PART II
• SKIN AND SOFT 11SSUE
CHAPTER 13 • DERMATOLOGY FOR PLASTIC
SURGEONS I-SKIN CARE AND
BENIGN DERMATOLOGIC
CONDITIONS
RENATO SALTZ AND BIANCA M. B. OHANA
INTRODUCTION
The skin is the largest organ in the human body. It serves
as a mechanical and immunologic barrier and is responsible
for thermoregulation and sensibility. Healthy skin imparts
the impression of health and beauty, while unhealthy skin
suggests premature aging and illness. Plastic surgeons
require a working knowledge of both benign and malignant
skin conditions; appropriate treatment can only be rendered
if the correct diagnosis is made. This chapter reviews the
most common benign skin changes and presents a protocol
for skin care that can be applied before or after facial aes-
thetic surgery or independent of aesthetic surgery. The next
chapter addresses malignant skin conditions.
ANATOMY
The skin is composed of two layers: the thin epidermis and the
thicker dermis (Figure 13.1). Deep to the dermis is subcutane·
ous fat. There are two types of human skin: skin with hair and
glabrous skin (without hair). The latter is found on the palms
and soles and has a much thicker epidermis.
The epidermis consists of four layers: stratum corneum,
stratum granulosu.rn. stratum spinosum, and sttatum basale.
In glabrous skin, an additional layer (stratum lucidum) lies
between the stratum comeum and the stratum granulosum.
The epidermis contains predominantly keratinocytes, melano·
cytes, Langerhans cells and Merkel cells.
The dermis is divided into the more superficial papillary
dermis and the deeper reticular dermis. The dermis contains
predominantly fibroblasts, mast cells, histiocytes, monocytes,
lymphocytes, and Langerhans cells. The integrity of the der-
mis is maintained by a supporting matrix containing ground
substance and two types of protein fibers: collagen, which has
great tensile strength and forms the major constituent of the
dermis, and elastin, which makes up only a small proportion
of the bulk.1 The skin appendages like hair follicles, seba-
ceous glands, and apocrine and eccrine glands are also found
in the dermis.
BENIGN LESIONS
Pigmented Lesions
Nevus or Melanocytic Nevus. Nevi are acquired
lesions that present after birth and consist of a concentra·
tion of nevus cells that are classified according to their
location as junctional (at the epidermal-dermal junction),
intradermal, or compound (both in the dermis and at the
junction). Junctional nevi are frequently found on the
palms and soles and tend to be uniform, macular, and
round with smooth and regular borders. Intradermal
nevi are found on the face and are usually homogeneous,
elevated, dome-shaped, skin-colored lesions. Compound
nevi are raised above the epidermal surface and may be
round or oval. The color varies with the natural pigmen-
tation of the patient and may be very dark. There is usu-
ally little if any pigment on the flat surrounding epidermis
in a classic, non-dysplastic, compound nevus.l Nevi are
rarely premalignant. See dysplastic (atypical) nevi below
(Figure 13.2).
Congenital Melanocytic Nevus. Congenital nevi are
present at birth, usually singular and small. They are clas-
sified in three types depending on the size: small, intermedi-
ate, and giant (>20 em) (Chapter 20). They have some poten·
tial to develop melanoma, although this risk is low except
in the giant variety. Except for size, the overall appearance
of congenital melanocytic nevi and acquired nevi is simi-
lar.2 Congenital nevi, however, may have dark, thick hair.
Histologically, congenital nevi are distinguished by the pres·
ence of nevomelanocytes in the epidermis and in the dermis
as sheets, nests, cords, or single cells. 2 For treatment, see
Chapter 20 (Figure 13.3).
Blue Nevus. Blue nevi appear bluish because the nevus
cells are deep in the dermis. These lesions are usually benign
but the literature suggests they can be malignant. Clinically,
blue nevi are solitary, nodular lesions with a smooth sur-
face that tend to be blue or blue-gray. These lesions are
generally treated conservatively unless there has been a
change in their appearance or the patient requests excision
for cosmetic reasons. The excision should include the sub-
cutaneous component to ensure complete removal of deep
dermal melonocytes. 3
Halo Nevus. When a melanocytic nevus is surrounded by a
hypopigmented halo, it is termed a halo nevus. These lesions
tend to occur on the torso in older children and teenagers.
They are common, frequently multiple, usually acquired and
asymptomatic. The central nevus tends to gradually disap-
pear leaving a macular area of non-pigmented skin. This
hypopigmented area may persist for years and may gradu-
ally return to a normal color. When biopsies are performed,
105
- 106 Part II: Skin and Soft Tissue

Epidem1is
Papillae of dermis
·I Dermis
ibi

Su bcutaneous fatty layer

Sebaceous glands
FIGURE 13.1. Cr05HeC!ion view of skin.

