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128 Part V&Noninvasive and Minimally Invasive Therapy
Answers
PREOPERATIVE EVALUATION
1. Which of the following Fitzpatrick skin types should you proceed with caution when considering
dermabrasion?
D. IV.
Fitzpatrick skin types I through III will have a uniform blended skin color postoperatively. Proceed with caution in type IV, and it is best to not dermabrade types V and VI due to hyperpigmentation postoperatively. A
review of Fitzpatrick skin type classification can be found below (Table 20.1).
Table 20.1 Fitzpatrick Skin Type Classification
Skin Type Characteristics Sun Exposure History
I Pale white, freckles, blue eyes, blond or red hair Always burns, never tans
II Fair white, blue/green/hazel eyes, blond or red hair Usually burns, minimally tans
III Cream white, any hair or eye color Sometimes burns, tans uniformly
IV Moderate brown (Mediterranean) Rarely burns, always tans well
V Dark brown (Middle Eastern) Rarely burns, tans easily
VI Dark brown to black Never burns, tans easily
(Source: Data from Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch
Dermatol 124:869, 1988.)
1
REFERENCE
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
PREOPERATIVE EVALUATION
2. When performing a “test spot” for a patient who is considering dermabrasion to the face or neck, what is a
reasonable anatomic location?
B. Postauricular.
The test spot should be located close to the area to be treated but in an obscured area that can easily be camouflaged or hidden if further treatment is not performed. For facial or neck candidates, placing the “test spot”
behind the ear can give a reasonable assessment of effect. This is usually a 1-cm spot that is abraded with the
patient under local anesthesia. It is important to stress that the test spot is not predictive of the overall
outcome. This point cannot be overstressed.
1
REFERENCE
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
PREOPERATIVE EVALUATION
3. A 30-year-old patient comes to you requesting dermabrasion. Her history is notable for occasional cold sores,
most recently 2 years prior. Which of the following should be part of your preprocedural instructions?
D. Acyclovir 1 g, twice per day, starting 1 day before the procedure and lasting 5 to 7 days.
Patients are generally given an antibacterial cleanser to wash and shampoo the night before and the morning
of surgery. Prescriptions for cephalexin 500 mg twice per day for 5 to 7 days, acyclovir 1 g once per day (twice
per day for patients with history of oral herpes, start the day before the procedure) for 5 to 7 days.
For this patient with a history of cold sores, acyclovir 1 g, twice per day, would be the recommendation.
Avoidance of reactivation of oral herpes during the healing process is very important.
1,2,3
Chapter 20&Dermabrasion 129
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Duffy DM. Informed consent for chemical peels and dermabrasion. Dermatol Clin 1989;7:183
3. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
INDICATIONS AND CONTRAINDICATIONS
4. Which of the following is a contraindication to dermabrasion?
E. Isotretinoin therapy within 6 to 12 months.
Dermabrasion has been used for numerous t raumat ic and medical conditions. Please see Box 20.1 and
Box 20.2 for indications (partial list) and contraindication (partial list). Of the choices listed, only history
of isotretinoin therapy within the last 6 to 12 months would be considered a contraindication to
dermabrasion.
BOX 20.1 CONDITIONS TREATABLE WITH DERMABRA SION
Acne rosacea
Actinically damaged skin
Active acne
Adenoma sebaceum
Angiofibromas of tuberous sclerosis
Basal cell carcinoma (superficial type)
Blast tattoos (gunpowder)
Chloasma
Chronic radiation dermatitis (mild)
Congenital pigmented nevi
Darier's disease
Dermatitis papillaris capillitii
Early operative scars
Facial rhytids
Favre-Racouchot syndrome
Fox-Fordyce disease
Freckles
Hair transplantation (elevated recipient sites)
Hemangiomas
Hypertrophic scars
Keratoacanthomas
Lentigines
Lichen amyloidosis
Lichenified dermatoses
Linear epidermal nevus
Discoid lupus erythematosus
Mibelli porokeratosis
Multiple pigmented nevi
Multiple seborrheic keratoses
Multiple trichoepitheliomas
Neurotic excoriations
Postacne scars
Pseudofolliculitis barbae
Rhinophyma
Scleromyxedema
Smallpox or chickenpox scars
Striae distensae
Syringomas
Syringocystadenoma papilliferum
Tattoos (decorative and traumatic)
1,2
130 Part V&Noninvasive and Minimally Invasive Therapy
Telangiectasias
Traumatic scars
Verrucous nevus
Vitiligo
Xanthelasma
Xeroderma pigmentosum
(Source: Data from Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 9:267, 2001.)
