in US- and Nd:YAG laser-treated samples after 20 minutes or 2 hours from exposure is shown in Figures 4 D E and shows the TLC chromatography of lipid standards: C (Rf=0.38), OA (Rf= 0.46), and POP (Rf= 0.82).
Histologically, the effect caused by US- and Nd:YAG laser treatments to the adipocyte membranes was also verified.
Figure 5 shows representative images of the histology of adipose tissue sections from samples after 2 hours from either US or Nd:YAG laser treatment ex vivo.
Sections stained with haematoxylin-eosin displayed a normal lobular architecture with regular and undamaged adipocyte membranes in untreated samples (Figure 5A).
The alterations of adipocyte morphology of US treated samples associated with cell membrane appeared unbundled and broken compared to the histology of Nd:YAG laser-treated sample (Figure 5B and C respectively).
Even if the effectiveness of both US-assisted and laser- assisted liposuction has been extensively investigated, comparative studies of these aesthetical surgical procedures have not been reported on and should be required.
Indeed, the previous studies have been mainly focused on comparing either US-assisted lipolysis or laser-assisted lipolysis versus conventional liposuction alone.
To our knowledge, the present study is the first to reproduce in a controlled environment, surgical procedures of clinical practice which demonstrates if both methodologies give overlapping results.
In terms of weight reduction and amount of lipid released, US irradiation provided more significant effects within 20 minutes after the exposure.
Moreover, the assessment of the released oily fractions following each treatment showed that the US exposure induced a significant increase of neutral lipid levels (C OA and TAG) when compared to the Nd:YAG laser-treated samples.
In addition, US irradiation caused a more effective adipocytolytic effect, which was also supported by microscopic evaluation of adipose tissue sections revealing a high number of injured cell in US treated samples.
However, all these results should be confirmed by additional experiments and clinical studies conducted on larger series of patients.
Our results highlight that ultrasound-assisted liposuction is more effective to reduce the adipose tissue weight probably due to physical phenomena generated into adipose thickness.
As known, an ultrasound device, during lipoaspiration procedure, generates compression and depression cycles of ultrasonic waves at appropriate frequency.
This action produces a negative pressure in the adipose tissue thickness leading to cavitation that allows a selective tissue lipolysis with adipocyte rupture and triglyceride release from the lipid vacuole to the extracellular space.
Of interest, Bani et al demonstrated that, after ultrasound treatment, signs of interstitial inflammation were absent and the cavitation-induced effects seem to be restricted only to adipocytes, without injury to skin, vessels, nerves, or connective tissue.
Moreover, it has been demonstrated that ultrasound-assisted lipoaspiration treatment does not impair the proliferative ability and osteogenic potential of Adipose Stem Cells (ASCs) normally present in adipose tissue.
On the contrary, a different physical process is generated into adipose tissue using the laser-assisted liposuction.
In general, laser device releases a beam that is converted to heat energy through the adipose tissue, connective tissue, and blood vessels.
The 1,064 nm Nd:YAG laser exerts a lipolytic action melting the subcutaneous adipose tissue and, also, the septae that connects the dermal and muscle layers are divided.
Anyway, the use of surgical 1,064 nm Nd:YAG laser, even if it is less traumatic than traditional liposuction methods20, has the disadvantage to provoke a thermal injury; it is known that thermal energy or heating induces cell morphology and tissue texture alterations when the laser cannula reaches the temperature ranged between 47°C - 52°C.
Even if preliminary, all the results from our experimental study could represent a stimulus for appropriate clinical studies designed to comparatively evaluate the efficacy of these two surgical approaches by examining tissue in vivo.
Since the second half of the twentieth century, stretch marks have increased exponentially among the female gender and has gradually started to affect young boys as well, becoming probably the most widespread imperfection in the new generations.
Biodermogenesi? has shown remarkable effectiveness in the regeneration of stretch marks1 and post- surgical scars and burns, favoring the production of collagen and elastic fibers.
The aim of this study is to verify the outcomes of the new synergy developed by Biodermogenesi? on a group of female patients, all burdened by very old stretch marks that are white and opaque in color with a deep and rigid structure.
The new synergy, which combines electromagnetic fields with electron flow and vacuum, provides a number of sessions drastically reduced compared to the previous Bi-one? technology, to regenerate a twenty-year stria; before it required at least 20 sessions.
Stretchmarks that are more than twenty years old are more difficult to work on to obtain a significant improvement.
The existing literature has recently focused on the analysis of the results obtained with various types of lasers, facing some consolidated limits: the greater efficacy documented regarding only the red stretchmarks, and therefore newly formed stretch marks.
However, we saw that at the end of laser treatment programs the results were varying from moderate to none and were not replicable on all the patients, especially on SA.
Furthermore the laser procedure caused the constant presence of edema and PIH and a recurrent pain detected by patients.
Briefly analyzing the existing literature in support of laser therapy, we note various evaluations of the results obtained.
The results obtained with a non-ablative fractional laser in the experience of Katz et al.3, limited to only two young patients (12 and 13 years) with striae dated 3 and 10 months, appear positive.
Other experiences speak instead of appreciable results on a part of the patients treated, compared to others whose outcomes have been minimal or none.
In this sense, we recall the experiences of Bach and his colleagues4: "six of the 22 patients (27%) showed good to excellent clinical improvement from baseline, whereas the other 16 (63%) showed various degrees of improvement".
This is confirmed also by Stotland and his colleagues who confirm that: "photographs of 8 randomly selected patients showed an overall improvement of 26% to 50% in 63% (5 of 8 patients)"?
Even the experience of Tretti Clementoni has obtained greater uniformity of results6, he confirms that some patients treated with non-ablative fractional laser do not show significant outcomes: "the volume of SD depressions improved by more than 50% (mean improvement 58%) in the majority of patients (11 of 12 patients) and the color of the lesions improved by more than 50% (mean improvement 54%) in 83,33% of patients (10/12)"?
Apart from Katz's experience3, the other researchers4,5,6 do not mention the visual appearance of stretch marks (white or red) and their dating.
The experience of De Angelis et al. is based on 51 patients treated with 1540-nm fractional nonablative Er: Glass laser and the evaluation was done both by researchers and blinded, always with positive outcomes, noting a reduction in striae generally greater than 50%.
With the same technology, Farhad Malekzad and coll.22 evaluated the efficacy on patients with skin phototype between II and V burdened by SA with different outcomes.
We note that after 3 sessions, 2 out of 10 patients left the study, 3 out of 10 patients declared no results (no improvement) and 5 poor results (poor); the same patients, after a follow-up of three months, 2 out of 10 declared no results and 6 out of 10 little result.
In addition to the controversial outcomes found by the authors, the non-ablative fractional laser is characterized by moderate pain during therapy, micro-crusting, recurrent edema and hyperpigmentation generally reabsorbed in the course of 5/10 days.
De Angelis and coll. recommend to patients a prophylaxis in the month before the treatments and in the following six months.
Particular attention of the present study is reserved to the hypochromia of the dated striae and to the possibility to recover the faculty of tanning by the same ones.
This aspect has already been studied in the past, with a therapy based on excimer lasers.
Goldberg treated patients with 8/9 sessions per patient, with an attenuation in 60 cases, while in 15 there was no improvement.
Alexiades-Armenakas et al. have always performed 9 sessions per patient and have documented a 68% improvement in hypopigmentation but only stable between 1 and 6 months.
At the end of the 6 months no residual outcome was found.
The practically zero stabilization of the improvements obtained has limited the spread of this therapy, leaving the problem of hypopigmentation unresolved.
?We analyzed a group of 20 patients aged between 34 and 66 years, all with SA aged between 20 and 35 years, and treated them with a cycle of 9 sessions of Biodermogenesi?? on a weekly basis.
The patients were all healthy and did not have any preconditions for being excluded from the trial.
The exclusion criteria are as follows: Pace-Maker users; cancer therapy in progress or during the last 5 years; epilepsy; vascular alterations such as varices, phlebitis and thrombophlebitis; pregnancy or breastfeeding; alterations and hormonal therapies manifested during the last 6 months; anti-coagulant therapy; phenomena of anorexia or bulimia during the last 2 years.
Biodermogenesi? treatment was performed with an electro-medical device called Bi-one? 2.0 MD, combined with three synergistic active ingredients.
Treated stretch marks were present on the breasts, arms, abdomen, hips, buttocks, thighs, calves; for the cases in question we treated a single area on each patient, as required by the official protocols.
The treatment was performed with a non-invasive electro-medical device :Bi-one? 2.0 MD"?and protected by some international patents (Expo Italia S r l , via Segantini, 34, Firenze, Italy).
The apparatus was equipped with a generator of electromagnetic fields, an electron flow generator, a pair of vacuum pumps and a series of handpieces.
The generator of electromagnetic fields emits a capacitive shielded signal at a variable frequency, ranging from 0.5 to 1 MHz ± 10%, and variable intensity up to a maximum value of 6W on a 500 Ohm resistance.
The device is equipped with a bio-feedback system that allows to change independently the intensity and frequency of the signal delivered according to the different biological characteristics of each individual patient, increasing the temperature of the treated area between 39° C and 40° C The electron flow generator emits a 5 Hz square wave signal with a maximum intensity of 0.36 mA on a 500 Ohm load.
Generators of the electromagnetic field and of the electron flow are separated mechanically and galvanically from each other and towards the network plant.
The brushless vacuum pumps allow delivering negative pressure with absolute precision and stability, with a maximum value of - 0.35 atmospheres.
The treatment procedure was divided into two distinct phases, during which several forms of energies are present for different biological actions.
The first phase was about a light mechanical peeling.
For this phase, we used a single-use abrasive pad placed inside the PEELING handpiece.
PEELING handpiece works with a gentle vacuum action, designed to lift the tissue with the stretchmarks, bringing the hollow area of the imperfection outwards.
The complete deconstruction of the elastic fibers that characterizes very old striae1,7 allows the striae to extend outwards, bringing the dense and compact corneous layer in relief, favoring a selective reduction.
The second phase, called ACTIVE PLUS, provides the synergistic action of vacuum and biocompatible electromagnetic field generated thanks to a capacitive radiofrequency with variable frequency and intensity.
The combination of these forms of energy activates a greater action by the arterial capillaries, it increases the caliber and brings to the matrix oxygen and nutritional elements, stimulates the lymphatic microcirculation, and helps to drain part of the toxins present.
The simultaneous flow of electrons, object of the new technology, allows a reduction to the electrical resistance of the skin tissue, effectively amplifying the yield of the electromagnetic field.
As the effectiveness and the useful dose of the applied electromagnetic field is inversely proportional to the electrical resistance; the flow of electrons reduces this value and consequently increases the regenerative efficacy of the electromagnetic field.
At the same time we observe a strong pumping of the Na + / K +, able to increase the fibroblast activity, leading to the synthesis of collagen and elastic fibers and favoring a tissue repair.
The technology adopted for the present study provides a platform developed by NXP, a company owned by Philips, able to compare the acceleration obtained with sodium and potassium through the cellular barriers: Previous Bi-one?? technology from 300 to 450 mV New Bi-one?? 2.0 MD technology from 750 to 850 mV Documenting an effectiveness on average by double with respect to the previous technology.
The full treatment session takes about 25 minutes in total.
The protocol provides a preliminary evaluation system of stretch marks that determines the level of difficulty and therefore anticipates the patient what the result will be, how many sessions will be needed to obtain this result and how long the treatment cycle will take to be completed.
All the patients examined, respected the indications provided by the protocol.
The evaluation of the results of the treatment of stretch marks was carried out by using the VAS (Visual Analogue Scale) scales of the patient and the doctor.
Assessments were made before the start of treatment, during the preliminary visit (T0), after the last treatment (T1) and after a period between 6 and 12 months from the end of the sessions (T2).
The VAS scale asks the patient to make the most of the following parameters: Improvement of the stretch marks to the touch (depth and fibrosis) Improvement of the visual stretch marks (color and opacity) Increase in the faculty of the stretch mark to get a tan The values are expressed from 0 = 0% (no improvement), from 1 =  1%  to 20% (poor  improvement), from 2 = 21% to 40% (minimal improvement), from 3 = 41%  to 60%  (moderate  improvement), from 4 = 61%  to 80%(good improvement), from 5 = 81% to 100% (excellent improvement).
The results obtained are summarized in the following Tables 1, 2 (patient’s VAS scale) and Table 3 (doctor’s VAS scale).
The scales measure the perceived improvement on the treated stretch marks.
At the end of the treatment program (T1), 11 patients (55%) found an improvement between 41% and 60%, while 9 patients (45%) found an improvement between 61% and 80%.
The perception of the improvement obtained was increased when the follow-up (T2) was performed after more than 6 months from the end of the treatment program: 1 patient (5%) found an improvement between 41% and 60%, 6 patients (30%) found an   improvement between 61% and 80%, while 13 patients (65%) found an improvement between 81% and 100%.
At the end of the treatment program (T1) the doctors in one case (5%) evaluated an improvement between 21% and 40%, on another patient (5%), between 41% and 60%, on 15 patients (75%), between 61% and 80% and on 3 patients, between 81% and 100%.
Also the evaluation of the improvements obtained was increased by the doctors during the follow-up (T2): in one patient (5%) they evaluated an improvement between 41% and 60%, on 8 patients (40%) between 61% and 80% and on 11 patients (55%) between 81% and 100%.
Analyzing the documented results, a noticeable overall improvement of the treated stretch marks is evident, both in the evaluation of the patients and the doctor.
In the T1 test, we notice an overall improvement of the SA, which tends to increase in the months after the treatment.
The progression of the improvement is due to the activation of virtuous reactions, which we have also found with the previous version of the technology.
The reactivation of the sodium and potassium pump allows restoring a better activity of the fibroblast, which physiologically manifests itself in the course of a few weeks after the treatments, during when the maximum regenerative response is obtained by the treated tissue.
Another aspect that the patients have greatly appreciated is given by the newfound ability of striae to tan with the sun exposure another aspect that we had found with the previous technology.
Early experiences, first of Dr Artigiani and coll.1 had documented a recovery of the ability to tan by the stretch marks treated with Biodermogenesi?.
This aspect has allowed patients to expose themselves to ultraviolet also during the treatments, highlighting a progressive tanning of the striae.
Of course, for the patients living in Sanremo and Palermo who were part of this study, it was much easier to obtain the tanning of the stria as both of the cities are known for their beach attractions.
The stabilization and progression of the outcomes, as shown by the conclusions made in T2, where the appreciation of patients and doctors is consolidated, is confirmed by Bacci, who performed a follow-up after more than 5 years from the end treatment with Biodermogenesi?.
In his study, Bacci highlighted a general improvement of the results previously achieved, without any regression of the outcomes obtained on the patients.
Unlike what was found with other technologies, the treatment of striae with Biodermogenesi?? did not cause pain, discomfort, or any side effects, even minimal, at the end of each treatment session.
Patients were able to regain their lifestyle immediately without any limitation.
The choice of evaluating the results obtained with the present therapy by means of the VAS scale exposes to the risk of subjectivity that would not occur with instrumental or bioptic tests.
However, we believe that the type of result obtained, which is the filling of the striae, eveniftheyarepresentformorethantwentyyears, and their subsequent tanning makes this assessment acceptable.
In fact, the filling and the rediscovered capability of tanning of the stretched skin derives exclusively from a reorganization of the epidermis and the dermis, a restored basal membrane, a correct positioning of the melanocytes and from an adequate dermal vascularization.
Basically, to completely tan the striae, it is essential to fully regenerate the skin tissue.
In our opinion, the results obtained on all patients adopting t the VAS scale is certainly subjective, but in the specific case it is not questionable.
Biodermogenesi? opens up a new perspective in the treatment of SA by applying for the first time a non- invasive method that is not based on damage and subsequent repair.
We know that collagen fibers change between 52° and 55° C and contract at 65° C and come to denature between 60° and 70° C.
The thermal effect induced by Biodermogenesi? stabilizes the dermis temperature between 39° and 40° C and therefore the variation of collagen and elastic fibers documented bioptically by Bacci6 and by Artigiani et all. 1 gives us a curiosity about the induced regenerative mechanism, presumably related to the Vant Hoff law.
In the case of Biodermogenesi?, it is believed that the thermal effect is the consequence of the increased activity of Na+ / K across the membranes, favored by the applied electromagnetic field 18,19, it determines this reaction for mere friction.
The regenerative faculty of the tissues subject to greater activity by these carriers is amply demonstrated by the literature in sports medicine, in the field of recovery of muscle injuries.
However, the evident improvement of the treated striae is obtained in total absence of side effects.
Biodermogenesi? can be used successfully in the treatment of SA, even if they are very old (more than twenty years), favoring both an aesthetic result and an effective regeneration of dermis and epidermis, as evidently demonstrated by the renewed ability to tan by the striae as a result of correct skin reorganization.
All patients treated in accordance with the protocols have noticed a significant improvement in the imperfection, also confirmed by the doctors, with no side effects and without limitations to a normal lifestyle.
Lips are one of the most injected areas on the human body.
Hyaluronic acid (HA) is a golden standard mostly used for this procedure1.
The main aspects in the treatment of lips are comfort (for both the practitioner and for the patient) and a long-lasting effect.
In addition, it is necessary to use safe substances with regard to their compatibility and local resistance.
Based of the proven safety of Agarose gel it has been a factor in its increased use.
Only rarely are complications reported.
Agarose is in principle not a completely new material in medicine.
It has been used in the dental field for more than a decade.
The substance class is a neutral polysaccharide, it is completely biocompatible and thus degradable.
The aim of this article is to show agarose gel as at least an equivalent to those for treatment of the lips.
The following overview describes the possibilities of this treatment method.
In the lower part of the face are the lips as a focal point, especially in the foreground of the interest.
Lip augmentation is a cosmetic procedure that can give you fuller, plumper lips.
These days, an injectable dermal filler is the most commonly used method of lip augmentation.
There are many types of dermal filler that can be injected into your lips and around the mouth.
But the most common fillers today are products that contain hyaluronic acid.
The goal of an ideal injection is to make, improve the appearance of lips by adding shape, structure, volume, but also a natural softness too, without causing a change in movement or in facial expression.
The best suited filler for the lip area is on one hand locally resistant, that means the injected substance remains in the addressed region and does not migrate in around tissue.
Other unwanted effects are also possible, such as pain, swelling and bruising, lip asymmetry, allergic reaction causing redness or itching around the lips.
For this reason, the knowledge of the diversity of different materials and techniques in aesthetic medicine in cases of lip augmentation, is essential to increases the quality of treatment and for the patient satisfaction.
A prerequisite for this process is a good cooperation between patient and doctor, and which techniques or products are best to be used.
As a new alternative to the previous substances a new filler is now available: Agarose-gel.
The agarose gel is available on the market fulfilling the expectations and requirements of the most demanding practitioners.
Agarose is a polysaccharide from D galactose and 3,6-anhydro-L galactose, which are glycosidically linked.
It puts the main component on the agarose.
As it is made up of 100% natural polysaccharides, it is complete biologically compatible and also degradable.
It contains for example no cross-linked synthetic chemicals BDDE (1,4-butanediol diglyceridyl ether).
The gel is sterile, very viscous and elastic, and clear and transparent.
Due to the isotonic property of the gel, this filler is almost painless when injected.
It is locally stable and it has very few side effects.
There is also an immediate result achievable without expected downtime.
The increase in volume is directly visible because no hydrophilic volume process has to be waited for.
The human organism has no specific enzyme, to break down agarose.
Compared to hyaluronic acid, which is degraded by hyaluronidase, agarose degradation is made slowly by macrophages, before it finally takes place in the pentose cycle, and it is eliminated in the endoplasmic reticulum.
Thereby agarose is a long lasting aesthetic effect expected to last.
Agarose has been the substance of choice in various studies regarding its biocompatibility and no cytotoxic and genotoxic properties.
Due to its biocompatible character agarose gel has been around for over 10 years already in frequent use in the field of dental medicine and in oral surgery.
It is described to be a soft tissue augmentation for the perioral region.
The occurrence of complications is extremely rare.
Another benefit of this new filler is the replacement of lost subcutaneous fat and remodeling of the upper and lower lip contours.
