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 largely determines which intervention is most suitable for a particular patient. The deep glabellar lines engender two aesthetically unattractive features: (a) glabellar creases themselves connote to the observer a sign of aging; and (b) 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 browsuspension surgery (Chapter 4). 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 BTX. Unfortunately, this procedure is only temporary and can be expensive with repeated treatment sessions. However, BTX injection is the best and only therapy that is recommended for early rhytidosis.

With glabellar rhytidosis that is present both at rest and in motion, more aggressive therapy may be warranted. Early, incipient rhytids may be treated with BTX as a first step to see whether the formed line will soften over time owing to muscle inactivity. Alternatively, if the patient has other dyschromias or signs of photodamage, a Jessner’s/35% trichloroacetic acid (TCA) peel may efface limited rhytidosis (Chapter 9).

More severe rhytidosis requires carbon dioxide laser ablation in this area. As discussed in Chapter 9, full-face laser therapy may be followed by a protracted recovery time that is 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., ePTFE or acellular dermis) may provide benefit for the patient and be well tolerated in the thicker glabellar skin. However, as with all solid fillers, the patient must understand the limitations of such augmentation (e.g., 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 the following section for a detailed description.) Surgical excision of the rhytid should be reserved only 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 stood the test of time and proved valuable in the surgical armamentarium. However, this modality is not necessarily appropriate in other facial areas; for example, excision of the nasolabial fold appears uniformly poor and is not recommended, as the scar ineluctably widens with repeated movement.

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 BTX therapy to abort the development of the former problem (i.e., so that the animated lines do not become permanently etched-in lines). Botulinum toxin must be continued indefinitely to ensure that the development of more permanent rhytids do not arise. The notion that the muscles become progressively more attenuated and eventually do not require BTX is a fallacy that has been proved 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 BTX.

Another preventative measure that can abort incipient lines and minimize the development of further rhytidosis is the newer technique of nonablative therapy (Chapter 9). Various laser and light devices have been used for nonablative therapy, including the pulsed-dye laser, the Q-switched 1064-nm Nd:YAG laser, 980-nm diode laser, 1320-nm Nd:YAG laser, Erbium:Glass laser, Erbium:YAG laser, and intense pulsed light. Nonablative 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, nonablative therapy only effectively treats fine and early periocular wrinkles and has limited benefit for deeper, perioral rhagades. The patient in his or her thirties who is a good candidate for BTX therapy may be equally well suited for nonablative laser therapy, which can be combined with BTX treatment. The results after a 3- to 6-month period can be outstanding if a patient understands the limitations of this technology.

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).

As mentioned, the nasolabial and labiomandibular folds are poorly treated with BTX therapy, because 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., ePTFE) 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 superficial musculoaponeurotic system (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% to 0.15%).⁵, ⁶ and ⁷ 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 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 surgeon alike.

If the patient elects to have a permanent soft-tissue filler, then ePTFE may be the most suitable option. Expanded polytetrafluoroethylene 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), and 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 may prove to be a favorable compromise between a permanent substance such as ePTFE and a temporary liquid injectable such as collagen. Although touted as permanent, the authors have found that acellular dermis is semipermanent to permanent, depending on the patient’s biophysiologic ability to degrade the foreign material. The benefit of acellular dermis is that usually the substance lasts considerably longer than collagen and is not as palpable (if at all) compared with Gore-Tex (W.L. Gore and Associates, Inc., Flagstaff, AZ) or another type of ePTFE. However, the degree of augmentation may be somewhat less than what may be achievable with ePTFE. The patient should be educated as to the derivation of acellular dermis (e.g., processed cadaveric dermis) and should understand the rigorous screening and mechanical process through which the materials have been subjected. Based on these advantages and drawbacks, the surgeon and patient can then arrive at a mutually agreed on, suitable modality.

Although not truly applicable in this chapter dedicated to “adjunctive” therapies, the nasolabial and labiomandibular folds also may be softened with SMAS excised during an 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 exhibits notable marionette, or labiomandibular, folds.