OX 20.2 CONTRAINDICATIONS TO DERMABRASION
B
Absolute Isotretinoin therapy within the last 6 to 12 months*
Relative History of hypertrophic scars
*Seven patients with atrophic acne scars on the face taking oral isotretinoin to treat facial acne had manual dermabrasion on
an area approximately 1 cm2. At the 6-month follow-up, all patients had normal cicatrization, and the atrophic acne scar
revision was deemed excellent. In another study, 10 patients treated with oral isotretinoin for acne had a medium-depth
chemical peel applied to the entire face and manual sandpaper dermabrasion (until the appearance of a blood dew) 1 to 3
months after the isotretinoin therapy was concluded. At the 6-month follow-up, all patients had normal cicatrization, and no
hypertrophic scars or keloids were observed. Depressed acne scar revision was satisfactory.
†
Personal decision of the surgeon.
(Source: Data from Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 9:267, 2001.)
Congenital ectodermal defects
Radiodermatitis (only if severe)
Pyoderma
Psychosis
Active herpes labialis
History of keloids
Burns—deep thermal or chemical
Fitzpatrick skin types IV, V, VI (test patch should be tried first)
History of hepatitis or HIV
†
REFERENCES
1. Bagatin E, dos Santos Guadanhim LR, Yarak S, et al. Dermabrasion for acne scars during treatment with oral
isotretinoin. Dermatol Surg 2010;36:483
2. Picosse FR, Yarak S, Cabral NC, et al. Early chemabrasion for acne scars after treatment with oral isotretinoin.
Dermatol Surg 2012;38:1521
INFORMED CONSENT
5. As part of the informed consent, the patient should understand that the most likely complication from derm-
abrasion is which of the following?
E. Milia.
The most common complication from der mabrasion is milia, which are small white cysts over the surface
of the treated area. One-third of patients will develop them. They typically appear within 2 to 4 weeks
after treatment and will clear spontaneously in most patients. These small cysts can be unroofed with a
buff puff or a mildly abrasive skin cleaner. Other less common complications include scarring,
catastrophic intr aoperative disaster (avulsion of soft tissue such as lips and eyelids), dyspigmentation,
and failure of the procedure to adequately improve the treated area. Additionally, while the surgeon (and
the patient) should always be aware of fire risk and minimizing potential for intraoperative fire, this risk
is less than from other devices such as cautery and lasers.
1,2
REFERENCES
1. Duffy DM. Informed consent for chemical peels and dermabrasion. Dermatol Clin 1989;7:183
2. Dubina M, Tung R. Management of complications of microdermabrasion and dermabrasion. In: Tosti A, Beer K,
De Padova MP, eds. Management of Complications of Cosmetic Procedures: Handling Problems and More
Uncommon Problems. Berlin, Heidelberg: Springer; 2012
y
Chapter 20&Dermabrasion 131
EQUIPMENT AND PREPARATION
6. Which of the following combination of abrading tips offers the greatest margin of safety?
B. Wide-barrel fraise with fine-grade diamonds.
For novice surgeons, a wide-barrel fraise with fine-grade diamonds offers the greatest margin of safety. The
wider the barrel, the less easily you can gauge through the skin. The coarser the diamond surface, the faster
the cutting speed, the greater the penetration into tissue. Wire brush tips should be used with great care
because tissue damage can easily occur. Similarly, the serrated wheel should only be employed by experienced surgeons because of its greater potential to cause tissue damage.
1,2
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
PERFORMANCE DETAILS
7. When working with tissues with leading (free) edges, which of the following is the correct combination of
movements?
A. Handpiece toward leading edge, drum rotation toward leading edge.
The correct way to move the handpiece of a dermabrader is depicted in Fig. 20.1. The tissue should be
swept away from the rotating drum. The handpiece should be moved toward the leading edge. This will
help prevent the free edge from being dragged up over the drum, which could forcefully avulse tissues
with free edges (lips and eyelids).
