Aesthetic Surgery Techniques: A

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Aesthetic Surgery
Techniques
A Case-Based Approach
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 Aesthetic Surgery
Techniques
A Case-Based Approach

James D. Frame FRCS, FRCS (Plast)

Consultant Plastic Surgeon,
Professor of Aesthetic Plastic Surgery,
School of Medicine,
Anglia Ruskin University, Chelmsford, Essex, UK

Shahrokh C. Bagheri BS, DMD, MD, FACS, FICD

Chief of Oral and Maxillofacial Surgery,
Northside Hospital, Atlanta and Forsyth, GA, USA

David J. Smith Jr. MD

Professor of Surgery, Division of Plastic and Reconstructive Surgery,
University of South Florida; Richard G. Connar Professor and Chairman, Department of Surgery,
University of South Florida; Chief Medical Officer, Center for Advanced Medical Learning and
Simulation, Tampa, FL, USA

Husain Ali Khan MD, DMD, FACS

Attending Surgeon, Oral and Maxillofacial Surgery,
Northside Hospital, Atlanta and Forsyth, GA, USA

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Edinburgh London New York Oxford Philadelphia St Louis Sydney 2019

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 Contents

Video Contents vii Section 4: Rhinoplasty

Preface ix David J. Smith
Acknowledgments xi
List of Contributors xiii
15 Prominent Nose 111
Igor Niechajev
16 Aesthetic Nasal Tip Surgery 121
Part 1: Introduction Kirill Pshenisnov
David J. Smith 17 Crooked Nose 133
Charles East
1 Informed Consent: Protecting the Patient
18 The Middle Eastern–Mediterranean Nose 137
and the Surgeon 3 Nazim Çerkeş
Neal R. Reisman, Hugh Henderson
19 The Asian Rhinoplasty 147
2 Aesthetic Medicine: Surgical Pearls 7 Naoyuki Ohtake, Kazunari Karahashi, Nobuyuki Shioya
Jaffer Khan, Zara Yousufzai, Natasha Jaffer Khan
20 Male Rhinoplasty 153
3 Aesthetic Applications for Fillers 25 Clifford Clark, Jared Troy
Phillipe Bellity
21 Medical Rhinoplasty 161
Christopher M.E. Rowland Payne
Part 2: Head and Neck
Section 1: Forehead and Brow
James D. Frame Part 3: Perioral Aesthetics and Dentistry
4 Brow Lift 33 Shahrokh C. Bagheri and Husain Ali Khan
Peter Scott, Philip Peirce
22 Aesthetic Orthognathic Surgery 169
5 Endoscopic Endotine Brow Lift Made Easy 39 Michael Miloro, Michael R. Markiewicz
Peter Arnstein
23 Implantology 185
Section 2: Eyes Edward R. Schlissel
James D. Frame and David J. Smith 24 Aesthetic Dentistry of the Smile Line 189
6 Upper Blepharoplasty 45 Arun Nayyar
Janek S. Januszkiewicz
7 Asian Blepharoplasty 53
Takanori Yamawaki, Naoyuki Ohtake, Nobuyuki Shioya
Part 4: Breast
8 Midface Descent and Malar Support 61
James D. Frame
Ernesto J. Ruas
9 Anatomic Relationship of SOOF and ROOF 25 The Small Breast 195
in Eyelid Rejuvenation 67 Henrique P.L. Cintra
Hazem M. Aly, James D. Frame 26 Breast Reduction: Superomedial Pedicle
10 Nonsurgical Rejuvenation of the Periorbital Area 73 Wise-Pattern Approach 205
Patrick J. Treacy Alexandre S.F. Fonseca, Guilherme Flosi Stocchero,
Gustavo Flosi Stocchero
Section 3: Face Lift
27 Mastopexy with Mesh for Breast Ptosis 213
James D. Frame
Petrus V. van Deventer
11 High SMAS Face Lift 81 28 Simultaneous Augmentation and Periareolar
Bud S. Alpert Mastopexy: Indications and Limitations 219
12 Management of the Neck 91 Alberto Rancati, Claudio Angrigiani
Gregory P. Mueller, Nicholas R. Nikolov 29 Asymmetric Breast 225
13 The Turkey Neck: Surgical Management 99 Garrick Georgeu
Darryl J. Hodgkinson 30 Transaxillary Excision of Gynecomastia
14 Platysma Bands 105 (Andromastia) 231
Miles G. Berry, Jan J. Stanek Paul Levick
vi Contents