there may be no trace of the originallesion.1 The treatment using the Q-switched ruby, neodymium:yttrium-aluminum-
is expectant. avoiding sun exposure at the hypopigmented gamet (Nd:YAG) or alexandrite lasers,4 or make up camou-
areas unless there are cosmetic concerns or the lesions have flage (Chapter 18).
atypical features.
Atypical Moles-Dysplastic Nevi. Dysplastic nevi are
Spitz Nevus. This is a common and usually acquired lesion melanocytic nevi that have the clinical features of mela-
predominantly in children and young adults but can be found noma: asymmetry, border irregularity, color variability, and
in older people as well. Spitz nevi are usually firm, domed- diameter greater than 6 mm (Chapter 14). When patients
shaped, reddish or dark brown nodules, frequently on the present with many atypical moles, they are at higher risk
head and neck. They are compound nevus variations, which for melanoma. Patients who present with many atypical
have distinctive histologic features that make the differen- moles and a strong family history of malignant melanoma
tiation from malignant melanoma difficult.1 The treatment are at much higher risk for melanoma and must have at
is surgical excision. There is controversy over whether an least annual full body examinations for their entire lives. It
entity known as a malignant Spitz nevus exists or if these is difficult for even an experienced dermatologist to know
lesions are malignant melanomas. For these reasons, Spitz
nevi require complete excision with histologic confirmation
of clear margins.
Nevus of Ota. Nevi of Ota are hamartomatous melanocytic
lesions that occur on the face in the distribution of the oph-
thalmic and maxillary division of the trigeminal nerve. They
are much more common in women. The sclera is involved in
two-thirds of cases.t The treatment consists of laser therapy,

FIGURE 13.2. Melanocytic: nevus. FIGURE 13.3. Congenital melanoc:ytic: nevus.