Subcutaneous filler is able to achieve a youthful and natural look by filling-out lines around the mouth, the nasolabial fold as well as chin augmentation (Figure 1).
Patients are trending to natural and biocompatible dermal fillers for a safe and effective solution to anti- aging.
Patients with acute or chronic skin pathologies or direct involvement in or around the lips to be treated were excluded.
Pregnancy, lactation and hyaluronic acid treatment less than 3 months earlier were also excluded criteria.
In total 11 patients were treated.
The patients were between 19 and 38 years old.
All patients were female.
Nobody had had a treatment with permanent fillers before.
Five patients had previously had an injection with hyaluronic acid in the lips.
It is recommended to use before treatment a local disinfection and also to apply anesthetic cream to the injection site to numb the area.
In some cases, there is also the need to consider a local injection with anesthetic (lip block).
The treatment should be as painless as possible for the clients.
For this, besides a topical anesthesia, also the application of a very thin cannula is recommended.
Agarose itself is an almost painless injectable because of its isotonic properties, as mentioned above.
Only in the expansion in the tissue does a burning symptom come.
Therefore, the agarose gel can be mixed with a local anesthetic, such as Lidocaine.
Due to the viscosity of the material generally it is possible to use the 30 gauge cannula for the lips.
The reduction of hematomas and swelling is avoided largely by the direct compression and cooling, for example with cool packs, for a few minutes after the injection.
This minimizes and closes the bleeding.
Patients should avoid for about half an hour hot drinks (Coffee and Tea) due to lip anesthesia.
A direct reintegration into social life is easily possible due to the fast convalescence.
For example, the treatment can also take place during lunch breaks or before important events (Weddings), and patients can return to work or participate in events after the treatment on the same day.
According to the principle "What you see is what you get"?the result is visible immediately after the injection as well the final result An additional benefit is the use for patients who have been previously demonstrated intolerance, incompatibility to hyaluronic acid or other ingredients.
The only adverse events described were hematoma, redness, bruising and swelling.
All adverse events lasted for a maximum of 7 days.
The sense of satisfaction by the patients were evaluated with the use of a subjective analog scale from 1 to 10.
The mean score of satisfaction of cosmetic result was 7-10 immediately after treatment, and the score decreased after some months (Table 3).
The results lasted 5 months with a gradual decline to baseline.
The injected Agarose gel was very well tolerated with only a few mild adverse reactions which resolved spontaneously after a few days only.
No major complications (e g infectious processes, palpable implants, nodularitiy, overcorrection, allergies) were observed.
Agarose gel is a safe, low-risk, easily applicable therapy option for practitioner and provides a particularly good alternative method for augmentation area of the lips.
The application of agarose shows through clinical studies and analysis a high safety.
This innovative filler is characterized by local stability and good compatibility.
Because of its biocompatible character, it does not matter what material was used previously in the injection area.
As this remedy is 100% natural and very viscous substance, patients will achieve a high degree of satisfaction, as their facial expressions remain very natural and harmonious even when they move.
Thus, a realistic satisfaction of the patient expectation can be achieved, with an excellent cosmetic effect.
In addition, agarose has a very fast convalescent period and subsequent changes in shape do not come after the injection.
In summary, treatment with agarose has many benefits.
Thanks to its properties, this filler represents an important and successful option in the modern aesthetic medicine.
Agarose Gel is available in four different strengths for very soft, moderate, mild and fairly deep wrinkles.
The ultra-sound evaluation of dermis, along with other instrumental examinations, medical history and traditional clinical examinations aimed at identifying the patien's request, is included in the aesthetic and medical checkup.
This non-invasive diagnostic technique is considered as a powerful tool in the diagnosis and management of dermatological conditions in the clinical practice, since it provides clinical data that would not be available at naked eye examination.
With regard to this, it is also important to highlight that ultra-sound evaluation with high-frequency probe (20- 100 MHz) can play a crucial role in the evaluation of age- related dermal change in the clinical practice.
Moreover, the presence and degree of a typical Subepidermal Low- Echogenic Band (SLEB) is strictly related to photoaging degree: the lower is SLEB echogenicity, the greater is photoaging.
The high-frequency probe helps evaluate the structural characteristics and dermal thickness.
The aim of the cutaneous ultra- sound examination is to provide a qualitative and quantitative evaluation of skin layers and surrounding structures, being an additional and reliable instrument in the diagnostic phase as well as in the evaluation of the activity and severity of cutaneous diseases.
Photoaging initially produces an increase in elastic fibers with consequent dermal hyperechogenicity, which then results in the loss of collagen and elastic fibers and a decrease in dermal thickness and echogenicity.
Several studies support the relationship between cutaneous thickness and skin aging.
A study by Gniadecka M et al 1998 showed the thickness and echogenicity of dermal layers by means of ultra-sound technique.
The author showed that changes in dermal layers differ according to which body region is evaluated.
In fact, in photo- exposed body regions, the most superficial dermal layers are characterized by a progressive reduction in echogenicity, while in the body regions that are not exposed to sun rays the author observed an increase in echogenicity.
The deepest layers of dermis have an increased echogenicity in all body regions.
The author concluded that although photoaging and chrono-aging increase and/or reduce skin thickness depending on the body region studied, no strict correlation was generally observed between skin thickness and age.
In a later study, Gniadecka M 2001 analyzed skin aging-related dermal change observed by means of ultra-sound evaluation with high-frequency probe.
The author showed that the presence of SLEB in photo-aging is strictly related firstly to the degeneration of elastic fibers in papillary dermis, secondly to the basophil degradation of collagen and thirdly to the accumulation of glycosaminoglycans (GAGs) and water in papillary dermis.
Based on these considerations, SLEB could be an ultra- sound manifestation of elastosis and edema in papillary dermis.
The correlation between age, SLEB thickness and echogenicity makes it possible to use these parameters to evaluate the level of cutaneous photoaging.
Based on a number of available scientific data, ultra-sound evaluation is a non-invasive diagnostic technique that supports anti-aging treatment monitoring and can be considered as a valid option for the future evaluation of the efficacy of tailored anti-aging injections and topical therapies.
All the above is supported by a clinical study conducted in 28 patients eligible for biostimulation treatment with a medical device (Sunekos 200) in injectable intradermal sterile solution, containing a functional complex of 6 amino acids (glycine, L proline, L lysine, L leucine, L valine, L alanine) in association with high-purity hyaluronic acid, of non- animal origin, at a concentration of 10 mg/ml.
It has been documented that the morphological structure of elastin is characterized by a prevalence of L alanine and L valine12-14 that make this product particularly active on the turnover of the proteins of the ExtraCellular Matrix in case of facial skin laxity.
According to the recommendations of the Italian Society of Mesotherapy (Societ? Italiana di Mesoterapia, SIM), the investigators administered one session for 1 month (4 infiltrations); one session every 15 days for 2 months (4 infiltrations) and one monthly maintenance session.
Monitoring by ultra-sound technique was performed just before the first administration, before the fifth administration and one month after the last maintenance administration, in the zygomatic and mandibular region on the right and left hemilates (Figure 1).
In the study group (Figure 1) an improvement was observed in the structure, as well as an increase in the dermal thickness, a hypoechogenicity of dermis and an improvement in SLEB with matrix reorganization, and these factors were maintained until the end of treatment.
The most important factor is matrix reorganization.
In conclusion, all subjects showed a reduction in the echogenicity of the dermis, associated with an increase in the thickness after only 4 weekly sessions; one month after the last treatment, an increase in the thickness was observed, as well as a normalization of echogenicity related to patient’s age, matrix reorganization and SLEB.
In summary, the ultra-sound evaluation of dermis, along with other instrumental examinations, medical history and traditional clinical examinations aimed at identifying the patient's request, is part of the aesthetic medical checkup.
This non-invasive diagnostic technique supports anti- aging treatment monitoring and can be considered as a valid option for the future evaluation of the efficacy of tailored anti-aging injections and topical therapies.
It is also an additional reliable instrument in the diagnosis and management of dermatological conditions in daily clinical practice.
Based on these considerations, in a recent clinical experience 28 patients were treated with a product containing hyaluronic acid and AA and showed a qualitative and quantitative improvement in most patients (Figure 1).
After 4 weekly administrations, the ultra-sound evaluation showed a reduction in echogenicity that could be related to the deposit of hyaluronic acid and an increase in edema in the acute phase.
At the end of treatment, the increase in thickness was maintained and echogenicity restored.
The evaluation performed in this undoubtedly positive experience should be further studied in a systematic clinical study, since the results could be extremely relevant.
Chrono-aging is the plethora of metabolic changes occurring in skin physiology as an effect of aging.
One well-known manifestation is skin laxity, which is due to both a decrease in collagen and elastin production and to changes in the extracellular matrix including reduction in hyaluronic acid (HA) synthesis.
The glycosaminoglycan HA is widely distributed in epithelial and connective tissues and is a chief component of the extracellular matrix.
Here it contributes to tissue hydrodynamics and viscoelasticity, protection from oxidative stress and, most crucially, tissue repair.
HA's regenerative action is due to its intrinsic anti-inflammatory and bio-stimulating properties, resulting in fibroblast proliferation and increased collagen production.
The aforementioned properties make HA a highly desirable dermal agent in the field of aesthetic medicine for the correction of soft tissue defects.
However, once injected in the dermis, native HA is rapidly degraded by hyaluronidase, making it non-viable for mid- to long-term results.
This led to chemically stabilizing HA via cross-linking, a process increasing the molecule's stability, rigidity and elasticity, but whose main drawback is the chemical alteration of HA's natural molecular structure.
This issue was bypassed by Profhilo?, a 2015 product developed by IBSA Pharmaceuticals, whose innovative thermal production process yields stable, cooperative hybrid HA complexes without the need for BDDE or other chemical agents.
The product formulation is a mixture of 32 mg of high molecular weight HA (110-1400 kDa) and 32 mg of low molecular weight HA (80-110 kDa), stabilized by a thermal process consisting of a high-temperature step followed by a low-temperature step.
Profhilo?’s unique characteristics include high HA concentration, excellent manageability, low viscosity, optimal tissue diffusion, a low tissue inflammatory response and a duration comparable to weakly cross-linked gel.
Profhilo?’seffectiveness has been proven in in vitro studies, where it demonstrated enhanced tissue repair, extra cellul are nvironmentre modeling and neofibrogenic and adipogenic properties, while maintaining optimal conditions for fibroblast, keratinocyte and adipocyte vitality.
Profhilo?’s clinical indications in the field of aesthetic medicine are in tissue remodeling and improvement of skin laxity of the face, neck and body, and its in vivo efficacy has been proven on 120 patients over the course of 4 independent published studies.
IBSA has furthermore developed the Bio Aesthetic Points (BAP) technique, a Profhilo?-specific injection procedure for the tissue remodeling of the malar and sub-malar areas.
The technique entails five 0.2 mL bolus injections in the superficial subcutaneous tissue compartment of each hemiface, localized in anatomically receptive facial areas identified for the lack of large vessels and nerve branches: the zygomatic protrusion, the nasal base, the tragus, the chin and the mandibular angles (Figure 1).
This minimizes the risks and maximizes the diffusion of the product in the lower third of the face.
The BAP technique allows for highly satisfactory results with only 2 treatments performed 4 weeks apart.
Previously published clinical experience on Profhilo?'s efficacy in tissue remodeling prompted the current study, which focuses on an ethnic subpopulation of the Slavs, i e the Central Eastern European group.
This ethnic group displays so-called Oriental mongoloid face features, which differ from the Caucasian craniofacial form in facial profile, shape of the orbits, cheekbones and mandibular angle.
Specifically, the oriental face is wide and round or square, with a flattened facial profile, shorter forehead, and broad nasal bridge with wide nasal wings.
The eyes are typically almond-shaped with an elongated intercanthal width, set in fuller upper eyelids with an absent supratarsal fold (so-called "single eyelid"?.
On the basis of gross histological findings, the single eyelid is due to the fusion of the levator palpebrae aponeurosis with the orbital septum closer to the eyelid margin than in non-Asians, hindering the aponeurotic fibers of the levator from reaching the subcutaneous tissues, which is responsible for the formation of a double eyelid crease.
Oriental mongoloid lips are fuller and more protuberant, and the chin more receded than in Caucasian individuals.
Overall, the skull morphotype is roughly rectangular, compared to the trapezoidal Caucasian morphotype.
Lastly, the mimetic- and chewing muscles are active and well developed: it has been posited that the peculiar Oriental structural features of the zygomatic area and the malaris muscle, which is inconsistent in Caucasian anatomy, prevents soft tissue ptosis, with an overall anti-aging effect of the midface.
Despite the numerical strength of the considered population, few studies have assessed facial skin aging in Asian populations.
One such study highlighted an increase in transepidermal water loss (TEWL), denoting a loss in stratum corneum barrier function, coupled with a decrease of sebum content, due to a decrease in estrogen-induced sebaceous gland activity.
Based on these observations, we investigated the efficacy of Profhilo? for facial skin rejuvenation in 10 individuals (9 females, 1 male) of Oriental appearance aged 26 to 62 (mean = 44 years).
We included only participants compliant to the following criteria: No rejuvenation procedures performed 6 months ago or later.
Relatively normal somatic health.
Not during pregnancy/lactation period.
No tendency to form cheloid scars.
Participants were requested to maintain the same habits on food, exercise, make-up, cosmetics, and detergent.
A comparative analysis was led between group 1 (5 participants), treated with Profhilo? following the BAP technique for injection points (29G needle) (Figure 1), and group 2 (5 participants), treated with diffuse injections of Profhilo?.
The latter technique consisted of diffuse 0.05 mL injections 1 cm2 apart in the subcutaneous layer of the right and left sumbalar areas (30G needle).
Both groups were treated in two sessions at 4-week intervals, and efficacy was evaluated pre- and post-treatment.
Comparison was performed via photographical evidence, Soft Plus and Antera 3D assessment systems.
The Callegari Soft Plus probe system was used to measure skin hydration (in terms of capacity measurement), elasticity (in terms of stress/deformation of the skin by suction application) and melanin (via a double wavelength reflectance photometer) at three points on the right side of the face: the center of the forehead, the outer corner of the eye (1 cm above the zygomatic arch and 2 cm laterally from the outer cantus) and the cheek (2 cm laterally from the labial commissure).
The Miravex Antera 3D macrophotography camera was employed for 3D topographical and chromophore analysis, specifically assessing overall wrinkle size, skin texture in terms of arithmetical mean roughness and average pigmentation concentration.
Again, three areas of the right side of the face were assessed: the glabellar area, the outer corner of the eye and the cheek area near the labial commissure27.
Statistical analysis was performed using Fisher's angular transformation (φ-method) to compare Group 1 (treated by diffuse injection) and Group 2 (treated by Bio- Esthetic Points).
Theφ-method estimates the statistical significance of difference between the percentages of two samples according to the null hypothesis (H 0): the percent of persons with apparent effect in sample 1 is no more than in sample 2.
Visual pre- and post-treatment comparisons showed a clear improvement in skin wrinkles and fine lines, with skin appearing brighter and more toned after completion of the procedure (Figure 2).
Visual pre- and post-treatment comparisons showed a clear improvement in skin wrinkles and fine lines with skin subjectively appearing brighter and more toned after completion of the procedure.
Though no objective measurements of volumetric changes or sebum changes were performed to support existing research, as this was not within the focus area of this case study.
The Soft Plus assessment outputs recorded a significant improvement (P value 0,008) in skin hydration with an average increase of 12,13 u c .
Skin elasticity and melanin levels also displayed an overall ameliorationof an average 0,59 u c and 2,7 u c respectively, albeit non-significant (P value 0,28 and 0,15 respectively) Macrophotographical evidence from the Antera 3D camera displays a clear improvement in topographical parameters facial atopic manifestations in wintertime such as skin reddening and peeling.
Likewise, after the first treatment sitting the patient noted a significant improvement in her skin condition and claimed complete remission of peeling after the second sitting.
Quantitatively, a significant improvement in wrinkle overall size (P value 0,01) was measured, with an average 8,5% size decrease (Figure 5).
Skin texture was also positively affected, with an average arithmetical mean roughness decrease of 9,2% (P value 0,002).
Lastly, a 4,5% average decrease in skin pigmentation was measured (P value 0,01).
Furthermore, two patients suffering from pre-existing dermatological conditions reported an improvement in their ailment after treatment.
Patient A (female, 26 years) (Diffuse Injections Group), who suffered from occasional eruptions of acne vulgaris, described a significant decrease in the rash after the second treatment sitting, and an overall reduction in the severity of stagnant post-acne stains.
Patient B (female, 36 years) (BAP Group), suffered from Regarding the injection technique, comparison between group 1, treated following the BAP technique, and group 2, treated with diffuse injections in the subcutaneous layer, revealed no significant difference in terms of efficacy in all the parameter measured.
No adverse events were reported during this study, except for some minor petechiae.
Facial aging is the product of cumulative effects of time on the skin, soft tissues and deep structural components of the face, and is a combined result of skin textural changes and loss of facial volume1,2.
Among the skin alterations, loss of tissue elasticity and skin laxity due to decrease in elastin, collagen and hyaluronic acid production strongly affects the phenotypic presentation of the face, causing superficial textural wrinkling and alterations of its 3D topography.
In recent years, there has been a steady increase in nonsurgical procedures for facial rejuvenation.
Factors which make the nonsurgical approach so appealing are the immediacy of the cosmetic result and a short recovery time.
Profhilo?? is an exclusive skin bioremodeling treatment designed by IBSA Pharmaceuticals to treat loss of facial volume and elasticity.
Profhilo?'s stabilized hybrid hyaluronic acid complexes stimulate the production of collagen and elastin, thus significantly improving the appearance of wrinkles and fine lines, while increasing tone and hydration across the face.
Previous published clinical experience has tested the efficacy and tolerability of Profhilo?? on 120 patients in 4 independent studies, with highly satisfactory quantitative results in terms of skin hydration, elasticity, trans-epidermal water loss (TEWL), validated clinical scales (WSRS, FVLS and Beagley and Gibson Scale) and patient and doctor satisfaction rates, with no relevant side effects.
Based on Profhilo?'s success in the Caucasian ethnicity, the present report aimed to test the treatment's efficacy on a different ethnic subpopulation, i e the Central Eastern European group, which exhibits so-called Asian mongoloid face features.
In this case report, 10 patients (9 female, 1 male) were treated with subcutaneous injections of Profhilo? 2,0 ml for facial skin rejuvenation.
Photographic pre- and post-treatment comparison revealed a smoothing and lightening of the skin, with macroscopic improvement of wrinkles and fine lines.
Quantitative analysis and topographical measurements further highlighted a significant increase in skin hydration and a slight improvement in skin elasticity, confirmed the improvement in skin texture and wrinkle severity, and recorded a decrease in skin pigmentation, probably due to the antioxidant activity of HA28.
Furthermore, two patients with pre-existing dermatological conditions, namely acne vulgaris and atopic dermatitis, achieved remission after treatment.
These results confirm the in vitro properties exhibited by Profhilo?: an increase in expression levels of collagen in fibroblasts and keratinocytes and of elastin in the extracellular matrix, combined with enhanced adipogenic differentiation and proliferation of adipose- derived stem cells (ASCs), resulting in excellent regenerative action.
The case report confirms Profhilo? as a unique product with polypotent properties, and as an effective and highly tolerable nonsurgical skin bioremodeling treatment in patients of diverse ethnicities.
Absorbable fillers have become increasingly popular to reverse signs of aging on the face.
Since bovine collagen fillers received Food and Drug Administration approval in 1981, these fillers gained popularity for more than a decade; however, bovine collagen had the potential for allergic reactions and required skin testing before the first treatment.
Since then, non-animal-based hyaluronic acid (HA), which had been used for intra- articular joint injection and ophthalmologic procedures for many years with a very good safety profile, was introduced and has become the most commonly used facial filler over the past several years.
HA fillers show excellent efficacy not only in correcting wrinkles but also in restoring tissue volume with minimal downtime.
These fillers are easy to use, allergy-free, and enzymatically degradable using an injection of hyaluronidase in case of a bad result1.