Part 5: Trunk and Abdominal Wall Part 6: Upper and Lower Extremity
James D. Frame James D. Frame
31 Improving the Waistline with the Modified 36 Upper Arms: Rejuvenation of the Arm 277
Brazilian Abdominoplasty 239 Graeme Southwick, Alenka Paddle
Bassem M. Mossaad 37 Aesthetic Management of the Aging Hand 283
32 Postbariatric Abdominoplasty 247 Kaushik Chakrabarty
Anne Dancey 38 Inner Thigh Lift 287
33 Nonexcisional Management of the Anterior Pedro S. Coltro, Fernanda B. Correa, Jayme A. Farina Jr.
Abdominal Wall 255 39 Inner Thigh Reduction: Reshaping Using a
Riccardo Frati, Grant Hamlet Two-Way Vector Technique 291
34 Body Contouring Following Massive Marcelo A. Cuadrado
Weight Loss 261 Index297
Shailesh Vadodaria, Dharmadev Trivedi
35 Gluteal Augmentation 269
Marcelo Olivan

Chapter 2: Aesthetic Medicine: Surgical Pearls
• Video 2.1 Botulinum toxin to corrugator, depressor
supercilli; botulinum toxin to frontalis muscle and
procerus muscle complex
• Video 2.2 Tear trough and lateral orbital rim
enhancement
• Video 2.3 Temple filler: volumization of temple area
• Video 2.4 Nonsurgical rhinoplasty
• Video 2.5 Periocular rejuvenation
• Video 2.6 Cheek filler
• Video 2.7 Upper lip augmentation
• Video 2.8 Lip augmentation
• Video 2.9 Hyaluronic acid to prejowl sulcus,
marionette, and lower nasolabial fold
• Video 2.10 Nefertiti lift with botulinum
• Video 2.11 Hand rejuvenation with hyaluronic acid
Chapter 12: Management of the Neck
• Video 12.1 oVio360 dynamic imaging link. 50-year-old
woman before and after trampoline platysmaplasty
and neck-defining suture. (Courtesy of G. Mueller,
M.D. and oVio Technologies, Newport Beach, CA,
USA.)
Chapter 13: The Turkey Neck: Surgical Management
• Video 13.1 Identification of elevation point and
window under platysma
• Video 13.2 Triple-cable suture fixation to Lore’s fascia
• Video 13.3 Horizontal and vertical tightening of
platysma to Lore’s fascia using the triple-cable suture
technique
• Video 13.4 Redundant platysma band resection by
submental incision
Chapter 35: Gluteal Augmentation
Chapter 16: Aesthetic Nasal Tip Surgery
• Video 16.1 Second interdomal stitch (SIDS)
Chapter 39: Inner Thigh Reduction: Reshaping Using a
Chapter 30: Transaxillary Excision of Gynecomastia
(Andromastia)
• Video 30.1 Surgical management of gynaecomastia
(andromastia): the Levick technique
Chapter 34: Body Contouring Following Massive
Weight Loss
• Video 34.1 Preoperative circumferential marking in
standing position
Video Contents
• Video 34.2 Prone position with marking
• Video 34.3 Right posterior skin excision following
liposuction for pseudoundermining
• Video 34.4 Left posterior skin excision following
liposuction
• Video 34.5 Completed bilateral posterior skin excision
• Video 34.6 Skin closure of posterior wound
• Video 34.7 Final dressing of posterior wound
following insertion of suction drain
• Video 34.8 Patient turned supine and ventral torso
prepared
• Video 34.9 Power-assisted liposuction with 4-mm
cannula
• Video 34.10 Incision for skin excision
• Video 34.11 Preserving Scarpa’s fascia
• Video 34.12 Midline dissection
• Video 34.13 Completed dissection for excision of skin
flap
• Video 34.14 Excised skin flap
• Video 34.15 Marking for plication of the anterior rectus
sheath
• Video 34.16 Completed plication
• Video 34.17 Progressive tension sutures (quilting
sutures)
• Video 34.18 Umbilical transposition
• Video 34.19 Skin approximation in lower abdomen
and exteriorization of umbilicus
• Video 34.20 Deep dermal sutures with the halving
method
• Video 34.21 Skin closure of lower abdomen
• Video 34.22 Appearance after closure of anterior
wound
• Video 34.23 Application of Steri-Strips
• Video 35.1 Gluteal augmentation: surgical technique
Two-Way Vector Technique
• Video 39.1 Skin markings for two-way vector
technique for inner thigh reduction
• Video 39.2 Operative technique for two-way vector
technique for inner thigh reduction
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This book is dedicated to all those who suffer from deformity
