Comprehensive Facial Rejuvenation: CHAPTER EIGHT



Rejuvenative surgery for the face has undergone nothing short of a revolution this past decade, from minimally invasive brow techniques to diverse approaches to the midface. The trend in surgical technique has been toward less invasive strategies that facilitate faster recovery. As part of this Zeitgeist, adjunctive procedures have risen to the forefront in the rejuvenative armamentarium to respond to the demand for quick fixes. Younger patients, who do not require extensive surgical intervention, are seeking prophylactic treatments, e.g., Botox, and minor improvements with soft-tissue injectables and solid fillers. Adjunctive therapies work equally well in more mature patients as part of a global strategy for rejuvenation. Technological triumphs have kept pace with public demand, and a myriad array of soft-tissue replacement products are under investigation or have entered the market.
Unfortunately, no ideal treatment material or method exists today, i.e., biocompatible, natural, permanent, and yet removable. This quandary is the crux of the problem. An alloplast must be stable and well integrated for perpetuity, yet be pliable and natural to palpation and examination, and be easily removable in the event of rejection or infection. Solid fillers may have a firm texture that is intolerable to some patients and may have a higher extrusion or infection rate. Injectable agents may achieve a more natural feel but should be temporary in nature so that they can be removed should infection or other deleterious outcome manifest. Permanent injectables, e.g., Artecoll, Bioplastique, and Dermalive, not currently approved in the United States, have been reported to engender granulomatous reaction several years after implantation and may only be partially extracted with mutilating surgical excision. Appropriately chosen materials and properly performed procedures will ensure patient satisfaction and optimal aesthetic benefit.

Preoperative Considerations: Patient Selection & Relevant Anatomy
Perhaps the first order of business for any patient who presents to the facial plastic surgeon for consultation is what that patient desires corrected. Besides the aesthetic deficit that the patient perceives, the surgeon should usually promptly establish whether the patient intends to undergo larger flap-type surgery or envisions only a more limited “adjunctive” procedure with less recovery time. Astute attention to the patient’s inclination toward less or more surgery will facilitate good rapport and ensure a mutual strategy for success. A patient’s demeanor and comments may serve as invaluable clues to the surgeon as to the patient’s true intentions and objectives. Furthermore, the patient may express hesitation as to whether a certain “look” would be ultimately attractive for him or her and request a temporary measure that can approximate a permanent solution. For instance, botulinum toxin (Botox) may act as a useful agent to demonstrate to the patient the benefit of a potential browlift in the future. Alternatively, collagen may act as a reliable indicator as to how the nasolabial fold would appear with a permanent solid filler, e.g., Gore-Tex. The age of the patient will also guide the surgeon as to what recommendations to make: a younger patient may not require or desire more radical surgical intervention, making a more limited surgical or dermatological procedure more appropriate.
This section on preoperative considerations will be divided according to particular zones of the face that would benefit from an adjunctive-type procedure, viz., the glabellar frown lines; the lateral-canthal crow’s feet; the nasolabial smile lines and marionette labiomandibular lines; thin, hypoplastic lips; and perioral rhagades. By classifying anatomic deficiencies in this manner, the surgeon can then evaluate a particular patient complaint and then work through the exercise of what modality would be most applicable in a certain situation. The following section on intraoperative considerations will then elaborate on each particular method of rejuvenation in a detailed and stepwise fashion.
Generally, a reasonable treatment strategy for adjunctive procedures divides the face into two vertical portions with an imaginary, horizontal line drawn through the bottom of the nose (Figure 8-1). Botox therapy is particularly well suited for early, wrinkles present in animation above this line but may be less appropriate for wrinkles below this line. Perioral botox therapy for an overactive depressor offers limited benefit with the attendant risk of oral incompetence. However, soft-tissue augmentation is effective below this horizontal line but less so above it. A fundamental difference in wrinkle quality above versus below this line explains the authors’ rationale for this strategy. Wrinkle lines that form above this line are generally etched-in lines from repeated motion and benefit from either Botox therapy early (incipient lines) or resurfacing later (mature lines). Deeper glabellar lines may also be appropriately excised if very advanced (as will be discussed). Solid or liquid soft-tissue augmentation in the periocular region cannot readily and evenly efface the fine, etched-in lines in this region. Although the glabella tolerates this type of augmentation, liquid fillers are contraindicated due to skin necrosis and retrograde thrombosis and blindness ; and solid augmentation may not be the best modality to treat this area (consider either resurfacing or excision as better alternatives). Nevertheless, solid soft-tissue augmentation has been successful for those patients willing to tolerate some palpability in this area.
Below this horizontal axis, the lines that develop usually do so due to gravitational ptosis, e.g., the nasolabial and labiomandibular folds. These folds, rather than wrinkles, are more amenable to soft-tissue augmentation with either liquid or solid fillers rather than Botox therapy. The one exception to this rule is the perioral rhagades, or smoker’s lines. These fine crevices around the mouth are more akin to the fine lines that circumscribe the eye. Therefore, solid or liquid augmentation of these lines is not very effective. Unlike the periocular rhytids, however, the perioral rhagades are not as amenable to Botox (which may be an apparent caveat) but should be treated with either laser ablation or dermabrasion. Hypoplastic lips, on the other hand, may be appropriately treated with soft-tissue augmentation materials like the other areas described below this horizontal axis.