Botulinum toxin injection for treatment of facial wrinkles is the most frequently performed cosmetic procedure in the Treatment of frown lines and crow's feet, which are the cosmetic indications approved by the U S Food and Drug Administration, and horizontal forehead lines, offers predictable results, has few adverse effects, and is associated with high patient satisfaction.
Wrinkles are formed by dermal atrophy and repetitive contraction of underlying facial musculature.
Botulinum toxin is a potent neurotoxin that inhibits release of acetylcholine at the neuromuscular junction.
Injection of small quantities of botulinum toxin into specific overactive muscles causes localized muscle relaxation that smooths the overlying skin and reduces wrinkles.
Botulinum toxin effects take about two weeks to fully develop and last three to four months.
Dynamic wrinkles, seen during muscle contraction, yield more dramatic results than static wrinkles, which are visible at rest.
Minimally Invasive Procedures for Nasal Aesthetics rests its therapeutic base on two pillars: first, the control of the muscular activity at the base of the nose that provokes the rotation and the dropping of the tip, through the use of botulinum toxin A (BTxA), and second, the improvement of the nasal profile and ageing with the use of absorbable fillers.
This article describes the procedure and clinical outcomes and discusses the indications of the treatment and possible mechanisms of the long-lasting effects.
The author successfully performed a Minimally Invasive Procedures for Nasal Aesthetics has developed mini- invasive techniques using botulinum toxin A (BTxA) and absorbable fillers hyaluronic acid (HA) for the correction of nasal imperfections. 48 carefully selected patients, between September 2017 and October 2018, with an eight - to twelve - months follow-up.
Patient ages ranged from 21 to 39 years.
All of the patients elected not to undergo any aesthetic nasal surgery but were requesting a slight improvement of their nasal shape.
Monophasic Hyaluronic Acid (HA) gel with the presence of two different molecular weights: 1000 kDa and 2000 kDa (Figure 1).
This is an advantage both from a biological and mechanical point of view.
In fact, different molecular weights allow the physician to act on different HA receptors, putting a number of mechanisms in place that are involved in the regeneration of skin tissue.
Furthermore, there is a mechanical advantage; a high molecular weight HA fills larger spaces, while a low molecular weight HA fills smaller spaces, resulting in a complete filling action.
Additional important features of product are its safety and manageability.
For example, as with most volumising fillers, it is indicated for use at the supraperiosteal layer and deep tissue, but with Monophasic hyaluronic acid (HA) gel no problems arise if it is injected at the mid or deep dermal level (Figure 2).
Therefore, it can be used safely throughout the nose area.
The smoothness of the gel reduces the possibility of side-effects such as swelling and bruising, as well as the risk of over-correction.
Monophasic hyaluronic acid (HA) gel is indicated in all patients who wish to create or redefine facial contour, in those who have lost subcutaneous tissue, and for correcting deficits following injuries.
Surface Appearance: the external nose has a pyramidal shape (Figure 3).
The nasal root is located superiorly, and is continuous with the forehead.
The apex of the nose ends inferiorly in a rounded 'tip'.
Spanning between the root and apex is the dorsum of the nose.
Located immediately inferiorly to the apex are the nares; piriform openings into the vestibule of the nasal cavity.
The nares are bounded medially by the nasal septum, and laterally by the ala nasi (the lateral cartilaginous wings of the nose).
Skeletal Structure: the skeleton of the external nose is made of both bony and cartilaginous components: bony component - located superiorly, and is comprised of contributions from the nasal bones, maxillae and frontal bone (Figure 4).
Cartilaginous component - located inferiorly, and is comprised of the two lateral cartilages, two alar cartilages and one septal cartilage (Figure 5).
There are also some smaller alar cartilages present.
Whilst the skin over the bony part of the nose is thin, that overlying the cartilaginous part is thicker with many sebaceous glands.
This skin extends into the vestibule of the nose via the nares (Figure 6).
Here there are hairs which function to filter air as it enters the respiratory system (Figure 7).
The muscles involved in the rotation of the nasal tip towards the maxillary bone, are the depressor septi nasi and levator labii alaeque nasi.
Their treatment with BTxA is easy.
The depressor septi nasi muscle can be injected along both its insertion above the columella and in the nasal spine.
In this case, we use 4 Units Botulinum Toxin (Botox? Allergan).
If there is hypertonia of the levator labii alaeque nasi muscle with a clear lift of the nasal sides and rotation of the tip downwards, we can give the injection of 4 Units Botulinum Toxin (Botox? Allergan) (Figure 8).
To appreciate the result, it is necessary to wait for 7 to 15 days.
We always perform a retouch session after 15 days, both to evaluate the results and for possibly enhancing it with another injection of a few units.
It is important to be careful while treating the levator labii alaeque nasi muscle, since it is possible that the length of the upper lip can increase, getting ptosis.
The risk is lower in youmg women with gummy smile, short lips (less than 1.5 cm) than in older people (over 60 years of age) with long lips.
When the distance between the nasal spine and the apex of the Cupid's arch is more than 1.8 cm, the treatment is strictly contraindicated.
Normally use average cross-linked hyaluronic acids, and in particular: Aliaxin? EV.
The safety of materials is fundamental to obtain good results, and so the advice is to use well-known materials with a very high safety profile.
We always start with topical anaesthesia with an anaesthetic lotion for at least 30 min.
Before the procedure, the midline and the most prominent spot of the nasal domes were marked.
A Cannula guide needle was used through the nose tip to create the entry point (center of domes tip defining point) (Figure 9).
First Step: with the columella angle needs to be enlarged by moving the columella through the entry point and placing the Aliaxin? EV dermal filler into the nasal septal cartilage.
The cannula is not removed at all during the procedure.
Forward and backward maneuvering places the Aliaxin? EV dermal filler into the columella9.
Second Step: it is necessary to move along the nasal dorsum from the entrance point and to put the Aliaxin? EV dermal filler over the nasal periosteum and proceed to the glabella to lift the nasal bridge.
The cannula is not removed at all during the procedure.
Forward and backward maneuvering places the Aliaxin? EV dermal filler into the nasal dorsum9.
The amount injected is variable depending on the imperfection to correct.
If the Nasolabial angle is also reduced (less than 90?), we proceed with an injection at the level of the nasal spine to open this angle that should be possibly more that 90?. 
This injection opens the Nasofrontal angle, so it is obvious that the best indication remains the one with a reduced angle, less than 115?.
It is better not to exaggerate with the injection and reach the optimum result , We use fan technique and, again the best results are obtained step by step. 
Between September 2017 and October 2018, 48 carefully selected patients, with an eight - to twelve - months follow-up.
Patient ages ranged from 21 to 39 years.
The results were satisfactory in all but 42 of the 48 cases based on patient feedback (Table 1).
Six patients found the results inadequate and those patients underwent normal rhinoplasty afterward.
The operation duration was under 30 minutes in all of the cases.
Our longest follow-up was 12 months, during which we observed that the final outcome appeared after the third month and did not undergo any change afterward.
No complication related to the Aliaxin? EV dermal filler and Botulinum Toxin (Botox? Allergan).
Facial rejuvenation involves a spectrum of interventions, ranging from topical cosmetic products to surgical tissue manipulation.
Botulinum toxin and Dermal filler injections fall somewhere in the middle of this spectrum.
Used alone or in conjunction with other modalities, botulinum toxin and dermal filler products play an important role in achieving a youthful, aesthetically pleasing facial appearance.
As demonstrated throughout this article, nonsurgical pproaches to facial rejuvenation have become enormously popular among both patients and practitioners in recent years.
Facial rejuvenation is comprised of a spectrum of interventions ranging from topical cosmetics to surgical restoration.
Injectable products fall somewhere in the middle of the spectrum, offering dramatic aesthetic results for a moderate cost and require minimal posttreatment recovery time.
The present article serves as a general conceptual outline regarding the use of injectable products to achieve facial rejuvenation.
Certainly, every patient warrants treatment approaches tailored to their specific situation, and when questions arise, specific recommendations should be sought from one's more experienced colleagues11.
In the author's experience, injection of HA gel is a valuable tool for minimally invasive nasal reshaping.
Experienced plastic surgeons can use HA injection as an alternative/ complement to many indications for rhinoplasty because of its versatility.
In the author's opinion, this is infrequently considered by many surgeons.
Benefits with HA injection include a quick and noninvasive method to change nasal features without need for general anesthesia.
The procedure is associated with no/minimal downtime and with lower cost per treatment compared with rhinoplasty.
Minor and sometimes time-consuming and risky secondary surgical procedures can sometimes be avoided with HA injection.
In addition, HA gel injections are useful for preserving the height of the nose, which can be challenging with a surgical reshaping rhinoplasty.
The nonpermanent nature of HA and reversibility with hyaluronidase are also favorable properties.
Limitations include a relatively short duration of effect in some cases and thus need for retreatment.
Although use of HA in aesthetic facial treatments is well established for treatment of wrinkles and folds, most patients are unaware of nasal indications.
As a nonsurgical minimally invasive alternative to rhinoplasty, it would likely appeal to many patients who wish to modify the appearance of their nose.
HA treatment may also serve as a door opener to surgery for patients who are reluctant to undergo rhinoplasty.
Rhinoplasty is one of the most common cosmetic procedures performed by plastic surgeons.
However, non-surgical nose jobs with a dermal filler are becoming increasingly popular in the world.
Filler rhinoplasty has become an advantageous choice for patients that are afraid of surgery or general anesthesia.
It is a fast, safe, simple, and effective method when compared with surgical rhinoplasty.
On the other hand, HA filler rhinoplasty can be completely reversed with hyaluronidase when needed.
Signorini et al. recommend an injection of 10 to 20 U hyaluronidase for areas less than 2.5 mm and two to four injections of 10 to 20 U hyaluronidase for areas greater than 2.5 mm.
In some patients, the use of BOTOX? increases the distance between the columellar base and the vermilion border, creating the appearance of a fuller and voluminous lip.
It can also correct the gingival smile.
If the toxin diffuses laterally in the base of the columella, it can affect the levator labii superioris and the orbicularis oris, provoking an unaesthetic elongation of the superior lip, filtrum flattening, and labial sphincter incompetence when talking and drinking.
The use of high doses in the nasal tip can produce an exaggerated opening of the nostrils and a strong elevation of the tip, leaving an unattractive appearance in the frontal view.
The clinical effect in this area usually lasts for a shorter time than other parts of the face.
The first days after the injection, the patient can experience pain in the nasal tip.
Nasal aesthetic problems are one of the few fields in which we are not able to offer our patients an acceptable, minimally invasive alternative.
Furthermore, we have patients who are incapable of arranging their daily programs to accommodate the required recovery period or who do not wish to undergo such a significant operation because of their associated health problems or anxiety over an irreversible change in their facial characteristics.
The main objective of the technique we describe is to provide patients with a simple method for nose reshaping, which can be performed in the office under topical anesthesia in less than 30 minutes and is therefore with Botolinum toxin or Fillers in the patient?€?s mind.
For selected patients, however, our method can be proposed as a simple, office-based procedure that can be performed under topical anesthesia in a matter of minutes with virtually no downtime.
At the end of the session, we normally use a camphor cream to disinfect and reduce the oedema which is usually modest.
The patient can immediately resume his or her daily activities.
The main indication of these procedures is in all minor defects of appearance of the nose, particularly for the plunging tip.
A second important indication is the flat nose, frequently seen in black/brown and yellow skin people.
Another useful indication is the correction of many post-surgical imperfections, which will be difficult to treat otherwise.
Corrective surgery is not always so easy to perform.
The training of doctors, who want to engage with this easy technique that gives extraordinary results, is always necessary and essential.
Rules, written long time ago and well documented, remain the best way to achieve good results and reduce to the minimum the incidence of side effects.
Potential major complications of injection rhinoplasty include infection, ischaemic necrosis from arterial embolism, pressure necrosis from overinjection of nasal tip and osteophyte from periosteal injection.
These risks may be reduced, with effective nasal analysis, meticulous injection technique, and a good understanding of nasal cartilaginous and vascular anatomy.
Radix and upper nasal third injections should be medially placed to avoid the dorsal and lateral nasal arteries.
Pre-injection palpation may aid identification, and aspiration before injection is mandatory.
Intravascular filler injection can lead to arterial embolisation and subsequent skin necrosis or retinopathy.
Visual impairment following middle facial third filler injection mandates urgent opthalmological review to exclude retinal embolism.
Prompt anticoagulation and hyaluronidase injection may be a useful adjunct should complications arise.
Injection of HA gel is a valuable tool for plastic surgeons to consider for nasal reshaping.
Small corrective refinements offered to patients may help achieve higher patient satisfaction and have in many cases had a surprisingly long duration of effect.
The clinical experience gained with HA gel injections for nasal treatments over 15 years has also shown that HA gel can be used for correction of minor postrhinoplasty defects in appropriate patients.
Minimally invasive procedures for nasal aesthetics described herein is one of very few minimally invasive alternatives for aesthetic nasal surgery.
For selected patients, our method can be used as a simple, office- based procedure that can be performed under topical anesthesia without any significant morbidity, a very high patient satisfaction, and a recovery period of only two to three days.
The reversibility of the result, at least for a short period of time, is also appealing to patients who are uncertain about the outcome of nasal surgery.
Injection rhinoplasty is not a substitution for surgical rhinoplasty.
There are many indications where it will be insufficient to achieve the desired aesthetic outcome.
Noses that are significantly overprojected, or overrotated, have a shallow radix, and tension noses are better suited to surgical correction.
It is however a useful postoperative adjunct to surgery or in those patients contemplating rhinoplasty.
The non-permanence and minimal morbidity of associated with degradable fillers is especially beneficial to those patients who seek cosmetic rhinoplasty but are discouraged by the risks and convalescence of surgery.
The story of melatonin dates back to the beginning of the evolution process.
In fact, this tiny molecule, known as a biogenic amine or indole (its molar mass is 232.278 g Mol) appeared very early in living organisms and was then ?€?conserved?€?throughout evolution; thus, the melatonin present in current living humans is identical to that present in cyanobacteria that have existed on Earth for billions of years.
In 1958 it was officially discovered by Lerner and, since then, the interest in this substance has never faded and given rise to a huge amount of papers, trying to unravel the mystery of its meaning24.
Initially thought to be produced by the pineal gland only, it is now known to be produced in many, and probably all, cells of the body.
Its first- described actions linked melatonin to circadian (and circannual) rhythm regulation, however more recent studies validated the great number of functions of this molecule, which include actions at the molecular level that are able to modify the physiology of organs and organisms.
The initial idea that melatonin could be produced only in animals with the pineal gland, was lately modified since it was demonstrated that it could be synthesized in every living organism, including bacteria, unicellular organisms and plants.
As far as melatonin signal transduction is concerned, the indole works via well-defined membrane receptors (MT1 and MT2)8, and also nuclear receptors (RZR/RORalpha).
However, its actions far transcend these receptors, since binding sites have also been described in the cytosol and mitochondria.
In addition, some of melatonin actions receptor-independent, due to its ability to permeate all barriers acting as a potent radical scavenger.
The sense of the above is that probably no cell or function in plants and animal kingdoms escapes the impact of melatonin.
In fact, it has a pivotal role in a bunch of different physiological processes, and it also may have a significant role in the etiology of many disorders.
Recently it has been postulated that the initial and primary action of melatonin in photosynthetic cyanobacteria, which appeared on Earth 3.5-3.2 billion years ago, was as an antioxidant.
This is due to the fact that photosynthesis is associated with the generation of toxic free-radicals.
The other functions came about much later in the evolution process.
Oxygen is an essential element for aerobic organisms because oxidative metabolism represents the main energy source.
However, the partial reduction of O2, derived from the normal physiology of the organisms, results in Reactive Oxygen Species (ROS) formation.
These molecules include two major groups: free radicals such as the superoxide anion and hydroxyl radical, and molecules such as hydrogen peroxide.
As we know, oxidative stress occurs when an imbalance between pro-oxidant and anti-oxidant molecules takes place, due to an increase of ROS and of Reactive Nitrogen Species (RNS), and a decrease of the activity of the antioxidant defense mechanism.
Melatonin has a major role in the antioxidant defense mechanism, in fact this multifunctional molecule, whose amphiphilic nature enables it to penetrate all morphophysiological barriers and all subcellular compartments, protects cellular membranes, the electron transport chain and mitochondria from oxidative injury.
As far as the latter are concerned, the measurement of subcellular distribution of melatonin has shown that the concentration of the indole in the mitochondria greatly exceeds that in the blood.
Melatonin presumably enters mitochondria through oligopeptide transporters (PEPT1 and PEPT2) and it seems to function as an apex antioxidant.
In addition to being taken up from the circulation, melatonin may be produced in the mitochondria as well, according to recent data, providing on-site additional protection as a powerful antioxidant.
Moreover, melatonin increases the permeability of membranes and acts as lipoxygenase inhibitor, helping in maintaining the efficiency of the local antioxidant system.
Therefore, melatonin's high concentrations and multiple actions as an antioxidant provide a potent antioxidant protection to these organelles which are commonly exposed to abundant free radicals.
However, it is important to underline that the melatonin molecule, in order to display its own antioxidant activity, needs to be oxidized and cannot be reduced to its former state because it forms several stable products upon reacting with free radicals.
For that reason, it is also called "terminal"?or"suicidal"?antioxidant and its concentration in physiological fluids decreases, as the scavenging process progresses.
In addition, its metabolites also have antioxidant properties; thus, the protection exerted by melatonin against oxidative damage to cells and particularly to DNA is a continuous process.
Health maintenance is strongly dependent by a proper internal organization which should be synchronized to the daily light/dark cycle of the external environment.
This organization is provided by a complex mechanism that includes a master clock (located in the suprachiasmatic nucleus: SCN) that is able to demonstrate an autonomous circadian rhythm of a little more than 24 hours.
At the cellular level, the macromolecular transcription-based oscillator is formed by the clock and the clock-controlled genes, which contribute to the rhythmic functions of the organism.
However, as said, despite the fact that the cells have a circadian rhythm to ameliorate their ability to survive, it is essential that the rhythm is well synchronized to the external light/dark cycle, in order to align endogenous processes.
This task is performed by melatonin (N acetyl-5methoxytriptamine), the well- known tryptophan-derived indole of the pineal gland, that is produced and secreted according to a circadian rhythm that is connected to the light/dark cycle.
At least four enzymes are involved in the synthesis of melatonin.
Among them, arylalkylamine N Acetyl- Transferase (NAT) is considered the rate-limiting enzyme in the regulation of melatonin biosynthesis.
In fact, the NAT enzyme exhibits a robust daily rhythm, reaching concentrations that are 100 times higher during the dark phase, compared to daylight hours.
Sympathetic nerve endings in the superior cervical ganglion release norepinephrine (NE) in accordance with a circadian rhythm, which is related to the light/dark cycle in the environment, increasing its secretion during the dark phase.
NE induces melatonin biosynthesis from the pinealocyte and, in this view, tryptophan is first converted into 5-hydroxytryptophan by the enzyme tryptophan hydroxylase, which is then decarboxylated into serotonin.
Serotonin is acetylated into N acetylserotonin (by NAT), which is finally O methylated into melatonin by Hydroxyindole-O Methyl-Transferase (HIOMT).
Once released into the circulation, roughly 70% of melatonin is bound to albumin, and another 30% diffuses to the surrounding tissues.
The main metabolic pathway of melatonin occurs in the liver where it is hydroxylated to form 6-hydroxymelatonin, then conjugated with sulphate or glucoronate and finally excreted in the urine.
Daily light exposure that affects the retina, directly influences melatonin production, blunting its rhythm.
This is due to a direct neural connection between the eye and the pineal gland, through which it receives information about light (or dark) conditions of the environment.
In addition, melatonin travels throughout the body without limitations and, therefore, it is considered as a ubiquitous molecule.
Finally, the chemical conservation of melatonin in all tested species makes it a candidate for a universal time messenger.
Measures of melatonin are considered the best peripheral index of human circadian timing based on an internal 24-hours clock.
Plasma melatonin reflects the melatonin synthesized in the pineal gland, since no storage compartments for the pineal indole do exist.