and disfigurement and seek an opportunity to improve their
appearance and restore function. The skills of the Aesthetic
Surgeon in helping Cosmetic Surgery patients, as illustrated
in this book, can be translated to helping those such individuals.
It is up to the Surgeons to learn these specialty skills and put
them into practice. This concept is known as Aesthetica and
our book, with elaborate illustrations and videos, provides
many tips and tricks on how to improve as a Surgeon and,
more importantly, improve patient outcomes. Congratulations
to Elsevier for their insight and support throughout.
There is no substitute for clinical experience in aesthetic
medicine and surgery. It is the Hippocratic responsibility of
those with experience to enhance the knowledge base of those
embarking on their new careers. We (the editors) represent the
current interdisciplinary approach to educating for the many
specialties associated with the beauty industry.
A clinician’s aesthetic practice should represent her or his
fundamental roots in medical training. There must be limitations
to the unqualified extension of practice, all in the patients’ best
interests.
There are many traps for the unwary clinician that can be
largely circumvented with an understanding of the needs
and realistic expectations of the patient. The dysmorphic and
psychologically vulnerable patient must be identified and
protected from harm at all times. Similarly, if a surgeon can
provide for an appropriately selected patient’s desires, then
modern aesthetic medicine and surgical practice can be
immensely satisfying and rewarding.
Preface
Like many surgical disciplines, the practice of aesthetic
surgery has evolved by developing improved surgical tech-
niques to meet increasing patient expectations. In most cosmetic
procedures, the vast majority of advances are from the teaching
of surgical skill sets to younger surgeons through operative
training, textbooks, lectures, and symposia. The difficulty of
developing randomized or prospective cohort studies and
multicenter analyses for aesthetic procedures contributes to
the progression via more traditional modes of teaching. Aesthetic
surgery is unique due to constantly changing trends, as well
as the racial and regional ethnic preferences that drive patient
desires to achieve what is considered an aesthetic result.
There are few books that deliver a case-based approach to
common aesthetic problems, particularly with a global perspec-
tive. The topics included in this book are based on the basic
competencies recognized for hands-on training of an aesthetic
surgeon and include the latest tips and tricks in the aesthetic
and beauty industry. The authors are selected from experienced
clinicians across the globe, and each presents cases that are
easily identified in a normal practice, describing their technique
and outcomes with minimal but relevant bibliography and
operative videos.
We the editors hope that the inquiring clinician will be
stimulated to improve his or her best practice.
JDF
SCB
DJS
HAK
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We would like to thank James D. Frame (Jnr), BSc, MSc, who
worked hard to help reorganize and, in some cases, rewrite
chapters to fit in with style and assisted with the electronic
submissions. Without his work, none of this would have started.
Also, we would like to thank our wives who have put up with
our 30 year “working friendship.”
JDF
DJS
Acknowledgments
This project would not be possible without the deduction and
hard work of our contributors, all of whom, without hesitation,
offered their time and expertise to realize this unique textbook
of Aesthetic Surgery. We thank you for your kind contribution
and time. We would like to also acknowledge the team at
Elsevier whose continuous support throughout this project
has once again resulted in an outstanding publication for the
readers of Aesthetic Surgery.
SCB
HAK
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 List of Contributors