Glabellar Frown Lines
As a review of basic anatomy, the vertical rhytidosis that forms in the glabellar region may be attributed to the overactivity of the horizontally aligned corrugator supercilii musculature. The horizontal rhytids, usually situated somewhat lower, arise from repeated motion of the procerus muscle. These furrows that form may either be present at rest and in motion or only in motion: this consideration will largely determine what intervention will be most suitable for a particular patient. The deep glabellar lines engender two aesthetically unattractive features: (1) glabellar creases themselves connote to the observer a sign of aging (2) deeper furrows may impart the impression of an angry, worried, or tired visage that may belie the patient’s true emotional disposition.
The medial brow complex is a recalcitrant area to brow suspension surgery (please refer to Chapter 4 Upper and Midfacial Rejuvenation). Meticulous dissection of the medial brow complex during brow surgery can lead to many undesirable complications, e.g., uneven contour deformity, return of function, inability to reduce established glabellar rhytidosis, and worse yet frank cutaneous necrosis. For all these reasons, the medial brow region is more amenable to localized adjunctive therapy.
Younger patients with rhytidosis limited only to animation or those who have incipient rhytidosis are best treated with botulinum toxin. Unfortunately, this procedure is only temporary in nature and can be expensive with repeated treatment sessions. However, for early rhytidosis, Botox injection is the best and only therapy that is recommended.
With glabellar rhytidosis that is present both at rest and in motion, more aggressive therapy may be warranted. Early, incipient rhytids may still be treated with Botox as a first step to see whether the formed line will soften over time due to muscle inactivity. Alternatively, if the patient has other dyschromias or signs of photodamage, a Jessner’s/35% tricholoroacetic acid (TCA) peel may efface limited rhytidosis.
More severe rhytidosis requires carbon-dioxide laser ablation in this area. As discussed in Chapter 9, full-face laser therapy will be followed by a protracted recovery time that may be insufferable to many patients. Therefore, a chemical peel may be done elsewhere on the face with a targeted laser ablation of the glabella to achieve a more uniform resurfacing if more global photodamage would cause treatment with laser alone in the glabella to appear discontinuous with the adjacent unresurfaced skin. Other temporary soft-tissue augmentation materials, e.g., collagen, have been associated with skin necrosis and retrograde retinal thrombosis and consequent blindness and are contraindicated in the glabella.
Besides laser ablation for deeper wrinkles, solid soft-tissue fillers, e.g., Gore-Tex or Alloderm (acellular dermis), may provide benefit for the patient and is well tolerated in the thicker glabellar skin. However, as with all solid fillers, the patient must understand the limitations of such augmentation, viz., palpability, possible mobility and migration, potential visibility, and some risk of extrusion and infection. Given these limitations, a well established and proven method of rejuvenation of the glabella is direct excision of the rhytid, attenuation of the underlying muscle, reconstruction with a geometric broken-line repair, and possible delayed dermabrasion (See following section for detailed description). Surgical excision of the rhytid should only be reserved for corrugator-derived vertical rhytids and not the procerus-related horizontal rhytids. The latter rhytids tend to be shallower in depth and do not tolerate this type of surgical technique. Albeit ostensibly aggressive, this technique has borne the test of time and proven valuable in the surgical armamentarium. However this modality is not necessarily appropriate in other facial areas, e.g., excision of the nasolabial fold appears uniformly poor and is not recommended, as the scar ineluctably widens with repeated movement.

Latheral-Canthal Crow’s Feet
Similar to glabellar frown lines, the presence of lateral-canthal crow’s feet should be classified as lines present at rest and motion versus motion only. The latter condition is amenable to Botox therapy to abort the development of the former problem, i.e., so that the animated lines do not become permanently etched-in lines. Botox must be continued indefinitely to ensure that the development of more permanent rhytids do not arise. The notion that the muscles will become progressively more attenuated and eventually not require Botox is a fallacy that has been proven with histological evidence. Nevertheless, patients often report that they “unlearn” certain behaviors that caused the wrinkles in the first place after many months and years of muscular inactivity, thus perpetuating the longevity of Botox.
Another preventative measure that can abort incipient lines and minimize the development of further rhytidosis is the newer technique of non-ablative therapy (see Chapter 9 Cutaneous Resurfacing). Various laser and light devices have been used for non-ablative therapy including the pulsed-dye laser, the Q-switched 1064-nm Nd:YAG laser, 980-nm diode laser, 1320-nm Nd:YAG laser, Er:Glass laser, Er:YAG laser, and intense pulsed light. Non-ablative therapy, which has no discernible downtime (no ecchymosis, erythema, or edema if the parameters are properly adjusted), works by stimulating the underlying dermal collagen that can in turn even out the overlying epidermis. However, non-ablative therapy really only effectively treats fine and early periocular wrinkles and has limited benefit for deeper, perioral rhagades. The patient in his or her 30s who is a good candidate for Botox therapy may be equally well suited for non-ablative laser therapy, which can be combined with Botox treatment. If a patient understands the limitations of this technology, the results after a 3-to-6 month period, can be outstanding.
More established, etched-in lines should be treated instead with an ablative resurfacing modality. Other than actual redundant skin that requires a blepharoplasty, the surgeon should be attentive to fine lower and lateral eyelid wrinkles that should be addressed with a chosen resurfacing technique. Excising skin when only rhytidosis is present can lead to vertical shortening of the lower lid and malpositioning. Fine wrinkles can be treated quite effectively with a Jessner’s/35% TCA peel; whereas deeper wrinkles may benefit from CO2 laser ablation (if the patient is willing to accept the longer recovery period).

The Nasolabial Smile Lines and the Labiomandibular Marionette Lines
As mentioned before, the nasolabial and labiomandibular folds are poorly treated with Botox therapy, as these lines represent actual ptosis of tissue rather than wrinkles in animation. Instead, these lines can be augmented with a soft-tissue filler, whether a temporary liquid injectable or a more permanent solid material, to soften these ptotic folds. The patient should be fully cognizant of the limitations in completely effacing these lines and understand that limited improvement is the goal and not the exception. In addition, the patient should realize that a liquid filler, e.g., collagen, is only temporary and that a permanent filler, e.g., Gore-Tex, may at times be both palpable and visible and may risk extrusion and infection. Furthermore, if this anatomic area is the primary focus of grievance, then the patient should understand that a facelift, whether deep plane or SMAS, will do little to improve this line and may actually worsen it on occasion.
If the patient is willing to accept these limitations, then the surgeon can reasonably discuss the possible types of favorable treatment options. Although hyaluronic acid (Restylane) has shown promising aesthetic benefit and longevity abroad, this liquid injectable material has not yet been approved for use in the United States. Although hyaluronic acid should be free of antigenicity (i.e., no skin test is required), the major adverse reaction that has been reported worldwide, albeit on a small scale, is hypersensitivity (0.06-0.15%). , , At this time, bovine collagen remains a mainstay of temporary liquid augmentation. The authors have the greatest experience with Zyplast, which has greater longevity than Zyderm, and is favored by the authors as the only type of collagen for lower facial rejuvenation. As mentioned, the authors do not support the use of collagen, or equivalent augmentation material, in the upper face or periorbital region. Therefore, Zyplast has served well as the only type of collagen needed. Other liquid implants, e.g., Cymetra, Dermalogen, Isologen, can be expensive and/or temporary and have not been reliably used in the authors’ experience. As a practical matter, stocking only one liquid injectable eases the burden of inventory and reduces confusion for the patient and the surgeon alike.
If the patient elects to have a permanent soft-tissue filler, then Gore-Tex may be the most suitable option. Expanded polytetrafluoroethylene (ePTFE) comes in many brands, each touting a theoretic advantage based on porosity and pliability. However, in the authors’ experience with these different implants, these considerations remain squarely within the realm of theory and carry very little practical import. As mentioned, the limitations that concern this type of implant are palpability, particularly when smiling or during extreme animation of the lower face, possible visibility, migration, extrusion, and infection. These latter three complications are relatively rare and can be managed by simple excision and removal of the implant if need be. Women tend to tolerate the issue of palpability much better than men, as is generally true for most cosmetic endeavors.
Alternatively, acellular dermis (Alloderm) may prove to be a favorable compromise between a permanent substance such as ePTFE and a temporary liquid injectable like collagen. Although touted as permanent, the authors have found that Alloderm is semi-permanent to permanent depending on the patient’s biophysiologic ability to degrade the foreign material. The benefit of Alloderm is that usually the substance lasts considerably longer than collagen and is not as palpable (if at all) compared with Gore-Tex, or other type of ePTFE. However, the degree of augmentation may be somewhat less than what may be achievable with Gore-Tex. The patient should be educated as to the derivation of Alloderm, viz., processed cadaveric dermis, and should understand the rigorous screening and mechanical process through which the material have been subjected. Based on these advantages and drawbacks, the surgeon and patient should arrive at a mutually agreed upon modality for intervention.
Although not truly applicable in this chapter dedicated to “adjunctive” therapies, the nasolabial and labiomandibular folds may also be softened with SMAS excised during a SMAS-imbrication rhytidectomy. If the patient consents for this treatment option, he or she may have the best of all possibilities: an autogenous, pliable material that should not be readily palpable and have an enduring quality. In addition, the risk of extrusion and infection is almost unheard of given the autogenous nature of the implant. The implant also does not cost any extra in terms of harvesting time, donor-site morbidity, or purchase cost. Therefore, the perfect candidate for this procedure is the individual who is undergoing a concurrent rhytidectomy and who also exhibits notable marionette, or labiomandibular, folds.

