Practical Plastic Surgery

belly perpendicular to the skin. It is useful to use facial animation to mark the areas that require treatment. Injections should be made with the patient reclined to 45˚. In addition, the practitioner should prospectively look for superficial vessels in the skin and avoid injecting them in order to decrease the risk for ecchymosis. If a bruise starts to develop, the practitioner should hold 5-10 minutes of pressure to avoid a hematoma, which could lead to migration of the toxin. Although the clinician may gently massage the site of injection at the time of treatment, patients should be told not to massage the area as it may cause diffusion of the drug and result in weakness

74of unintended muscles. Patients should contract the treated areas as it may increase local uptake of the toxin.

Patient Counseling

Similar to other surgical procedures, treatment should be individualized. Clinicians should set realistic expectations and discuss if off-label use is planned. The effect of Botox may not manifest for 24-72 hours after injection, with optimal results seen at 2 weeks. Results typically last 2-3 months, but clinicians have reported results lasting 6 months or more. In general, assessment and possible retreatment can be done 14 days postinjection. To assess efficacy, photography is essential for guiding preinjection and postinjection treatment plans. The main side effects that a patient may encounter include: pain at the injection site; bruising (avoiding NSAIDs for 10-14 days prior to injection is helpful); and unexpected weakness of muscle groups (for example, eyelid ptosis).

Treatment Areas

FDA Approved Uses

Glabellar Complex/Vertical Frown Lines

The main muscles treated in the glabella include the corrugators and procerus. Fibers from the orbicularis oculi may also contribute to the glabellar complex. These muscles are brow depressors and are responsible for the vertical frown lines. The most common number of injection sites is five (two per corrugator and one to the procerus), and a total Botox starting dose of 20-30 U for women and 30-40 U for men can be used. This dose does not have to be divided equally among injection sites.

Off-Label Uses

Frontalis/Horizontal Forehead Lines

The frontalis elevates the brow and is responsible for horizontal forehead wrinkles. The number of injections varies from four to ten, depending on the severity of the rhytids. Injections are done 2 cm above the brow and should be lateral enough to avoid a “quizzical” eyebrow appearance. A total starting dose of 10-20 U for women and 20-30 U for men is used in equally divided doses. Complete paralysis of the frontalis should be avoided; rather, the goal should be to weaken the muscle. In addition, the forehead should not be treated without the glabella, as this will lead to a potential increase in rhytids due to loss of activity of the antagonist muscles.

Orbicularis Oculi/Crow’s Feet

The orbicularis oculi functions for voluntary and involuntary closing of the eyelids. The usual number of injections is two to five per side. The injections should be superficial (to avoid bruising), lateral, and 1 cm from the orbit. The total starting dose is typically 12 U, divided equally per injection site. Similar to the treatment of the frontalis muscle, the goal should be to weaken the muscle rather than cause complete immobility.

The orbicularis oris surrounds the mouth and acts as a sphincter to close the lips. Wrinkles of the upper lip are often treated by multiple modalities such as with fillers or resurfacing, but Botox can aid in improving the appearance of the perioral area. In general, four sites are treated—one injection per lip quadrant. If more sites are treated, the injections should be symmetrical. Avoid the midline of the upper lip and the corner of the lips. The total starting dose is 4-10 U, divided equally among each injection. Injections should be started with low doses and repeated as necessary to avoid oral incompetence or an increase in dental show.

Platysma/Platysmal Bands

The platysma acts to depress the lower jaw and pull the lower lips and corners of the mouth down and sideways. Bands are treated with three to five injection sites per band at 1 cm intervals. Injections are done by grasping the band and injecting directly into the belly of the muscle. A total starting dose of 10-30 U for women and 10-40 U for men is used in equally divided aliquots. Treatment can be expected to last 3 to 4 months.

Pearls and Pitfalls

1.Glabellar complex: Assess preinjection brow position and symmetry because treatment can affect eyebrow shape and position. Injections should be directed outside the orbital rim.

2.Frontalis: Stay 2 cm above the brow and start with a low dose to avoid complete forehead immobilization.

3.Orbicularis oculi: Avoid the delicate veins around the eye to prevent bruising, and evaluate lid laxity prior to treatment because excessive laxity increases the risk of an ectropion.

4.Orbicularis oris: Avoid injections too far from the lip margin and avoid using Botox in patients who rely on their lips for their professions (for example, singers).

5.Platysma: Avoid injecting the strap muscles.

Suggested Reading

1.Carruthers J, Fagien S, Matarasso SL et al. Consensus recommendations on the use of botulinum toxin type A in facial aesthetics. Plast Reconstr Surg 2004; 114:1S.