Bernard S. Alpert MD Henrique P.L. Cintra MD Jayme A. Farina Jr. MD, PhD
Plastic Surgeon Assistant Professor of Plastic Surgery Professor
California Pacific Medical Center Davies Pontifical Catholic University of Rio de Janeiro Head of Division of Plastic Surgery
Campus (CPMC) Rio de Janeiro Ribeirão Preto Medical School
San Francisco, CA, USA Medical Director University of São Paulo
11. High SMAS Face Lift Craniofacial Surgery Center Brazil
State University of Rio de Janeiro 38. Inner Thigh Lift
Hazem M. Aly MBBCh, MSc, PhD
Rio de Janeiro, Brazil
Professor of Plastic Surgery
25. Small Breast
Ain Shams University Alexandre S.F. Fonseca MD, PhD
Cairo, Egypt Clifford Clark MD Plastic Surgeon
Assistant Professor of Plastic Surgery Medical Director Breast Reconstruction Division
Dalhousie University Orlando Aesthetic Institute ICESP Cancer Center
Saint John, New Brunswick, Canada Orlando, FL, USA University of São Paulo School of Medicine
9. Anatomic Relationship of SOOF and ROOF in Assistant Clinical Professor São Paulo, Brazil
Eyelid Rejuvenation University of South Florida Centro Médico Viver Melhor
Tampa, FL, USA São Paulo, Brazil
Claudio Angrigiani MD
20. Male Rhinoplasty 26. Breast Reduction: Superomedial Pedicle
Chief of Plastic Surgery
Wise-Pattern Approach
Hospital Santollani Pedro S. Coltro MD, PhD
Buenos Aires, Argentina Professor of Plastic Surgery James D. Frame FRCS, FRCS (Plast)
28. Simultaneous Augmentation and Periareolar Ribeirão Preto Medical School Consultant Plastic Surgeon
Mastopexy: Indications and Limitations University of São Paulo Professor of Aesthetic Plastic Surgery
São Paulo, Brazil School of Medicine
Peter Arnstein FRCS (Plast)
38. Inner Thigh Lift Anglia Ruskin University
Consultant Plastic Surgeon
Chelmsford, Essex, UK
McIndoe Hospital Fernanda B. Correa MD
9. Anatomic Relationship of SOOF and ROOF in
East Grinstead, Sussex, UK Plastic Surgeon
Eyelid Rejuvenation
5. Endoscopic Endotine Brow Lift Made Easy Ribeirão Preto Medical School
University of São Paulo Riccardo Frati MD, PhD
Phillipe Bellity MD
Brazil Consultant Plastic Surgeon
Plastic Surgeon
38. Inner Thigh Lift Highgate Private Hospital
Hartmann Clinic
London, UK
Paris, France Marcelo A. Cuadrado MD
33. Nonexcisional Management of the Anterior
3. Aesthetic Applications for Fillers Plastic Surgeon
Abdominal Wall
Hospital Britanico de Buenos Aires
Miles G. Berry MS, FRCS (Plast)
Buenos Aires, Argentina Garrick Georgeu MBChB, MSc, FRCS
Cosmetic Surgeon
39. Inner Thigh Reduction: Reshaping Using a (Plast)
Cosmetic Surgery Partners
Two-Way Vector Technique Consultant Aesthetic Plastic Surgeon
London Welbeck Hospital
Cadogan Clinic
London, UK Anne Dancey, FRCS (Plast), MBChB
London
14. Platysma Bands (Hons), MMedSci (Hons) MCh (PASP)
Consultant Aesthetic Surgeon
Plastic and Reconstructive Surgeon
Nazim Çerkeş MD Chelmsford, UK
Birmingham, UK
Aesthetic Plastic Surgeon 29. Asymmetric Breast
32. Postbariatric Abdominoplasty
Cosmed Aesthetic Plastic Surgery Center
Grant Hamlet MBChB
Istanbul, Turkey Petrus V. van Deventer MBChB, BSc,
Director
18. The Middle Eastern–Mediterranean Nose MMedSc (UOVS), MMed (US)
The Hamlet Clinic
Lecturer in Plastic & Reconstructive Surgery
Kaushik Chakrabarty MBChB, MD, FRCS, Harley Street
University of Stellenbosch
FRCS (Plast) London, UK
Bellville, Western Cape, South Africa
Consultant Plastic Surgeon 33. Nonexcisional Management of the Anterior
27. Mastopexy with Mesh for Breast Ptosis
University Hospital of South Manchester Abdominal Wall
Wythenshawe, Manchester, UK Charles East MBBS, FRSC
Hugh Henderson FRCS
37. Aesthetic Management of the Aging Hand Consultant Surgeon at the Royal National Throat
Consultant Plastic Surgeon
Nose and Ear Hospital and University College
Leicester
London Hospitals
Medico Legal Advisor and Claims Examiner
NHS Trust
Leicester, UK
London UK
1. Informed Consent: Protecting the Patient and
Director of Rhinoplasty
the Surgeon
ENT@150
Harley Street
London, UK
17. Crooked Nose
xiv List of Contributors

