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158 Part V&Noninvasive and Minimally Invasive Therapy
TREATMENT OF SELECT AREAS
8. When treating the lips, what layer is the preferred layer for fat injection?
B. Immediately deep to the mucosa or vermilion.
When fat grafting to the lips, fat needs to be precisely placed to achieve a favorable result. Specifically,
the fat needs be injected in the plane immediately deep to the mucosa or vermilion. Placement of fat
within the muscle only creates a fat lip. Fat should not be placed deep to the muscle given the location of
the blood supply of the orbicularis oris (Fig. 23.2).
Correct superficial fat placement
Fig. 23.2 Fat used for lip augmentation should be placed with precise accuracy in the plane immediately deep
to the mucosa or vermilion and should not be infiltrated into the muscle. (Source: Coleman SR, Mazzola RF, Pu LL,
eds. Fat Injection: From Filling to Regeneration, 2nd ed. New York, NY: Thieme; 2018.)
1,2
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
COMPLICATIONS
9. Which of the following is the most common potential complication in fat grafting to the face?
E. Inaccurate volume.
The most common potential complication in fat grafting to the face is inaccurate volume causing
undercorrection or overcorrection. Some surgeons will slightly overfill with the idea that not all of the fat
will be viable postoperatively while others would rather undercorrect and fat graft again than manage an
overcorrected face.
1,2,3,4,5
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19:421
4. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
5. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002;110:1731; discussion 1745
COMPLICATIONS
10. Although rare, blindness is the most feared potential complication in fat grafting to the face. This complica-
tion generally occurs from induction of fat (or filler) around which artery?
C. Supratrochlear artery.
Although rare, arterial occlusion is the most feared potential complication of fat grafting to the face. This will
result in excruciating pain followed by skin loss. More importantly, this complication is even more
devastating in the periorbita as central arterial injection can cause blindness. This complication generally
occurs from induction of fat (or filler) around the supratrochlear, supraorbital, and dorsal nasal
arteries.
1,2,3,4,5
Chapter 23&Fat Grafting 159
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg
1995;19:421
4. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
5. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002;110:1731; discussion 1745
COMPLICATIONS
11. Which of the following potential complications is more likely to be associated with direct trauma rather
than intraarterial fat injection?
E. Numbness.
Intra-arterial injection is a feared complication of surgeons who perform fat grafting to the face. Severe
pain, skin/soft tissue loss, and blindness are all documented complications from arterial occlusion. Intraarterial injection of fat will not affect the sensory nervous distribution; this would only occur through
direct trauma to a sensory nerve. A strong understanding of vascular anatomy should be obtained prior to
performing these procedures and great caution should be taken prior to injecting in the periorbita.
1,2,3,4,5
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19:421
4. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
5. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002;110:1731; discussion 1745
FATE OF TRANSPLANTED ADIPOCYTES
12. How long can adipose-derived stromal cells remain viable in vitro?
C. 3 days.
In vitro studies have shown that transplanted adipocytes are susceptible to an ischemic death, whereas
adipose-derived stromal cells can remain viable for 3 days. It has been shown that most adipocytes die
on day 1, with some survivors. After 7 days of grafting, there is an increase in viable adipocytes,
suggesting that repair and regeneration of adipocytes occurs during this time period.
1,2,3,4,5,6,7
REFERENCES
1. Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and
replacement of adipocytes. Plast Reconstr Surg 2012;129:1081
2. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
3. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
4. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg
1995;19:421
5. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
6. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002;110:1731; discussion 1745
7. Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascularized fat grafting: evidence of early death and
replacement of adipocytes. Plast Reconstr Surg 2012;129:1081–1092
24. Treatment of Prominent Veins
Sammy Sinno, Jeremie Oliver Piña
See Essentials of Aesthetic Surger y, pp. 313–320
TREATMENT OPTIONS
1. What is the standard preoperative workup for an asymptomatic patient desiring sclerotherapy of varicose
veins?
A. Ultrasound.
B. D-dimer blood test.
C. CT scan.
D. Venous duplex imaging.
E. Physical examination only.
TREATMENT OPTIONS
2. For symptomatic patients, why is it necessary to obtain venous duplex imaging prior to treatment?
A. Decrease risk of pulmonary embolism.
B. Identify superficial or deep venous insufficiency.
C. Identify vascular calcification or plaque.
D. To measure vessel patency.
E. Symptomatic patients do not require preoperative venous duplex imaging.
TREATMENT OPTIONS
3. When both superficial and deep veins are affected, in which order should you treat them?
A. Superficial first, then deep.
B. Deep f irst, then superficial.
C. Treat simultaneously with multiple injectors.
D. Does not matter.
E. Treatment of superficial veins may obviate the need for deep vein treatment.
TREATMENT OPTIONS
4. How should the surgeon counsel a patient about expectations of sclerotherapy treatment for varicose veins
and telangiectasias?