2.Klein AW. Dilution and storage of botulinum toxin. Dermatol Surg 1998; 24:1179.

3.Allergan, Inc. Botox Cosmetic purified neurotoxin complex (package insert).

4.Carruthers JD, Lower NJ, Menter MA et al. Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines. Plast Reconstr Surg 2003; 112:1089.

5.Fagien S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: Adjunctive use in facial aesthetic surgery. Plast Reconstr Surg 1999; 103:701.

Indications

The following are the common indications for dermabrasion:

•Unacceptable appearance of a scar

•Scarring from long-standing acne

•Fine wrinkles

•Tattoo removal

•Removal of seborrheic keratoses

•Removal of a number of other benign skin tumors

•Treatment of the rhinophyma of acne rosacea

75

Relative Contraindications

The following are conditions under which dermabrasion should be postponed:

•History of Accutane® use in the past 12 months due to the risk of hypertrophic scarring in those who have been taking isotretinoins

•Predisposition to keloid scarring

•Active herpes simplex infection at the site of dermabrasion

•Severe immunosupression

Preoperative Considerations

A number of preoperative steps can be taken that will minimize the risk of complications. Many of these deal with decreasing the risk of infection in certain higher risk patients:

•Smoking cessation for at least 2 weeks

•Avoidance of anticlotting medications for at least 10 days

•Face scrubbing the night before and morning of surgery

•Prophylaxis with valacyclovir in those with a history of oral herpes (Valtrex® for 10-14 days)

•Prophylaxis with antistaphlococcus antibiotics in patients with impetigo who have a positive nasal swab culture

•Daily Retin-A® application for two weeks is recommended by some dermatologists

Anesthesia

Some patients will undergo additional procedures requiring general anesthesia. Most, however, will undergo dermabrasion while receiving local anesthesia and intravenous sedation. A common routine is to provide an amnestic the night before surgery for anxious patients. A benzodiazepine such as diazepam can be given the morning of surgery, as well as an antiemetic such as Zofran®. Commonly used intraoperative sedation regimens are fentanyl and midazolam, or fentanyl and propofol. These medications are discussed in greater detail in the chapter on conscious sedation. Local anesthesia is administered, and additional anesthesia can be provided by regional nerve blocks.

Intraoperative Considerations

Some surgeons will pretreat the areas to be abraded with a cryoanesthetic right up to the time of dermabrasion. Allowing the skin to rewarm can result in vasodillation and consequently increased bleeding. In addition, a refrigerant, such as Frigiderm®, can be admininstered for 10 seconds following the cryoanesthesia. This creates a firm surface for dermabrading.

The area to be dermabraded should be under tension, ideally with three-point fixation. This obviously requires the hands of an assistant. The correct hand position is to grasp the dermabrader firmly, with the thumb extended along the shaft. The movement of the hand engine should be perpendicular to the direction of the rotating burr or wire brush. It is preferable to begin dermabrading centrally and move towards the periphery so that the blood will run away from the field in the supine patient.

The most important consideration is the depth of dermabrasion. It is easy to go too deep. In the superficial papillary dermis, small red dots will appear. White parallel lines of collagen can be seen in the reticular dermis. The appearance of seba-

75 ceous glands indicates a very deep plane.

Upon completion, gauze soaked in 1% lidocaine with epinephrine should be placed over the abraded area for 5-10 minutes. This will help both postoperative pain and hemostasis. A semipermeable dressing should then be used; however, if the area is small, some surgeons will use only ointment.

Postoperative Considerations

It is important to keep the abraded region moist and clean for the 7-10 days required for complete reepithelialization. Vitamin A&D ointment, Vaseline® or aquaphor® are some of the more commonly used ointments. Any crusty buildup should be removed, and the area washed with soap and water daily.

Many have advocated a short course of postoperative steroids to decrease the swelling, especially when dermabrasion has been performed near the eyes. Kenolog® or a Medrol Dosepak® are often used.

Redness persists for 1-2 weeks, and the skin then becomes more pinkish. This lasts for 2-3 months. Avoidance of strong sun and wind is advised during this period. Judicious use of sunscreen with the highest SPF value is recommended. Swelling will also persist during this 2-3 month postoperative period.

The patients should be advised not to resume Retin-A® use until a month after surgery. As mentioned above, valacyclovir treatment, if it was given preoperatively, should continue for 7-10 days postoperatively. For patients with a history of acne, some surgeons will give tetracycline for two weeks.

Complications

The most common complication from dermabrasion is hypoor hyperpigmentation. The darker the skin, the greater the risk of developing permanent hypopigmentation. Hyperpigmentation is almost always reversible with sun avoidance and hydroquinone treatment.