In humans, melatonin secretion increases soon after the onset of darkness, with a peak in the middle of the night (between 2:00 and 4:00) followed by a gradual decrease during the second half of the dark phase.
Serum melatonin concentrations during nighttime also vary considerably according to age and among individuals, the highest amount being in the first years of life, falling immediately before puberty and then maintained throughout adulthood, followed by a progressive decrease during the aging process that leads to minimal levels with old age.
According to its circadian rhythm, melatonin is mostly secreted during the night, with lowest plasma levels during the day.
In this view, light is recognized as the most efficient stimulus to blunt melatonin secretion and, in fact, the exposure to light during the night determines chronodisruption that may have deleterious consequences on well-being and it is called light pollution (especially with short wavelength light in the 460- 480nm spectrum: blue light).
Unlike our ancestors, who lived in natural environments, the modern generations of people residing in developed Countries have self- selected their light-dark cycle.
The most important differences between these two lifestyles, with respect to light exposure, are: a progressive general decrease in light intensity and regularity; a modification in light timing, with delayed and reduced exposure during the day and increased light at night; and finally, a shift in the light spectrum towards artificial light sources with a strong blue component.
It has been demonstrated that light at night enriched with wavelength between 460- 480nm can cause toxic effects to the eye inasmuch they can penetrate the cells and their organelles, inducing the generation of ROS in retinal epithelium mitochondria and even apoptosis.
Thus, nocturnal lighting, and specifically that with a high short wavelength content (i e mobile phone and tablet screens), should be avoided also because blue light at night has a greater impact on retina cells, with respect to Sun-derived blue light during the day, due to retinal physiology changes between day and night.
Even though some applications have been recently developed and released to reduce the negative effects of the use of electronic devices at night by adjusting the display color temperature according to the natural light/dark cycle (namely, reducing the blue light content during nighttime and increasing it during light hours), attention should be paid because the melatonin-inhibiting activity of light can be initiated at extremely low lux levels.
However, in order to maintain a good health of our circadian system, appropriate lighting levels during the day should also be recommended.
Diurnal light should not be poor in short wavelength, since the maximum human circadian spectral sensitivity, in terms of melatonin suppression ability, occurs in this part of the spectrum.
There are several situations in which individuals are particularly exposed to a chronodisruptive illumination, with significant effects on human health.
Among them, shift work is one of the most frequent in modern population.
In fact, approximately 15 to 20% of workers in Europe and US participate in shift work, including work at night, and rises up to 30% when manufacturing, mining, transportation, health care, communications and hospitality sectors are considered.
Epidemiological studies have demonstrated an increased risk of some cancers, namely breast, prostate, colorectal and endometrial cancers.
The reason being the disruption of the circadian oscillator, with the consequence of melatonin circadian rhythm alteration, and the decrease of melatonin concentrations, due to light at night.
In this view, a recent paper suggests that women with hereditary breast cancer predispositions should avoid using light at night.
Since the circadian oscillator is involved in the regulation of cellular division pathway, its disruption may be linked to disturbances of the cell cycle control, with the consequence of an acceleration of malignant growth.
In addition, the concomitant decrease in melatonin concentrations may induce a decrease in its overall availability as antioxidant molecule, therefore increasing tumorigenesis and acceleration of malignant growth.
This assumption is in line with the repeatedly observed increases in lipid peroxidation and decreases in glutathione peroxidase and superoxide dismutase in pinealectomized animals.
In addition, the association of shift work with metabolic syndrome, cardiovascular diseases and type II diabetes has also been demonstrated.
In fact, altered food intake and obesity, eventually associated to high blood pressure, are shown to be induced, or aggravated by shift work which also acts causing sleep disturbances.
Sleep deficit and interruption are also known to be associated to changes in eating behavior and obesity, however the relationship between the increased body mass index related to eating at night and the aspects of circadian rhythmicity in nutrient uptake is not simple to demonstrate.
Recently, it has been shown that insulin resistance is promoted by circadian perturbance, under conditions of controlled sleep loss.
Importantly, the change in insulin sensitivity was associated with increases in inflammation markers in those subjects.
One of the predictable consequences of the concomitant nocturnal shutoff of melatonin blood concentrations by light at night is, therefore, an increased oxidative damage to biomolecules.
Moreover, circadian perturbations due to repeated phase shifts have also been shown to increase oxidative damage, to reduce lifespan in animals and to increase the amount of 8-hydroxydeoxyguanosine (a product resulting from free radical damage to DNA) in the DNA of shift workers.
Another frequent situation that is capable to disrupt our internal circadian rhythm is the so-called jet- lag that depends on a rapid travel across multiple time zones, associated to the fact that the change is considered by the organism too drastic to allow the circadian system to adapt smoothly.
In fact, melatonin rhythm is shifted and does not resemble the light/ dark cycle of the external environment.
Common symptoms are sleep impairment, anxiety, depressed mood, gastrointestinal complaints and dizziness.
In recent years, the fact that many individuals (especially the younger ones) shift their sleep and activity times by several hours between workdays and the weekends gave rise to what is now called "social jet-lag"? which is comparable to jet-lag.
In addition, as noted above, the internet, email, video games and television until late not only contribute to later bed times, but also induce a decrease of the physiological melatonin rise at nighttime, due to the exposure to modern LED screens which are known to blunt melatonin secretion because of their higher blue light content, with respect to white incandescent bulbs and compact fluorescent bulbs.
As a result, adolescents experience a misalignment between biological and social rhythms which, added to sleep loss, results in fatigue, daytime sleepiness, behavioral problems and poor academic achievement, also opening the door to future problems as obesity, metabolic syndrome, diabetes, increased cardiovascular risk and infertility.
Epidemiological studies demonstrated that children sleep approximately 1.2 hours less than their counterparts of a century ago.
In addition, the sleep of exposed adolescent becomes irregular, shortened and delayed in relation with later sleep onset and early waking time, which results in rhythm desynchronization.
It is noteworthy that, according to several studies, among adolescents 47.8% of high school students in India, 25% in Japan, 22.8% in the US, 16.1% in China and 9.9% in Spain suffer from insomnia due to many causes, but probably as the result of disturbed habits and irregular lifestyles.
In this view, the expanding use of leisure technology seems to have substantially contributed to this sleep deficiency.
Therefore, the permanent social jet-lag resulting in clock misalignment and melatonin rhythm decrease and disruption experienced by a high number of adolescents should be considered as a matter of public health.
In this view, very recent data obtained in preschool-age children indicate that this specific population is particular sensitive to evening light exposure, in terms of melatonin suppression, with the consequence of easily and rapidly disrupting the circadian rhythmicity1.
On the other hand, melatonin treatment of these patients may have beneficial effects on sleep disturbances.
It is well known that, inadequate timing, spectrum and intensity of retinal light input produced by nocturnal activities and sleep during daytime is a key factor to explain the incidence of chronodisruption, since it not only induces instability of the master internal pacemaker, but it also reduces melatonin synthesis.
As noted above, this reduction, due to repeated light exposure at nighttime (and the consequent decrease in melatonin production) may have an important role in the pathogenesis of a number of illnesses, such as breast cancer, cardiovascular problems, diabetes, cognitive dysfunctions, male and female reproductive problems, among others.
As far as the latter is concerned, a strict link between melatonin and female reproduction has been already established.
Since decades ago it has been demonstrated that melatonin is involved in the regulation of the reproductive system of both, males and females, and the most recent data of the literature confirms and ameliorates our knowledge in that field.
In fact, melatonin is able to control the reproductive axis through a quite complex mechanism which includes the regulation of the secretion of Gonadotrophin-Releasing Hormone (GnRH), and of the activity of the gonadotrophin release-inhibitory hormone (GnIH), which has been recently shown to have a role in the mechanism that regulates male and female reproduction, acting directly on GnIH neurons through its receptors to induce (birds) or to inhibit (mammals) the expression and release of GnIH55.
In this view, in mammals it is able to inhibit the activity of components of the Hypothalamic-Pituitary-Gonadal (HPG) axis, including a reduction of sexual behavior.
The GnIH content of the brain is influenced by changes in day length and, on the other side, melatonin stimulates the release of GnIH from the hypothalamus of birds and mammals.
It is noteworthy that GnIH neurons express melatonin receptors, thus suggesting a strict regulatory connection between the pineal hormone and the GnIH action within the brain.
In addition, melatonin stimulates the secretion of progesterone from granulosa cells.
Another important melatonin target tissue is the pituitary gland and, in adult mammals, the dominant pituitary site of melatonin action is the Pars Tuberalis (PT), a thin layer of the anterior pituitary that surrounds the pituitary stalk and extends rostrally along the ventral surface of the median eminence.
In fact, it is now believed that melatonin signal duration (long in winter and short in summer) drives the photoperiodic control over multiple aspects of neuroendocrine physiology, including the lactotrophic and reproductive axes, via the PT in adult mammals.
However, differently from seasonal breeders, human reproductive efficiency seems to be less dependent by seasonal day length variations, but this does not mean the melatonin has no effects on human reproductive organs.
In fact, data from the last two decades indicates that the pineal indole has multiple effects directly at the level of the gonads and their adnexa in the human and other mammals.
In particular, both stable circadian rhythm and cyclic melatonin availability are critical for optimal ovarian physiology, gestation and parturition.
In particular, as far as the latter is considered, light at night impedes regular uterine contractions in late term human pregnancy, reinforcing the importance of a correct melatonin rhythm in coordinating nocturnal myometrial contractions such that delivery of offspring more frequently occurs at night than during the day.
On the other hand, women with higher nocturnal melatonin surges display more vigorous and coordinated uterine contractions at parturition.
In addition, chronodisruption during pregnancy has also deleterious effects on the health of progeny, including metabolic, cardiovascular and cognitive dysfunctions.
In this view, since light exposure after darkness onset at night disrupts the master circadian clock and suppresses elevated nocturnal melatonin levels, leading to pathophysiology and/or diseases, light at night should be avoided.
Melatonin is also produced in the peripheral female reproductive organs, including granulosa cells, the cumulus oophorus, and the oocyte.
These cells, along with the blood, may contribute to follicular fluid melatonin content, which is higher than that in the blood by a three-fold factor.
The origin of melatonin in the follicular fluid was commonly thought to be the exclusive result of its uptake from the blood.
However, there is a bunch of evidence indicating other ovarian cells (as indicated above) that are able to synthesize melatonin which could be appropriately released into the follicular fluid.
The fact that follicular fluid melatonin concentrations in humans are two times higher in large follicles just prior ovulation, with respect to those in smaller antral, immature follicles induces to speculate that because melatonin is such a potent antioxidant, the elevated concentrations in the follicular fluid at the time of ovulation could be physiologically advantageous.
In this view, recent data demonstrates that there is a strong positive relationship between melatonin levels in the follicular fluid and the quality and quantity of oocytes and that melatonin concentrations in the follicular fluid can be considered as a marker of in vitro fertilization techniques and ovarian reserve.
In addition, melatonin is able to reduce granulosa cells oxidative damage, in an animal model.
The presence of the indole acting as a potent antioxidant molecule is so important because mammalian gametes and embryos are highly vulnerable to oxidative stress due to the presence of high lipid levels and the ovulatory processes have been linked to inflammation and high free radical production.
Briefly, the inflammatory-like process identified in the ovary at the time of ovulation include augmented synthesis of prostaglandins and cytokines, increased activation of proteolytic enzymes and elevated capillary permeability, which are all associated to a higher production of damaging reactive oxygen species.
In addition, it is known that macrophages, leucocytes and vascular endothelial cells residing in the vicinity of large follicles contribute to free radicals production at the time of follicle rupture.
Free radicals influence the balance between oxidation-reduction reactions, disturb the trans-bilayer-phospholipid symmetry of the plasma membrane and enhance lipid peroxidation.
Therefore, in order to protect the ovum from oxidative damage during the ovulation process, the presence of melatonin would ensure that it escapes molecular damage, with the consequence of a healthy embryo and fetus.
In this view, recent data indicates that melatonin is able to significantly improve the cytoplasmic maturation of bovine oocytes through the amelioration of organelles distribution, the increase of intracellular glutathione and ATP levels, the enhancement of antioxidant genes expression, and the modulation of the so-called fertilization-related events, all of which results in increased fertilization capacity and developmental ability.
Other Authors recently demonstrated that the experimental damage of mouse oocytes induced by the administration of Bisphenol A (BPA, which is a known potent disruptor of mammalian oocytes quality) may be reversed by melatonin administration in vivo, increasing the fertilization rate by restoring the BPA-induced defects of fertilization proteins and events through the reduction of ROS levels and inhibition of apoptosis.
Additionally, a recent paper indicates that melatonin may be considered as a promising pharmacologic agent in the prevention of reproductive toxicity caused by endocrine-disrupting chemicals, as BPA60.
Finally, melatonin has also been shown to modulate cell cytoskeleton, therefore ameliorating the physical cell resistance.
In this view, a recent paper demonstrated that melatonin could become an important tool in the management of ovarian and luteal diseases.
Female fertility inhumansisnotconstant throughout the reproductive period (from menarche to menopause), but it peaks at about 25 years and rapidly declines after 35 years.
Nowadays, due to current cultural and social trends, many women around the world decide to delay their "pregnancy project"?
In fact, in recent decades maternal age has progressively increased from about 5% of women who became pregnant when older than 30 years old in 1975, to about 26% in 2010 and, therefore, many of them become exposed to infertility when they decide to conceive, due to the ovarian aging process.
More recent data obtained by an Indian study group confirmed the beneficial role of younger age in reproduction, emphasizing its importance especially when in vitro fertilization techniques are concerned.
From a biological point of view, the ovarian aging process is characterized by a decline in mitochondria function, in the integrity of the cytoskeleton and especially in telomere length (which is considered as a biomarker of cellular senescence and is highly sensitive to oxidative events), oocyte reserve as well as an obvious increase in the number of low-quality oocytes.
In this view, mitochondria, which are the primary energy generators and are also the main source and target of free radicals, and mitochondrial oxidative stress in particular is considered a major factor in contributing to the aging process.
Recent data of the literature clearly indicates that melatonin is able to significantly delay the fertility decline associated to reproductive aging by improving both the quality and the quantity of oocytes.
In particular, melatonin is effective to either ameliorate mitochondria oxidative damage (preventing cardiolipin oxidation, which is known to be a key component of mitochondria membrane) and apoptosis, and to preserve optimal mitochondria function in the aging ovary, also contributing to maintain the length of the telomeres in aging mouse ovaries.
Therefore, acting on mitochondria seems to be an attractive perspective for health and lifespan, since rejuvenating aged mitochondria could be an interesting strategy to improve health.
In fact, a recent paper dealing with the aging process was able to demonstrate that melatonin may have beneficial effects at different levels of the anti-inflammatory network.
Since obesity in humans is associated to poor outcome across the reproductive spectrum, an obese animal model has been used to demonstrate that oral administration of melatonin is able to significantly reduce ROS generation and stimulate sirtuins, to prevent chromosome abnormalities and meiotic defects in oocytes, with the result of healthier embryos.
In addition, melatonin supplementation significantly improves oocytes mitochondria membrane potential, enhances their ATP production and induces a more uniform, granulated distribution of active mitochondria in maturing oocytes, which is an important index of oocyte quality.
Of particular interest is the recent data that suggests a role for melatonin in protecting the endoplasmic reticulum (ER) of the cells from oxidation and damage and, therefore in preserving the reproductive organs from premature aging.
For example, mice intraperitoneal lipopolysaccharide (LPS) injections during pregnancy retard intrauterine growth and induce fetal death.
In addition, the placenta of pregnant mice displays an important ER stress, which is almost completely alleviated by previous melatonin administration, ultimately protecting fetuses.
Poor oocyte quality is one of the major problems where Assisted Reproductive Techniques (ART) are concerned, even though the methodologies have greatly improved within the last two decades.
This is generally believed to be the result of oxidative damage of the gamete.
In this particular case, the presence of radical scavengers, as well as antioxidative enzymes which metabolize ROS to inactive products, is essential in protecting the ovum from oxidative damage.
Since melatonin is considered to be either a direct free radical scavenger, and a stimulator of gene expression and activities of antioxidant enzymes, it seems reasonable to consider this indole to have a utility in improving the quality of human ova, both in normal conditions or to be used for ART.
In fact, melatonin administration to infertile women who failed to become pregnant in previous ART trial, was able to induce a marked improvement of the fertilization rate, by reducing free radical damage and elevating the percent of oocytes that reached maturity.
In a more recent study, melatonin started before ART cycles and continued during pregnancy resulting in improved fertilization success (50% higher in melatonin treatment cycle, with respect to non-melatonin cycles), pregnancy rates and pregnancy outcomes.
In addition, recent data from a randomized, controlled, double blind study indicates that melatonin supplementation to PCOS patients undergoinginvitrofertilizationforpooroocytes quality is able to ameliorate oocyte and embryo quality, acting synergistically with inositol, which is also known to have an important role in reproduction.
More recent data, obtained in a PCOS animal model, demonstrated that melatonin has the potential to induce oocyte nuclear maturation and guarantees the fertilization potential.
In this view, studies designed to evaluate the effects of melatonin administration to young female patients undergoing ART for reduced ovarian reserve are now on the way to be completed.
Again in the PCOS field, a very recent paper demonstrated that melatonin supplementation to PCOS women for a 12 week period resulted in a significant amelioration of hirsutism, total testosterone concentrations, while reducing oxidative stress and inflammation biomarkers.
Once pregnancy is achieved, either naturally or through ART, maternal melatonin levels progressively increase until term, in order to transfer a high amount to the fetus, due to its important role in brain formation and differentiation.
In fact, serum melatonin concentrations reach a peak in the third trimester, with values that are more than the double of those in non-pregnant women, and rapidly decreasing to non-pregnant levels on the 2nd day postpartum.
On the other hand, in pathological pregnancies, melatonin levels are lower after 32 weeks of gestations.
Maternal melatonin provides the first circadian signal to the fetus and it is also important due to its well-known antioxidant protective effect.
Therefore, in presence of lower plasma melatonin levels or circadian rhythm disruption (i e light at night) during pregnancy an alteration of fetal brain programming may occur, with long-term effects.
The pathophysiological basis of this outcome, besides cycle disruption, may also be the induction of high oxidative stress in compromised pregnancies (those with gestational diabetes mellitus, intrauterine growth retardation, preeclampsia, maternal undernutrition, maternal stress).
In this view, suppression of maternal plasma melatonin circadian rhythm by continuous light exposure during the second half of gestation is able to induce several effects on fetal development as, among them, intrauterine growth retardation, altered a decreased corticosterone rhythm, altered brain development, in experimental animals.
The shift work while pregnant is associated with a higher risk of prematurity and/or low for gestational age babies, spontaneous abortion.
Finally, recent data indicates that the administration of melatonin to women with pregnancy disorders has been established as an efficient therapeutic approach against fetal brain injuries.
Antioxidant properties of melatonin may also be demonstrated in the placenta, where the indole is highly produced and protects against molecular damage and cellular dysfunction due to local oxidative stress.
In fact, recent studies demonstrated that placenta owns the machinery to produce melatonin throughout pregnancy (from week 7 to term), with a maximal expression around the third trimester.
In addition, the primary villous cytotrophoblast seems to be the main melatonin production site in the placenta and the in vitro melatonin treatment is able to induce an increase in human chorionic gonadotropin (hCG) secretion, probably mediated by MT1 and MT2 melatonin receptors, which contributes to the correct function of the placenta.
In this view, since a precise balance between formation and degeneration of the syncytiotrophoblast syncytium, which is derived by the proliferating cytotrophoblats, is necessary to prevent placental pathologies, melatonin may have a major influence in creating a stable villous cytotrophoblasts/syncytiotrophoblast homeostasis.
In fact, it is well known that the indole has a prominent regulatory effect on apoptosis, showing anti-apoptotic actions in normal cells, while being pro-apoptotic in cancerous cells and that these dual functions are believed to be utilized by the placenta cells to maintain the necessary balance between cyto- and syncytio- trophoblasts.
In a recent report, using a mid- to late- gestation animal model, the authors demonstrated that melatonin supplementation increased heifers umbilical arterial blood flow that was previously reduced by food restriction, suggesting that these specific responses on umbilical arterial hemodynamics and fetal development may be partially mediated through vascular melatonin receptors.