1,2
Direction of
handpiece movement
Correct way
Drum rotation
(clockwise)
Free edgeFree edge
Wrong wa
Fig. 20.1 Correct way to move the handpiece of a dermabrader. When the handpiece is moved in the direction
of rotation (correct way), the tissue is swept away from the rotating drum. When the handpiece is moved in
the direction opposite the drum's rotation, the abrasive tip will clutch the tissue; the rotating drum, in combination with the moving handpiece, will “dig into” the tissue and cause the upcoming tissue to be forcefully and
rapidly pulled toward the rotating drum. A free edge would be dragged up and over the drum. This can forcefully avulse tissues with free edges (lips and eyelids).
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
(Source: Performance Details. In: Janis J, ed. Essentials of
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
PERFORMANCE DETAILS
8. What is the endpoint for dermabrasion?
E. Uniformly spaced, punctate bleeding.
The abraded surface needs to be wiped frequently with a gauze to observe the bleeding pattern. The
endpoint of dermabrasion is uniformly spaced, punctate bleeding. After dermabrasion treatment, the skin
is cleaned using a saline solution rinse and a soft bristle brush or rough gauze is used to remove excess
skin debris.
1,2
132 Part V&Noninvasive and Minimally Invasive Therapy
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
POSTOPERATIVE CARE
9. A patient who had dermabrasion several weeks ago comes in with persistent redness. There is no concern for
infection. What treatment adjunct can you offer to this patient?
E. Topical steroid cream.
Patients should continue or finish both oral antibiotics and antivirals initially prescribed. The patient in
this scenario does not have a bacterial or viral infection. Ascorbic acid (vitamin C) can be recommended
for hyperpigmentation, but not persistent redness. Instead, the patient has persistent redness that can be
treated with topical steroid cream (Temovate [clobetasol propionate] 0.05%) applied twice per day for 2
weeks. This regimen is repeated until normal skin color returns. Patients should not use this continuously
and should not use it on the eyelids. Patients should be wearing sunblock every day—regardless of the
season and whether the patient works inside or outside. This must be stressed.
1,2
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
MICRODERMABRASION
10. What is the endpoint for microdermabrasion?
A. Erythema.
With microdermabrasion, longer contact of the abrasive crystals with the skin by slowly moving the
handpiece and performing more passes will result in a deeper abrasion. Two passes will exfoliate to a
depth of 15 to 25 μm causing epidermal exfoliation in the appearance of erythema. This should only
affect the epidermis and is ineffective for deeper wrinkles and scars. Two treatments per session are
sufficient for the face. Usually, 5 to 12 treatments are needed, although more may be warranted in
heavily scarred/damaged areas. The endpoint for each session is erythema.
salicylic acid peels when the salicylic acid crystalizes.
1
Pseudofrost only applies to
REFERENCE
1. Holck DE, Ng JD. Facial skin rejuvenation. Curr Opin Ophthalmol 2003;14:246
COMPLICATIONS
11. When does hypopigmentation occur following dermabrasion?
B. When treatment was too deep.
Proper patient selection is the best treatment for hyperpigmentation and hypopigmentation. In general
hypopigmentation occurs from dermabrasion that is too deep. Usually this problema corrects with time.
1,2
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
COMPLICATIONS
12. When does hyperpigmentation most likely occur following dermabrasion?
C. When performed in patients with darker skin types.
Hyperpigmentation occurs most commonly in patients with type III or IV skin and in those who have not
used sunblock. Hyperpigmentation can sometimes be minimized with 2 g of ascorbic acid (vitamin C)
Chapter 20&Dermabrasion 133
daily. Pigmentation is usually limited to the superficial epidermis and is treatable with topical
applications of Retin-A, hydroquinone, and glycolic acids. If pigment persists for several months, a
medium-depth peel may be necessary.