Darryl J. Hodgkinson MBB (Hons), FRCS Gregory P. Mueller MD, FACS Alberto Rancati MD, PhD
(C), FACS, FACCS Plastic Surgeon Chief Division Oncoplastic Surgery
Plastic and Reconstructive Surgeon Private Practice Instituto Oncologico Henry Moore
The Cosmetic and Restorative Surgery Clinic Beverly Hills, CA, USA Universidad de Buenos Aires
Sydney, Australia 12. Management of the Neck Buenos Aires, Argentina
13. The Turkey Neck: Surgical Management Assistant Professor Plastic Surgery
Arun Nayyar DMD, MS
Florida International University
Janek S. Januszkiewicz MBChB, FRACS Private practitioner in Prosthodontics
Miami, FL, USA
(Plast) Former Director of Fixed Prosthodontics
28. Simultaneous Augmentation and Periareolar
Plastic Surgeon Medical College of Georgia School of Dentistry
Mastopexy: Indications and Limitations
New Zealand Institute of Plastic and Cosmetic Augusta, GA
Surgery Former Principle Research Scientist, (Adjunct) Neal R. Reisman MD, JD, FACS
Auckland, New Zealand Georgia Tech Research Institute Past President
6. Upper Blepharoplasty Atlanta, GA, USA The Aesthetic Surgery Education and Research
24. Aesthetic Dentistry of the Smile Line Foundation
Kazunari Karahashi MD
Clinical Professor Plastic Surgery
Clinical Fellow of Plastic Surgery Igor Niechajev MD, PhD
Baylor College of Medicine
St Luke’s International Hospital Chief
Immediate Past Chief Plastic Surgery
Tokyo, Japan Plastic Surgery
CHI Baylor St. Luke’s Medical Center
19. The Asian Rhinoplasty Lidingö Clinic
Attorney at Law
Stockholm, Lidingö, Sweden
Jaffer Khan MBBS, FRCSI, FRCS (Plast), Houston, TX, USA
15. Prominent Nose
FACS 1. Informed Consent: Protecting the Patient and
Chief Executive Officer Nicholas R. Nikolov MD, FACS the Surgeon
Aesthetics International Plastic Surgeon
Christopher M.E. Rowland Payne MB, BS,
Consultant Plastic and Reconstructive Surgeon The Nikolov Center for Plastic Surgery
MRCP
Aesthetics International Beverly Hills, CA, USA
Consultant Dermatologist
United Arab Emirates 12. Management of the Neck
The London Clinic
Senior Lecturer in Aesthetic Surgery
Naoyuki Ohtake MD, PhD Harley Street
Anglia Ruskin University
Director of Plastic Surgery London, UK
Cambridge, UK
St Luke’s International Hospital 21. Medical Rhinoplasty
2. Aesthetic Medicine: Surgical Pearls
Tokyo, Japan
Ernesto J. Ruas MD, FACS
Natasha Jaffer Khan MBBCh, BAO, LRCP, 7. Asian Blepharoplasty
Associate Clinical Professor
LRCSI 19. The Asian Rhinoplasty
Plastic Surgery
Aesthetics International
Marcelo Olivan MD, PhD University of South Florida College of Medicine
United Arab Emirates
Consultant Plastic Surgeon Tampa, FL, USA
2. Aesthetic Medicine: Surgical Pearls
University of Sao Paulo 8. Midface Descent and Malar Support
Paul Levick MS, FRCS (Ed), FRCS (Eng) São Paulo, Brazil
Edward R. Schlissel DDS, MS
Consultant Plastic Surgeon 35. Gluteal Augmentation
Professor Emeritus
Birmingham, UK
Alenka Paddle MBBS (Hons), FRACS General Dentistry
30. Transaxillary Excision of Gynecomastia
(Plast), PGDipSurgAnat Stony Brook University School of Dental
(Andromastia)
Advanced Aesthetic Plastic Surgery Fellow Medicine
Michael R. Markiewicz MD, DDS, MPH Melbourne Institute of Plastic Surgery New York, NY, USA
Assistant Professor Melbourne, Australia 23. Implantology
Department of Oral and Maxillofacial Surgery 36. Upper Arms: Rejuvenation of the Arm
Peter Scott, MBBCh, BSc (Hons), FRCS
University of Illinois
Philip Peirce MBBCh, FCS (SA) (Ophth) (Edin)
Chicago
Ophthalmic and Oculoplastic Surgeon Consultant Plastic Surgeon
Attending Surgeon
Sandhurst Eye Centre Morningside Clinic
Northwestern Memorial Hospital and Ann &
Sandton, South Africa Johannesburg, South Africa
Robert H. Lurie Children’s Hospital of Chicago
4. Brow Lift 4. Brow Lift
Chicago, IL, USA
22. Orthognathic Surgery Kirill Pshenisnov MD, PhD Nobuyuki Shioya MD, FACS
Professor and Chief of Plastic Surgery Professor Emeritus of Plastic Surgery
Michael Miloro MD, DMD, FACS
European Medical Center Kitasato University School of Medicine
Professor and Head of Department of Oral and
Moscow Sagamihara, Kanagawa, Japan
Maxillofacial Surgery
Professor of Plastic Surgery 7. Asian Blepharoplasty
University of Illinois
Russian National Research Medical University 19. The Asian Rhinoplasty
Chicago, IL, USA
Moscow
22. Orthognathic Surgery
Professor of Traumatology and Plastic Surgery
Bassem M. Mossaad MRCS, MSc (Aesth Yaroslavl State Medical University
Plast), FEBOPRAS, MD Yaroslavl, Russia
Lecturer and Consultant Plastic Surgeon 16. Aesthetic Nasal Tip Surgery
Plastic Surgery Unit
Suez Canal University
Ismailia, Egypt
31. Improving the Waistline with the Modified
Brazilian Abdominoplasty