 Chapter 13: Dermatology for Plastic Sw:gcons 1-Skin Care and Benign Dermatologic Conditions
when to recommend excisional biopsy. The best indica-
tion for biopsy is a change in clinical appearance. The ideal
surveillance involves total body photographs, which are
compared annually with the patient's current condition in
order to determine if any lesions have changed over time.
The treatment is excisional biopsy. If step-sectioning of the
entire specimen reveals melanoma, then further treatment is
required (Chapter 14).
Solar Lentigo. Solar lentigines oa:ur on sun-exposed areas
of the face, arms, and dorsum of hands, especially in lighter
skinned white people with light eye color. These acquired
lesions are pigmented macules that can be small or large,
with a tendency to confluence and range in size from 0.2
to 2 em. They become more numerous with advancing age.
Treatment is not required. A biopsy is taken to exclude
melanoma from any lentigo that develops a highly irregu-
lar border, a localized increase in pigmentation, or localized
thickening.z Bleaching agents like hydroquinone are not par-
ticularly effective. Topical tretinoin, microdermabrasion, or
cryotherapy can be used.
Ephelides (Freckles). These are small, less than 3 mm, red
or light brown macules that appear on sun-exposed areas pre-
dominantly in fair skinned people with red or blond hair, but
can appear in darker skinned individuals as well. There is no
increase in the number of melanocytes, but rather an increase
in the amount of melanin in the skin. They are co.rwnon in
childhood; however, they can be seen at any age. They are
usually confined to the face, arms, and back. The number
varies from a few spots on the face to hundreds of confluent
macules on the face and arms. Treatment is not required, but
sunscreen is recommended. Bleaching agents such as hydro-
quinone, peels, and intense pulsed light (IPL) can be used for
cosmetic reasons.
Epidermal Lesions
Seborrheic Keratosis. This is a common benign, usu-
ally pigmented, neoplasm in elderly people, arising from the
basal layer of the epidermis and consisting of keratinocytes.
The etiology is unknown, and factors like virus infection,
genetics, and sun exposure can be related. Usually sebor-
rheic keratoses are not photoinduced. These lesions occur
in any body site (frequently in the face and upper trunk) and
are usually asymptomatic or associated with itching. They
are superficial verrucous plaques, smooth or rough, varying
from 1 mm to several centimeters in size and varying from
dirty yellow to dark brown. Histologically, they are char-
acterized by hyperkeratosis, acanthosis, and papillomatosis.
The classic description is of a "stuck-on," waxy appear-
ance. Surgical excision or shave excision is appropriate if the
patient complains of cosmetic appearance. Other treatment
options include curettage, cryotherapy, or trichloroacetic
acid (TCA). There are times when the lesion is atypical and
an excisional biopsy is indicated for diagnostic purposes
(Figure 13.4).
Keratoacanthoma. This is a common epithelial tumor
related to sun exposure than may be better placed in the
next chapter on malignant lesions. It is more co.rwnon in
white phototypes and is usually found on the face or upper
limbs. Classically, it presents as a solitary papule that devel-
ops a crater-like central, keratotic core;' The history is one
of rapid growth over a few weeks. Spontaneous regres-
sion is said to occur, but most lesions are excised before
it becomes clear if regression would have ever occurred.
The histology is similar to squamous cell carcinoma and
many consider it a low-grade squamous cell cancer. Surgical
excision is usually the treatment of choice. Other potential
treatment options are curettage, coagulation, and topical
5·fluorouraciL
107
Verrucous Nevus. These are congenital lesions that pres·
ent as verrucous papules or plaques that are skin colored
or brown. A linear configuration is common and it can be
found in any body site. Malignant transformation is very rare.
The treatment options due to cosmetic concerns are surgical
excision, laser, electrodissection, dermabrasion, cryotherapy,
TCA, or topical retinoic acid.
Skin Tags (Acrochordon). Skin tags are composed of
loose fibrous tissue and usually occur as multiple skin-colored
or tan, filiform or smooth-surfaced papules that are 2 to 3
.rwn in diameter. These small, soft, pedunculated lesions are
frequently located on the neck or major flexures. The simplest
and most expeditious treatment is shave excision with scissors
or a scalpel blade.
Premalignant Lesions
Actinic Keratosis. Actinic keratoses may be the most com-
mon of the premalignant skin conditions. Caused by sun
exposure in people with Fitzpatrick skin types I, n, and m,
they are macules or papules with a scaly surface, generally
between 1 mm and 2 em in diameter. Actinic keratoses occa-
sionally evolve into squamous cell cancers and are therefore
considered premalignant. These lesions frequently require
biopsy to rule out a carcinoma. Multiple lesions are usually
treated with S-fluorouracil or the immune stimulator imiqui-
mod (Aldara) (Figure 13.5).
Leukoplakia. Leukoplakia is white intraoral plaque and
is the most common precancerous lesion of the oral cavity.
These lesions do not frequently become squamous cell cancer
but must be followed and biopsied if they persist or undergo a
change in appearance.
Cutaneous Hom. A cutaneous hom is different from a