On the basis of the above considerations, it is easy to understand that melatonin can be used as a pharmacological agent, and in this view, the ability of exogenously administered melatonin to phase shift human circadian rhythms was firstly described in the mid ‘80s3.
If given before the natural rise of endogenous melatonin, phase advances in sleep, core body temperature have been observed.
On the other hand, if given in the early biological morning it can induce a phase delay in circadian timing.
This ability of the indole to advance or delay clock timing depending on the biological time of administration has been used in the treatment of circadian rhythm disorders in which the sleep/wake cycle is desynchronized from the circadian timing system.
In fact, appropriately timed melatonin (0.3-5mg p o ) has been shown to alleviate symptoms of jet-lag (social jet-lag included) and night shift work.
A great deal of effort has focused on trying to identify the optimal treatment regimen and, at the moment, it is widely accepted that melatonin, in order to synchronize the sleep/wake rhythm, should always be given at the same time, roughly at 22:00 and at a dosage that is dependent on the subject.
In particular, due to the fact that melatonin night peak physiologically decreases with advancing age, the amount needed to obtain the effect is higher in the older population, with respect to younger people who need lower amounts.
It is noteworthy that young and young/adults if treated with high amounts of melatonin may experience sleep disturbances like nightmares and hangover symptoms the next morning.
Therefore, it seems that an amount of melatonin as low as 1-2mg per night is the most suitable to obtain the results without unwanted side effects in younger populations.
Regarding the so called "social jet- lag"?is concerned, which mainly involves the young and young/adult population, it is important to underline that it is able to induce a circadian rhythm disruption and a decrease of melatonin plasma concentrations, with the risk of reproductive, metabolic, cardiovascular and cancer problems.
The administration of melatonin has been shown to ameliorate circadian rhythm synchronization, with the achievement, as far as reproduction is concerned, of higher fertility score.
The increase of melatonin plasma concentration may also be achieved by endogenous stimulation.
In fact, the overnight acupressure of the so-called wrist HT7 point resulted in an amelioration of sleep parameters in a number of insomniac patients.
Despite the efficacy of exogenously administered melatonin as a synchronizing agent in circadian rhythm disorders, its use to exploit the potent antioxidant ability opens wide scenarios, especially as far as the reproductive system is concerned.
In fact, it is quite evident that melatonin is an essential part of the mechanism that physiologically regulates the reproductive system, acting on every component and positively influencing them.
In addition, not all melatonin is pineal-derived, since there is clear evidence that peripheral reproductive structures have the machinery to actively produce melatonin for their own use.
The fact that mitochondria are able to produce melatonin and that, therefore there is no cell that does not synthetize this important indole, added to the knowledge that melatonin's functions, both in terms of its receptor-mediated and receptor-independent actions, are ubiquitous, leads to suggest that the indole may be critical not only to maintain reproductive health, but health in general.
Regular physiological rhythms are important to ensure a stable maternal environment which provides the fetus with a series of stimuli that facilitate prenatal perceptual learning and development of his/her internal and external environment.
As a consequence, the occurrence of circadian rhythms that are already present during fetus life as regular repetitions of identical sequences (i e light/dark cycles), may help the fetus to develop the ability to adapt to change in an environment characterized by high regularity.
In this view, melatonin, which plays a pivotal role in the regularity and synchronization of central and peripheral oscillators, allowing the development of harmonious internal functioning and adaptation of the internal milieu to the external environment, is generally considered to be the best peripheral biomarker of human circadian timing.
For that reason, its use, alone or as adjuvant therapy, is highly recommended not only to preserve good health in general, but also in particular cases such as when female reproductive problems are concerned, in young and older females.
As stated above, melatonin administration is able to induce a higher quality of oocytes and therefore to ameliorate ART outcomes, with the consequence of better embryos, fetuses and newborns.
In conclusion, the story of melatonin as a therapeutic agent is far from being completed.
On the contrary, it seems that the more the knowledge advances, the wider the clinical use of melatonin becomes, especially in the field of aging process and female reproduction where the main actors are the mother, the oocyte, the placenta and the embryo/fetus/newborn.
All of them may benefit from the presence of adequate amounts of melatonin, in order to correct either circadian rhythm disruptions, and/or increased oxidative damage of very sensitive structures.
In this view, the gold standard for the next years is to extend the use of melatonin in routine clinical practice, in the prevention and treatment of an increasing number of pathologies, considering that the utility of this essential biogenic amine is not only for reproductive well-being, but for the improved health of other tissues as well, and ensuring, in this view, that melatonin may be considered the most important endogenous compound that is able to display anti-aging activities, acting at different levels.
The oncological patient needs to adapt their cosmetic needs (hygiene, hydration, sun protection and make up) to their new situation.
Their skin, mucous membranes and extremities (hair and nails), can be subject to changes and adverse effects either directly (radiotherapy, surgery), or indirectly (chemotherapy, directed treatments, immunotherapy, hormonotherapy) produced by the treatments.
There exists evidence of the beneficial, and even therapeutic, benefits that cosmetics play in managing some of the adverse dermatological effects produced by antineoplastic therapies.
A cosmetic product could be a very useful contributory therapeutic to: i prepare and strengthen the skin before receiving a treatment, ii) reduce the skin toxicity produced by antineoplastic treatments (xerosis, itching, erythema, paronychia, fissures, rashes, hyperkeratosis, radiodermititis, photosensitivity), iii) increase the oncology treatment adherence and iv) allow image recovery and improve the quality of life.
The cosmetic needs of an oncological patient start from before the beginning of the treatment: to prepare the skin, avoid irritation, sensitivity and allergenic substances.
Later, during the treatment, it will be necessary to relieve the increased dryness, protect from the sun, and be covered by concealing make up.
Finally, after treatment the skin will need regeneration.
When choosing a cosmetic product, the oncological patient must not only take into account personal care use but also those uses carried out during professional treatments, whether they are aesthetical, for illness or physiotherapy.
The main aim of this work is to define the criteria that a cosmetic product must complete for its use by oncological patients, identifying both the suggested ingredients and those that aren't recommended.
S such we have focused our work on the following areas: Raise awareness of the importance of suitable oncological cosmetic products, both to medical professionals and to patients.
Create a list of non-recommended ingredients that allow for avoidance protocols to be carried out, identifying inappropriate agents for oncological patients.
Create a list of recommended ingredients, to maintain and improve skin qualities, and contribute to limit adverse dermatological effects caused by treatments.
Assess the producers of these products -?? Produce guides to therapeutic cosmetic products  that improve the choice of ingredients for cosmetic products based on their different uses.
Pub med, Cochrane, Ovid; III) filters: reviews, full text articles, from the last 5 years.
Compilation of the information from cosmetic care before, during and after oncological treatment, cit-  ed in: i) specialist studies in oncology and aesthetics (Masters in Quality of Life and Medical Aesthetic Care edition I and II) and ii) in health institutions and scien- tific societies such as: ASCO (American Society of Clin- ical Oncology), SEOM (Spanish Society of Oncological Medicine), SEOR (Spanish Society of Oncological Ra- diotherapy), OMS (World Health Organisation), AEDV (Spanish Academy of Dermatology and Venereology), ADD (American Academy of Dermatology), SKF (Skin Cancer Foundation).
A review and adjustment of algorithms an criteria of cosmetic care for other at-risk group (immunocom- promised, photosensitive, atopic, sensitive skin and al- tered dermal barrier patients).
A review of the profile of more than 500 ingredients: evaluation of their valuation, ratings and security analysed in the following databases: Scientific Com- mittee on Consumer Products (SCCS) of the European Commission, Cosmetic Ingredient Review (CIR), Envi- ronmental Working Group (EWG), Cosing (database of cosmetic ingredients proposed by the European Com- mission).
 Note: SCCS and CIR emit judgements that direct legal changes in Europe and North America, respectively. 
The ingredients have been selected from current cosmetic products catalogued by their pro- ducers as “for oncological use and other ailments”, such as sensitive and atopic skin and those suitable for children.
The three recommended cosmetic products with most consensus have been: Hydrating emulsions free of alcohol, perfumes  and hypoallergenics, ph neutral soaps, high photoprotection
Of the ingredients analysed, there are approximately 40% with studies that show potentially harmful effects to oncological patients: irritation, allergic reactions, endocrinic disruption, toxicity, photosensitivity, carcinogenicity, toxic effects on reproduction, mutagenic.
This paper gives the conclusions taken from analysis of more than 100 ingredients selected according to their beneficial properties, perjudicial effects and/or frequency of appearance in current European cosmetic products (Table 1).
The results of this complete work (analysis of 500 ingredients) will be published in the 1st edition of the Vadem?cum de Cosm?tica Oncol?gica, which will be presented at the 35th SEME Congress.
The antineoplastic treatments reduce the skin's tolerance to cosmetic products, and this has been attributed to an imbalance in the corneal layer (modifications in the proliferation/maturity of the keratinocytes or keratinization mechanisms) which affects the functioning of the dermal barrier.
The use of appropriate cosmetic products can control the seriousness of the symptoms derived from this disruption.
This still isn't an accepted definition of "barrier repair products?
It is believed that use of cream moisturiser is an excellent therapy to counteract the disruptions in altered or diseased skin.
The ingredients of a cosmetic product formulated to improve skin quality before, during and after oncological treatment must be: i active ingredients, ii) auxiliary ingredients (water, moisturisers, emollients, firming oil, emulsifiers, gelling agents, surfactants and conservatives), iii) gentle and free of alcohol (colorants, perfumes, aromas and essential oils), iv) non-sensitising or hypoallergenic and v non-blocking.
According to European Parliament regulations regarding cosmetic products, it is possible to guarantee the safety of finished cosmetic products on the basis of the security of the knowledge relating to the ingredients that they contain.
Various active ingredients with antimicrobiotic, anti- oxidant, cleansing, deodorant, antiperspirant, emollient, hair conditioning, moisturising, keratolytic, hy- drating, refreshing, skin conditioning, skin protecting, and calming cosmetic functions have been evaluated, such as those used in cosmetic products.
These ingredients can produce anti-inflammatory effects (alpha-bisabolol, vit.
E calendula, shea butter, etc.), antipruritic (dexpanthenol, niacinamide, evening primrose oil), restoratives (rose hip oil, dexpanthenol, alpha- bisabolol, vit.
E omega 3, omega 6, allantonin, Asiatic pennywort, marigold, niacinamide, vit F growth drivers, etc.), and hydrators (Aloe Vera, hyaluronic acid, Urea, etc.) but in some products irritants, sensitizers, endocrinic disruptors, CMR (carcinogens, mutagenic and toxic for the reproduction) and nanomaterials have been found that could be counterproductive in the oncological patient.
Fragrances are the most common cause of allergies in cosmetic products, followed by conservatives and hair dyes; but all of the components must be considered potentially sensitizing.
The sensitivity to fragrances refers to those both of a synthetic and natural origin.
According to the SCCS report on essential oils, it hasn't been demonstrated, in the scientific literature reviewed, that the compounds of natural fragrances are safer than synthetic ones.
Neither do they justify that it might be possible to establish the concentration in which it would be improbable that sensitivity is induced by the fragrance.
A recent study on the presence and distribution of conservatives in more than a thousand products advised to prompt measures that lead to a restriction in the use of problem conservatives, and they consider that compiling cosmetic ingredients allows the creation of"prohibited"?product lists for sensitive people.
The conservatives that are added to cosmetic products can cause the skin to become sensitized for the exposed user.
Cases of allergy to safe conservatives are increasingly frequent where they have made damaged skin more sensitive.
We must choose the least sensitizing conservatives with special attention to skin with an altered dermal barrier.
It should be highlighted that the term natural is not synonymous with innocuous, and that the extracts of many plants are chemically complex.
The cosmetic products are considered to be within the elements that can be exposed to humans and the endocrine disruptors.
These chemical substances are capable of altering the hormonal equilibrium and their exposition has been related to different endocrine disorders (obesity, diabetes, etc.), alterations in the reproductive functions and different types of cancer (breast, prostate, pancreas, brain).
The European Union REACH (Registration, Evaluation, Authorization, and Restriction of Chemicals) considers that chemicals of endocrine alteration are products of a similar risk as substances classed as "high concern"?or SVHC (Substances of Very High Concern).
In 2018 the UN published a list prepared by the commission of The International Panel on Chemical Pollution (IPCP) of 45 chemical substances that have been identified as chemical substances of endocrine alteration (EDC) or potential EDC (until the end of July 2017).
In it are found substances that could be present in cosmetics, such as: triclosan, parabens, phthalates, sun filters (benzophenone-3 (Oxybenzone), 4-Metyhlbenzylidene camphor (4-MBC), Ethylhexyl methylcinnamate (Octinoxate,OMC).
The intrinsic photoprotection mechanisms of the skin can become diminished and be insufficient to prevent photoaging and photo photocarcinogenesis23, making the skin of the oncological patient more vulnerable to sun exposure.
The increased photosensitivy owing to treatments requires that the protection adequately covers the UVA spectrum, which causes the majority of the photosensitivity mechanisms, and the visible and infrared light because of the risk of hyperpigmentation.
Chemical solar filters can have photodegrading problems because of the action of sunlight.
They can also cause the possibility of producing irritation and variable phototoxicity, presenting a higher risk of causing contact reactions compared with mineral screens.
For this reason there is a special risk of intolerance in sensitive skin after chemotherapy and/ or radiotherapy.
EU legislation on the regulation of cosmetics establishes that they must be produced to the standards of best practice, which include an evaluation of safety for human health of the finished cosmetic product, before it is launched on the market.
Even so, there are still concerns about the release and/or possible presence of trace contaminants during some manufacturing processes.
For example, the CIR emphasized that the polymerization in benzene of carbomer and other acrolytes must be avoided and limits the impurities of heavy metals present in zinc salts.
The SCCS recommends using amines for cosmetics that aren't easily nitro sated and/or give rise to non-carcinogenic nitrosamines.
Some publications have found that residues of ethylene oxide remain after the manufacture of some cosmetics.
Many compounds have received favourable reports from expert commissions on the grounds that they are manufactured in concentrations and dosages as "non- irritant"?
The manufacturer must provide information if they are produced as non-irritant.
There are contradictory reports and studies which has made it difficult to catalogue some ingredients.
Other ingredients have favourable reports when applied to healthy or intact skin or with sunburn, and these have been classed as apt.
However because of their characteristics, such as size, it is not recommended to apply these on skin with an altered dermal barrier (nano titanium dioxide, nano zinc oxide), because of the risk of percutaneous absorption.
The use of nano ZnO in cosmetic products must not imply a risk to the consumer in the absence of a substantial systemic exposure.
Oncological treatments can alter the functioning of the skin barrier, making it more permeable and sensitive to certain ingredients.
The terms of use of cosmetics can go further than hygiene purposes.
Many of the ingredients of cosmetic products which are left on can accumulate with time and contribute to long term toxic effects which are hard to evaluate.
The following composition recommendations are given for a cosmetic product for an oncological patient: - It must not contain more ingredients than are strictly necessary.
It must not contain substances (including impurities or traces) with the following properties: carcinogenic, mutagen, reproductively toxic properties (CMR), with disruptive endocrine activity, potentially allergic nor with criteria included in lists of substances subject to authorization.
The legislation advises this for vulnerable people (children under three years old, the elderly, pregnant or breastfeeding women and people with altered immune responses).
They must not contain substances under suspicion, which are included in credible lists such as VHCs (Very High Concern Chemicals) compiled by REACH.
They must not contain substances which are being studied, as The Scientific Committee on Consumer Safety can take up to five years to emit judgements.
Priority must be given to substances with reports compiled by expert commissions and which are supported in the scientific literature.
Cosmetics destined for patients with skin diseases must have been clinically proved and have demonstrated a good tolerance profile.
Studies are needed on absorption through skin with an altered dermal barrier.
The production methodology must be of maximum security.?
Many new ingredients show highly allergenic properties with use and over time.
For this reason, that the formulation of a cosmetic product aimed at altered skin should not only not contain potentially allergenic substances, but also contains those which have been proven to not be so.
The evaluation of ingredients and the creation of lists must be open, reviewable, updateable and be subject to modifications according to judgements and evaluations published by expert commissions.
The oncological cosmetic criteria proposed by the authors of this work are the following:
Free of sensitising substances allergenics, fragrances, perfumes, some sun screens, conservatives and colo- rants, etc.)
surfactants, acids, alcohols, formaldehydes, parabens, etc.)
(resorcinol, 4-cloro methylphenol, DEP or diethyl phthalate, benzophenone 1, Oxybenzone, 4-Methylben- zylidene Camphor, Octinoxate, Methylparaben, Butyl- paraben, Ethylparaben, Propylparaben, Triclosan, Ho- mosalate, etc)
(Titanium Dioxide, Zinc Oxide, Drometrizole trisilox- ane, etc.)
(Alpha bisabolol, Vit. E, calendula, shea butter, Dexpan- thenol, niacinamide, evening primrose oil, rosehip oil, Alpha- bisabolol, Vit. E, Omega 3, Omega 6, Allantoin, Asian pennywort, Calendula, Niacinamide, Vit F, Aloe Vera, hyaluronic acid, Urea, etc.)
(emulsions, lotions, pastes, ointments, cleansers with- out soap, etc.)
(good tolerance profile tested and clinically proven in patients with skin diseases and oncological patients)
(octamethylcyclotetrasiloxane, nitrosamines, boric acid, phthalates, formaldehyde, etc.)
Several studies have shown that skin can be stimulated by intradermal injection of biological substances that induce dermis revitalization, in order to prevent and reduce aging-related alterations1.
With regard to this, several products are used in Aesthetic Medicine to prevent and reduce skin aging.
Among these products, Hyaluronic Acid (HA), which is often used alone or in combination with other substances, certainly plays a key role thanks to its natural stimulating and hydrating properties.
However, it is necessary to clarify the criteria underlying the choice of the different products currently available.
Collagen is the main protein in human connective tissue accounting for 25% of the total mass and 6% of body weight.
The most stable molecular disposition and re- arrangement of collagen is proline-rich triple helix.
Collagen structural unit is represented by tropocollagen, a protein with a molecular mass of approximately 285 kilodaltons made of three left-handed polypeptide chains that join to form a right-handed triple helix.
For collagen Type I there are usually two alpha 1 chains and one alpha 2 chain, while collagen Type III consists of three alpha 1 chains.
As previously said, our body produces a number of different collagens, the types involved in the biostimulation process being Type I and Type III3, the structural differences of which are responsible for their effects on the skin.
Besides structural differences, the two types of collagen have a strong expression of receptor sites to attack metalloproteases.
Although collagen Type I (fibrotic) is responsible for biological aging and characterizes mature age, it has been previously highlighted that its increase leads to aesthetic improvement2,3; while the presence of collagen Type III (reticular) characterizes young skin.
Although there is no recognized correlation between molecular structure, fibrotic collagen and reticular collagen, a review of the available data shows a different structural role of collagen Type III, characterized, within its ?±2 chains, by the presence of an amino acid, cistein, which is absent in other chains and appears to prevent the action of metalloproteases (MMPs) in the degradation of the collagen produced.
Collagen Type I has been recognized to be a collagen of fibrotic nature; however, we should be noted that some studies have shown to argue this data, by recognizing that collagen Type I (fibrotic) is a fibrillar collagen with a different biochemical structure and does not necessarily result in biological aging.
Zigrino P et al 2016 highlighted the role of fibroblasts in activating metalloproteases and regulating collagen homeostasis in adult skin.
Fibroblasts produce several types of collagen based not only on patients' age but also on the stimulations they receive and the environment they live in (Extra Cellular Matrix-ECM).
The difference in response is to be found both at receptor level, in stimulated fibroblasts, and at environmental level where procollagen is released.
The reduced synthesis of collagen that characterizes adult age reflects two mechanisms:
Fibroblast aging, characterized by a reduction in their number.
Low mitotic activity, resulting in reduced activation and production of collagen fibers, hyaluronic acid and elastin.
Moreover, clinical studies show that the possible effect caused by mechanical stimulation of the skin and the alteration of cellular matrix would trigger the aging process with subsequent reduction in the production of collagen6,7.