Graeme Southwick OAM, MBBS (Hons),
FRACS, FACS
Consultant Plastic Surgeon
Chairman
Melbourne Institute of Plastic Surgery
Adjunct Senior Lecturer
Anatomy and Cell Biology
Hudson Institute of Medical Research
Monash University
Melbourne, Victoria, Australia
36. Upper Arms: Rejuvenation of the Arm
Jan J. Stanek MA, FRCS
Cosmetic Plastic Surgeon
Surgical Aesthetics
London, UK
14. Platysma Bands
Guilherme Flosi Stocchero MD
Plastic Surgeon
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
Gustavo Flosi Stocchero MD
Plastic Surgeon
University of São Paulo Hospital
São Paulo, Brazil
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
List of Contributors xv
Patrick J. Treacy MBBCh, LRCSI, MICGP, Shailesh Vadodaria MBBS, MS, MCh, FRCS
MBCAM, HDip Derm, BSc (Hons) (Plast)
Dermatologist, Founder and President of the Consultant Plastic and Reconstructive Surgeon
Ailesbury Clinic London Welbeck Hospital
Dublin, Ireland London
10. Nonsurgical Rejuvenation of the Periorbital Consultant Plastic and Reconstructive Surgeon
Area Clementine Churchill Hospital
Harrow
Dharmadev Trivedi MBBS, MS, MRCS,
Middlesex
FHEA (UK)
Director
Registrar in Upper Gastrointestinal /
Medical Arts for Cosmetic Surgery
Hepatopancreatobiliary Surgery
Watford, UK
Bristol Royal Infirmary
Consultant Plastic and Reconstructive Surgeon
Bristol
Kokilaben Dhirubhai Ambani Hospital and
Research Registrar in Cosmetic Surgery
Medical Research Institute
Medical Arts for Cosmetic Surgery
Mumbai, India
Watford, UK
34. Body Contouring Following Massive Weight
34. Body Contouring Following Massive Weight
Loss
Loss
Takanori Yamawaki MD
Jared Troy MD
Plastic Surgeon
Plastic Surgeon
St Luke’s International Hospital Tokyo
Winter Park, FL, USA
Japan
20. Male Rhinoplasty
7. Asian Blepharoplasty
Zara Yousufzai MBBS, MS (Plast)
Aesthetics International
United Arab Emirates
2. Aesthetic Medicine: Surgical Pearls
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PA R T 1
Introduction
David J. Smith
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Informed Consent: Protecting the Patient and
the Surgeon
The Process of Informed Consent
Neal R. Reisman MD, JD, FACS
The process of informed consent is very important to the practice
of plastic surgery. Not only is it a requirement from a legal
standpoint, but it should assist in clarifying goals and expecta-
tions. Understanding informed consent is a process and not
specifically the document that becomes signed; the process
should include not only the surgeon, but the team interacting
with the patient. There are legal standards that every jurisdiction
adheres to defining requirements in accomplishing informed
consent. The majority of states in the United States follow a
“reasonable patient” standard which defines informed consent
information necessary for a reasonable patient to make an
informed decision. The minority standard is what a “reasonable
physician” deems appropriate to accomplish informed consent.
Such standards do not mean that all information pertinent to
a procedure must be discussed but only such information as
a reasonable prospective patient would need to understand
to make an informed decision. Practices spend much time
creating and discussing informed consent. The reality is that
there are very few litigation cases specifically lost on a lack of
informed consent. It is important to have the consent discussion
and documents in the patient’s language. In addition to language
issues, the bigger task is having the patient “understand” what
the risks, hazards, inherent risks, and concerns are. The
understanding of this information becomes the main issue in
creating and achieving informed consent. A mere signature at
the bottom of the document only demonstrates that the patient
signed it and not that it is understood.
Informed consent documents present and discuss death and
significant morbidity. It may be difficult for a jury to believe
the plaintiff is objecting to a scar or a less than desirable result
when they have understood and signed to say that they
acknowledge that death is an acceptable risk. The scar seems
much less significant. Herein lies the challenge to achieve
informed consent, and I suggest to accomplish the legal
The Process of Informed Consent 3
1
Neal R. Reisman MD, JD, FACS
Hugh Henderson FRCS
requirement by going beyond the document itself and using
the discussion to better interpret and decide whether goals
can be reached.
The reasonable patient would inquire about the different
procedures suggested, their complications and inherent risks,
anesthesia concerns, drug interactions, cost and expenses, and
the risk of doing nothing. It behooves the practice to see the
prospective patient more than once and to utilize multiple
learning style techniques in providing necessary information.
There are many learning styles, but the most common three
are visual, auditory, and kinesthetic. Understanding is enhanced
when all three styles are incorporated in the informed consent
process. Many patients are visual learners and achieve under-
standing by looking at photographs, schematics, and other
tools the patient can see. One must be cautious in not having
photographs interpreted as a warranty of results but rather
representative of different aspects of the procedure. Demonstra-
tive tools should clearly not be presented as the prospective
patient’s result but rather a general representation. Patients
may bring in their own photographs of goals and expectations
that are helpful in defining their desires, but these should not
be made part of or included in the medical record. Auditory
learners are the next most common group. The auditory learner
listens in great detail to describing information pertaining to
the procedure, follow-up, and care. Your words paint a picture
for them, achieving a better understanding of the procedure
and inherent risks. Often the more detail you can provide in
advance, the more comfortable the patient is with the entire
event. The third learning style is the kinesthetic learner. This
can be more of a challenge in discussing how the procedure
specifically relates to the patient and past experiences the patient
can recognize. An example might be, when attempting to
determine size goals in a breast augmentation, to have the
patient reflect on a past pregnancy where breast size dramati-
cally increased. The patient may disclose that they liked their
shape as they reached a full C in size, but the full D size they
reached was too large. Such a personalized experience and
understanding significantly helps the patient in understanding
options and achieving their goal.
3
4   CHAPTER 1 • Informed Consent: Protecting the Patient and the Surgeon
Achieving informed consent can be a team event. The
surgeon has the responsibility to discuss aspects of the treat-
ment; however, some portions can be delegated to the office
team nurse or coordinator. In my opinion it is difficult to allow
or delegate others beside the surgeon to discuss and obtain
informed consent when these non-surgeon team members have
not received the training or credentials, or had the privilege