skin tag and is considered a premalignant lesion. They are
usually yellowish brown protuberant "horns" and are found
on the face and ears. Histologically, they are characterized by
a compact proliferation of keratin. The treatment is surgical
excision.
Bowen's Disease. Bowen's disease is squamous carcinoma
in situ of the skin. This tumor presents as a slowly grow-
ing, red lesion with a scaly surface and irregular borders.
tnceration or bleeding may be a sign of invasive malignancy.
The treatment of choice is surgical excision, but cryotherapy,
curettage, cauterization, topical agents like S-fluorouracil, and
topical photosensitizer can also be considered.
- 108 Part II: Skin and Soft Tissue
FIGURE U.S. Actinic keratosis.
HAIR FOLLICLE TUMORS
Trichofolliculoma
This is a rare hamartoma of the pilosebaceous follicle. They
are typically solitary, small, raised nodules with two or three
hairs, usually white, protruding together in a tuft. They
frequently appear on the face and scalp. Malignant change
is not typical but has been reported in a single case with
perineural invasion.1 The treatment recommended is surgical
excision.
Pilomauicoma, or Benign Calcifying
Epithelioma of Malherbe
A pilomatricoma is a hamartoma characterized by a firm,
solitary nodule covered with intact but often discolored skin.
The calcification makes the lesions particularly firm. They
can occur on any body part but are most commonly found
on the face and upper extremities. ln general, the lesions are
O.S to S em in diameter. There is no malignant potential. The
treatment is surgical excision.
Trichoepitheliomas
Trichoepitheliomas are hamartomas of the hair follicle
typically found in the center of the face. They tend to be
small, skin-colored or slightly pink papules that are usually
distributed symmetrically on the cheeks, eyelids, and the
nasolabial region. Treatment is not required; excision may
be contemplated for cosmetic reasons. Other options include
electrodissection and curettage or cryotherapy. Recurrence
is common.
ECCRINE TUMORS
Syringomas
This is a benign tumor that usually presents as firm, skin·
colored to yellowish dermal papules on the lower eyelids, pre·
dominantly in females. Syringomas can be sporadic or familial
and are frequently associated with Down's syndrome. The
treatment is punch or surgical excision for cosmetic reasons
only. Electrodissection, curettage, and carbon dioxide laser
can be considered.
Eccrine Poroma
An eccrine poroma is a solitary, firm, skin-colored or erythem·
atous papule, usually on the sole or palm in adults. Ulceration
and bleeding may occur at points of pressure. The treatment
is surgical excision.
Cylindroma
Cylindromas can be solitary or multiple. The multiple lesion
type has a genetic component. They are classically found on
the scalp as numerous small papules or large nodules with
smooth surfaces. Sometimes they cover the entire scalp like
a turban explaining the name tu1ban tumo1. They are usu·
ally benign, but malignant development has been reported.
Treatment options include surgical excision, electrosurgery,
and carbon dioxide laser.
Clear Cell Hidradenoma
Clear cell hidradenoma is an eccrine sweat gland tumor.
It occurs as a slow growing usually solitary nodule.
Classically, it is a firm nodule, 0.2 to S em in size. Some
of these tumors discharge serous material, whereas others
tend to ulcerate. Lesions may occur on any body part, but
are most frequently found on the arms, thigh, and scalp.
They can develop malignant tumors. The treatment is surgi-
cal excision.
APOCRINE TUMORS
Apocrine Cystadenoma
This lesion results from a cystic dilatation of an apocrine
secretory gland. It is generally a solitary, nodular lesion on the
face that tends to be skin colored to bluish. The treatment is
surgical excision.
Chondroid Syringoma
This tumor is a firm intradermal nodule usually found on the
head and neck that is composed of both sweat gland elements
and cartilaginous elements.4 It is rare and there can be malig-
nant degeneration. Surgical excision is recommended.
Syringocystadenoma Papilliferum
These lesions are benign tumors, present at birth, usu·
ally on the scalp and neck, that present as multiple trans·
lucent or pigmented plaques or papules. The lesions
can be verrucous with a central depression that oozes
fluid. Treatment options include surgical excision and
electrocoagulation.
SEBACEOUS TUMORS
Sebaceous Nevus
Sebaceous nevi are common tumors of childhood. Two·
thirds are present at birth; the remaining one-third develop
in infancy or early childhood. The lesions are usually soli·
tary, oval to linear, yellowish in color, varying from O.S
em to several centimeters, and frequently present on the
scalp. Surgical excision is recommended before adoles·
cence because of the potential for development of basal
cell carcinoma (BCCA) and other malignant tumors. The
rare nevus sebaceous of Jadassolm syndrome consists of the
triad of a linear sebaceous nevus, convulsions, and mental
retardation.
Sebaceous Epithelioma
This lesion looks like a BCCA, but tends to be more yel-
lowish because of the sebaceous cellular elements. It is most
frequently located on the scalp and face. Treatment is recom·
mended for cosmetic reasons only. Options include surgical
excision, radiation, electrocoagulation, curettage, and carbon
dioxide laser.
 Chapter 13: Dermatology for Plastic Sw:gcons 1-Skin Care and Benign Dermatologic Conditions 109