Perioral Rhagades, or Smoker’s Lines
Perioral rhagades, or smoker’s lines, are best treated with a resurfacing modality (see Chapter 9 Cutaneous Resurfacing). However, treatment of this pathology is mentioned again in this chapter for sake of completeness and to caution the reader about the use of soft-tissue augmentation or Botox to address this entity. These deeply etched lines can only be effectively treated with laser therapy or dermabrasion and attains limited improvement with a TCA peel. Phenol, which is not covered in this book, is a viable alternative. Soft-tissue augmentation with collagen, or equivalent filler, or solid implant does very little to address these wrinkles and is not advisable.

Thin, Hypoplastic Lips
Full, pouty lips are an emblem of sensuality, and thin, attenuated lips signify aging and reduced sexual allure. Many young women who are born with congenitally thin lips seek to amplify their lip volume even at a relatively tender age. More mature women suffer from a longer white lip, reduced vermilion height, and less pronounced Cupids’ Bow. Treatment of hypoplastic lips may be divided into two principal strategies: soft-tissue augmentation and advancement cheiloplasty.
As described above, soft-tissue augmentation may be effected with either temporary liquid injectables, e.g. collagen, or more permanent materials, e.g., Alloderm or Gore-Tex. The patient must weigh the benefits and drawbacks (already explained) to decide which would be the most appropriate for that individual. However, the authors would like to emphasize that Gore-Tex, or any kind of ePTFE, may not be the most suitable choice for lip augmentation. Unlike the nasolabial fold, the lip is subjected to much more movement and is more proximal to the contaminated oral cavity. For these two reasons, the incidence of infection with lip augmentation tends to be much higher than with nasolabial-fold augmentation, especially with ePTFE. However, Alloderm has been noted to be much less prone to extrusion and infection and, as mentioned, less palpable than ePTFE. Therefore, Alloderm may be a reasonable alternative for semi-permanent to permanent lip augmentation. These conclusions have been arrived at after many years of trial and error and represent empirical observation rather than a controlled study protocol.
Advancement cheiloplasty, or lip advancement, should be discouraged, as it often creates an unnatural result, particularly in the younger patient who requires little additional augmentation. Even in the best surgical hands, the risk of an unnatural outcome may be significant. This treatment modality should be reserved for women who are more advanced in age and fully comprehend the limitations of this technique. Even more importantly, these ladies must be willing to wear lipstick as a camouflaging agent on a routine basis. If the patient does not meet these selective, exclusion factors, then the surgeon should resist the temptation to go forth with the operation.

Intraoperative Considerations: Technique & Salient Technical Points

Instrumentation/Equipment for Alloderm/Gore-Tex Augmentation

Prep Stand:
Non-sterile gloves
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine
Surgical marking pen

Introducer, also known as a Passer- a device that resembles a Freer but has a
sharper edge as well as a central groove that accommodates a needle used to draw
the implant through the pocket.
Hemostat (to grasp the free end of the implant so as to prevent pulling the implant
Accidentally too far into the pocket.)
Tiny, double-hooks (2)
Metzenbaum or Mayo scissors

0 silk with a 60 mm Keith-type KS (SC2) [SC2]? needle (to suture the implant)
6-0 prolene, P-3 (P-13) needle (to close the skin incision)
5-0 chromic, P-3 (P-13) needle (to close the lip incision)

Other Supplies:
No. 11 or 15c blade
Alloderm graft, 3 x 7 cm graft (See Table 8-1)
Gore-Tex implant

Instrumentation/Equipment for Geometric Broken Line Repair for Deep, Vertical Glabellar Rhytidosis

Prep Stand:
Non-sterile gloves
10 cc syringe (2), 27-gauge (1 1/4 inch long) needle (2) with
lidocaine 1% and 1:100,000 epinephrine
Surgical marking pen
Castroviejo calipers

Wide double hooks
Tiny, double-hooks
Dissecting scissors

4-0 polydioxanone, PS-3 (PRE-3) [PC-34] needle
6-0 fast-absorbing suture, PC1 (SBE-2) needle

Other Supplies:
No. 11 or 15c blade
Bipolar cautery
Wire-brush dermabrader (at additional session 6 weeks later if necessary for
maximal scar camouflage)

Summary of Botox Principles and Technique

Reconstitution (Recommended Dilution):
4.5 cc Preservative-Free Saline
18-gauge needle
5-cc syringe

30-gauge, 1/2″ needle
1-cc tuberculin syringe

Zone I Zone II Zone IIIA Zone IIIB Zone IIIC
Area Glabella Forehead Upper Lateral Periocular Region Middle Lateral Periocular Region Lower Lateral Periocular Region
Muscles Targeted Corrugator & Procerus Frontalis Upper Lateral Orbicularis Oculi Middle Lateral Orbicularis Oculi Lower Lateral Orbicularis Oculi
Objective Eliminate medial depressor rhytidosis Attenuate forehead rhytidosis Effect chemical browlift Eliminate lateral rhytids, or crow’s feet Eliminate lower-lid hypertrophic roll of orbicularis oculi and lower-lid rhytidosis
# Units 15-20 units 10-15 units 5-7 units* 5-7 units 5-7 units
Volume 0.6-0.8 cc** 0.4-0.6 cc 0.2-0.3 cc 0.2-0.3 cc 0.2-0.3 cc
Technique Fanning Percutaneous Fanning Fanning Fanning
Cautions Eye opening and closing dysfunction, ptosis Brow ptosis Brow ptosis, eye opening and closing dysfunction, ptosis,
ecchymosis*** Eye opening and closing dysfunction, ptosis,
ecchymosis*** Ectropion,ecchymosis***,
worsening of festooning