to ever perform such surgeries. It is wise to develop a team
approach in presenting such information, with the patient
coordinator and the nurse confirming and corroborating the
surgeon’s discussions.
The details of the informed consent document should reflect
the discussions had on the multiple visits prior to the actual
procedure. I have chosen to divide the document into general
risks and specific procedure risks to help the patient understand
what is involved.
General risks of surgery include healing issues, delayed
or undesirable results, bleeding, infection, scarring, pain,
complications related to anesthesia, cardiac pulmonary, deep
venous thrombosis (DVT) and sequelae, allergic reactions,
drug reactions, and unsatisfactory results, to name some of
the included discussions. Additional general advisories relate
to smoking and its negative effect on healing, off-label US
Food and Drug Administration issues, the negative effects
of sun exposure, and general concerns in the postoperative
period relating to travel and family interaction. Additional
discussions should include the possible need for additional
surgery, the importance of patient compliance, a revision policy
covering how long and what, and a separate financial disclosure
document covering patient responsibility, cosmetic surgery
component, present and future expenses, and cancellation policy.
The revision policy should include the period of time after
surgery in which a revision will not incur a fee. Ten months after
surgery might not be unreasonable for the surgeon to consider
a scar revision without additional fees while five years later
might be unreasonable. In addition, the limitations of a revision
would only cover the performed surgeries and not additional
areas or procedures. Revision of an abdominal scar might be
appropriate but additional liposuction or a body lift would not
be considered a ‘revision’. Lastly it is wise to state the revision
policy will only be effective when the patient attends their
postoperative appointments and adheres to recommended care.
Non-compliance waives the revision policy. A communications
consent is important to document and acknowledge how the
practice may communicate with the patient. This should include
permission for telephone numbers, email choices, texting and
cell phone permissions, and social media and other methods.
A general consent should also include the use of photographs
to be kept by the practice and commercial photograph consent
should any patient medical information or likeness be used for
marketing, advertising, or educational purposes. The general
Health Insurance Portability and Accountability Act (HIPAA)
consent would not be adequate for any use beyond practice
storage. The commercial consent is specific regarding where the
likeness would be used, for how long, and for what purpose.
Specific procedural consent should include technical and
specific information relevant to the selected treatment question.
This is the area where specific options related to the procedure
and patient choices are covered. Inherent risks and complications
specific to the procedure should be outlined carefully and in an
educational fashion. Choices offered to a patient or demanded
by a patient should fall within a peer-approved appropriate
selection choice. I have issues with the propriety of less than
desirable options being selected by the patient. One might say
that a patient cannot consent to a negligent procedure. The
surgeon has a duty to protect the patient, sometimes from
themselves. Remember that the informed consent standard is a
reasonableness standard. That is, what a reasonable physician
or a reasonable patient would want to discuss or know for the
patient to make an informed decision. Many have utilized a
checklist to cover the large amount of information that may be
necessary in a complex case. The concern with a large checklist is
that one item may be unintentionally omitted. If that is the one
complication the patient suffers, the perception may be that it
was omitted intentionally. Educational aids to assist with visual,
auditory, and kinesthetic learning are valuable. The concern is
not to create a warranty, either express or implied. An express
warranty includes a specific demonstrative in the medical record
that establishes an agreed-upon result. Patients bring pictures
from magazines and the Internet as a goal for their expectation.
While these are valuable, I would suggest they not be made
part of the medical record. Similarly your preoperative and
postoperative photographs should clearly represent a range of
results and not imply specific results for this patient. An implied
warranty can be more confusing, as it relates to expressed
concerns and desires the patient has that are not negated or
addressed. An example might be an important meeting 2
weeks following surgery that must be attended. Failing to offer
rescheduling or a disclaimer that meeting attendance may not be
possible may establish an implied warranty that the patient will
be able to attend. I like the additional paragraph “no warranties
express or implied are included and the patient understands
what can and cannot be done and, understanding this, elects to
proceed.”
Additional information as part of this informed consent
process includes a financial disclosure statement and a surgi-
cal revision policy statement. Finances are always significant
to the patient, and misunderstandings are quite common. It
is important to have a separate document that incorporates
expectations of named procedure, estimated time, and fees
including surgeon, anesthesia, facility, and any additional costs
that may be incurred, such as devices and instrumentation.
The patient should understand and acknowledge such a docu-
ment in advance of the procedure. The revision policy is also
important to avoid misunderstandings. Despite best intentions
patients may heal quite differently and unexpectedly. I like the
revision policy to include an understanding that the patient is
required to be compliant and not miss follow-up appointments
or postoperative suggestions of care. The surgeon can certainly
for some period not charge for agreed revisions, but there may
be additional charges for anesthesia, facility, or devices. I do not
believe that not billing is an admission of negligence and have
advised adding a clause in the policy manual stating “from
time to time, as an executive decision, fees may be waived,
discounted, or not created.”
There are so many aspects of the informed consent document;
I do not want to minimize its importance. I would, however,
seize the opportunity to have a robust and complete discussion
with the prospective patient about their goals and desires and
use this interactive informed consent process to determine
if such goals are realistic and achievable. Avoid letting the
patient dictate care and procedure selections unless such choices
are well within an appropriate peer-accepted range. Failed
expectations still remain a leading cause of unhappy patients