Sebaceous Hyperplasia
This is a small tumor composed of sebaceous glands that is
commonly located on the forehead, cheeks, lower eyelids, or
nose. lt begins as a pale yellow and slightly elevated papule
and can become dome shaped, and sometimes umbilicated.
Sebaceous hyperplasia does not have any relationship with
solar expotro.te. Treatment options are electrodissection. curet·
tage, cryosurgery, or surgical excision.

Rhinophyma
Rhinophyma is a localized telangiectatic enlargement of the
nose, most often in men. Histologically, it is characterized
by sebaceous gland hyperplasia, fibrous infiltration, and
lymphedema. Rhinophyma is considered a glandular form of
acne rosacea. The reported incidence of occult cancer in the
setting of rhinophyma varies from 15% to 30%. BCCA is
the most common malignant neoplasm.2 Treatment options
include dermabrasion or other form of deep resurfacing or
surgical excision with reconstruction using a forehead flap
(Figure 13.6}.

CYSTS
Epidermal Cyst (or Sebaceous Cyst)
This is the most common type of cyst and occurs because
of proliferation of surface epidermal cells within the der·
mis. Epidermal cysts are rare in children but common in
adults. They are generally round, protruding, smooth-
surfaced masses, varying in size from a few millimeters
to several centimeters. Epidermal cysts grow slowly and
are not symptomatic unless they become infected. Once
infected, rupture is common. The only effective treatment
is surgical excision. If infected, a course of antibiotics is
recommended in an effort to prevent rupture and drain-
age so that excision can be accomplished. Staphylococcus
aureus is the most common pathogen. The entire capsule FIGURE 13.6. Rhinophyma.
must be removed to avoid recurrence. Genetic syndromes
like Gorlin and Gardner may be associated with epidermal
cysts.
Pyogenic Granuloma
Milium This lesion is a common vascular nodule that exhibits rapid
growth, not unlike a keratoacanthoma, but pyogenic granu-
A milium (plural: milia) is a superficial, white epidermal cyst lomata are totally benign. They can appear at any age and
that appears immediately beneath the epidermis. They are vary in color from brown to bluish-black. They are com·
most common on the eyelids and cheek and often appear pressible and do not pulsate, with a thin surface. Treatment
along a healing upper blepharoplasty incision. The treatment options include curettage and surgical excision.
is unroofing and removal of the central kernel with a #11
blade or needle, or light electrodissection.
FIBROUS TUMORS
Pilar Cyst Dermatofibroma
A pilar cyst is similar to an epidermal (sebaceous) cyst and is This lesion is a myofibroblast proliferation, characterized by a
a common scalp lesion containing keratin. The treatment of firm, skin-colored or reddish brown sessile papule or nodule,
choice is surgical excision. Like epidermal cysts, if they pres- more commonly in women. They vary in number from 1 to
ent in an inflamed, infected state, they may require drainage. 10 and can be found anywhere on the extremities and trunk.
A course of antibiotics to "cool off" and shrink the lesion is They appear as 3- to 10-mm slightly raised, pink-brown,
worth an attempt, in hopes that the lesion can be excised. dome-shaped, sometimes scaly, hard growths that retract
beneath the skin surface during attempts to compress and
SMOOTH MUSCLE TUMORS AND elevate them. They tend to remain stable for years as discrete
MESENCHYMAL TUMORS solitary lesions. Treatment options include surgical excision
for cosmetic reasons only, cryotherapy, or 600-nm pulsed dye
Leiomyomas laser (Figure 13.7).5
Like leiomyomas elsewhere, these benign smooth muscle
tumors present as solitary, firm, round, flesh-colored nodules, GENERALIZED DISORDERS
more commonly in the limbs, which are either subcutaneous,
or in the deep dermis. The recommended treatment is surgical Telangiectasias
excision to eliminate what can be a tender lesion and rule out Telangiectasias are vascular malformations characterized
a malignant lesion. by chronically dilated capiUaries or smaU venules. They are
- 110 Part II: Skin and Soft Tissue
FIGURE 13.7. Dennatofibroma.
small, red and linear and may appear like a spider or star
design (Figure 13.8).
Xeroderma Pigmentosum
This is an autosomal recessive disorder, characterized by
damage to DNA repair. These patients have extreme sun
sensitivity and develop many cutaneous malignancies. The
lesions require surgical excision, but the outcome is usually
poor.
Dystrophic Epidermolysis Bullosa
This disorder is characb:rized by fragility and blistering after
trauma to the skin. It can be autosomal recessive or domi·
nant. lt does not have any specific treatment,. except to avoid
trauma. The slightest friction or scrape may result in skin
lesions that are also prone to infection.1"
Cutis Laxa
This is a rare elastolysis disorder with lax skin and loss
of elastic tissue. It can be autosomal dominant or reces-
sive. The skin develops large redundant folds. Treatment
consists of plastic surgical procedures such as facelift and
blepharoplasty.
FIGURE 13.8. Telangiectasias.
Pseudoxanthoma Elasti.cum
This can be an autosomal dominant or recessive disorder
causes calcification of elastic tissues and blood vessels arte·
riosclerosis. Skin lesions generally appear as yellow papules
or plaques and skin laxity. The most important aspect of
treatment is to ensure that complications from vascular
involvement are prevented or dealt promptly.1 Plastic surgi-
cal procedures can be performed to improve appearance.
Ehlers-Danlos
This is a connective tissue disorder, characterized by skin
and blood vessel fragility, hyperextensibility, and hyper·
mobility. There are 11 subtypes.1 Patients must avoid preg-
nancy and trauma to soft tissues and be referred for genetic
counseling.
Acne Rosacea
This is a common chronic disorder of the face, usually in
white skin characterized by flushing, erythema, and telangi·
ectasias. Bouts of inflammation with swelling, papules, and
pustules may occur. The goal is to avoid skin irritation and
use sunscreen creams. Oral medications like tetracycline and
isotretinoin (retin-A) can be effective. Topical treatment with
metronidazole 1%, phototherapy, and makeup camouflage
are also helpful.
Hidradenitis Suppurati.va
This is a disorder of apocrine glands, more commonly in dark
skin, and usually in the axilla, perineal regions, or beneath
the breasts. The disease can be devastating with numerous,