* 5-7 units total are used per side and per subzone (i.e., for Zone IIIA, IIIB, or, IIIC)
**Volume calculated based on the double-dilutional method (0.2 cc = 5 units)’
***Direct digital pressure should be applied for ten sustained minutes using a 4 x 4 gauze immediately after injection to minimize ecchymosis.
A. Permanent/Semi-Permanent Rejuvenation
Gore-Tex/Alloderm/SMAS (Nasolabial Fold, Labiomandibular Fold)
Besides the preparation of Alloderm or harvesting of SMAS, the actual procedure of insertion for Alloderm, Gore-Tex, or SMAS are identical and will be discussed herein as one procedure. Alloderm, Gore-Tex, and SMAS tissue will be hence referred to collectively as the implant. This procedure can be undertaken with local anesthesia alone (1% lidocaine with 1:100,000 epinephrine) or with some Versed sedation depending on the patient’s disposition and temperament. Clearly, SMAS insertion implies a full rhytidectomy has been performed concurrently, and the reader is directed to Chapter 5 for further details in regard to SMAS harvesting and implantation during rhytidectomy. For details of Alloderm preparation, the reader is referred to the following section that describes Alloderm implantation for lip augmentation. The amount of Alloderm that is required for labiomandibular, nasolabial, and lip augmentation is also discussed in the following section and summarized in Table 8-1.
For the nasolabial fold, a stab incision is made with a Bard-Parker No.15C or No.11 blade parallel and within the crease of the nasolabial fold about 5 mm away from the alar-facial groove and another stab incision is made at the lowest extent of the nasolabial fold. For the labiomandibular fold, the stab incision is made at the inferior extent of the fold (Figure 8-2) and inside the buccal mucosa that parallels the fold (Figure 8-3). Starting from the inferior incision, a standard passer, or introducer, device is used to tunnel in the subcutaneous plane along the fold toward the distal incision (Figure 8-4A, B). The non-dominant hand should guide and control the tunneling of the instrument. Furthermore, the tunnel should be made just large enough to accommodate the implant. For the nasolabial fold, the surgeon should create the tunnel along the nasolabial fold crease, erring slightly medially rather than laterally. As the nasolabial fold is defined as a mound laterally and a valley medially, the surgeon should place the implant medially to raise the depression to soften the transition between the two elevations.
After the tunnel has been successfully created, one end of the implant is securely fastened to a 0 silk on a Keith-style needle about 0.5 to 1 cm from the end of the implant to avoid slippage of the suture off the implant.? The needle is then passed into the groove of the introducer (Figure 8-5), and then the introducer is withdrawn leaving the needle in place. The wound edges of one stab incision are retracted laterally and upwards with opposing tiny double hooks. Gore-Tex, which has a higher likelihood of implant infection, does not require any preparatory soak in povidone-iodine, or equivalent solution, as the material is hydrophobic and will not benefit from immersion in a disinfectant. The implant is gently pulled through the tunnel until it fully occupies the space (Figure 8-6). The non-dominant hand should again guide the implant so that it does not kink or fold on itself during insertion.
The length of the implant should be at least 1 cm longer than the tunneled pocket so that the ends may be tucked further distal to both incisions by 2 to 3 mm (Figure 8-7). For the side of the implant that passes into the buccal mucosa, a more conservative amount should be visible, i.e., less than 5 mm rather than 1 cm in length (Figure 8-8). The portion of the implant fastened to the 0 silk suture is amputated and discarded. As mentioned, the distal aspects of the implant are then tucked distal to the incision on both ends, using a tiny double hook and Bishop forceps to facilitate ease of entry and placement. The rationale for the extension of the implant past the incision site is several fold. First, if the implant terminates at the incision site, a tendency may arise for the wound to contract downward over a void: the implant would buttress against this possibility. Second, if the end of the implant buckles somewhat overtime, it may tend to apply pressure against the wound edge and have a greater likelihood for extrusion. Third, the implant may tend to contract over time so the implant is placed as distally as possible to protect against this event. The incisions are then closed with 6-0 prolene in a simple, interrupted fashion with 2 to 3 sutures placed for each incision site, as determined by wound length (Figure 8-9). These sutures are removed at 1 week.

Lip Augmentation with Alloderm
As mentioned earlier, the authors believe that for semi-permanent to permanent lip augmentation, Alloderm is the preferred method due to the safety profile of the material and the ultimate natural look and feel. Although a fuller lower lip has sensuous appeal, most patients have a more attenuated upper lip and also derive greater satisfaction with augmentation of the upper lip (Figure 8-10). Accordingly, often patients desire only selective augmentation of the upper lip. However, simultaneous upper and lower augmentation remains a common request.
1% lidocaine and 1:100,000 epinephrine is infiltrated into the upper lip, and ten minutes are allowed to transpire during which time the Alloderm is properly prepared (Figure 8-11). Typically, a 3 x 7 cm Alloderm graft is sufficient to augment both the upper and lower lips. 2/3 of this graft is sectioned lengthwise (i.e., along the long axis of the graft), to be used for the upper lip, and the remaining 1/3 is reserved for the lower lip. Use of two 3 x 7 cm grafts for lip augmentation (i.e., one for the upper lip and one for the lower) is an aggressive augmentation that may potentially risk extrusion and also increase the period of postoperative edema. Given the expense of acellular dermis, use of two sheets is also not financially justifiable. If the patient desires only selective augmentation of the upper lip, then usually the entire 3 x 7 cm graft is placed into the upper lip so that none is wasted. However, if the lip appears too full after this degree of augmentation, a more conservative amount can be used as aesthetically demanded. For nasolabial augmentation, 1/2 of the 3 x 7 cm graft is inserted into each smile line. Similarly, 1/2 of the 3 x 7 cm graft is inserted into each marionette line. Table 8-1 summarizes these recommendations. The Alloderm is rolled and sutured with a 5-0 chromic suture (Figure 8-12) and tied at one end to the an 0 silk which in turn is tied to the straight needle that is designed to fit into the groove of the introducer (Figure 8-13). It is imperative that the 0 silk suture be firmly tied to the end of the implant using a square knot, as it may easily slip off the end of the implant during the forceful draw through the pocket. Stab incisions are made with a No.15 blade approximately at the junction of the wet and dry lip on either end of the upper lip about 4 to 5 mm medial to the oral commissure (Figure 8-14). The introducer is then passed through the upper lip using the non-dominant hand to guide device toward the other side (Figure 8-15 A, B, C). The proper plane of passage is below the outer mucosa but above the orbicularis-oris muscle. The straight needle is then passed into the groove of the introducer and pulled through as the introducer is withdrawn (Figure 8-16 A, B). Before the implant is drawn through, the free end of the implant (i.e., the end without the attached suture) should be clamped with a hemostat to prevent the implant from being pulled too far into the pocket. The straight needle is drawn through until the implant is situated properly in the pocket with only a short 1 cm tail showing on the proximal side (Figure 8-17). When properly situated, the suture is cut free from the implant, and the hemostat clamp, removed. The distal end is trimmed to the same 1 cm length tail. The Alloderm is then tucked further distal to each incision using fine, toothed forceps and tiny double-pronged hooks (Figure 8-18). The incisions are closed with 2 interrupted 4-0 chromic sutures (Figure 8-19).
Of note, if cupid’s bow appears to be too full, the implant should be removed and a small wedge excised from the superior aspect of the implant along its central aspect to reduce this fullness. Some texts recommend that the implant should be placed as two separate segments, with each portion falling on either side of Cupid’s bow. However, due to inevitable and unpredictable contraction of the implant, the aesthetic result may be suboptimal over time. Therefore, the authors do not advocate this technique. The exact same technique is used to augment the lower lip as explained for the upper lip, except the implant is proportionally narrower (as mentioned above) in a 1-to-2 ratio but retains the same length as that of the upper lip implant.

