Evaluation and Treatment of the Aging Face

Melvin L. Elson Editor

Evaluation and Treatment of the Aging Face

With a Foreword by John M. Yarborough, Jr.

With 286 Illustrations in 345 Parts 83 Pieces in Color

Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Hong Kong Barcelona Budapest

Melvin L. Elson The Dermatology Center, Inc. 4535 Harding Road Nashville, TN 37205-2120, USA

Library of Congress Cataloging-in-Publication Data Evaluation and treatment of the aging face I [edited by] Melvin L.

Elson. p. cm.

Includes bibliographical references and index. ISBN-13: 978-1-4613-8403-8 e-lSBN-13: 978-1-4613-8401-4 DOl: 10.1007/978-1-4613-8401-4

ISBN 0-387-94237-8. - ISBN 3-540-94237-8 : 1. Facelift. 2. Skin-Surgery. 3. Face-Surgery. I. Elson,

Melvin L. [DNLM: 1. Face-surgery. 2. Surgery, Plastic-in old age.

3. Surgery, Plastic-methods. WE 705 E916 1994] RD119.5.F33E93 1994 617.520592-dc20 DNLM/DLC

Printed on acid-free paper.

10 1995 Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1995

94-14223

All rights reserved. This work may not be translated or copied in whole or in part without the written permission of the publisher (Springer-Verlag New York, Inc., 175 Fifth Avenue, New York, NY 10010, USA), except for brief excerpts in connection with reviews or scholarly analysis. Use in connection with any form of information and retrieval, electronic adaptation, computer software, or by similar or dissimilar meth­odology now known or hereafter developed is forbidden. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accord­ingly be used freely by anyone. While the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Production coordinated by Chernow Editorial Services, Inc., and managed by Natalie Johnson; manufacturing supervised by Jacqui Ashri. Typeset by TechType Inc., Upper Saddle River, NJ, USA.

9 8 765 432 1

To the memory of J. Lamar Callaway, M.D., James B. Duke Professor of Dermatology and Chairman of the Dermatology Division at Duke University Medical Center from its inception until June 30, 1986, who taught me not only to look but to see, and to my dear wife Betty, who has shown me what true beauty - both inside and out-is really all about.

Foreword

There are individuals a tad past the full bloom of maturity who verily venerate the stigmata and effluvia of aging. These are folk who loftily display a needlepoint pillow whose legend trumpets "I've earned every wrinkle." Most of us, however, exert some effort to maintain or to reclaim vitalization of our torpid bodies and impercipiate minds. Hard-won gains in mental and physical revivification lead many of us to consider synchronous rejuvenation of our tracked faces.

Evaluation and Treatment of the Aging Face is a text for physicians who practice the art of facial refinement. Presented by international experts in dermatologic surgery from such disparate parts of the globe as Rome, Hamamatsu, and Nashville, the text provides instructional and practicable insights into optional surgical techniques, as well as information from the experienced vanguard regarding appropriate use of sunscreens, retinoids, alphahydroxy acids, and dermal fillers.

Although dermatologic surgery has occupied only a brief span in the history of medicine, its accelerated evolution during the last decade has challenged dermatologic surgeons to master these stimu­lating advances. Evaluation and Treatment of the Aging Face is a source that can enhance the skills of all physicians who refine skin of the aging face. This advanced text, however, should not intimidate the novice as it incorporates much basic information about technique, appropriate anesthetics, design of office-based surgery centers, psy­chosocial aspects of cosmetic surgery, and the esthetician's role in care of the skin. Adequate information is provided to assist the physician with decisions about personal mastery of individual techniques or the need for referral. Particularly relevant is the precaution to perform only those procedures for which one is trained and with which one feels comfortable.

As dermatologists, care of the skin is our right and responsibility. Expanding understanding of the biology and physiology of aging has afforded us more control of retardation as well as rejuvenation. The contributors, all dermatologists, have compiled a near global refer-

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ence that should be useful for all physicians who treat the aging face. It is hoped that this effort also will encourage conscientious interspe­ciality cooperation so that all physicians who care for the aging face will do so skillfully and harmoniously.