The therapeutic use of hyaluronic acid in several clinical settings requires a few considerations on the possible interactions of this molecule with cells.
This is certainly a new era for biological studies that will improve understanding of HA functions, properties and roles.
The crucial steps have been the following.
Identifying cellular receptors.
Identifying HA-synthetase.
Identifying intracellular HA.
It has been demonstrated that the different types of HA receptors, hyaladerins, are located on the cellular membranes, on the extracellular (pericellular) matrix and inside the cells.
In particular, the membrane receptors are mainly located on the fibroblasts of isoform CD-44.
CD-44 receptors are stimulated by fragments of the dermal matrix, which suggests that this substance needs to be continuously formed, and by growth factors.
CD-44 binding to HA appears to affect cellular adhesion, angiogenesis, cellular proliferation, cellular migration and cell-to-cell adhesion.
Moreover, it has been shown that the stimulus induced on CD44 receptors would induce the neoformation of reticular collagen.
Conversely, some authors highlight that the stimulation of CD39 and CD40 receptors leads to the neoformation of fibrotic collagen.
Fibrosis causes an increase in fibrotic Type I collagen that, by exerting a tensive action on the dermis, is responsible for the lifting effects on skin.
This aesthetic improvement is actually caused by the implementation of an inflammatory process, responsible for the functional damage to tissue.
The international literature confirms that inflammation includes the production of Transforming Growth Factor Beta 1, which in turn stimulates the production of collagen Type I and dermal fibrosis8.
In a recent review, Kavasi RM et al have highlighted some HA properties depending on its molecular weight.
The analysis of the literature shows that the biostimulation treatment with free High Molecular Weight Hyaluronic Acid (HMWHA) is reported to stimulate the production of inflammatory cytokines.
The subsequent fragmentation of hyaluronic acid is reported to produce fragments that in turn would be able to stimulate CD44 receptors with the consequent production of reticular collagen.
This degradation process, resulting in the formation of fragments with increasingly low molecular weight, is reported to induce the production of inflammatory cytokines.
Therefore, the inflammatory reaction seems to be induced by any hyaluronic acids, regardless of whether their molecular weight is low or high.
Hyaluronic acid has been shown to be produced by several cell populations located both in the dermal layer and in the epidermis, such as keratinocytes.
Although the authors have recognized that HA plays a key role in these processes and that the effects produced in the tissues are determined by the size and concentration of HA, they concluded that the complexity of these processes makes it extremely necessary to further analyze these issues in additional studies.
Quan T et al.10 have highlighted that fibroblasts can maintain their functional activation capacity, but it is crucial to stimulate the extracellular matrix.
Although it is commonly thought that non-crosslinked, non- reticulated hyaluronic acid (HA) in concentrations ranging from 0.8 to 2%, with molecular weight (MW) > 1.000.000 Dalton produces the lowest number of inflammatory cytokines, the fragments produced by degradation seem to maintain an inflammatory action.
An important aspect to be highlighted concerns recommendations about contraindications to the biostimulation/biorevitalization treatment.
A product that contains an association of more substances in the same mixture is more likely to produce adverse reactions, in particular if there is nickel which excludes its use by allergic patients.
Biostimulation contraindications are: acute articular rheumatism; presence of previous non-resorbable fillers at the infiltration sites (this is a sufficient reason to avoid the use of other fillers); patients under anti-coagulant treatment (sodium warfarin); patients with cancer who receive chemo- and/or radiation therapy.
For the treatment of patients with previous cancer diseases, who are not currently receiving any pharmacological treatment and/or radiation therapy, it is appropriate to reach a multidisciplinary case-by-case consensus.
Several preparations indicated for biostimulation/ biorevitalization are available on the market with different characteristics in terms of molecular weight (MW), concentration and viscosity.
These products can contain: Free non-cross-linked HA, Weakly cross-linked or stabilized HA. 
HA associated to amino acids (AAs). In these formulations, HA can be full-sized or fragmented.
HA associated to amino acids and other substances.
These products require the activation of hyaluronidases and they undergo a prolonged degradation process; HA associated to glycerol, Glycerol has a protective action against HA and slows down the degradation process, HA associated to mannitol. Mannitol maintains homeostasis and allows HA to remain longer in the area where it has been injected.
One of the most important factors that plays a crucial role in the choice of a product for biostimulation treatment is HA concentration.
The different HA concentrations can drive a targeted use based on the area to be treated and the desired result: prevention of skin aging and restitution of tissue integrity on mature skin.
The available concentrations are (Figure 1): 0.8% concentration: Indicated in particularly thin skin areas (periocular and perioral regions, neck region) and in prevention and maintenance treatments.
It is advisable to inject the product into the superficial and medium dermis, possibly with the picotage technique.
The maintenance protocol includes monthly sessions.
1.4-1.6% concentration: Indicated for the treatment of face, neck, d?collet?, hands and body areas in prevention, restitution and maintenance treatments.
It is advisable to inject the product into the medium and deep dermis with linear technique and / or picotage technique.
The protocol includes 3 fortnightly sessions, followed by monthly maintenance treatment. 1.8-2% concentration: Indicated for the treatment of areas with thick skin, in restitution treatments and to obtain a temporary filler effect.
The protocol includes: 3 fortnightly sessions, followed by monthly maintenance treatment.
It is advisable to inject the product directly into the deep dermis/superficial subcutaneous layer with linear technique and/or picotage technique. 2% concentration: Indicated only for face treatments in the restitution phase.
It is advisable to inject the product into the medium and deep dermis / superficial subcutaneous layer with linear technique and / or picotage technique.
The protocol includes 3 fortnightly sessions, followed by monthly sessions.
The association of stable hybrid cooperative complexes of high HA (1.100-1.400 KDa) and low molecular weight HA (80-100 KDa) is characterized by a concentration of 32 mg H-HA + 32 mg L-HA in 2ml (pre-filled syringes).
The combined action of stable hybrid HA complexes allows to obtain a bioregeneration and remodeling action on the dermis.
The treatment pattern includes two treatments at 1-month interval followed by a maintenance treatment at 2 months depending on the aging level.
Among the hyaluronic acid-based products associated with amino acids there are several formulations.
A HA formulation with a concentration of 10 mg/ml, P.M. 200 – 400 Kd associated with lyophilized amino acids (glycine, l-proline, l-leucine, l-lysine) that are involved in the process of production of collagen is a Class 3 medical device and its administration is recommended in superficial and medium dermis of face, neck, d?collet?. 
The protocol includes 4 fortnightly sessions followed by monthly sessions, possibly with administration of non-crosslinked HA between sessions.
It is indicated in dehydrated skin with medium degree cutaneous relaxation.
In the formulations that include the association of fragmented HA with AA, HA is in micromolecular form (20-38 monomers) i.e. fragmented with MW from 1440 to 2736 kD; it is associated to amino acids (l-isoleucine, l-leucine,    l-lysine    hydrochloride,    l-proline,  l-valine, l-glycine, l-serine, l-alanine).
The protocol includes 4 weekly sessions, 2 fortnightly sessions, followed by monthly sessions.
It is advisable to inject the product in the superficial and medium dermis of the face, neck, d?collet?, back of hands.
It is indicated in dehydrated skin with mild-degree skin relaxation.
Finally, a particular association of HA + AA with concentration of 10 mg/ml (3 ml) PM 200 Kd is an association with lyophilized amino acids (glycine, l-proline, l-leucine, l-lysine, l-alanine, l-valine), with L-alanine and l-valine being the amino acid constituents of elastin, making this product particularly active on the turnover of ExtraCellular Matrix proteins and in case of skin laxity of the face where the biostimulation treatment is indicated.
The latter is a crucial element in the physiological promotion of neocollagenesis and elastogenesis through the migration of fibroblast in the injected area.
A recent in vitro study conducted on human dermal fibroblasts showed the efficacy  of  extracellular  matrix  proteins, in particular elastin, on biosynthesis; it has been demonstrated that by changing the quality and quantity of amino acids in the mix, it is possible to increase the expression of elastin, at gene and protein level, while maintaining collagen stimulation.
In summary, several products are used to prevent or reduce damage caused by skin aging.
Among these, the HA-based preparations play a crucial role.
Available data show that HA is often used either free or in combination with other substances, thanks to its natural stimulating and hydrating properties.
There are several HA-based preparations available for biostimulation that differ in terms of molecular weight, concentration and viscosity.
Although the available scientific evidence supports an increasingly important role of HA in skin biostimulation, recent findings allow to define bioregeneration as a process that physiologically promotes neocollagenesis and elastogenesis through the migration of fibroblast chemiotaxis in the injected area.
With regard to this, the involved factor would be the presence, in the injected area, of constituting amino acids such as L alanine and L valine that seem to regulate the biosynthesis of proteins of the extracellular matrix, especially elastin.
A final consideration, not to be forgotten, is that the wide range of available products allows to personalize the treatment based on the patients’ age and degree of skin aging.
Over the last few years, the search for aesthetic treatments aiming at improving image and self-esteem has increased.
Among the complaints presented in aesthetic clinics, localized abdominal fat is recurring in the daily routine of these centers, especially from the feminine public, who has greater difficulty in decreasing it.
In fact, women present a higher number of adipocytes compared to men, due to gestation and because the lipogenesis process is better favored in comparison to lipolysis, a phenomenon caused by a greater concentration of lipolysis inhibiting receptors in relation to lipolytics.
In order to treat this aesthetic illness, new technologies are being developed every year.
One of the technologies that has been increasingly used in the field of aesthetics is shock waves, which consist of the conversion of electric energy into mechanical energy which is generated by electromagnetism, electro-hydraulic methods, pneumatic methods, or through piezoelectric effect.
Such energy is capable of significantly altering a specific area without modifying the structures that surround it, and it can be used to decrease localized fat and improve the appearance of the gynoid lipodystrophy (GLD) acting upon the adipocytes and leading to collagen remodeling.
The most important mechanical effects of the shock waves are reflexes with pressure and tension forces on the thresholds of different impedances, the generation of cavitation and the formation of micro-jets that cause erosion and micro-perforations in vases and membranes.
Shock waves induce membrane hyperpolarization, the formation of free radicals and generate oxygen radicals that should perform a fundamental role in the translation of the mechanical energy of the shock waves into a biological effect that, when applied to the skin, promotes the formation of micro-bubbles in the fluids, whose flow is made difficult by the obstacle created by the interface areas.
This phenomenon prevents the micro-bubbles from collapsing in a symmetric manner, generating cavitations.
The lipid profile is comprised of triglycerides, HDL, LDL, total cholesterol, non HDL, VLDL and total lipids.
Based on these biochemical exams, it is possible to verify whether the patient in question presents dyslipidemias or not.
These changes may be due to the high concentration of circulating fatty acids generated in the liver of patients with excessive body fat.
The aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are markers of liver lesions and, because lipid metabolism is performed in the liver, the change of its profile may be related to pathologies in this organ and, consequently, interfere with hepatic markers.
Therefore, lesions may occur in this organ when there is an increase in body fat.
Finally, C reactive protein (CRP) is a marker present in acute inflammatory processes, whether the latter are or not related to infectious frameworks.
Increased body fat also elevates the serum levels of CRP, because adipocytes release pro-inflammatory markers, the adipokines.
Taking into account the metabolic changes due to the action of adipokines secreted by adipocytes, such as their effect on hepatic functions, this study aimed at evaluating not only the efficiency of shock wave therapy on decreasing measures in the abdominal area, but also the influence of the action mechanism of the technique on both lipidic and hepatic metabolism.
In order to proceed with the survey, the project was submitted to the Research Ethics Committee at Universidade Positivo, the institution in which it was undertaken.
After the approval under the report number 2,658,312, a public notice was published for volunteers in social media and a selection was performed after an analysis, in which 11 volunteers complying with inclusion and exclusion criteria were selected.
The following criteria were applied: women between 30 and 50 years of age with a Body Mass Index (BMI) equal or above 30Kg/m2 and waist-hip ratio equal or above 0.80cm.
During the selection, the following exclusion criteria were applied: individuals presenting hypertension and/ or non-controlled diabetes; referred dislipidemies; liver, heart and/or kidney diseases; neoplasms; epilepsy; pregnant women; nursing women; individuals whose skin in the abdominal area was not whole; individuals who underwent surgeries in the area less than a year ago; individuals with copper IUD or metallic prosthesis in the area; smokers; individuals taking medicines: antihyperlipemic drugs, drugs controlled by legislation, phyto-therapeutic or nutricosmetics substances accelerating metabolism or weight loss, and individuals under treatment with restrictive diets.
These criteria were aimed at the maximum decrease of any external interference in the research.
The volunteers signed an Informed Consent allowing the use of anthropometric and biochemical data and photographic records and declared to be aware of the study's goals, indications, possible complications, the technique to be used, and number of sessions.
Blood collection (after an eight-hour fasting), the nutritional evaluation (comprised of bioimpedance), anthropometric measures (circumference and weight) and photographic records (front and profile) were carried out in two phases: at the beginning and at the end of the sessions, with the aim of verifying the changes in composition before and after the treatment, At the end of the treatment, the volunteer was asked to fill out a satisfaction survey.
Circumference measurement was done 5 centimeters above the umbilical scar (supra abdominal), right over it (waist), 5 centimeters below the scar (infra abdominal) and of the highest portion of the glutes (hip).
The equipment used in the research was Hygiapulse? provided by KLD Biosistemas?, which is registered at the Ag?ncia Nacional de Vigil?ncia Sanit?ria (ANVISA – National Hygiene Vigilance Agency) – register number 10245230022 –, with a 25mm radial transmitter and set for localized fat, a 100 mJ intensity, a 15 Hz frequency and an emission of 3000 discharges per area (10 X 15 cm).
In order to perform the applications, the abdomen was divided into six quadrants, four in the central portion and two on the sides of the abdomen.
Neutral carbopol gel was used as a conducting agent.
In order to guarantee the reproducibility of the application technique, the manipulation of the gauntlet was standardized: it was moved vertically, horizontally and diagonally during the emission of the shock waves, in a consecutive manner until the end of the 3,000 pulses.
?During the treatment, one of the volunteers gave up treatment for personal reasons.
After the end of the treatment of the 10 volunteers, a comparison was performed of the anthropometric measures and the biochemical parameters of each one.
In relation to circumference, it was observed that 9 patients presented an average decrease of 3.9 cm in the supra abdominal area, 7 volunteers decreased an average 4.14 cm on their waists, 8 models lost 4.06 cm on their infra abdominal portion, and 9 patients presented an average decrease of 5.1 cm on the circumference of their hips.
Volunteers 3, 4, 5, 6 and 8 showed decreased measures in the four areas, and it is important to emphasize the fact that patient 8, who did physical activities three times a week, presented the greatest decrease in measurements in the treatment area.
Model 7, who does not do any physical activities and has visceral fat, did not present any decrease in abdominal circumference (Table 1).
The parameters gauged by bioimpedance were the following: BMI, lean mass, percentage of body fat and weight (Table 2).
Of the 10 volunteers, 4 practice some type of physical activity (walking, body building) between one and three times a week and all have a normal diet.
Despite these features in common, patient 8 presented a decrease in BMI and weight, model 9 only in BMI, volunteer 2 only in percentage of fat, and patient 1 presented an increase in all of the parameters analyzed by the bioimpedance equipment.
The decrease in body fat percentage took place only in four patients, and only two presented decreased weight.
The only model who did not present changes in her BMI and weight, and presented gains in her lean mass and loss of body fat was patient 2, who, 31 years old, was the youngest of the group being studied.
From the results obtained in the biochemical analyses (Table 3), it can be observed that all the patients presented increased triglycerides and VLDL, some presented a decrease in serum levels of AST (7 volunteers) and ALT (6 volunteers), 8 patients presented increased HDL and 7 presented decreased LDL.
There was also an increase in serum levels of total cholesterol in 5 models and total lipids in 9, and CRP was detected as non-reagent on all of them before the treatment, turning into reagent in 6 volunteers after 10 sessions.
In the satisfaction survey based on the Likert scale that was filled by the volunteers, the following topics were verified: skin texture related to tissue flaccidity, decrease in localized fat, definition of body contour, bowel motility, diuresis, changes in menstrual flow and cramps, post-application discomfort, sensibility in the local of application, and positive and negative aspects in relation to the services provided.
In the skin texture item, 71.42% reported significant improvement in local tissue flaccidity, 14.28% did not notice any differences, and 14.28% reported worsening conditions.
In relation to decreased localized fat, 42.85% noticed decreases, the same percentage did not notice any differences, and 14.28% reported that it did not decrease. 57.14% of the participants reported an improvement in the definition of body contour, 28.57% did not notice any differences, and 14.28% reported worsening.
None of the models presented any changes in bowel motility, presented any post-application discomfort or had any sensitization that might be provoked by the conducing gel.
Regarding diuresis, 57.14% did not present any changes and 42.85% noticed an increase in urination frequency.
71.42% did not present any changes in their menstrual cycle nor menstrual cramps different from those they normally have, 14.28% presented some changes in their cycles and dysmenorrhea, and 14.28% use some type of contraceptive method so that they do not menstruate.
All of the volunteers classified the services during the period of the treatment as excellent.
Figures 1 and 2 show the result obtained as well as the improvement in skin texture.
In this study, the increase in lean mass presented by bioimpedance cannot be directly related to the practice of physical activities, because of the five volunteers that presented muscle gains, only one declared doing some physical activities.
The results pointing to weight and body fat gains, regardless of practicing physical activities or not may be related to the fact that energy spent by the volunteers is lower than the calories obtained through food, which is the most common mechanism of weight gain.
The 31-54 age range was adopted because after the age of 25 there is a significant progressive decrease in metabolism10.
The increase in VLDL and HDL lipoproteins indexes and the changes in AST and ALT hepatic markers remained within the normal parameters and suggest that, during the employment of the technique, triglycerides are metabolized by the liver and transported by blood circulation, but without compromising the organ in healthy individuals and producing mainly higher- density lipoproteins, which are more difficult to be found in higher levels in patients presenting cardiovascular diseases.
It is believed that VLDL, even though they are not the main lipoproteins associated to pathologies, were higher because they are the second lipoproteins that are produced by hepatocytes to transport triglycerides, chylomicrons being the first11.
The elevation in total lipids concentrations in all of the patients, in addition to the increase in total cholesterol in 5 of them, is also justified by the circulating triglycerides released by adipocytes12.
The fact that the C Reactive Protein went from non- reagent to reagent in 60% of the volunteers suggests that the extra-corporal therapy by shock waves provokes an inflammatory process in the adipose tissue through its mechanical action, as it is expected that every aesthetic procedure causes a controlled inflammatory reaction.
The results of the four patients who did not present this difference may be justified by the use of anti- inflammatory medication near the day or on the very day that blood was collected; by an anti-inflammatory diet, which is comprised of food that is able to inhibit or block the action of inflammatory agents; and by a greater resistance of the body to inflammatory processes.
The physiological effect of mechanical and thermal stress by the shock waves equipment entails tissue damages to the adipocytes which triggers off an inflammatory response and the release of important cytokines13.
In 2011, Ferraro et al.14 conducted a study with 50 patients associating shock wave extra- body therapy after the application of cryolipolysis.
In the study, the techniques were applied for the treatment of abdominal localized fat in 14 patients, five females and nine males.
The average decrease in abdominal circumference at the end of the treatment was of 6.86 cm, showing that when one associates shock waves to cryolipolysis there is an improvement in the results, especially in males, due to the body composition and metabolism that facilitates both lipolysis and apoptosis.
In his 2017 study, Diogo et al.15 analyzed the lipid profile of six male individuals before and after they were submitted to an ultra-cavitation procedure that, like the shock wave equipment, also promotes lipolysis and cellular apoptosis.
In the study, it was found that the serum levels of triglycerides and VLDL increased both in the active group, that practiced some type of physical activity, and in the sedentary group, so that in the first this increase doubled in comparison with the second group, having found out that lipolysis is more effective when there is an association of an aesthetic treatment and physical activity.
The decrease in abdominal circumference confirms the efficacy of the treatment mainly on the outlook of the volunteers.