A. It is reasonable to expect 100% clearance of treated varicose veins and telangiectasias after 4 to 6 treatment
sessions.
B. Sun exposure after sclerotherapy will complement treatment and enhance results.
C. Compressive stockings are recommended for the morbidly obese.
D. New telangiectasias will tend to occur over time, thus annual maintenance t reatments are recommended.
E. Exercise immediately after treatment sessions will help maintain results.
TREATMENT OPTIONS
5. Which of the following sclerosing agents carries the lowest risk of telangiectatic matting?
A. Sodium tetradecyl sulfate.
B. Polidocanol.
C. Hypertonic saline.
D. Normal saline.
E. Glycerin.
Chapter 24&Treatment of Prominent Veins 161
TREATMENT OPTIONS
6. Which of the following potential complications of sclerotherapy treatment for prominent veins has the high-
est relative risk of occurrence?
A. Ulceration.
B. Telangiectatic matting.
C. Hyperpigmentation.
D. Skin necrosis.
E. Thrombophlebitis.
TREATMENT OPTIONS
7. In which of the following scenarios should you consider laser therapy for telangiectatic veins rather than
sclerotherapy?
A. Telangiectasias are too small or superficial for needle cannula diameter.
B. Patient has a history of a deep vein thrombosis.
C. Patients who have a Fitzpatrick score of III to VI.
D. Patient has a history of phlebitis.
E. Deep telangiectatic veins.
TREATMENT OPTIONS
8. When treating prominent veins with laser therapy, what is the maximum number of attempts over the same
area that can be safely made before risking burns?
A. Single pass.
B. Two.
C. Three.
D. Five.
E. There is no maximum.
TREATMENT OPTIONS
9. How does the postoperative care differ in patients who undergo laser therapy compared to sclerotherapy for
prominent veins?
A. No differences exist.
B. Avoidance of sun exposure to treatment areas is heavily advised.
C. Repeat therapy is typically needed.
D. Immediate return to normal daily activities.
E. Bed rest for 1 to 2 days.
TREATMENT OPTIONS
10. Before proceeding with laser treatment of varicose veins in a patient with Fitzpatrick skin type IV, what pre-
operative assessment should be documented?
A. Complete blood count (CBC).
B. Skin biopsy.
C. Wood's lamp test.
D. Test spot.
E. Proceed without preoperative evaluation.
TREATMENT OPTIONS
11. Which of the following varicose vein treatment options yields the highest reported recurrence rates?
A. Sclerotherapy.
B. Laser.
C. Surgery.
D. Nonendothermal endovenous ablation.
E. Radiofrequency ablation (RFA).
162 Part V&Noninvasive and Minimally Invasive Therapy
Answers
TREATMENT OPTIONS
1. What is the standard preoperative workup for an asymptomatic patient desiring sclerotherapy of varicose
veins?
E. Physical examination only.
Asymptomatic patients presenting for cosmetic sclerotherapy treatment of varicose veins do not require
further preoperative workup beyond a standard physical examination prior to administering
treatment.
REFERENCES
1. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev 2011;18:
CD008826
2. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2006;(4):
CD001732
TREATMENT OPTIONS
2. For symptomatic patients, why is it necessary to obtain venous duplex imaging prior to treatment?
C. Identify vascular calcification or plaque.
While asymptomatic patients do not require preoperative diagnostic workup beyond a standard physical
examination, symptomatic patients should undergo venous duplex imaging to identify potential presence
of superficial or deep venous insuf ficiency.
1,2
1,2
REFERENCES
1. Callam MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167
2. Chiesa R, Marone EM, Limoni C, et al. Chronic venous disorders: correlation between visible signs, symptoms,
and presence of functional disease. J Vasc Surg 2007;46:322
TREATMENT OPTIONS
3. When both superficial and deep veins are affected, in which order should you treat them?
B. Deep first, then superficial.
Larger underlying reticular varicose veins should first be treated with sclerotherapy before more superficial,
telangiectatic vessels are addressed.