John M. Yarborough, Jr., M.D. Clinical Professor of Dermatology

Tulane University School of Medicine New Orleans, LA

Foreword

Preface

Dermatology has always been a specialty full of changes. As general practitioners of the skin, dermatologists have had the opportunity to observe a vast array of disorders in both sexes and in all age groups from the cradle to the grave. As the population has become increas­ingly older, it falls to the dermatologist and the dermatologic surgeon to treat the most common of all skin diseases-aging. Dr. John M. Yarborough, Jr., the president of the American Society for Derma­tologic Surgery, sets the tone for the text in the foreword.

This text presents an overall picture of the aging face, the factors that comprise it, and how these factors are treated. To begin to treat a problem, one must have a comprehensive understanding of its characteristics, as well as the dynamic factors that comprise the continually changing picture of the aging face. The successful inter­action of the various factors and the available procedures is crucially important in treating the aging face. Treatment may begin only after the evaluation is made and the precise plan for a particular patient has been determined.

All patients should use a sunscreen daily. Only a generation ago, most individuals believed that sun exposure was either beneficial or not so harmful that they should miss the warmth and "healthy glow" afforded by sun exposure. We now know, of course, the damaging effects of the sun not only in regard to the production of basal cell carcinoma, but in the development of malignant melanoma and photoaging. Dr. Rigel's chapter on sunscreens is an up-to-date com­pendium of what is available, what to avoid, and what to recommend. The controversies regarding appropriate levels of SPF, the determi­nation of SPF as to UV A and UVB, government guidelines, and many other issues are clearly and concisely addressed.

No one is more qualified to discuss the use of retinoids in the treatment of photoaging than Dr. AI Kligman. As the inventor of Retin A, as well as the first to discover its ability to treat photoaging, he is also the foremost expert on all aspects of skin aging and has led dermatology into this field almost singlehandedly. We all owe a great debt to him and I feel most privileged to have his contribution in the textbook.

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Dr. David Harris is well known for his innovative ideas, especially with regard to treating the aging face. His contribution on the use of glycolic acid in the treatment of aging is one of the most timely chapters, as the popularity of the AHAs continues to soar in both dermatology and cosmetics.

Dr. Paul Collins has lectured worldwide on the process of chemical peeling, and his chapter is complete and up-to-the-minute from the history of peeling to the future.

Dr. Bruce Katz is representative of the shining stars on the horizon of dermatologic surgery. His keen mind and innovative ideas come through in his chapter on dermabrasion.

Dr. Rhoda Narins and Dr. Bill Coleman team up to produce all the necessary information on liposuction and lipotransfer for the aging face in concise, practical chapters.

Dr. Tom Alt is one of the most respected cosmetic surgeons in the world today, and his practical presentation of rhytidectomy provides the necessary introduction to the procedure as well as pointers for the accomplished surgeon.

Dr. Larry David and Dr. Sterling Baker present an up-to-date picture of one of the most elegant of the cosmetic procedures - upper and lower lid blepharoplasties. Many dermatologists are now per­forming this increasingly common procedure, but even those who are not should have a working knowledge of it.

Dr. Bill Hanke, a triprofessor at Indiana University and president­elect of the International Society for Dermatologic Surgery, reminds us that not all lumps and bumps are due to the sun and that the patient seeks treatment from the dermatologic surgeon to improve the appearance in many ways.

An internationally respected surgeon, Dr. Bluford (BIu) Stough, discusses how to make certain that the frame around the picture of the aging face presents the best possible appearance.

Almost everyone speaks with both the muscles of the face and the hands. Dr. Bob Clark's chapter on the aging hand is particularly important to prevent a mismatch from occurring, as when the face is treated and the hands are not.