The significant improvement in tissue flaccidity in the abdomen takes place because of the lesion caused by cavitation generated by the shock waves, which leads to the production of vascular endothelial growth factor (VEGF) and endothelial nitric oxide synthase, inducing the neocollagenesis process, improving the structure and quality of collagen and elastic fibers of the tissue16.
Because of its ability of tissue decompression and lipolysis through its mechanical and cavitational effects described in the review by Modena et al. 201717, the greater definition in body contour and the decrease in localized fat were noticed at a great scale by the models, in addition to being proved through measures and photographs.
Increased diuresis and dysmenorrhea reported by the majority of the patients may be due to the vibration provoked by the equipment, which stimulates the contraction of the smooth muscles, both in organs and vessels, increasing kidney overload and may cause accentuated menstrual cramps during the treatment period.
?This study showed that, when having an extra-corporeal shock wave therapy, the volunteers presented decreased abdominal located fat as well as improved body contour and skin appearance.
Through the analysis of the biochemical parameters obtained, it was observed that shock wave therapy does not appear to cause liver lesions and consequently leads to pathogenic metabolic changes.
It is suggested that a future survey is carried out with a greater number of participants, taking into account predisposing genetic factors and feeding habits that might interfere with the investigation, in addition to comparing the efficiency of the technique in patients who practice physical activities and sedentary ones.
Hyaluronic acid (HA) is a linear polysaccharide composed of repeating b 1,4-linked D glucuronic acid (GlcA) andb-1,3-linked N acetyl-D glucosamine(GlcNAc) disaccharide units, which is found ubiquitously in the extracellular matrix (ECM) of all vertebrate tissues, although in widely variable concentrations and bound to different partners.
It is also named ‘‘hyaluronate’’ referring to its salt form, or  ‘‘hyaluronan”,  a  term that includes all forms of the molecule1.
More than 50% of HA in our body is localized in the skin, where it is synthesized by fibroblasts, keratinocytes, and endothelial cells of the dermal microcirculation in many variants of different molecular weight2.
Under normal circumstances, HA is quite abundant in the dermis, where, due to its viscoelasticity and capacity to retain water, it plays a crucial role in controlling tissue hydration, keeping an appropriate tissue volume to protect skin cells from mechanical damage, and maintaining structural stability3.
In the epidermis, it carries out a trophometabolic activity, contributing to the preservation of cutaneous homeostasis.
HA is a non-immunogenic molecule, a polymer devoid of protein epitopes, and it also has the advantage that, regardless of the problem, it can be easily removed by digestion with hyaluronidase4.
HA plays important and different roles in the process of tissue repair.
Its interactions with specific signaling receptors maintain structural cell integrity and promote recovery from tissue injury1.
Since aesthetic medicine is nowadays not only aimed at alleviating (skin) diseases but also at improving one's perception of wellness, the repairing properties and the safety characteristics of HA have made it, in the last decades, the most commonly used material for soft tissue augmentation in aesthetic medicine4.
In fact, the marked reduction in HA content characteristic of the aged skin plays a crucial role in dermal thinning and wrinkles formation.
Therefore, injected HA-based fillers are largely used to"fill-up"?the dermis and improve facial wrinkles.
The different HA dermal fillers vary widely in their physical and chemical characteristics and the many variables affect their overall performance.
In general, they improve skin turgor and elasticity.
In recent years, different techniques have been developed with the aim of improving HA stability, thus slowing its degradation in tissues and allowing manufacturers to control the gel stiffness.
Interestingly, besides improvement of deep wrinkles and volume deficiency, new objectives are being pursued with HA-based fillers, such as deep skin hydration.
Intradermal injections of HA may be used to boost the water content in the extracellular matrix of the dermis, resulting in deep dermal hydration and improvement of skin surface roughness and fine wrinkles.
The studied product is a ready-to-use solution of stabilized, injectable HA which has unique rheological properties (Table 1), that give the product high deformability and low stiffness and viscosity.
For these reasons, the product offers a dual function, called "hydrostretching"? consisting of both a process of dermal hydration and tissue bio-restructuring, and a mechanical stretching action on superficial wrinkles.
The low stiffness and viscosity and the high plasticity also favor an optimal tissue integration and enable the product to be injected into different layers of the dermis, up to the most superficial ones, making it particularly effective on the most dynamic facial areas (perioral and periocular areas and the forehead).
The studied product is suitable to improve dry skin, with poor elasticity and/or poor skin texture, and to stretch superficial wrinkles, in particular mimic wrinkles, and to correct acne scars.
A recent study on 18 volunteers who had undergone two injections of the studied product 2 months apart and followed up for a further 3 months, demonstrated a significant improvement of wrinkles grade around the eyes and the lip, and wrinkles severity of nasolabial folds already after the first injection.
In addition to this there was an improvement of the aging/photoaging grade and surface microrelief after 2 months, following the second injection, and a parallel improvement of instrumental skin profilometry and optical colorimetry.
This study also confirmed the good tolerability profile of the product and the duration of its effect.
One hundred women with Glogau Wrinkle Scale grade 2-3, requiring deep hydration according to medical advice, have been consecutively enrolled from March to June 2018 by three Italian physicians within their patients.
Patients were asked to maintain their habits (food, physical activity, make-up use, facial cosmetics and cleansing products) and not to expose their face to strong UV irradiation without proper sun protection.
Patients with the following characteristics were excluded: pregnancy; lactation; smoking; alcohol or drug abuse; having received skin treatments for esthetic correction 6 months prior to the study treatment; having already performed permanent dermal fillers; dermatological diseases as well as general diseases (diabetes, endocrine disease, hepatic, renal, cardiac and pulmonary disorders, cancer, neurological diseases); drugallergy; inflammatoryand/orimmunosuppressive diseases.
All the patients signed an Informed Consent allowing the use of photographic record for scientific publications, in which they declared to be aware of the product, treatment choice, alternative treatments and alternative products, possible complications and number of sessions.
The studied product was administered with three different techniques.
A microlinear or microbolus technique (<0.05 ml each) in the areas of the face requiring deep hydration (malar/submalar areas).
A microbolus technique to stretch the dynamic facial wrinkles (microdroplet injections ?0.01 ml each along the path of the wrinkle).
A combined technique to stretch the static facial wrinkles (microlinear retrograde technique ?0.01 ml each below the path of the wrinkle, followed by microdroplet injections ?0.01 ml on the same wrinkle).
Two injections were administered to each  patients 60 days apart.
The most commonly treated areas were the periocular and perioral zones, which are highly dynamic and have thin skin, being quite difficult to treat.
In these areas 30G or 33G needles were preferred.
Subjects were asked to express their degree of satisfaction about the improvement  of  facial microroughness, by answering to the question “How satisfied are you with the improvement in you facial microroughness  following  the  treatment?”  on a 1 to 10 verbal rating scale (VRS), where  1  means “not at all satisfied” and 10 “completely satisfied”. 
Evaluations were requested twice: 2 months after the first injection (T1) immediately before performing the second injections and then 3 months after the second injection (T2). 
At the same timepoints, physicians as well were asked to grade their degree of satisfaction with the treatment on 1-10 VRS.
The mean score expressed by patients and physicians at the two study timepoints is reported in Table 2.
In particular, at the end of the study, the mean scores were 8.5 and 8 respectively.
Pictures of some example cases are reported in figures 1-4.
From a tolerability standpoint, only a few deposits were observed in some patients with particularly thin skin, that remained perceivable for 2 weeks before complete reabsorption.
No adverse events related to the product have been reported.
Approximatively 20% of the treated patents reported discomfort/unpleasant sensation, which is in line with a previously published study.
Viscoderm? Hydrobooster is a stabilized HA injectable preparation, characterized by low viscosity and stiffness and high deformability.
Its rheological properties favor tissue integration and allow to inject the product in different layers of the dermis, thus providing a dual function: deep hydration and tissue restructuring on one side, together with a mechanical action aimed at stretching the most superficial wrinkles on the other.
Clinical experience has shown a good tolerability and a high degree of satisfaction by both patients and physicians.
The skin is a sense organ that covers the body.
It regulates the body temperature, gets pale with sweating, serves as both a thermostat and a protection barrier.
Its thickness is between 1 mm and 4 mm.
It is the largest and heaviest organ of the body, constituting 16% of the total body weight.
The thinnest skin is to be found on the eyelids while the thickest on the sole of the foot.
The basic structure of the skin has three different layers: Epidermis: It is the outermost layer of the skin that acts as a protective layer.
The skin renewal takes place in this layer.
Dermis: It is the middle layer which is effective in the durability of the skin.
Hair follicles, sweat glands and sebaceous glands are found in this section.
Hypodermis: An inner layer of subcutaneous fat.
It provides energy to the skin and is responsible for the insulation function.
Poly-L Lactic Acid (PLLA) based filler was first introduced in Europe in 1999 under the trade name"New Fill"?and then in 2004 in the United States market under the trade name Sculptra L for use in HIV-related lipoatrophy cases.
Approximately 150,000 patients were treated in the 10-year period after use9,10.
Several studies have been conducted on PLLA safety, efficacy and persistence11-13.
PLLA is mostly used in the face but there are sources in the literature that show it can be used in other areas.
PLLA has been used as a suture material and absorbable screw for approximately 40 years in medicine.
Its biocompatibility and efficacy have been shown in previous studies.
In a study conducted in Brazil in 2008, it was reported that the injection to nasolabial folds still persists after 3 years.
PLLA creates a foreign tissue reaction at the site where it is applied, increasing the number of macrophages, mast cells and lymphocytes in that region, decreasing fibroblastic activity and increasing neocollagenesis slowly.
New collagen formation appears at 1 month, and until the 9th month, the formation is observed to increase.
In the previous studies the PLLA particles showed signs of disappearance in the 6th month and they are eliminated completely in the 9th month.
The experiment was performed on patients aged between 34 and 61 years old, some of whom had undergone medical aesthetic treatments, while the remaining patients had not.
The participants were divided into 2 groups.
There were 10 participants in each group.
All the patients signed an Informed Consent allowing the use of photographic record for scientific publications, in which they declared to be aware of the product, treatment choice, alternative treatments and alternative products, possible complications and number of sessions.
Information about the groups is given below: Group 1: In this group, 10 patients received APTOS brand PLLA/CL.
No other medical aesthetic procedures were performed at the same time and no other medical aesthetic procedure was performed for 3 months.
Group 2: In this group, 10 patients were treated with HiFu application and PLLA / CL were applied to the face during the same week.
No other medical aesthetic procedure was applied for 3 months.
After the applications, the participants were evaluated with VAS questionnaire from 0 to 10 points.
The questions were answered by both the practitioner and the participant before, during and after the application twice, first, 1 month after the application and then 3 months later.
The skin color and stains, skin moisture, fine lines, elasticity and sag (especially in the jaw line) were evaluated.
A statistical program and photographs were used to evaluate the results.
Statistical analyses were performed using SPSS software (version 25.5).
Basic descriptive statistics were assessed to describe the survey results as the means ± standard deviations.
The total VAS score was found to be 32.8±6.08 before the treatment and 53.0±5.92 after 3 months of treatment, and the healing rate was 62% according to doctor evaluation.
In the second group with HIFU and PLLA/PCL Aptos thread combined application, the total VAS score was found to be 30.8±11.9 before the treatment, 39.6±11.5 after the treatment, 46.2±9.97 1 month after the treatment and 54.2±8.48 3 months after the treatment.
The rate of recovery was 29% after treatment, 50% after 1 month of treatment and 76% after the 3 month- treatment.
In this group, the total VAS score was found to be 35.9 ± 9.82 before the treatment and 55.8±7.65 after the treatment and the recovery rate was found to be 55% according to doctor evaluation.
Table 2 shows the skin characteristics according to the patients.
In the evaluation of the study, the skin hydration was found to be 5.10 ± 1.79 before the treatment in the first group and 7.20 ± 1.31 the third month after the treatment.
In the second group, the mean pre-operative average was 4.5 ± 2.8, and the mean value after treatment was 3.40± 2.01.
Skin hydration increased by 42% in the first group and 65% in the second group.
Before the treatment the mean skin color was 4.90 ± 2.42 in the first group and 4.8 ± 2.29 in the second group.
In the first group, mean skin color was measured as 5.30 ± 2.00, 1 month after the treatment and as 6.01 ± 0.56, 3 months after the treatment.
In the second group, the mean skin color was 6.50 ± 2.41 after 1 month and 7.20 ± 2.20 after 3 months of treatment.
An improvement of the skin color was observed by 22% and 50% for the first group and the second group respectively.
The presence of fine lines was determined as 6.5 ± 2.71 in the first group and 5.2 ± 3.15 in the second group before the treatment.
At the end of the treatment, there was an improvement of 17% in the first group and 50% in the second group.
In the evaluation of the jaw line, the mean value was 3.30 ± 1.63 in the first group and 3.4 ± 1.57 in the second group before the treatment.
The evaluation on the third month following the treatment revealed that, the mean of the first group was 8.0 ± 0.94 and the second group was 8.30 ± 1.15.
The flatness and tension of the jaw line increased by 142% in the first group and 144% in the second group.
The recovery rate of the lines around the mouth was 112% in the first group and 142% in the second group.
The improvement in the lines around the eyes was recorded at 25% in the first group and 58% in the second group.
In the evaluation of skin elasticity, the mean pre- treatment in the first group was 3.30 ± 1.33, 5.01 ?± 0.05 1 month after the treatment and 6.90 ± 0.87 3 months after the treatment.
In the second group, the mean pre- treatment, 1 month after the treatment and 3 months after the treatment was 4.6 ± 1.83, 6.51 ± 0.26 and 7.60 ± 1.26 respectively.
The increase in skin elasticity was 109% in the first group and 65% in the second group.
During the treatment, the pain level was determined as 7.20 ± 2.04 in the first group and 9,6 ± 0,69 in the second group.
Table 3 shows the skin characteristics evaluations by the doctor.
The skin hydration was evaulated at 5.10 ± 1.79 before the treatment in the first group and 7.70±0.82 the third month after the treatment.
In the second group, the pre-treatment average was 5.1±1.83, and the mean value after 3 months of treatment was 7.80±1.81.
Skin hydration increased by 50% in the first group and by 53% in the second group.
The mean skin color was 4.8±2.52 in the first group and 5.50±2.22 in the second group.
In the first group, skin color after 1 month was measured as 5.40±2.01, and after 3 months of treatment as 6.40±1.57.
In the second group, the skin color was 7.30±1.88 after 1 month and 7.90±1.72 after 3 months of treatment.
An improvement of the skin color was observed at 33 % for the first group and 44 % for the second group.
The presence of fine lines was determined as 6.50±2.79 in the first group and 5.90±2.68 in the second group before the treatment.
After the end of the treatment, there was an improvement of 17% in the first group and 36 % in the second group.
In the evaluation of the jaw line, the mean value was 3.20±1.93 in the first group and 4.10±1.52 in the second group before the treatment. 3 months after treatment, the mean of the first group was 8.40±0.96 and the second group was 8.20±1.13.
The flatness and tension of the jaw line increased by 162% in the first group and by 100% in the second group.
The recovery rate of the lines around the mouth was 130% in the first group and 93% in the second group.
The lines around the eyes were improved by 33% in the first group and by 32% in the second group.
In the evaluation of skin elasticity, the mean pre-treatment in the first group was 3.10±1.37, 5.20±1.03 after 1 month of treatment and 7.30±1.15 after 3 months of treatment.
In the second group, the mean pre-treatment, after 1 month-treatment and after 3 month-treatment was 5.20±1.54, 6.90±1.37 and 8.0±0.81 respectively.
The increase in skin elasticity was 135% in the first group and 54 % in the second group.
During the treatment, the pain level was determined as 7.70±1.49 in the first group and 9.70±0.48 in the second group.
The main reason for patients trying an aesthetic treatment is to counteract the symptoms of ageing.
However, most facial treatments and methods offer relief only for some wrinkles or shrink-wrapped failing skin outwardly responding to the volume and forms of a fresh face.
Injectable poly-L lactic acid is a biodegradable artificial polymer for the improvement of lipoatrophy and is widely used in Europe.
Sculptra was famously applied for improvement of nasolabial folds, lack of medial and lower face volume, jawline slack, and another type of facial ageing.
Sculptra treatment is a minimally invasive and efficient method.
There are main directions for the application of PLLA: bone resorption, fat death and skin laxity; and at which layer of the face and at what level PLLA is determined depends on the patien's health.
Also, for skin laxity, the contrast happens“as PLLA needs to be practised just under the skin, into the subdermal level, with needles or cannulas, but with no fat in connecting tissues.
It is in this layer that the best skin quality results can be achieved, which is the idea of this study20,21.
Whenever PLLA is injected into a subdermal plane there is an improvement in skin quality of three types.
The first being clear glow-luminosity produced by the hydration of the treated skin, providing the effect of a healthy, young and well-ageing skin.
An addditional benefit is the reduction of skin atrophy associated with aging.
Moreover, it reduces skin laxity by increasing skin adherence to lower-level tissue.
This is normally due to the generation of collagen fibres resulting from the PLLA applications22.
In the study carried out by Avelar et al.23 three sessions were applied to the patients at intervals of 45-60 days.
Notwithstanding PLLA being supported for many uses - bone resorption, fat loss and skin laxity - there is a regular increase in skin quality after treatment.
However, not only is it necessary to know PLLA but also to define the level of injection.
In a previous study, a patient with poor skin quality was treated with a 12-week PLLA treatment.
Due to the poor quality of the skin, the first and second treatments were applied for four weeks, allowing sufficient time for collagen restoration and repair.
Four weeks after her initial treatment, the patient showed little or no cosmetic improvement.
After the second treatment, an improvement of between 20% and 30% in tissue quality was observed according to the comparison of the photos of the patient before and after the treatment and the patient?€?s opinion on the results of the treatment.
Eight weeks after the second treatment, a third treatment was performed to resume collagen repair.
No side effects related to treatment were observed.
After completing the treatment, visual inspection and skin quality improvement resulted in significant results in terms of elasticity.
In addition, as a result of the 12-week PLLA administration, an increase in fibrotic layer in the dermis and subdermal layer and skin shine were observed.
In addition, collagen restoration resulted in a healthier skin, reduced pores and a more youthful appearance.
No adverse effects were observed during the annual follow- up of the patient.
In another study, participants were treated with injectable PLLA or human collagen for 3 weeks.
There is a 3-week period between treatments.
For the members of the PLLA group, 3 injection sessions were completed.
Three weeks after the last treatment with injectable PLLA, an important development was recognised in the wrinkle assessment scores compared to the baseline.
Changes continued to appear until the 13-month evaluation period and were reported during the 19 and 25-month evaluation points.
After the injection of PLLA, the number of nodules and papules was 7% and 9%, respectively.
Further investigations can serve to maintain the advantage of injectable PLLA performance for aesthetic improvement of facial shape dysfunctions and help manage suitable patient choice criteria for treatment of this strategy.
In a similar study, 210 female participants were chosen to correct injectable (PLLA) age and disease-related facial volume deficits.
The questionnaire was sent to patients treated with PLLA 6 months earlier or more.
After the treatment, some of the patients had papules or nodules.
After treatment, some of the patients had papules or nodules.
One questionnaire was posted to 281 patients previously treated with PLLA for 6 months or more.
PLLA was reconstituted by adding 5 mL of sterile water before injection and 1 mL of 1% xylokine before injection.
Patients treated with PLLA had a recovery time of 24 months.
The maximum improvement was seen after several treatment sessions31.
In our study we evaluated the effect of PLLA.
Similar to the results reported in the literature, PLLA use increased skin collagen.
A skin increase of 42% was observed in the skin group with PLLA.
This rate was higher in the HIFU and PLLA group.
There was a moderate improvement in skin color.
In particular, there was a significant improvement in the jaw line, and both groups had close rates in skin flexibility only.
In the PLLA group, a higher rate than in the HIFU and PLLA group was found.
This can be considered as evidence that PLLA significantly increases skin elasticity and eliminates the signs of aging.
In this study, it was observed that there was little recovery immediately after application.
However, a high rate of improvement was achieved 1 month and 3 months after the treatment.
This is in line with the studies in the literature.