interconnecting comedones or subcutaneous pustules. Local
care and antibiotics tend to keep the lesions somewhat quies-
cent but the only definitive treatment is surgical excision. The
heavily contaminated wounds usually have to heal by second·
ary intention, which is a slow, painful process.
Pyoderma Gangrenosum
This is rare disorder, which is not infectious in origin, and
presents as solitary or multiple, fragile papules that can
progress to ulcers and necrosis. Treatment options include
antibiotics, topical or systemic steroids, and immunosuppres·
sant agents.
SKIN CARE
Nonsurgical skin care plays a role in the preoperative and
postoperative management in many aesthetic surgery prac·
tices. Some plastic surgeons choose to provide services and
treatments to complement surgical rejuvenation procedures.
Topical treatments, soft tissue fillers, neurotoxins, skin tight-
ening devices, chemical and laser peels, facial treatments,
makeup consultations, lymphatic drainage massage (LDM),
and a wide variety of other medical spa services have become
integral components of many practices. Other plastic surgeons
develop relationships with dermatology colleagues who pro·
vide these treatments.
The nonsurgical treatments mentioned above appeal to
several groups of patients:
1. Younger patients who seek preventive measures to uslow"
the aging process.
2. Patients who cannot afford or who do not have the time
to recover from expensive and more extensive surgical
procedures.
3. Patients who do not want surgical intervention and prefer
procedures with reduced morbidity, rapid recovery, and a
more rapid return to work.
 Chapter 13: Dermatology for Plastic Sw:gcons 1-Skin Care and Benign Dermatologic Conditions
THE COMPLETE AESTHETIC
PACKAGE
In the senior author's practice, surgical and nonsurgical
treatments are integrated in a comprehensive team approach.
The "consulting team" includes the plastic surgeon, surgi-
cal nurse, medical aesthetician, and patient coordinator. The
extended team of providers includes a massage therapist.
micropigmentation artist. personal trainer, nutritionist. and
others (Figure 13.9, Case 1). Admittedly, this form of prac-
tice does not appeal to all plastic surgeons who prefer to con-
centtatl: on surgical procedures or who perceive the benefit of
cross-referral from other specialists who offer these modalities.
THE CONSULTATION AND
EVALUATION
The objectives of the consultation are to evaluate the patient
and provide education and recommendations on the different
nonsurgical and Nrgical alternatives including a discussion of
risks, complications, and the financial implications of the vari-
ous options.
The evaluation, or aesthetic consultation, is performed by
the plastic surgeon accompanied by the nurse and the aestheti-
cian. A facial evaluation regarding skin type (dry, oily, or a
combination), texture, thickness, photoaging damage, wrin-
kles, and age-related and gravitational changes is included
in every patient. A skin care regimen may be recommended
before or after the surgical procedure.
COMPREHENSIVE SKIN CARE
PROGRAM
A skin care program consists of cleansing, hydration, moistur-
izing, repair, protection, and prevention.
Cleansing
Dirt, oil, grease, makeup, and microorganisms are removed
from the sk.in in order to allow skin care renewal and cos·
metic creams to be absorbed. Cleanser is prescribed according
to the skin type and is applied in the morning and again at
night. Application of cleanser is important at night because
the lower pH increases microcirculation and allows greater
absorption of the skin products.
FIGURE 13.,. Case 1-Complet:e aesthetic package. This S6-year~ld woman presented with significant tun damage and facial aging. The
complete aesthetic package was perfonned. She had an aggressive skin cue treatme:Dt preoperatively, with intense pulsed light treatments to the
face and Deck every 21 days, alternated with facial peels. She then underwent an endoscopic brow lift, bilateral ptosis repair, rhytidectomy with
SMASectomy, and cenicoplasty. The lymphatic: drainage massage treatment wu started S days postoperatively and continued once a week for
3 weeks. She is shown 1 year postoperatively.
111
Hydration
Water is required to maintain the smoothness of the skin. The
simplest and most important way to maintain hydration is
by drinking water. Moisturizers are a helpful adjunct by aug-
menting the barrier function of the epidermis. Moisturizers
contain humectants, emollients, and occlusives. The emol-
lients are lipids that hydrate the skin. The occlusives decrease
transepidermal water loss. Humeaants enhance water absorp-
tion from the dermis into the epidermis, and in humid con-
ditions they also help the stratum corneum to absorb water
from the external environment.'
Repair
To achieve repair, the formulations must reach the basal
layer of the epidermis and the superficial dermis. The most
effective are alpha-hydroxy acids (AHA) and topical tretinoin
(retin-A).
Glycolic acid (sugarcane), lactic acid (milk), malic acid
(apple), citric acid (citrus fruits), and tartaric acid (grape)
are examples of AHA. Glycolic and lactic acid are the most
commonly used and are safe and effective. AHAs are indi-
cated for dryness, rough texture, acne, rosacea, photodam-
age, melasma, and hyperpigmentation disorders. They can
be found in different vehicles and concentrations, such us
within moisturizers or in the form of peds. They can also be
used in dark sk.in types. In the case of melasma and hyperpig-
mentation disorders, AHAs can be used in combination with
bleaching agents.
Tretinoin (retin-A) is a vitamin A derivative that, when
used for the long term, is extremely effective in reversing sun
damage. It promotes histologic changes such as increased
epidermal and granular layer thickness, decreased mela-
nin content. compaction of the stratum corneum, decreased
cytologic atypia, increased collagen synthesis, an increase in
collagenous anchoring fibrils, and an increase in the number
of blood vessels. Tretinoin can be found in cream, gel, and
liquid preparations. Available concentrations include 0.02%,
0.02S%, O.OS%, and 0.1 %.
The clinical changes from long-term tretinoin use include
smoother skin texture, reduced fine wrinkles, decreased sal-
lowness, improved skin appearance, and a decrease in actinic
keratoses. The treatment can cause irritation, and some
patients find tretinoin difficult to tolerate. During the treat·