The next two chapters discuss new directions in dermatologic surgery. Dr. Jeff Klein's personal look at the establishment of a cosmetic surgery center gives a great deal of insight into the many ramifications of taking such a step, with practical sensible advice.

More and more, paramedical personnel are alleviating the load on the dermatologist and dermatologic surgeon. Dr. Mark Lees and Dianne Young graciously accepted the assignment of discussing how the roles are meshing. They are two of the most outstanding aesthe­ticians in the world and highly respected both within their field and outside of it.

The last full chapter puts all this together. What are we about? How does aging affect our patients and what happens when we intervene? Dr. Judith Waters and George Ellis put it in perspective. What we are doing in treatment of the aging face is by no means frivolous. Looking at the psychosocial impact of our procedures is one way to grasp the importance. Another way is to look at our patient's eyes-the sparkle after the procedure.

Preface

Preface xi

The final chapter combines the knowledge of many of the leaders in dermatologic surgery and dermatology from around the world. From innovative techniques, new devices, and new material for soft tissue augmentation, to the role of the dermatologic surgeon, this chapter leads us into the future.

We are really only beginning to understand aging and the treat­ments that can be provided to our patients. Certainly, with the surgical advances on the horizon as well as new materials for soft tissue augmentation, topical agents to reverse aging, and better and more elegant sunscreens, we are poised to make tremendous advances. In addition, research into aging of the skin may very well provide insight into what aging really is, and how it can be treated and reversed.

Melvin L. Elson

Acknowledgments

A textbook of this magnitude requires the concerted and sincere efforts of a great number of people. There would have been no way to dedicate the amount of time required for this task without the support of my family and office staff. My two secretaries, Ruth Norfleet and Kathy Fullerton, worked many hours typing, correcting, calling, and cajoling all the authors. Esther Gumpert and her very capable staff at Springer-Verlag have always been available and open to my ideas.

A great deal of thanks must be given to my patients without whom there would be no textbook. I learn from them every day. Finally, I am very fortunate to have the contributions from so many of the world's best dermatologic surgeons and dermatologists, whom I am also fortunate to be able to count as my friends. They made this monumental task a pleasure.

There are, of course, many dermatologists who, over the years, have taken our specialty forward. As the specialty continues to change and grow, many more step forward to lead us into the next era. Hopefully, this textbook will inspire the next generation to excel, improve, and stretch the limits of current knowledge.

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Contents

Foreword ......................................................................... vii Preface ............................................................................ ix Acknowledgments ............................................................. xiii Contributors .................................................................... xix

1. Evaluation and Treatment of the Aging Face..................... 1 Melvin L. Elson

2. Sunscreen: Prevention of Aging and Skin Cancer ............... 9 Darrell S. Rigel

3. Topical Tretinoin Can Correct the Structural Abnormalities of Human Photoaged Skin ........................ 16 Albert M. Kligman

4. Treatment of the Aging Skin with Glycolic Acid ............... 22 David R. Harris

5. Chemical Face Peeling ................................................. 34 Paul S. Collins

6. Dermabrasion ............................................................ 68 Bruce E. Katz

7. Soft Tissue Augmentation ............................................ 79 Melvin L. Elson

8. Liposuction Surgery of the Face and Neck ....................... 93 Rhoda S. Narins

9. Lipotransfer ............................................................. 101 William P. Coleman III

10. Facelift Surgery ........................................................ 110 Thomas H. Aft

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11. Blepharoplasty. . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . . . . . . . .. . . . . . . . .. 169 Laurence M. David and Sterling S. Baker

12. Skin Lesions of Aging ................................................ 187 C. William Hanke and Lisa A. Francis

13. Hair Restoration ....................................................... 212 D. Bluford Stough and Craig S. Schauder

14. Treatment of the Aging Hands .................................... 243 Robert E. Clark and Susan C. Carson

15. Establishing a Dermatologic Surgicenter ........................ 255 Jeffrey Alan Klein

16. The Esthetician's Role in Skin Care .............................. 261 Mark Lees and Diane Young

17. The Psychosocial Aspects of Cosmetic Surgery ................ 272 Judith Waters and George Ellis

18. Surgical Vignettes ...................................................... 283

Manual Dermasanding and Low Strength Trichloroacetic Acid Peeling: A Simple Technique to Improve Photodamaged Skin ................................................... 283 David R. Harris