In this study, we investigated the effect of PLLA/PCL Aptos thread treatment on 20 female patients.
The treatment covers a period of 3 months.
No side effects were reported by the patients.
Evaluations were made through questionnaires and photographs.
Both the patient and the physician evaulated the results and similar data were obtained.
When the survey data were evaluated, an improvement of only 65% in the PLLA /PCL Aptos thread group and 76% in the combined treatment group was observed. 
These results showed close values in the evaluation of patients and doctors.
Combined treatment with skin hydration and skin color gave better results.
In the presence of fine lines, there was a moderate improvement in PLLA/PCL Aptos thread application.
A high improvement was observed in the jaw line and mouth lines. A smoother and taut image was obtained.
As for skin elasticity, only PLLA/PCL Aptos thread application showed a better result than combined application.
In general, when the results are evaluated, it can be said that PLLA/PCL Aptos thread application is effective on skin quality.
This effect depends on the time of the application and the patien's condition prior to the treatment.
A minimal improvement immediately after the application but a high recovery after 3 months emphasize the importance of application time.
Facial skin aging is a phenomenon involving a set of microscopic and macroscopic complex volumetric changes.
These changes can be explained by several factors, including deep three-dimensional structural support, subcutaneous fat redistribution, bad habits or environmental factors.
Skin aging is caused by a disruption in the vascular and connective tissue architecture of the dermal and hypodermal layers associated with a reduction in the number and activity of fibroblasts1.
It should be highlighted that skin aging is due to intrinsic factors, mainly responsible for physiological aging (intrinsic ageing)2,3,4,5 and extrinsic factors responsible for photo-induced aging (extrinsic ageing)2 elastic fibers, reduced number of fibroblasts, mastocytes and Langerhans cells.
With regard to connective tissue, physiological aging causes a reduction in proteoglycans and glycosaminoglycans, thickened elastic and collagen fibers as well as elastin structural changes.
Another important issue is photo-induced aging that is characterized by skin thickening, capillary dilation, sebaceous gland hyperplasia, collagen and elastin degradation, epidermal damage (on keratinocyte nuclei), and dermal damage with elastic fiber degeneration (solar elastosis).
This aspect is responsible for visually evident cutaneous manifestations (Figure 2), including deep and irregular wrinkles, thick texture, resulting from the anarchic production of abnormal elastic tissue (elastosis), collagen loss and degradation, impaired vessel regeneration5.
One of the most important aspects is physiological aging which includes, at the epidermal level, early keratinization, reduction in Langerhans cells, irregular distribution of melanocytes, reduction in dermal papillae and epithelial crests; at the dermal level, reduced thickness, disorganized  and  fragmented collagen and Kligman classification (Figure 3) distinguishes several types of wrinkles.
 Linear or expressional wrinkles: they are initially reversible, caused by the contraction of facial mimic muscles, run always perpendicular to the muscles; they are more marked in emotional and expressive people and are sub-divided into periocular wrinkles or “crow’s feet”, glabellar folds (frown lines), which run horizontally on the forehead, from the nose root in cranial-caudal and  medial-lateral  direction,  and peri-labial (“smoking”) wrinkles that are localized vertically on the upper lip and around the mouth.
Glyphic wrinkles: they are the clinical sign of actinic damage, caused by an accentuation of normal skin folding, run obliquely and perpendicularly to the other types of wrinkles, and are mostly localized on the chicks.
Sleeping lines (creases): they are created by prolonged facial positions, are initially reversible, run perpendicularly to linear lines, are  usually  localized on the forehead  and  chicks.
Ripples  (crinkles):  are small wrinkles found on the arms, thighs and gluteus muscles, related  to  physiological  aging,  due to collapse of subepidermal vertical elastic fibers (due to lack of adherence between dermis and epidermis); they are also  present  in  non-photo-exposed  regions in elderly people, but can be seen at all ages.
Naso- labial wrinkles are deep folds between the upper lip and the nose wings; they delimit the most important muscular masses of the face (especially the orbicular oris muscle and the masseter).
They are formed when the anterior fascial attachments between the skin and the Superficial Musculo-Aponeurotic System (SMAS) become weaker, which results in the collapse of excess skin.
Another important aspect that affects skin aging is a change in the structure of dermis, characterized by a reduction in the cellular component that is submerged in the extracellular matrix formed by the fundamental substance.
The fundamental, or amorphous, substance consists of glycosaminoglycans (GAGs) and proteoglycans which are glycosaminoglycans bound to large proteins (LP) and fibrillar proteins.
The GAGs, D glucosamine or D galactosamine are polysaccharides consisting of disaccharide units, each containing one amino hexose.
Commonly-known GAGs are hyaluronic acid and heparin, while the most abundant GAGs in the skin are hyaluronate and dermatan sulphate.
In young dermis, there is a prevalence of chondroitin-4-sulfate and chondroitin-6-sulfate, while in adult dermis, there is a prevalence of keratan sulfate with depletion of hyaluronic acid7.
It is of note that in dermis all GAGs, with the exception of hyaluronic acid, are bound in large amounts to fibrous proteins thus forming proteoglycans.
Proteoglycans are the intercellular "concrete" that fills the space between the cells of most tissues, including articular cartilage and dermis.
This aspect seems to be particularly important, as GAGs play a crucial role in the fundamental substance of dermis and articular cartilage thus optimizing its structure.
In fact, they are guarantors of isoionia, isoosmia, isotonia of the fundamental substance; thanks to their molecular structure they can fight the positive charges of lytic enzymes such as hyaluronidase, protease, elastase, glucuronidase.
The fundamental substance is the environment where fibroblasts, the cells for the synthesis of elastin, collagen and glycosaminoglycans are submerged.
With regard to this, skin aging involves the so-called "escape"?of glycosaminoglycans of dermis, including hyaluronic acid, with a reduction in cellular synthesis reactions and an increase in catabolic reactions with subsequent dehydration and impairment of the functions of the fundamental substance.
The last important aspect is the alteration of the micro-circle that causes a metabolic change due to which the high-energy producing aerobic glycolytic metabolism switches to a low-energy producing anaerobic metabolism.
The ATP availability is reduced with consequent impairment of anabolic metabolism and reduced biosynthesis of glycosaminoglycans and collagen.
Therefore, we observe a reduced synthesis of collagen Type I / collagen Type III typical of young age as well as a generalized extracellular atrophy in intrinsically aged skin; moreover, photo-aged skin is characterized by catabolic and anabolic remodeling events specific for the matrix components9.
The reduced bioavailability of ATP slows down cellular mitoses with subsequent reduction in skin thickness, while the reduced ability of GAGs to fix cations is responsible for the alteration of the micro-circulation and non-enzymatic glycosylation of collagen.
In Aesthetic Medicine, any type of flaws (wrinkles, so- called cellulitis, overweight, etc.) must be evaluated from the medical point of view with a diagnostic approach.
The first Aesthetic Medicine visit, consistently with the recommendations of the Italian Society of Aesthetic Medicine (SIME), includes medical history and traditional clinical examinations aimed at identifying the patient's request, and includes a number of morphological and functional evaluations, including psychological evaluation, morpho-anthropological and postural evaluation, phlebological evaluation of lower limbs, adipose tissue ultrasound, skin evaluation with cutaneous checkup according to C A Bartoletti-G Ramette?€?s method, and blood chemistry (Figure 4).
This approach allows to design a customized, preventive and site-specific treatment.
In particular, cutaneous checkup according to C A Bartoletti/G Ramette's method includes inspections at naked-eye, magnifying lens, natural light, cold light, Wood?€?s light, corneometry, sebometry, pHmetry, 15% lactic acid sensitivity test and evaluation of reactivity with dermographism.
The evaluation obtained by cutaneous checkup, in particular with instrumental examination, is crucial to formulate a correct diagnosis, to make a cosmetological prescription and to define appropriate treatments for the prevention and management of skin aging.
This procedure helps identify the skin biotype, classify the phototype, make a functional balance, determine the degree of skin aging and monitor skin values over time.
The diagnostic path allows to implement a tailored preventive and corrective program.
It is recommended to use official methods that have been implemented for at least two years and are supported by referenced scientific evidence, published in indexed journals and involving an appropriate number of patients.
According to SIME recommendations, the Board of experts agrees that the interventional approach to patient-reported flaws includes a diagnostic evaluation, a phase of normalization of abnormal parameters, a patient education program on the importance of daily skin care at home and at the clinician?€?s of preventive and corrective treatment based on a shared plan of action, of monitoring of results and the related corrective measures when any changes occur.
Based on these considerations, skin biostimulation is one of the medical-aesthetical procedures used to fight or slow down the process of skin aging whose manifestation is the onset of wrinkles and folds.
The word biostimulation (from the Greek “β?ο?”  (b?os), life and from the Latin “stimulate”, spur) refers to a technique, method or practice that can trigger a response in a living system through the application of a stimulus. 
It is a site-specific intradermal injection treatment (face, neck, d?collet?, hands, body) of substances aimed at stimulating fibroblasts, not only to produce elastin, collagen, hyaluronic acid, being therefore eligible to prevent, delay and affect chrono- and photo-aging.
The crucial aspect of biostimulation is the protection of the physiology of the patient's skin, especially to provide elements useful to cellular regeneration, starting from the improvement of the entire tissue and the restoration of the structures that the aging processes and diseases impoverish through biochemical and biophysical procedures.
Therefore, biostimulation carried out with a site-specific intradermal treatment allows to slow down skin aging by ensuring a better physiological skin brightness, elasticity and turgor.
In summary, before implementing any therapeutic techniques, it is important to collect medical history and carry out traditional clinical examination aimed at identifying what is the patient's request, through a number of morphological and functional evaluations, including morpho-anthropological and postural assessment, phlebological evaluation of lower limbs, hypodermal ultrasound, skin evaluation with cutaneous checkup according to Bartoletti-Ramette?€?s method, psychological evaluation and blood chemistry.
This approach allows to design a customized, preventive and site-specific treatment.
Several types of injectable materials have been used for facial rejuvenation and soft tissue augmentation.
The popularity of facial fillers has grown substantially worldwide due to its effectiveness and safety as a non-surgical procedure.
The ideal injectable material should offer good esthetic results with lasting effects, be safe, biocompatible and stable at the place of implantation, with minimal complications and no risk of migration1.
However, this kind of product has yet to be discovered.
All filling substances, to a greater or lesser extent, have some adverse effect2.
Depending on their permanence in the tissues, cosmetic fillers are classified in two categories: temporary or permanent.
All injectable fillers can produce unexpected adverse reactions, from small to large responses, with severe complications.
Temporary agents may induce serious complications, which usually resolve spontaneously over a variable period of time.
Permanent fillers can also generate minimal adverse reactions such as pain, swelling, erythema, ecchymosis; and large responses such as nodules or granulomas that do not resolve spontaneously4.
Liquid injectable silicone (LIS) is a product without odor or color, composed of polymerized dimethyl- siloxane chains.
Its popularity is based on the fact that it is permanent, economical, minimally antigenic and non-carcinogenic.
Although it is used as a facial filler material, it has not been approved by the US FDA for this application1.
In some cases, it has been associated with displacement or migration which can occur after many years, leading to an accumulation of particles and nodular granulomas at sites far removed from the points of injection7.
These granulomas are also called "siliconomas"? and were described for the first time in 1964.
The inflammation induced by LIS may occur as a response from the immune system to silica per se or its additives (or contaminants) such as platinum, an amorphous aggregate of silica, or fumed silica.
Previous studies support the fact that a small fraction of the granulomas formed in reaction to silicone injections are infectious9.
In addition, patients are not always aware of the material that has been injected or recall if they have previously received treatment with another compound10.
We present a case of "iatrogenic allogenosis"?
Its definition was established by Coiffman in 2012 as a term that defines the disastrous results produced by several permanent substances, months or years after being injected.
It is called "Allogenosis"? because it is caused by allogenic substances, that is, foreign to the organism; and "Iatrogenic"? because it is caused by medical intervention.
The goal of this article is to report a case of filler migration with foreign body granulomas (siliconomas) at a distant site, and to raise awareness of the late complications of soft tissue filler injections.
Autologous fat infiltration (lipofilling) was subsequently performed to correct the hypotrophic defect.
Four years after the first intervention, the patient presented a subcutaneous nodule in the right malar region and nasal root, of approximately 2 x 2 cm, with overlying erythema.
A new MRI was performed showing a collection of subcutaneous material in both malar/ zygomatic areas with left predominance (Figure 3).
Surgical removal of the right malar lesion was performed again, with good scarring.
Two years after the last intervention (16 years after being treated with silicone), the patient kept the small residual erythematous nodules described above and swelling, and began to develop new facial nodules, one at the level of the medial canthus of the right eye and nasal root, approximately 2 x 1.5 cm; and some about 5 mm in the right and left ?€?marionette lines?€?
These lesions did not have clinical signs of infection (Figure 4).
We performed a high frequency ultrasound (HUS) (Figure 5) in which we observed image in"snowstorm"? which suggested the presence of a permanent material, typical of silicone.
Since the lesions were distributed extensively in the dermis of almost the entire facial region, due to the esthetic consequences (scars) of an extirpation, a new surgery was not considered.
She started treatment with Minocycline 100mg / day.
Within 4 weeks of treatment, the swelling and erythema improved substantially.
During the following weeks, the nodules became softer and smaller; however, small nodules around the left eye were still visible.
Minocycline was continued and a follow-up visit 4 months after initiation of therapy showed a significant clinical improvement (Figure 6).
Complications due to injection of LIS are rare.
They include chronic cellulitis, nodules and subcutaneous plaques, foreign body reactions, and migration of silicone.
Treatment of silicone-induced granulomas has been based on case reports, proved difficult to manage and was in many cases unsuccessful.
The treatment must be individualized.
Erythema, swelling, induration, pain, deformity and hyperpigmentation may also appear.
Some authors propose that complications due to LIS are due to the use of adulterated silicone, large volume injections or because of administration by inexperienced/untrained professionals.
Subsequent to injection, silicone is encapsulated in the fibrous tissue due to the host inflammatory response, resulting in increased volume.
Histologically, silicone- induced granulomas contain multinucleated giant cells and histiocytes that are seen in the dermis and subcutaneous cellular tissue, together with polymorphic pseudocystic spaces representing LIS particles.
Our case presented a similar pattern.
In addition, another exogenous material different from silicone could also be observed in the histopathological exam of the patient, similar to what has been published by Wang et al, who suggest that granulomas can also be induced by the injection of adulterated silicone or when injected in conjunction with other substances.
A large volume of injection results in silicone migration thereby leading to granuloma appearance in areas distant from the site of infiltration.
Due to this, our patient presented granulomas in the zygomatic area and medial canthus of the eye, even though the silicone was injected into the "marionette lines".
The pathogenesis of granuloma formation is uncertain.
Granulomas may be caused by a generic response to a foreign body, or to an adulterant in the silicone or by an infectious process.
One of the proposed hypotheses is that liquid silicone can act as a niche for bacterial proliferation.
Non-tuberculous mycobacteria at the subcutaneous level have been reported in adulterated liquid silicone.
Additionally, bacteria can form a biofilm around the silicone.
Treatments range from surgical resection for localized granulomas to treatments with oral or systemic corticosteroid, minocycline, 5-fluorouracil or isotretinoin, among others.
In cases in which a surgical removal is necessary, the patient may present scars.
In addition, sometimes it is necessary to remove thick layers of tissue and the cosmetic result may not be satisfactory.
This happened to our patient, who presented a hypotrophic scar after surgical removal of the"siliconoma"? subsequently needing a new procedure to correct the defect.
Antibiotics, especially minocycline, have been used successfully due to their anti-inflammatory, immunomodulatory and antigranulomatous effects, as well as their coverage for mycobacteria.
Suchismita et al14, have reported a case treated with doxycycline (100 mg every 12h for 3 months) with improvement of granulomatous reactions at 3 months.
We report the successful treatment of multiple silicone granulomas of the face (siliconomas) with a low dose minocycline regime (100mg/day).
Current studies suggest that high frequency ultrasound (HUS) is an economical, useful and non-invasive diagnostic tool to determine the nature and type of material and to identify the injection site and quantity of injected filler.
Grippaudo et al23 demonstrated that the use of HUS helps to identify the place and quantity of silicone injected into the soft tissue.
In ultrasound, permanent fillers such as silicone show "snow storm" image with posterior acoustic shadow.
In this case HUS allowed to identify the actual location and confirm the type of filler injected in the soft tissue of the face.
Granuloma formation by silicone should be considered as a differential diagnosis in any patient with a history of cosmetic injections who develops facial swelling.
In our opinion, monotherapy with minocycline is a good alternative treatment for patients who present facial granuloma.
When EC law-makers decided to regulate the cosmetic sector with Regulation 1223/2009 to establish precise rules for cosmetic manufacturers, they certainly did not foresee how much and fast the web would change and the huge amount of information, sometimes incorrect, that goes around on it and which led to a rapidly growing trend: DIY homemade cosmetics.
The Cosmetic Regulation establishes strict norms - and sanctions for those who break them - aimed at protecting end users on three aspects: the ingredients used, the manufacturing process, the labelling describing the product.
Conversely, homemade cosmetics shirk the laws governing commercial cosmetic products and stand as a sector with no rules and which exposes the unaware users to a number of serious consequences.
Homemade cosmetics are the consequence of misleading and inaccurate information that has been spread over the web and the media on certain ingredients used in cosmetics, supposedly dangerous or anyway inappropriate for skin, thus unnecessarily demonised.
On the one hand, this generated mistrust for everything that appeared artificial and industrially processed or manufactured and, on the other hand, it led to the exasperation of the idea that everything that is natural is also healthy.
This new trend triggered a number of personal care enthusiasts, who unfortunately lack specific professional qualifications, to disseminate increasingly sophisticated recipes through the web, developed through home-based, unprofessional testing, in kitchens and with the little household tools available - a phenomenon that has rapidly gone viral.
The recipes of soaps, creams and deodorants, yet also nail polish and makeup, have spread rapidly over the web and entered the homes of ?€?DIY cosmetic makers?€?through Youtube and internet blogs managed by the pioneers of homemade cosmetics.
As it seems, the reliability and efficacy of the final product is basically given by the number of positive reviews that each recipe obtains, not by rigorous and scrupulous laboratory testing that guarantees product safety and efficacy, as it should be.
Therefore, self-manufactured cosmetics face a number of limitations.
Firstly, there is the purchase and imprudent use of ingredients, which can be harmful if not handled with the proper precautions and may not always meet the required quality standards.
The purchase of ingredients, especially by inexperienced cosmetic makers, on the internet from non-certified ingredient manufacturers or suppliers can indeed prove to be a very bad idea.
In addition, besides sourcing ingredients whose quality is impossible to verify, there is a high risk of inaccurately measuring and combining those ingredients to form the recipe, especially if using household tools, which are clearly inadequate ?€“ clearly, far too many risks that may compromise the quality of the final product.
Another aspect not to be underestimated is ensuring micro biological stability of the cosmetic product, which is definitely not in the ability of homemade cosmetic makers because safety tests cannot be carried out at home.
Finally, also the containers the final products are stored in can release substances that alter the final product, if the quality of such containers is not proven and certified.
If "DIY cosmetic makers"?use the cosmetics they makeon themselves, no particular law is being broken.
On the other hand, if homemade products are used by other people, given as gifts (as certain bloggers like to underline) or marketed through private stores, there may be some serious legal consequences.
In the event that the cosmetic product causes damage to the end user, for instance a bad allergic reaction, though regulation 1223/2009 cannot be enforced, civil law will apply instead - in Italy, it would be article 2043 of the Civil Code - on the grounds that anyone who causes damage to third parties is obliged to pay compensation.
Unfortunately, in this case the burden of proof lies with the injured party, with the consequent difficulty in identifying the culprit.
In addition, besides the combination of ingredients, damage to the user may also occur due to the poor quality of a single ingredient, which may have been purchased anywhere in the world, clearly making it even more difficult to trace back where it came from in the first place.
The hope for the future is to put the spotlight on the need to define the rules for DIY cosmetics, a trend that is silently but rapidly growing in popularity in Italy and all over Europe.