1,2,3
REFERENCES
1. Callam MJ. Epidemiology of varicose veins. Br J Surg 1994;81:167
2. Chiesa R, Marone EM, Limoni C, et al. Chronic venous disorders: correlation between visible signs, symptoms,
and presence of functional disease. J Vasc Surg 2007;46:322
3. Langer RD, Ho E, Denenberg JO, et al. Relationships between symptoms and venous disease: the San Diego pop-
ulation study. Arch Intern Med 2005;165:1420
TREATMENT OPTIONS
4. How should the surgeon counsel a patient about expectations of sclerotherapy treatment for varicose veins
and telangiectasias?
D. New telangiectasias will tend to occur over time, thus annual maintenance treatments are
recommended.
In the sclerotherapy consultation, it is important to inform patients that new spider veins will tend to
recur over time and annual maintenance treatments are encouraged.
1,2,3,4
Chapter 24&Treatment of Prominent Veins 163
REFERENCES
1. Chiesa R, Marone EM, Limoni C, et al. Chronic venous disorders: correlation between visible signs, symptoms,
and presence of functional disease. J Vasc Surg 2007;46:322
2. Langer RD, Ho E, Denenberg JO, et al. Relationships between symptoms and venous disease: the San Diego population study. Arch Intern Med 2005;165:1420
3. Chang CJ, Chua JJ. Endovenous laser photocoagulation (EVLP) for varicose veins. Lasers Surg Med 2002;31:257
4. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev 2011;18:
CD008826
TREATMENT OPTIONS
5. Which of the following sclerosing agents carries the lowest risk of telangiectatic matting?
E. Glycerin.
Among those listed, glycerin (ideally 72%) carries the lowest risk of associated telangiectatic matting, as well
as ulceration and necrosis. However, the disadvantages of glycerin include potential contact sensitivity, urethral colic, hematuria (although rare), as well as the fact that it is off-label for treatment of prominent veins
(Table 24.1).
Table 24.1 Common Sclerosing Agents for the Treatment of Prominent Veins
Agent Vessel
Sodium
tetradecyl
sulfate
Polidocanol <0.5
Hypertonic
saline
Glycerin <125–72 0.25 10 mL of
1,2,3
Size
(mm)
0.3–1
1–3
3–5
>5
0.5–1
1–3
<0.5
0.5–1
1–3
Concentration
(%)
0.1–0.25
0.25–0.5
0.5–1
1–3
0.25
0.5
1
11.7
11.7
23.4
Volume
(mL)
0.25
0.5
0.5–1
1–2
0.1–0.3
0.1–0.3
0.1–0.3
0.25
0.5
0.5–1
Maximum
Dose
10 mL of
3%
2 mg/kg Painless
None No allergy Pain
72%
Advantages Disadvantages
Less
telangiectatic
matting
Nontoxic
Rare ulceration No
necrosis
No matting
No ulceration No
necrosis
Allergy
Hyperpigmentation at high
concentrations
Ulceration/
necrosis
Allergy
Telangiectatic
matting
Hyperpigmentation
Muscle cramping
Ulceration/
necrosis
Hyperpigmentation
Contact sensitivity
Urethral colic
Hematuria
(rare)
Off-label, not
FDA approved
REFERENCES
1. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev 2011;18:
CD008826
2. Tisi PV, Beverley C, Rees A. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev 2006;
CD001732
3. Leach BC, Goldman MP. Comparative trial between sodium tetradecyl sulfate and glycerin in the treatment of
telangiectatic leg veins. Dermatol Surg 2003;29:612; discussion 615
164 Part V&Noninvasive and Minimally Invasive Therapy
TREATMENT OPTIONS
6. Which of the following potential complications of sclerotherapy treatment for prominent veins has the high-
est relative risk of occurrence?
C. Hyperpigmentation.
Hyperpigmentation, caused by deposition of hemosiderin within the treated skin areas, has a relative
occurrence rate of 30% in patients undergoing sclerotherapy; however, this tends to be transient,
resolving spontaneously in 80% of patients within 2 years of final treatment. Comparatively, the risk of
ulceration is between 1 and 5% (usually small, heals with home wound care within 4–6 weeks), and the
risk of telangiectatic matting is about 15 to 24% (also transient, resolving within 3–12 months).
1
REFERENCE
1. Gillet JL, Guedes JM, Guex JJ, et al. Side-effects and complications of foam sclerotherapy of the great and small
saphenous veins: a controlled multicentre prospective study including 1,025 patients. Phlebology 2009;24:131
TREATMENT OPTIONS
7. In which of the following scenarios should you consider laser therapy for telangiectatic veins rather than
sclerotherapy?