Perioral rhagades, or smoker’s lines, are best treated with a resurfacing modality (Chapter 9). 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 BTX to address this entity. These deeply etched lines can be effectively treated only with laser therapy or dermabrasion and attain limited improvement with a TCA peel. Phenol, which is not covered in this book, is a viable alternative. Soft-tissue augmentation with collagen, equivalent filler, or solid implant does very little to address these wrinkles and is not advisable.

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 Cupid’s bow. Treatment of hypoplastic lips may be divided into two principal strategies: soft-tissue augmentation and advancement cheiloplasty.

As described, soft-tissue augmentation may be effected with either temporary liquid injectables (e.g., collagen) or more permanent materials (e.g., acellular dermis or ePTFE). The patient must weigh the benefits and drawbacks (already explained) to decide what is most appropriate for that individual. However, the authors 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, acellular dermis has been noted to be much less prone to extrusion and infection and less palpable than ePTFE. Therefore, acellular dermis may be a reasonable alternative for semipermanent to permanent lip augmentation. These conclusions have been arrived at after many years of trial and error and represent empiric observation rather than a controlled study protocol.

Advancement cheiloplasty, or lip advancement, should be discouraged, because 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 important, 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 operate.

As mentioned, the authors believe that for semipermanent to permanent lip augmentation, acellular dermis is the preferred method because of 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 generally derive greater satisfaction
with augmentation of the upper lip (Fig. 8-11). Accordingly, often patients desire only selective augmentation of the upper lip. However, simultaneous upper- and lower-lip augmentation remains a more common request.

One percent lidocaine and 1:100,000 epinephrine is infiltrated into the upper lip, and 10 minutes are allowed to transpire, during which time the acellular dermis is properly prepared (Fig. 8-12). Typically, a 3- 7-cm acellular-dermal graft is sufficient to augment both the upper and lower lips in a conservative fashion. Two thirds 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 one third is reserved for the lower lip. This amount of augmentation is particularly well suited for a more mature woman who desires subtle but definitive augmentation. As acellular dermis comes in different thicknesses, the thickest 3- 7-cm sheet should be ordered to achieve maximal augmentation. Use of two 3- 7-cm grafts for lip augmentation (i.e., one for the upper lip and one for the lower) is an aggressive augmentation that may risk extrusion and also increase the period of postoperative edema. Nevertheless, this amount of augmentation can be used for the more outspoken patient who demands significant increase in lip volume. Given the expense of acellular dermis, routine use of two sheets may not be financially justifiable except for the vocal patient who insists on considerable lip augmentation. If the patient desires only selective augmentation of the upper lip, then usually the entire 3- 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, one half of the 3- 7-cm graft is inserted into each smile line. Similarly, one half of the 3- 7-cm graft is inserted into each marionette line. Table 8-1 summarizes these recommendations. The acellular dermis is rolled and sutured with a 5-0 chromic suture (Fig. 8-13) and tied at one end to the 0-silk, which in turn is affixed to the straight needle that is designed to fit into the groove of the introducer (Fig. 8-14). It is imperative that the 0-silk suture be firmly tied to the end of the implant using a square knot, because 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 (Fig. 8-15). The introducer is then passed through the upper lip using the nondominant hand to guide the device toward the other side (Fig. 8-16A-C). The proper plane of passage is below the outer mucosa but above the orbicularis-oris muscle. The instrument should be advanced slowly and deliberately in order to avoid inadvertent puncture through the outer lip with control provided by the nondominant hand. The straight needle is then passed into the groove of the introducer and pulled through as the introducer is withdrawn (Fig. 8-17A,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 (Fig. 8-18). 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 acellular-dermal graft is then tucked further distal to each incision using fine-toothed forceps with tiny, double-pronged hooks for retraction (Fig. 8-19). The incisions are closed with two interrupted 4-0 chromic sutures (Fig. 8-20).