Postoperative infections are unlikely but should be treated immediately when suspected. Valtrex® is used for a suspected herpes outbreak to prevent permanent scarring. Contact dermatitis is not unusual and can be caused by antibacterial ointments. Treatment consists of topical steroids.

Enlarged skin pores and milia formation can occur in the dermabraded area for several weeks. These are usually self-limited. Acne flare ups can also occur in acne-prone individuals. This too is temporary and will usually not cause new scarring.

Worsening of the dermabraded scar (e.g., hypertrophic scarring) or even new scarring is the most dreaded complications. Scarring is preceded by persistent erythema. If suspected early on during the hyperemia phase, topical steroids can be used. Intralesional Kenalog is useful once it becomes apparent that a scar is forming. Silicone sheeting has shown some promise in treating hypertrophic scars and can be tried in this setting.

Pearls and Pitfalls

•When applying traction on the skin to create a planar surface for dermabrading, avoid using gauze since it easily becomes entangled in the dermabrasion instrument.

•If the patient is under sedation and not general anesthesia, either the surgeon or the assistant should brace the patient’s face in case of sudden movement.

•It is essential to continuously watch the dermabraded skin for the transition

Suggested Reading

1.Coimbra M, Rohrich RJ, Chao J et al. A prospective controlled assessment of microdermabrasion for damaged skin and fine rhytides. Plast Reconstr Surg 2004; 113(5):1438.

2.Fulton Jr JE, Rahimi AD, Mansoor S et al. The treatment of hypopigmentation after skin resurfacing. Dermatol Surg 2004; 30(1):95.

3.Harmon CB. Dermabrasion. Dermatol Clin 2001; 19(3):439.

4.Hirsch RJ, Dayan SH, Shah AR. Superficial skin resurfacing. Facial Plast Surg Clin North Am 2004; 12(3):311.

5.Koch RJ, Hanasono MM. Microdermabrasion. Facial Plast Surg Clin North Am 2001; 9(3):377.

6.Poulos E, Taylor C, Solish N. Effectiveness of dermasanding (manual dermabrasion) on the appearance of surgical scars: A prospective, randomized, blinded study. J Am Academy Dermatol 2003; 48(6):897.

7.Shpall R, Beddingfield IIIrd FC, Watson D et al. Microdermabrasion: A review. Facial Plast Surg 2004; 20(1):47.

8.Szachowicz EH. Microepidermabrasion: An adjunct to medical skin care. Otolaryng Clin North Am 2002; (35)1:135.

Intraoperative Considerations

Grafting

Anesthesia for hair grafting is achieved using IV sedation (e.g., midazolam) combined with local ring block of the recipient and donor areas (1% lidocaine with 1:100,000 epinephrine). Creation of the new anterior hairline is key; generally the central forelock should be no less than 10 cm from the orbital rim (or 8.5-10 cm above the root of the nose). The frontotemporal recessions should be no less than 12 cm lateral to the orbital rim. Following injection of either tumescent solution or saline, two rows of donor hair are harvested. A Tori-style scalpel with three No. 10 blades spaced 2 mm apart is directed parallel to the follicles at an upward angle of 20-30˚. Donor areas can typically consist of two sites, one inferior to the occipital area and the other superior (and contralateral) to the occipital, parietal or temporal areas. Hair of different textures and colors is obtained in this way. During subsequent sessions, more strips can be taken from the analogous contralateral areas. Donor sites may be closed with running, locking 2-0 polypropylene sutures. Micrografts (1-2 hairs) and minigrafts (3-7 hairs) are then dissected from the donor

strips. To create the most natural effect, micrografts are placed most anteriorly along the neo-hairline and micrografts behind them providing more density and volume posteriorly. Slits for the micrografts are created using a no. 15c Bard-Parker blade or a 16 gauge needle; holes for the minigrafts are created by a 1-2 mm punch or a 1.75 mm rotating hand drill. Atraumatic handling of the grafts and constant moisture are essential to maintaining graft viability.

Recreation of frontal forelocks on average will utilize 4000-4500 hairs, achieved in one session of 600-700 grafts or a single 1250 graft session. Care should be taken to transplant bald as well as thinning areas to prevent chasing an enlarging area of alopecia; 90-95% graft take can be expected.

76 Scalp Reduction

Following sedation, local anesthetic is administered in a ring block fashion with a 10 minute delay before incision to ensure adequate hemostasis. A “Mercedes” or inverted-Y incision is made at the vertex down to the galea and dissection is carried out laterally and posteriorly in the subgaleal plane. About 2 cm of midline advancement is possible for the parietal flaps and 1-2 cm of anterior advancement is available for the occipital flap. Following resection of appropriate bald tissue, a silastic band with titanium hooks running along each of its long sides is placed under tension beneath the wound edges of the skin flaps. Use of this extender device prevents “stretch back” of the skin during healing by absorbing tension along the suture line.