A. Telangiectasias are too small or superficial for needle cannula diameter.
There are certain circumstances under which the surgeon should treat telangiectatic veins with laser
therapy rather than sclerosing agents. These include the following: the patient does not tolerate
sclerotherapy well or has already tried and failed to respond to treatment; superficial telangiectatic veins
are too small in diameter for sclerotherapy needle; the patient is too afraid of the needle to undergo
treatment; history of acute venous thrombosis or phlebitis; and pregnancy. Other relative
contraindications include diabetes mellitus, peripheral arterial disease, as well as Fitzpatrick skin types
III to VI.
1
REFERENCE
1. McCoppin HH, Hovenic WW, Wheeland RG. Laser treatment of superficial leg veins: a review. Dermatol Surg
2011;37:729
TREATMENT OPTIONS
8. When treating prominent veins with laser therapy, what is the maximum number of attempts over the same
area that can be safely made before risking burns?
C. Three.
As a preventative technique to avoid risk of burning the skin, the surgeon should avoid exceeding a maximum of three attempts passing over the same area with laser therapy of prominent veins.
1,2,3,4
REFERENCES
1. Munavalli GS,Weiss RA. Complications of sclerotherapy. Semin Cutan Med Surg 2007;26:22
2. Gillet JL, Guedes JM, Guex JJ, et al. Side-effects and complications off sclerotherapy of the great and small saphe-
nous veins: a controlled multicentre prospective study including 1,025 patients. Phlebology 2009;24:131
3. McCoppin HH, Hovenic WW, Wheel and RG. Laser treat ment of superficial leg veins: a review. Dermatol Surg
2011;37:729
4. Eremia S, Li C, Umar SH. Aside-by side comparative study of 1064 nm Nd:YAG, 810 nm diode and 755 nm alex-
andrite lasers for treatment of 0.3–3 mm leg veins. Dermatol Surg 2002;28:224
TREATMENT OPTIONS
9. How does the postoperative care differ in patients who undergo laser therapy compared to sclerotherapy for
prominent veins?
D. Immediate return to normal daily activities.
Unlike in postoperative care for sclerotherapy (which requires compressive stockings and avoidance of exercise for 2–4 weeks), laser therapy allows patients to resume daily activities immediately.
1,2,3,4
Chapter 24&Treatment of Prominent Veins 165
REFERENCES
1. Hamahata A, Yamaki T, Sakurai H. Outcomes of ultrasound-guided foam sclerotherapy for varicose veins of the
lower extremities: a single center experience. Dermatol Surg 2001;37:804
2. Eremia S, Li C,Umar SH.A side-by-side comparative study of 1064 nmNd:YAG, 810 nm diode and 755 nm alexandrite lasers for treatment of 0.3–3 mm leg veins. Dermatol Surg 2002;28:224
3. Chen JZ, Alexiades-Armenakas MR, Bernstein LJ, et al.Two randomized, double-blind, placebo-controlled studies
evaluating the S-Caine Peel for induction of local anesthesia before long- pulsed Nd:YAG laser therapy for leg
veins. Dermatol Surg 2003;29:1012
4. Desmyttère J, Grard C, Wassmer B, et al. Endovenous 980-nm laser treatment of saphenous veins in a series of
500 patients. J Vasc Surg 2007;46:1242
TREATMENT OPTIONS
10. Before proceeding with laser treatment of varicose veins in a patient with Fitzpatrick skin type IV, what pre-
operative assessment should be documented?
D. Test spot.
Given the heightened risk of hyperpigmentation (can be transient) and hypopigmentation (more
typically permanent), a test spot should be performed before proceeding with laser therapy on patients
with Fitzpatrick skin types III to VI.
1
REFERENCE
1. McCoppin HH, Hovenic WW, Wheeland RG. Laser treatment of superficial leg veins: a review. Dermatol Surg
2011;37:729
TREATMENT OPTIONS
11. Which of the following varicose vein treatment options yields the highest reported recurrence rates?
C. Surgery.
Of the options listed, surgical management of varicose veins has largely been replaced by less-invasive methods of treatment (for varicose veins <1.5 cm diameter), as surgical techniques are associated with a 20 to
28% recurrence rate of varicose veins.
1,2
REFERENCES
1. Ravi R, Trayler EA , Barrett DA, et al. Endovenous thermal ablation of superficial venous insufficiency of the lower
extremity: single-center experience with 3000 limbs treated in a 7-year period. J Endovasc Ther 2009;16:500
2. Merchant RF, Pichot O; Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of
saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005;42:502; discussion 509
PART VI
Adjuncts to Aesthetic Surgery