Direct Excision (Glabellar)
If the patient presents with extremely advanced, canyon-like fissures in the glabellar region, the most effective modality for this type of pathology is direct excision of the rhytid and reconstruction (See Case #3). Of note, direct excision is only recommended for vertical rhytids and, as explained before, is not indicated nor tolerated by horizontal-oriented rhytids. It is also worth repeating here that direct excision of the nasolabial fold is contraindicated in all circumstances because of the inevitable, unfavorable widening of the wound over time due to repeated motion in this area.
Direct excision of the rhytid may take many forms, according to scar revision principles: straight-line excision, multiple z-plasties, a running w-plasty, or geometric broken line. This last technique represents the definitive technique for optimal camouflage and will be reviewed here, as it is the most technically intricate and the most ideal technique for glabellar rhytidosis.
A fusiform outline centered over the rhytid (about 1 to 2 mm on each side) is drawn with a surgical marking pen (Figure 8-20). Then the alternating geometric configurations (squares, rectangles, trapezoids, and triangles) that line either side of the wound edge are drawn in the following manner. The shapes should approximately extend about 3 to 4 mm from the proposed wound edge, as smaller shapes experience compromised vascularity and are difficult to handle surgically, whereas larger shapes create undue wound tension and are harder to camouflage. First, a dotted line is drawn parallel to and 3 to 4 mm from the fusiform excision line, which represents the edge of the proposed geometric limbs. A pair of calipers or ruler should be used so that the limbs are exactly the same size on each side of the wound edge along the entire length to ensure that the geometric shapes fit precisely into the corresponding, contralateral defects (Figure 8-21). The surgeon should then mark out the geometric shapes that fit within the 3-to-4 mm limb distance as described above by drawing one shape at a time and the corresponding, contralateral defect thereafter (Figure 8-22). If the surgeon elects to draw one entire side of geometric shapes before venturing to the contralateral, matching side, he or she will find it quite difficult to ensure that an error is not made in pairing shape with defect.
Local anesthesia (1% lidocaine with 1:100,000 epinephrine) is infiltrated into the incision and adjacent tissue, and the standard ten minutes are allowed to transpire for maximal hemostasis. The geometric shapes are created using a Bard-Parker No.11 blade again in an alternating fashion between sides to ensure that no error is committed. In order to maintain the integrity of the dermal sling, the skin is only perforated with the No.11 blade so that tiny bridges of epidermis remain intact between perforations (Figure 8-23). This technique permits wound tension to be maintained during the entire excisional process. The tiny skin bridges are then transected with the No. 11 blade before dissecting the skin island from the underlying muscular bed and discarded. Dissection is carried out laterally several millimeters in the subcutaneous plane to permit wound eversion and to reduce wound tension.
The corrugator is then transected on either side of the wound with sharp scissors and partially avulsed (Figure 8-24). Dissection should remain primarily in the central aspect of the wound to minimize inadvertent injury to the supratrochlear neurovascular bundle. In addition, over dissection of the corrugator complex may yield mild depression in the void created below the incision line. After hemostasis is achieved with selective cautery, the wound edges are approximated in the following prescribed fashion. First 1 to 2 deep sutures of 4-0 polydioxanone are placed as needed in an inverted orientation to reduce superficial wound tension and promote proper wound healing (Figure 8-25). A 6-0 fast-absorbing suture is fastened at one end of the wound and run in a locking fashion toward the other end by suturing only the free corners of the created shapes on the surgeon’s right side to the corresponding defects on the left side as a right-handed surgeon faces the wound. This technique follows the surgical technique of always suturing “ship to shore”, i.e., from free edge to anchored defect. Similarly, a 6-0 fast-absorbing suture is fastened on the contralateral end of the wound and run toward the other end of the wound in a running, locking fashion as described above: as the surgeon is now situated on the other side of the wound, the remaining unsutured shapes are again on the right and approximated to the defects on the left (Figures 8-26A, B). Steri-strips are applied in a transverse direction to the wound in order to minimize tension. The skin sutures may remain in place, as they are dissolvable, but may be properly trimmed at 1 week if need be. If any irregularities exist at 6 weeks, the incision line can be dermabraded to achieve an inconspicuous scar. Botox may be required to reduce muscle activity if corrugator resection is ineffective or returns over time.