The above procedure achieves about 2-3 cm of scalp reduction, with successful treatment of 12 cm of vertex alopecia requiring about 4 sessions each separated by 1 month. Adequate treatment of greater than 13 cm of vertex alopecia is not usually possible. For the final reduction procedure, closure is performed using multiple Z-plasties to disguise the scar. At that point, hair direction can also be reoriented to create the crown-vertex “whorl.”

Scalp Rotation

The twice-delayed Juri flap has been found by some authors to be the ideal method for scalp rotation coverage of frontotemporal alopecia. The new frontal hairline is designed using the aforementioned guidelines. The Juri flap is designed as a single flap intended to arc the entire length of the new hairline and is based anteriorly off the posterior branch of the superficial temporal artery (identified by Doppler) and posteriorly off the occipital and postauricular arteries. The base of the flap is made 4 cm superior to the helical crus and extends anteriorly with a width of roughly 4 cm at an angle of 30-40˚ from the horizontal. The first stage of the procedure is a delay, in which the distal third of the flap is raised and then replaced with staple closure. In the second stage performed one week later, the proximal portion of the flap is delayed. After three weeks, the entire flap is elevated, the bald scalp is excised, and the flap is rotated into position to create the new hairline. The flap may be sutured with 6-0 polypropylene sutures anteriorly and 4-0 sutures posteriorly. The donor site is closed following considerable subgaleal undermining.

After completion of these stages, minor corrections including triangle reduction of the kink produced anteriorly at the base of the flap (although this often settles down on its own and does not require correction), and grafting to refine the anterior hairline at the incision.

Postoperative Considerations

Following surgery, no dressing is necessary and patients can begin shampooing their hair on the first postoperative day. Complications are not common and are usually due to poor surgical design. Misuse of donor site hair resulting in an inadequate supply for complete hair restoration is the most frequent complication and is best avoided by careful planning. Infection, bleeding, and graft failure occurs in fewer than 1% of cases. Epidermal inclusion cysts (1-2 mm pustules) may form in 2-5% of hair grafting cases but are easily treated with warm compresses and mechanical unroofing of the cysts. Hairs adjacent to transplants may also enter a telogen phase in 5-10% of cases, although this phase should last no more than 3 months for

the majority of these hairs. In scalp reduction, the most common complication is a 76 “slot deformity” scar centrally caused by stretch of the scar and telogen of the hair flanking the scar. This tendency can be minimized by use of the extender device described above. Scalp rotation methods are subject to distal tip flap necrosis caused

by the conventional errors of excessive tension or kinking of the flap base. Other risk factors for distal necrosis are overly aggressive cautery and excessive galeal dissection. Early debridement of compromised areas of the flap may be postponed since hair that has fallen out may be in the telogen phase and regrow within 3-6 months. Micrografting may also be used to selectively treat areas that have healed by secondary intention.

Pearls and Pitfalls

Tips on microand minigrafting:

•Achieving a natural appearance when transplanting coarse black hair can be quite challenging. Even more so if the recipient site is a shiny, oily surface. A random distribution of implants should be used, and the temple recessions should be maintained.

•When harvesting a donor ellipse of skin, bevel the blade at an angle to avoid damaging the hair follicles.

•The epidermis should be preserved on harvested grafts.

•Prior to implantation, infiltration of the recipient scalp should be performed with a generous amount of tumescent solution. It should have a ballooned, marbled appearance prior to grafting.

•After a slit is made with a microsurgical blade, inserting the graft prior to removal of the blade can help with it “sticking” into place.

Suggested Reading

1.Epstein JS. Follicular-unit hair grafting: State-of-the-art surgical technique. Arch Facial Plast Surg 2003; 5:43.

2.Juri J. Use of parieto-occipital flaps in the surgical treatment of baldness. Plast Reconstr Surg 1975; 55:456.

3.Lam SM, Hempstead BR, Williams EF. A philosophy and strategy for surgical hair restoration: A 10-year experience. Dermatol Surg 2002; 28:11.

4.Martinick JH. The latest developments in surgical hair restoration. Facial Plast Surg Clin N Am 2004; 12:249.

5.Unger RH, Unger WP. What’s new in hair transplants? Skin Therapy Letter 2003; 8(1):5.

6.Uebel CO. The use of micrograft and mingraft megasessions in hair transplantation. In: Nahai F, ed. The art of aesthetic surgery. St. Louis: Quality Medical Publishing, Inc., 2005.

7.Vogel JE. Advances in hair restoration surgery. Plast Reconst Surg 1997; 100(7):1875.