1,2
REFERENCES
1. Baker JL. Dermabrasion. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques. New York: Thieme
Publishers; 2005
2. Hruza GJ. Dermabrasion. Facial Plast Surg Clin North Am 2001;9:267
21. Botulinum Toxin
Sammy Sinno, Simon Moradian, Aaron M. Kearney
See Essentials of Aesthetic Surger y, pp. 269–279
BOTOX PHYSIOLOGY
1. What is the mechanism of action of botulinum toxin?
A. Acts at presynaptic nerve terminals to inhibit the release of acetylcholine.
B. Acts at postsynaptic receptors to prevent binding of acetylcholine.
C. Prevents production of acetylcholine.
D. Binds muscarinic receptors.
E. Stimulation of Rho/Rho kinase pathway.
BOTOX PHYSIOLOGY
2. On average, how long is Botox usually effective?
A. 1 month.
B. 3 months.
C. 6 months.
D. 9 months.
E. 1 year.
CLINICAL CONSIDERATIONS
3. What muscle forms only vertical glabellar lines?
A. Depressor supercilii.
B. Nasalis.
C. Procerus.
D. Corrugator supercilii.
E. Frontalis.
CLINICAL CONSIDERATIONS
4. A 42-year-old male is seeking treatment of his forehead rhytids with Botox. He has a friend who had this done
but told him one eyebrow was lower than the other for several months after. He asks what can be done to
prevent this from happening to him. What would be the safest way to minimize brow ptosis when injecting
for forehead rhytids in this patient?
A. Inject in a supraperiosteal plane.
B. Inject at least 2 cm above the eyebrow.
C. Do not inject forehead lines.
D. Inject along the upper border of the eyebrow.
E. Inject along the superior border of the levator palpebrae superiorus.
CLINICAL CONSIDERATIONS
5. Where should perioral rhytids be injected to avoid adverse effects on the lip?
A. Deep, at least 5 mm from the vermilion border.
B. Deep, within 5 mm of the vermilion border.
C. Superficial, within 5 mm of the vermilion border.
D. Superficial, 5 mm from the vermilion border.
E. Superficial, 10 to 15 mm from the vermilion border.
Chapter 21
Botulinum Toxin 135
CLINICAL CONSIDERATIONS
6. What portion of the masseter should be injected to correct masseteric hypertrophy?
A. The most prominent point of muscle.
B. Along the inferior border of the angle of the mandible only.
C. The superf icial layer.
D. The middle layer of muscle.
E. The deep layer of muscle.
CLINICAL CONSIDERATIONS
7. When is the typical onset of action of botulinum toxin following injection?
A. 1 hour.
B. 1 day.
C. 3 to 4 days.
D. 14 days.
E. 21 days.
CLINICAL CONSIDERATIONS
8. What is the most commonly reported adverse effect of botulinum toxin?
A. Hypersensitivity.
B. Dysphagia.
C. Headache.
D. Ecchymosis.
E. Transient eyelid ptosis.
136 Part V
Noninvasive and Minimally Invasive Therapy
Answers
BOTOX PHYSIOLOGY
1. What is the mechanism of action of botulinum toxin?
A. Acts at presynaptic nerve terminals to inhibit the release of acetylcholine.
The neurotoxin acts at presynaptic nerve terminals to inhibit the release of acetylcholine, producing
chemodenervation. The protein consists of a heavy chain and a light chain. The heavy chain irreversibly
binds to the nerve terminal, and the toxin is internalized through endocytosis, where it renders the
nerve terminal nonfunctional and blocks the release of acetylcholine into the neuromuscular junction.
Botox inhibits Rho kinase which inhibits smooth muscle cell constriction directly through interference
with the Ca
REFERENCE
1. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003;112(5 Suppl):
S117
BOTOX PHYSIOLOGY
2. On average, how long is Botox usually effective?
B. 3 months.
Botox is usually effective for approximately 3 months with the upper end of extreme being closer to 6
months. This varies depending on the preparation (Botox, Dysport, and Xeomin) as well as the number of
units injected into a given area.
2+
sensitivity of vascular smooth muscle cells and the NO system.