ment sunscreen is mandatory. If patients undergo a facelift,
the tretinoin can be restarted after 3 to 4 weeks.
- 112 Part II: Skin and Soft Tissue
Bleaching agents may be helpful in some patients, such as
hydroquinone, kojic acid, azelaic acid, and also retinoic acid.
Hydroquinone is used for reversible pigmentation of skin,
usually at 4% concentration. It can be combined with other
agents, such as prepeeling creams. The 1% kojic acid and
20% azelaic acid may be equally efkctive.1 All these topical
agents can cause skin irritation and should applied first as a
patch test.
Protection and Prevention
Antioxidants and sunscreen are used to protect what has been
achieved and prevent further damage. Antioxidants act to
eliminate the free radicals caused by sunlight. The most popu-
lar are vitamins C (ascorbic acid) and E (tocopherol and toco-
trienols), alpha-lipoic acid, soy isoflavones, tea extracts, grape
seed extracts, niacinamide, and coenzyme Q 10.
Vitamin C is a topical antioxidant agent that stimulates
collagen synthesis, inhibits elastin synthesis, reduces pig-
mentation, improves epidermal barrier function, regenerates
the oxidized forms of vitamin E. and has anti-inflammatory
effects. Smoking cigarettes appears to deplete vitamin C from
the skin.
Vitamin E (tocopherol) is an antioxidant found in veg·
etables, seeds, and meat. Vitamin E prevents lipid peroxi·
dation and therefore protects the cellular membrane from
free radicals. Vitamin E is a helpful ingredient in daytime
moisturizers and sunscreen, because of its photoprotective
properties and also as an anti-inflammatory agent. Alpha·
lipoic acid is another strong antioxidant with anti-inflamma·
tory proprieties. lt is stable and easily absorbed and should
be applied every other day initially and then daily when the
skin permits.7
lsoflavones work by raising hyaluronic acid production,
increasing the thickness and collagen of the skin.7 Topical
green tea and grape seed extracts are antioxidants with anti-
inflammatory action.7•1 Vitamin B improves protein produc·
tion, decreases melanosome transfer, and reduces redness.7
Coenzyme Q10 is used to combat sun damage and therefore
reduces wrinkles, reducing oxidation levels.7•8
Sunscreens are important to prob:ct the skin from ultravio·
let light. The sun protection factor indicated on the container
only indicates the extent to which that product blocks UVB.
Since UVA causes wrinkles and skin cancer, it is also impor-
tant to use a product that also blocks UVA. Unfortunately,
UVA blocking agents are not as well developed as UVB block-
ers. At best; the current UVA blocking agents only partially
block UVA. The only complete sun blocker is zinc oxide, but
it is thick and greasy and not practical to cover all of one's
exposed skin. Sunscreen should be applied daily, before
makeup, and reapplied during the day (Figure 13.10, Case 2;
Tables 13.1-13.3).
NONSURGICAL lREATMENTS
FOR SKIN QUALITY
The most effective nonsurgical procedures are microderm·
abrasion, dermabrasion, lPL, laser resurfacing, chemical
peels, neurotoxins, and fillers. The procedures will be men-
tioned briefly because they are covered in depth in other
chapters.
Microdermabrasion
Microdermabrasion is a nonsurgical procedure that uses alu-
minum oxide (ALzO ) or sodium chloride (NaCl) crystals to
exfoliate the skin. Topical anesthesia is not required and it
is a safe and well-tolerated procedure. The treatment may
be helpful for three to six sessions, every 2 weeks, before
FIGURE 13.10. Case 2-Sunsc:reen. This 70-year-old woman
presented with a combination of sun damage and fac:ial aging.
A complete aesthetic: package was performed, with sun protectors
daily, avoidance of sun exposure and skin care treatment preoper-
atively, and microdermabrasion treatments. Surgically, she under-
went an endoscopic brow lift, rhytidectomy with SMASec:tomy,
and cervicoplatty. The lymphatic drainage massage was intro-
duced during the first week postoperatively. She is shown 1 year
postoperatively.
surgical procedures on the face. The best indications are oily
skin, dilated pores, thick skin, mild acne scarring. melasma,
and solar lentigines. Contraindications include severe acne
rosacea, telangiectasias, uncontrolled diabetes, active acne,
skin cancer, dermatitis, sunburned skin, oral isotretinoin. and
blood thinners.
Dermabrasion
Dermabrasion is the mechanical removal of epidermis and
superficial dermis that will stimulate re-epithelialization. This
can be performed with sandpaper, wire brush, or diamond
fraise powered by a hand engine. The technique is performed
under anesthesia in the operation room. Indications include
wrinkles, facial scars, rhinophyma, syringoma, and epidermal
nevus (Chapter 41).3
Intense Pulsed Light
The IPL is a noninvasive system used for photorejuvena-
tion (Chapter 18). It is a system that emits a broad spec·
trum of non-coherent, polychromatic light in the range of
500 to 1,200 nm. These features allow great variability in
adapting to different skin types and indications by vary-
ing the light spectrum, impulse length, impulse sequence,
and fluence.7 Three to six sessions are recommended, every
2 to 3 weeks.
The best indications are photoaging, telangiectasias, port
wines stains, poikiloderma, red hypertrophic scars, hyper·
trichosis, irregular pigmentation (lentigines, melasma, and
ephelides), and postinflammatory hyperpigmentation. The
contraindications are an abnormal response to sunlight, cur·
rent treatment with oral tretinoin,. suspicious lesions, preg·
nancy, conditions that affect wound healing, and blood
thinners.
Before treatment; the skin is cleansed and topical anesthetic
applied for comfort. The skin can look like a sunburn and
have some swelling from 2 to 48 hours after the procedure.
The pigmented lesions appear much darker immediately
after treatment. After a week, the skin starts to dear and
microdermabrasion can be added to expedite this process
(Figure 13.11, Case 3).
 Chapter 13: Dermatology for Plastic Sw:gcons 1-Skin Care and Benign Dermatologic Conditions 113
TABLE 13.1
FnzPATRICK CLASSIFICATION
. • SKIN TYPE • SKIN COLOR/SUN EXPOSURE
I Highly 9ellsitive, never tans, always bums illld severely, fair skin
n Usually bums, tans mjnjmally, very SUD. 9ellsitive
m Bums moderately, tans moderately, sun-seDsitive skiD
IV Tans moderately and easily, burns minimally
V Rarely bums, dark brown skin, sun-insensitive skin
Vl Never bums, dark brown or blade skin, sun insensitive