Cosmetics vs. Cosmeceuticals: A New Rational Science ....................................................... 292 Nia K. Terezakis

Cryosurgery ............................................................. 293 Gloria F. Graham

Evaluation and Treatment of the Aging Face .................. 294 Richard G. Glogau

The Ligmaject .......................................................... 295 Arnold William Klein

The Dermatologist's Role in Treating the Aging Skin ........ 296 Sheldon V. Pollack

Microsurgical Treatment of the Aging Face .................... 296 Toshio Kobayashi

Vitamins: Therapy for Aging? ..................................... 300 Wilma F. Bergfeld and Thomas N. Helm

European View of Evaluation and Treatment of the Aging Face ..................................................... 301 Eckart Hancke

Contents

Contents xvii

The "How Did This Happen to Me?" Syndrome .............. 301 Daniel A. Gross

The Use of Gore-Tex Combined with Other Fillers .......... 302 Alejandro Camps-Fresneda

The "Sandwich Technique" for Filling the Nasolabial Fold ........................................................ 304 Antonio Picoto

Crosslinked Hyaluronic Acid (Hylan Gel) as a Soft Tissue Augmentation Material: A Preliminary Assessment ........................................... 304 Daniel Piacquadio

Surgical Correction of Neck Flaccidity in the Older Male ...................................................... 308 Arthur K. Balin

Index ............................................................................. 315

Contributors

Thomas H. Alt, M.D., Department of Dermatology, University of Minneapolis Medical School, Minneapolis, MN 55455, and Alt Cos­metic Surgery Center, 4920 Lincoln Drive, Minneapolis, MN 55436-1701, USA

Sterling S. Baker, M.D., Department of Ophthalmology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA

Arthur K. Balin, M.D., 2129 Providence Avenue, Chester, PA 19013-5506, USA

Wilma F. Bergfeld, M.D., Department of Dermatology, Case Western Reserve University School of Medicine, Cleveland, OH 44106-4915, and Department of Dermatology, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195-0001, USA

Alejandro Camps-Fresneda, M.D., Department of Dermatology, Hospital General de Catalunya, San Cugat Del Valles, 08790 Barce­lona, Spain, and c/Balmes 347, 08006 Barcelona, Spain

Susan C. Carson, M.D., 335 Penny Lane, Concord, NC 28025, USA

Robert E. Clark, M.D., Department of Medicine, Division of Der­matology, Duke University School of Medicine, Durham, NC 27710, and Dermatologic Surgery and Cutaneous Oncology Unit, Duke University Medical Center, Durham, NC 27710-0001, USA

William P. Coleman III, M.D., Department of Dermatology, Tulane University School of Medicine, New Orleans, LA 7012, and Coleman Clinic, 4425 Conlin Street, Metairie, LA 70006, USA

Paul S. Collins, M.D., Department of Dermatology, Stanford Uni­versity School of Medicine, Stanford, CA 94305, and 84 Santa Rosa Street, San Luis Obispo, CA 93405-1812, USA

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Laurence M. David, M.D., Department of Dermatologic Surgery, Institute of Laser Cosmetic Surgery, 415 Pier Avenue, Hermosa Beach, CA 90254, USA

George Ellis, M.A., Department of Psychology, Fairleigh Dickinson University, Madison, NJ 07940, USA

Melvin L. Elson, M.D., The Dermatology Center, Inc., 4535 Harding Road, Nashville, TN 37205-2120, USA

Lisa A. Francis, Department of Dermatology, Pathology and Oto­laryngology, Indiana University School of Medicine, Indianapolis, IN 46202-5267, USA