Advancement Cheiloplasty
As mentioned above in the preoperative section of this chapter, advancement cheiloplasty should be reserved only for select cases: mature women who request this procedure and are willing to wear lipstick on a routine basis to camouflage any obvious scarring. This technique is not recommended in younger women. Further, a subnasal excision of skin rather than a vermilion excision of skin is also discouraged due to a higher likelihood for an unnatural result in the authors’ opinion. However, other surgeons have reported good results with this technique. Prior to the advent of soft-tissue augmentation options, advancement cheiloplasty was the mainstay for lip rejuvenation, but current techniques e.g. collagen and Alloderm have made this technique antiquated and more of historical interest in the authors’ opinion. Further, as mentioned, perioral rhytidosis should not be treated with an augmentation technique but deep resurfacing (CO2 laser, phenol, or dermabrasion) instead.
If the patient consents to the above limitations, then the surgeon can carry out the procedure with good conscience. The operation begins with the patient in the upright position for marking. The surgeon marks the anticipated extent of advancement, generally twice the distance that is desired, as some loss of vertical height will occur over time. The surgeon should begin to mark the proposed line of excision at 5 mm medial to the oral commissure to avoid scarring from excessive lateral dissection. The surgeon should mark the line of skin excision at slightly less than a 2-to-1 ratio (proposed excision to desired vermilion height) for the majority of the lip and slightly more than a 2-to-1 ratio at the philtrum, i.e., at the peaks of Cupid’s bow (Figure 8-27). However, restraint should be exercised in making the points of Cupid’s bow too exaggerated as this peaked appearance is an identifiable stigma of a surgically operated lip. If the lip appears too high at Cupid’s bow several months after the operation and the patient is dissatisfied, then the surgeon can elect to reduce the height at the philtrum via a V-Y advancement.
After the patient is carefully marked out and anesthetized with the standard mixture of 1% lidocaine with 1:100,000 epinephrine, the surgeon can begin to excise the intended skin. A No.15 blade should be used to score the skin superficially along the entire perimeter of the incision just to the depth of the mid-dermis, all the while beveling away from the center of the wound. Bishop forceps or tiny double hooks are used to retract the skin upwards as the surgeon meticulously dissects the skin at the mid-dermal level with a No.15 blade: the white dermis should be noted above and below the knife blade as dissection continues. The remaining dermis is left intact as a platform so that after the lip is closed, it will not retract downward. In addition, the intact dermis provides volumetric fullness to the lip, which is a favorable aesthetic objective. The wound edges are everted and approximated with interrupted vertical-mattress sutures at the key anatomic landmarks, i.e., at the height of Cupid’s bow and at the central depression point between Cupid’s bow. Similarly, interrupted vertical-mattress sutures are then used to close the remainder of the wound in an everted fashion. Sutures may be removed at 1 week postoperatively.

B. Temporary Rejuvenation
Collagen (Zyplast)
As a review, the authors advocate use of collagen only below an imaginary line drawn through the nasal base, principally to soften the nasolabial and labiomandibular lines and to augment hypoplastic lips. It is not recommended to augment fine wrinkles around the lips, which should be effaced with an appropriate resurfacing modality. However, if the patient has a few deep crevices at the vermilion border that he or she would like effaced, then collagen may be a suitable temporizing agent. Further, apart from using collagen for rejuvenation of the aging face, it may be safely used throughout the entire malar region for acne scarring (This is an exception to the horizontal-line rule).
As a reminder to the reader, the patient must undergo an antecubital test patch with 0.1 cc with bovine collagen injected in the intradermal plane approximately 30 days before planned treatment. During this time, the patient observes for any induration or erythema that correlate with an allergic reaction according to symptoms outlined in the package insert. Although the instructions advocate repeating the test patch twice at 30-day intervals, most patients will not tolerate this delay for an intervention that appeals to the “quick-fix” mentality. Furthermore, a double negative test does not necessarily confirm a lack of allergy. The authors have not experienced any adverse reactions to date after a primary negative test.
Although the cross-linked Zyplast is more stable and longer lasting than Zyderm, Zyplast is more prone to beading, or a lumpy-bumpy appearance, if injected too superficially or rapidly. Therefore, Zyplast should be infiltrated cautiously, requiring a learning curve to master the proper technique. The preferred plane of injection for Zyplast is deep dermis to ensure maximal longevity and to minimize bead formation. The skin should either manifest delayed or no blanching after injection, and the surgeon should technically not feel the needle give way through the reticular dermis into the subcutaneous adipose tissue. If implanted into the subcutaneous tissue, Zyplast may not endure as long a time as intradermal placement. However, the authors would like to stress that even in the most experienced hands some beading will inevitably occur and that the surgeon should err on the side of placing the collagen too deeply than superficially. If beading does arise, then the surgeon should gently massage the area to even out the contour and further recommend that the patient do likewise until the area returns to a smooth contour.
Zyplast is packaged in either 1 cc or 1.5 cc syringes. Generally speaking, 1.5 cc is preferred for nasolabial-fold, labiomandibular-fold, and moderate lip augmentation. For all the above indications, 1.5 cc is more cost effective for the patient in terms of per dollar augmentation and is therefore more versatile. However, if a younger woman (< 35 years old) requests some mild to moderate lip augmentation or if an individual would like only a few cutaneous depressions raised, then the 1-cc allotment may be a better choice.
For the nasolabial fold, the surgeon should inject at the nasolabial crease or slightly medially to soften the fold (Figures 8-28A, B). The marionette, or labiomandibular, fold is only present along the upper one-third at rest. This depression near the oral commissure cannot really be easily over augmented, as it usually requires quite a substantial amount of collagen to efface it (Figure 8-29). The lower two-thirds of the labiomandibular fold only appears in motion and cannot be readily addressed. In addition, collagen should not be used to correct jowling. As previously mentioned, correction of perioral rhytids is often less desirable with collagen because Zyplast is less forgiving in these finer lines and Zyderm has less longevity. Zyplast can be used for discrete areas of deeper, crevice-like rhytids (Figure 8-29), and Zyderm used for the finer lines. For lip augmentation, the collagen should be injected at the vermilio-cutaneous junction aiming slightly toward the underlying vermilion. Two-thirds of the collagen should be placed into the upper lip and the remaining one-third should be reserved for the lower lip. Although a full lower lip may be associated with a pouty, seductive appeal, most patients desire a fuller upper lip, as it tends to be more visible to them. In addition, the flattened contour of the aged upper lip is a particularly more unpleasant feature to the patient than a more attenuated lower lip. Therefore, the surgeon should not only try to augment the aged upper lip but focus on restoring a disproportionate amount in the flattened central aspect of Cupid’s bow. The surgeon should infiltrate only 90% of the collagen and then have the patient assess the augmentation with a handheld mirror to determine where the remainder of the collagen should be placed (Figures 8-30A, B). This technique minimizes patient dissatisfaction and accords some responsibility to the patient for the ultimate outcome of the procedure.