TAILE 13.2
GLOGAU CLASSIFICATION
. • PHOTOAGIN'G GROUP • DEGREE OF SKIN WRINKLIN'G AND PHOTOAGING
I Mild (age 28-35 y) MiDimal. wriDkles; no keratosis; requires little or no makeup
n Moderate Rarely w:riokl.iiJg, mild scarring; sallow color with early
(age 35-50 y) keratosis; requires little makeup
m Advilllced Persistent wrinkling; discoloration with telilllgiectasias illld
(age 5()-65 y) visible keratosis; wears makeup always
----------------------
IV Severe Wrinkl.iog: photoaging, gravitational, dynamic; actinic kera-
(age 6~75 y) tosis with or without skin cancer; wears makeup with poor
coverage.

TAILE 13.3
SKIN CARE

Cleansing Cleansing
Hydrate and moisturizers Hydrate and moisturizers
Protection (illltioxidilllts illld Repair (alpha-hydroxy acids, topical tretinoin, bleaching
sun protectors) agents)

Radiofrequency
Radiofrequency is a nonsurgical treatment for skin rejuvena-
tion. It causes a thermal injury to the dermis, stimulates the
fibroblasts, increases collagen production. and provides some

-
skin tightening.
The indications are skin laxity in the face, neck, limbs, and
abdomen. The best candidates are patients between 30 and 60
years and who have reasonably good skin quality and have no
history of smoking. The response is variable.7

Lasers
Lasers produce stimulation of fibroblasts and increase col-
lagen deposition. They can be used for rejuvenation, hair
removal, and treatment of vascular lesions.
The most popular lasers for skin resurfacing are carbon
dioxide and erbium:YAG, which, as described in Chapter 18,
can be fractional or not (Chapters 18 and 41). FIGURE 13.11. Case3-Intense pulsed light (IPL). This 65-year-
olcl woman was conc:c:.med about her appearance aftu a c:utanwus
Chemical Peels faa:lift. An aggn:ssive skin care regimen of IPL treatments to the face
and neck every 21 days was initiated and continued after Nrgety. An
Chemical peels can be superficial, medium, or deep endoscopic brow lift, rhytidectomy with SMASec:tomy, and c:ervic:o-
depending on their penetration into the dermis where they plasty were performed. The lymphatic: drainage massage treatments
result in improvement of collagen organization. A vari- were started S day• postoperatively and continued once a week for 3
ety of chemical peels can be used, such as glycolic acid, weeks. She is shown 7 years postoperatively.
TCA, beta-hydroxy acid, Jessner solution, and Croton
- 114 Part II: Skin and Soft Tissue
oil. Each one has specific characteristics and indications
(Chapter 41).
Neurotoxins
Botulinum toxin is a temporary paralyzing agent that works
by causing a chemical denervation at the neuromuscular junc-
tion providing temporary improvement in dynamic wrinkles.
Patients should be informed that wrinkles that are present at
rest will not be improved by bot:W.inum toxin. although they
will not get deeper with animation (Chapter 43).
Fillers
Fillers are designed to replace volume in dermis or subcutane-
ous tissue of the face. The most commonly used are hyaluronic
acid (such as Juvederm and ~tylane), calcium hydroxyapa-
tite (Radiesse), poly-lactic acid (Sculptra), and others men-
tioned in Chapter 42.
Lymphatic Drainage Massage
LDM is a helpful tool that can be started before or after sur-
gery. It is meant to deaease swelling, bruising, and recovery
time. Preoperatively, LDM helps to remove stagnant fluids,
increase blood flow, and provide the psychological benefit of
reducing stress/anxiety and focusing the patient on positive
results. Postoperatively, the technique decreases inflamma-
tion, speeds up recovery time, reduces bruising, opens lym-
phatic channds, reduces the scar tissue buildup, and continues
to reduce stress and tension.7
References
1. Bums T, Breatlmach S, Cox N, Griffiths C. Rook'3 T~:ctbook of
Dm~S#tology. Malden, MA: Blackwell PublishiDg; 2004.
2. Mathes SJ, ed. Pltutic SNrgny. 2nd ed. Philadelphia, PA: Saunders
Elsevier; 2006.
3. Wolff K, Goldsmith LA, Kat!: sr, GUcllrest BA, Paller AS, Lelfell DJ.
fitzyurid:'1 Demt~~~ology in Ge'!U!'rtll M~Jid~. Columbus, OH: The
~Graw Hill Companies; 2008.
4. Thorne CH, Beasley EW, Aston SJ, Bartlett SP, Gunner GC, Spear SL,
eds. Gt'Rbb Cl' Simth Pltutic S'"gt!'fY. 6th ed. Philadelphia, PA: Lippin~tt
Williams & Wilkins; 2007.
5. Lee PH, Nehal KS. Disa lJ. llenigu and premalignant skin lesions. Pltut
R~CQMtr Swg]. 2010;125(5):188-198.
6. Krait JN, Lynde CW. Moisturizers: what they are and a practical approach
to prodll4't selection. SIUn ThtmJPy Lm. 2005;10(5):1-8.
7. Salt!: R, ed. Comsetic M~Jicine Cl' Mltbetic S'"gt!'fY. Str#tt!gia for Stu:ee/1$.
St Lollis, MO: Qwillty Medical Publishing, In~.; 2009.
8. Bogdan Allem&DD I, Baumann L. Antioxidants used in skin care formula-
tioiD. Skin TberRP'Y Lm. 2008;13(7):5-8.