Richard G. Glogau, M.D., Department of Dermatology, University of California San Francisco, San Francisco, CA 94116, USA

Gloria G. Graham, M.D., 12949 Caminito Pointe Del Mar, Del Mar, CA 92014, USA

Daniel A. Gross, M.D., Department of Medicine, Division of Der­matology, UCLA School of Medicine, Los Angeles, CA 90033, and Valley Dermatology Medical Group, Inc., 18364 Clark Street, Tar­zana, CA 91356, USA

Eckart Hancke, Prof Dr. med., Dr. med. habit., Department of Dermatology, Ferdinand-Sauerbruch-Klinikum, Arrenbergerstrasse 20-56, 1 Wuppertal 42117, Germany

C. William Hanke, M.D., Departments of Dermatology, Pathology and Otolaryngology, Indiana University School of Medicine, India­napolis, IN 46202-5267, USA

David R. Harris, M.D., Department of Dermatology, Stanford University School of Medicine, Campbell, CA 95008, USA

Thomas N. Helm, M.D., Department of Dermatology, State Univer­sity of New York at Buffalo, Buffalo, NY 14203, USA

Bruce E. Katz, M.D., Department of Dermatology, College of Physicians and Surgeons of Columbia University, New York, NY 10032, and 14 East 82 Street, New York, NY 10028, USA

Arnold William Klein, M.D., Department of Medicine, Division of Dermatology, UCLA School of Medicine, Los Angeles, CA 90033, and 435 North Roxbury Drive, Beverly Hills, CA 90210, USA

Jeffrey Alan Klein, M.D., Department of Dermatology, University of California at Irvine, College of Medicine, Irvine, CA 92717, and 30280 Rancho Viejo Road, San Juan Capistrano, CA 92675, USA

Albert M. Kligman, M.D., Ph.D., Department of Dermatology, University of Pennsylvania, Philadelphia, PA 19104, USA

Contributors

Contributors xxi

Toshio Kobayashi, M.D., Hamamatsu Clinic of Dermatologic Sur­gery, 11-1 Asahicho, Hamamatsu 430, Japan

Mark Lees, Ph.D., Mark Lees Skincare Inc., 4400 Bayou Boulevard, Pensacola, FL 32503, USA

Rhoda S. Narins, M.D., Department of Dermatology, New York University School of Medicine, New York, NY 10016, and 33 Davis Avenue, White Plains, NY 10605, USA

Daniel Piacquadio, M.D., Department of Dermatology, University of San Diego, San Diego, CA 92103-8420, USA

Ant6nio Picoto, M.D., Av. General Carmona No. 17, Estoril 2765, Portugal

Sheldon V. Pollack, M.D., Department of Medicine, Division of Dermatology, Faculty of Medicine, University of Toronto, Toronto, Ontario M5S lA8, Canada, and 200 St. Clair Avenue West, Toronto, Ontario M4V lRl, Canada

Darrell S. Rigel, M.D., Department of Dermatology, New York University Medical Center, New York, NY 10016, and 213 Madison Avenue, New York, NY 10016-3814, USA

Craig S. Schauder, M.D., One Mercy Lane, Hot Springs, AR 71913, USA

D. Bluford Stough, M.D., Department of Dermatology, University of Arkansas for Medical Sciences, Hot Springs, AR 71913, USA

Nia K. Terezakis, M.D., Department of Dermatology, Tulane Uni­versity School of Medicine, New Orleans, LA 70112, and 2633 Napoleon Avenue, New Orleans, LA 70115, USA

Judith Waters, Ph.D., Department of Psychology, Fairleigh­Dickinson University, Madison, NJ 07940, USA

Diane Young, Diane Young Anti-Aging Salon, 38 East 57th Street, New York, NY 10022, USA

John M. Yarborough, Jr., M.D., Department of Dermatology, Tulane University School of Medicine, New Orleans, LA 70112, USA