Botulinum Exotoxin A (Botox)
Botulinum toxin A (Botox) should be used to efface rhytids observed in motion only or incipient lines at rest and is reserved for wrinkles that occupy the upper half of the face (above the imaginary line drawn through the nasal base). In this section, the reader will be presented a systematic fashion in which to inject Botox according to outlined zonal patterns of the upper face. Zone I is defined as the glabellar region; Zone II is the forehead; and Zone III refers to the lateral-canthal region, which in turn is subdivided into vertical thirds (Zones III A, B, C) (Figure 8-31). The rationale for this zonal design will become apparent as the reader completes the study of this section.
The first step in Botox preparation is reconstitution of the refrigerated solid form. 4.5 cc of preservative-free saline is used for reconstitution (Figure 8-32): this amount is twice the recommended dilution, as the authors have found that increased volume permits more even distribution across a wider expanse of tissue than a more concentrated mixture. However, no greater dilution than this advised amount should be undertaken because very dilute (> 15 cc) mixtures will markedly decrease the potency of the Botox. Further, a greater chance of toxin migration may occur at these higher volumes (> 10 cc) that may lead to complications such as blepharoptosis or brow ptosis. A 5-cc syringe outfitted with an 18-gauge needle is used to draw up the 4.5 cc of preservative-free saline, which is then in turn injected into the Botox bottle containing the unreconstituted solid. The mixture is gently swirled to ensure full dissolution of the unreconstituted Botox. It is very important not to shake the bottle vigorously, as the toxin is easily denatured. The above-recommended dilution yields a concentration of 5 units per 0.2 cc of reconstituted Botox. Zone I (the glabella) typically requires 15 to 20 units (0.6 to 0.8 cc) depending on the extent of rhytidosis and the desired degree of restricted expression. Even though Zone II (the forehead) covers a greater expanse of tissue, the frontalis is less active than the medial brow complex and requires usually 10 to 15 units (0.4 to 0.6 cc). Zone III (the lateral-canthal area) deserves between 10 to 20 units (0.4 to 0.8 cc) total depending on the number of subdivided zones treated, requiring 5 to 7 units (0.2 to 0.3 cc) for each subzone.
Before needle injection of Botox is carried out, the patient is typically asked to apply an ice pack to the proposed treatment areas for 5 to 10 minutes. The ice pack acts to anesthetize the area and reduce ecchymosis. Ecchymosis is diminished via two mechanisms: vasoconstriction of the muscular bed, which in turn minimizes the chance of needle laceration of a vessel, and diminution of the inflammatory cascade. Ice packs immediately after injection can also benefit the patient in a similar fashion. For the particularly sensitive patient, EMLA (containing 2.5% lidocaine and 2.5% prilocaine) cream should be applied to the area at least one hour before the treatment time and held in place with transparent cling wrap If the physician elects to use an alcohol preparatory wipe before Botox injection, he or she must wait until the alcohol has completely evaporated prior to injection, as the alcohol can reduce the efficacy of the toxin.
Two principle techniques exist for Botox injection: fanning and percutaneous injection methods. Each technique has its benefits and drawbacks and is selected based on the intended Zone for treatment. The fanning method involves a single percutaneous insertion with multiple fanning strokes of the needle through the muscle belly. This method permits a more even distribution of Botox through the bulk of the muscle than the percutaneous technique. However, the 30-gauge needle attached to a 1-cc tuberculin syringe that is recommended for Botox injection is shorter (1/2″) as compared with the 27-gauge needle that has a 1 1/4″ length. Nevertheless, given the less traumatic caliber of the 30-gauge needle, the authors recommend use of this needle for Botox injection, whether for the fanning or percutaneous technique. The percutaneous technique involves multiple transcutaneous injections that are oriented perpendicular to the skin. Zone I (the glabella) has a particularly thick muscle (the corrugator) in a more discrete location, and the fanning method is recommended for an even and controlled treatment of this area. Conversely, Zone II (the forehead) is a larger, flatter muscle that benefits from the percutaneous technique in order to deliver adequate botulinum toxin over a greater territory. Zone III (the lateral canthus) is similar to Zone I in that the muscle surface area is more discrete and benefits from the even distribution afforded by the fanning technique.
Treatment for Zone I, the glabellar region, will be addressed first. As mentioned, a total of 15 to 20 units (0.6 to 0.8 cc) is required to treat the area of rhytidosis effectively. The first time that a patient is treated, the authors recommend a more conservative amount of toxin, especially if multiple areas are to be treated or if the patient expresses concern about the inability for emotional display. The perimeter of Zone I that should be respected for safety and efficacy is as follows: between the medial club of the eyebrows down to the sellion (or deepest recess) of the nasal root, remaining at all times on the bony prominence of the glabella (Figure 8-31). Superiorly, Zone I blends into Zone II above the root of the corrugator muscle. If the injection is placed down the slopes of the orbital rim toward the eye, the levator aponeurosis (the lid opening mechanism) and/or the central preseptal/pretarsal orbicularis-oculi muscle may be affected, impairing lid opening or closing. Injection further inferiorly past the sellion does not improve any horizontal rhytidosis, as the procerus muscle fibers become attenuated at this level. The patient should be asked to squint and frown so that the rhytidosis can be reproduced and the over active muscles targeted. Usually the corrugators are more developed and cause the more apparent rhytidosis. During active squinting and frowning, the surgeon rolls the corrugator muscle between the index finger and thumb of the non-dominant hand and injects the Botox in the above-described fanning technique with the other hand (Figures 8-33A, B, C). As the 30-gauge needle is rather short (1/2″), 2 to 3 injections may be required to cover the entire muscle. The surgeon should be cognizant at all times of the amount of delivery so that an equal amount of toxin is applied to each side. The double-dilution method ensures a more even delivery and avoids the inadvertent delivery of too much toxin in an overly localized area. The remainder of the Botox, if properly planned, may be used to treat the procerus according to the presence of horizontal rhytidosis
Zone II refers to the forehead region and is defined as the area extending above Zone I from the medial club of the eyebrow upwards and laterally toward the trichion (hairline) at the midpupil level (Figures 8-31; 8-34 A, B, C). The recommended dose for this area is 10 to 15 units, with the upper end of the suggested dosage be used particularly in men who may have a more developed frontalis muscle. If the surgeon ventures too far laterally past the proposed perimeter of Zone II, he or she may accidentally cause brow ptosis. Therefore, a very active frontalis muscle may be reduced in activity in its central zone but not completely effaced in its lateral zone, which is a favorable outcome, as complete inactivity of the muscle looks unnatural and expressionless. Unlike the fanning technique that should be used for Zone I, the surgeon should use the multiple, percutaneous approach for the frontalis muscle in order to ensure adequate and even treatment of the central aspect of the frontalis. If Zone I and II should be concurrently treated, Zone I should be performed first, then Zone II starting from the inferior aspect in order to avoid accidental overlap of toxin injection.
Zone III defines the final area suitable for aesthetic Botox injection, i.e., the lateral-canthal region. This area is in turn subdivided into three smaller zones. Zone IIIA refers to the upper third of the lateral orbicularis oculi that extends from the lateral canthus (medially) to the orbital rim below the eyebrow (superiorly) down to the upper crow’s foot noted upon squinting (inferiorly) to 1 cm lateral to the orbital rim (laterally). Zone IIIA is treated in order to effect a chemical browlift of the redundant lateral brow tissue and to raise the hairy eyebrow to a more aesthetically pleasant configuration. However, this area may be the most treacherous area to inject, as too medial an injection (over the preseptal or pretarsal orbicularis oculi) may cause blepharoptosis or interfere with the blink mechanism and too far superiorly above the eyebrow (over the frontalis) may induce brow ptosis. Therefore, it is recommended that the surgeon stay in the lateral aspect of this area over the bony orbital rim but below the eyebrow, using 5 to 7 units total per side or a more conservative amount initially (Figures 8-35A, B, C). In rare circumstances, an overactive temporalis muscle may pull the unopposed eyebrows up dramatically making the patient appear actually angry, which can be ameliorated with injections into the temporalis muscle. (The authors have never personally encountered this situation but have observed an anecdotal case.) In addition, excessive medial or superior injection will gain little aesthetic benefit. The preferred technique of injection in this area is the above-described fanning technique for a more even infiltration of toxin.
Zone IIIB refers to the middle third of the lateral orbicularis oculi that spans from the upper to the lower rhytid noted during squinting or at rest to 1 cm lateral to the orbital rim. Zone IIIB is treated in order to efface the lateral periocular rhytidosis, or crow’s feet. Again, the surgeon should be wary of excessive medial infiltration over the preseptal or pretarsal orbicularis oculi, especially superiorly toward the levator. The fanning technique is again recommended starting 1 cm lateral to the orbital rim and injecting the span of the needle length (1/2″) with the recommended 30-gauge needle using 5-to-7 units per side and per subzone (i.e., for each Zone IIIA, IIIB, and IIIC).
Zone IIIC represents the area that traverses the lower eyelid and appears as the fine rhytids and hypertrophy of the orbicularis muscle that develops either upon animation or at rest. The perimeter of this zone is defined superiorly by the lowest lateral rhytid (crow’s foot) down to the orbital rim inferiorly and laterally and medially toward the midpupil below the ciliary margin by 3 mm. The surgeon may more safely inject the preseptal and even pretarsal orbicularis oculi to efface the hypertrophic roll of the orbicularis oculi or lower-lid rhytidosis without any notable adverse effect on the blink mechanism (as eye closure is primarily derived from upper-lid closure). However, the lower-lid tone must be carefully evaluated before injection, as any lower-lid laxity may lead to post-injection rounding or ectropion. Therefore, astute attention must be paid to the patient’s anatomy to determine the level of impunity that the surgeon may exercise. The same technique and recommended dosage as for Zones IIIA and IIIB are advocated for Zone IIIC as well. An important contraindication should be mentioned for treatment of Zone IIIC: malar bags or orbicularis festooning may be exacerbated by Botox as the muscle then becomes more lax causing further outpouching of the muscle.
Zone III, in general, reveals the greatest extent of ecchymosis postoperatively that should be addressed with immediate and sustained digital pressure with a 4 x 4 gauze for a period of ten minutes. The assistant should resist the urge to remove the gauze temporarily for inspection, as this will compromise the effect of pressure application. Further, ice is not used in combination with pressure, as the ice interferes with the ability for maximal and even pressure on this area. At the conclusion, patients are handed postoperative-care instructions that inform them not to massage the treated area, as this behavior will disperse the toxin to unintended regions.