1,2
1
REFERENCES
1. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003;112(5 Suppl):
S117
2. Kim EJ, Ramirez AL, Reeck JB, et al. The role of botulinum toxin type B (Myobloc) in the treatment of hyperkinetic
facial lines. Plast Reconstr Surg 2003;112(5 Suppl):S88
CLINICAL CONSIDERATIONS
3. What muscle forms only vertical glabellar lines?
D. Corrugator supercilii.
The corrugator supercilii, procerus, and depressor supercili (medial orbicularis oculi) are the muscles
responsible for brow depression and make up the glabellar muscle units. The corrugator supercilii muscles
are the only paired muscles that contribute to a dynamic vertical line. The procerus is a flat, pyramidal muscle on the bridge of the nose which contributes to form a transverse rhytid. The depressor supercilii muscle is
a portion of the medial orbicularis oculi muscle which contributes to both vertical and transverse glabellar
lines and a lower static medial brow position. The nasalis forms bunny lines and is not involved in the glabellar muscle unit.
1,2
REFERENCES
1. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-Aexotoxin. J Dermatol Surg
Oncol 1992;18:17
2. Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg 2004;114(Suppl 6):S1
Chapter 21
Botulinum Toxin 137
CLINICAL CONSIDERATIONS
4. A 42-year-old male is seeking treatment of his forehead rhytids with Botox. He has a friend who had this done
but told him one eyebrow was lower than the other for several months after. He asks what can be done to
prevent this from happening to him. What would be the safest way to minimize brow ptosis when injecting
for forehead rhytids in this patient?
B. Inject at least 2 cm above the eyebrow.
Brow ptosis can be avoided by staying at least 2 cm above the eyebrow when injecting. Especially in a
male patient, who likely will have lower set eyebrows compared to a female, this may be an unreliable
landmark to use. Therefore, staying at least 2 cm above the upper brow should lower the risk of brow
ptosis. In general, one should inject above the superior orbital rim in order to prevent the neurotoxin
from diffusing inferiorly and paralyzing the levator palpebrae superioris, which is innervated by a branch
of the oculomotor nerve leading to ptosis. Injecting supraperiosteal or within the forehead lines will not
make a difference in relation to brow ptosis.
1,2,3
REFERENCES
1. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003;112(5 Suppl):
S117
2. Kim EJ, Ramirez AL, Reeck JB, et al. The role of botulinum toxin type B (Myobloc) in the treatment of hyperkinetic
facial lines. Plast Reconstr Surg 2003;112(5 Suppl):S88
3. Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg 2004;114(Suppl 6):S1
CLINICAL CONSIDERATIONS
5. Where should perioral rhytids be injected to avoid adverse effects
on the lip?
C. Superficial, within 5 mm of the vermilion border.
Injecting in a deep plane or further than 5 mm from the vermilion can affect the function of the lips. This should be considered
especially in patients such as musicians. The perioral region
should generally not be injected in patients who are dependent
on their lips for their professions. Addit ionally, perioral region is
often more sensitive, and topical anesthesia is often beneficial in
this location (Fig. 21.1).
1,2,3,4
REFERENCES
1. Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group.
Consensus recommendations on the use of botulinum toxin type
a in facial aesthetics. Plast Reconstr Surg 2004;114(Suppl 6):S1
2. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum
toxin. Plast Reconstr Surg 2003;112(5 Suppl):S117
3. Kim EJ, Ramirez AL, Reeck JB, et al. The role of botulinum toxin type
B (Myobloc) in the treatment of hyperkinetic facial lines. Plast Reconstr Surg 2003;112(5 Suppl):S88
4. Kwiat DM, Bersani TA, Bersani A. Increased patient comfort utilizing botulinum toxin type a reconstituted with
preserved versus nonpreserved saline. Ophthal Plast Reconstr Surg 2004;20:186
Fig. 21.1 Injection points for perioral
rhytids.
Essentials of Aesthetic Surgery. 1st
Edition. New York: Thieme; 2018.)
(Source: Injection. In: Janis J, ed.
CLINICAL CONSIDERATIONS
6. What portion of the masseter should be injected to correct masseteric hypertrophy?
A. The most prominent point of muscle.
The most prominent portion of the masseter should be injected to correct hypertrophy. Masseter
hypertrophy can lead to a wide contour of the lower face. In 1994, Moore and Wood first used botulinum
toxin for functional reasons. Rijsdijk et al later used the toxin for aesthetic wrinkle reduction. The
masseter consists of three layers of skeletal muscle: superficial, middle, and deep layers. The myofibers