Postoperative Considerations: Care, Follow-up, & Complications
A. Postoperative Care & Follow-up
Postoperative care for the above adjunctive procedures is relatively straightforward for the surgical, incision-based procedures, e.g., routine antibiotic ointment applied to incision sites and suture removal at 1 week postoperatively. However, a few salient points should be mentioned regarding proper postoperative care for collagen and Botox patients.
For Botox patients, a postoperative care sheet should be given to remind them of one essential preventative measure, i.e., not to massage the treated areas. The risk of massaging the toxin into adjacent muscles such as the levator complex that would lead to blepharoptosis is a real concern. Some caveats that have often been suggested by other physicians  such as to reduce physical activity for a day and to maintain an upright posture for several hours  have not been found to be necessary in the authors’ clinical experience. The other purpose of the care sheet is to inform the patient of the 2 to 3 day latency of toxin activity and to encourage them to call if any problems or inquiries should arise.

Collagen & Botox
As patients who have undergone collagen or Botox injection do not require any formal postoperative-care visits (e.g., suture, drain, or dressing removal), the surgeon is advised to contact the patient by telephone if a scheduled visit has not been made. This personal communication is much appreciated by the patient and permits the surgeon to establish whether the intended aesthetic objective has been properly met. As a general rule, a postoperative call to the patient regardless of procedure facilitates good rapport and is always recommended. If the surgeon does not have time to contact all of his or her patients who have undergone minor office procedures, then his nurse or office assistant should place the call instead. The phone call should be made about 3 to 5 days postoperatively, and the surgeon should inquire as to patient satisfaction and as to whether any adverse outcomes were encountered, e.g., allergic reaction, bruising, asymmetry, etc. If the patient expresses any concern about the aesthetic result, he or she should be promptly scheduled for a postoperative visit. At the postoperative visit, the surgeon will be able to assess whether the patient’s complaints are justified or whether they reflect ignorance on the part of the patient regarding a projected outcome. Education using a handheld mirror will oftentimes alleviate the frustration or misperception about the intended result. Furthermore, preoperative photographs may further enhance patient education and can be used if necessary. If the surgeon and the patient agree that no discernible result is evident, then the patient should be offered retreatment without payment. Although this policy may seem costly to the surgeon’s practice, the long-term dividends reaped by patient retention and satisfaction are incalculable.

B. Complications & Management

Fortunately, complications arising from Botox injections remain relatively rare in properly trained hands. The principle complication that may arise after Botox injection is asymmetry. However, oftentimes, asymmetry may have already been present preoperatively but went unnoticed by the patient until subjected to the obsessive scrutiny that is characteristic of the postoperative period. If asymmetry results from improper technique, then the surgeon should attempt to ameliorate the condition with additional Botox as deemed achievable. For instance, if a unilateral brow ptosis arises from laterally placed injection in the frontalis muscle, then the surgeon may opt to restore symmetry by carefully placing additional toxin in Zone IIIA on the affected side to weaken the depressor effect of the orbicularis and thereby elevate the brow. However, care should be taken not to venture too far medially and disturb the levator mechanism, compounding the problem. If blepharoptosis arises after a Botox injection, then injury to the levator, albeit temporary, most likely has transpired. The surgeon should then assess whether any visual-field deficit has occurred and attempt to correct this condition with appropriate topical eye drops, e.g., neosynephrine, iodopine, or naphzoline. If lagophthalmos arises, then the surgeon’s primary goal is ocular protection from exposure keratitis.

*Patient Results May Vary
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