FIGURE 1.1 An infected abdominoplasty wound.
and litigation. The wise old statement “if I tell you in advance
of a complication and you get it, I look smart, where if I tell
you the same statements after your complication I’m making
excuses” becomes significant when complications occur. Use the
informed consent process as an educational tool, recognizing
learning styles as well as the dialogue assessing patient goals.
Such a process often results in an educated, content, and satisfied
patient and a successful postoperative course.
Informed Consent: Protecting the
Surgeon
Hugh Henderson FRCS
The Legal Situation
“Justice must not only be done, but must be seen to be done,”
and so it is with informed consent. Surgeons need written proof
about what they have advised a patient. You are as often as
not assumed guilty until you prove your innocence (Fig. 1.1).
Courtroom Scenario
“Well Mr. Jones, did you really spend 45 minutes explaining
this operation to Mrs. Smith or only the 10 minutes as she
alleges? Did you think to make note of the duration of your
consultation and did you give her any written information
about the common risks of what you were proposing? Did
you show her photographs and suggest a second consultation
to ensure that she really understood…?”
If you want to avoid this sort of courtroom confrontation
with an aggressive barrister, you must get a watertight informed
consent which will convince a judge that the patient was well
informed and able to make a considered decision about whether
to have the operation and that the patient understood the risks.
Different surgeons have different ways of achieving this and
there are no mandatory or statutory rules about how to do it.
You can make a close record of what your verbal discussion
covered, you can enclose it in a letter to the general practitioner,
or you can give it to the patient in the form of an information
sheet that you can prove was actually delivered to the patient.
You can get photographs in hard copy on which you and the
Informed Consent: Protecting the Surgeon 5
FIGURE 1.2 Breast augmentation: the available implant options to be discussed
with a patient.
FIGURE 1.3 High right breast implant and sliding ptosis of breast tissue. Patient
unaware that this could happen after augmentation mastopexy.
patient have drawn to show the areas to be treated and the
type of changes that you agree will be attempted.
A recent court of appeal ruling (The Montgomery Case)1
not only expects you to inform the patient of the details of the
operation which you have agreed, but also requires that you
have explained all the alternative options and their merits and
demerits (see Fig. 1.2).
Patients tend to remember only 50% or less of what they
are told verbally in an initial consultation. The longer the
consultation, the more likely that they will “switch off” after
a certain time and forget important points. A lot of surgeons
think that one consultation is sufficient, but if you test a patient’s
knowledge of what has been discussed in that first consultation,
you will be saddened to find that they haven’t really taken in
quite a lot of important matters (Fig. 1.3).
If you give them one consultation plus a detailed informa-
tion sheet and then test them, their knowledge is much better.
If you give them one consultation and an information sheet
and make sure they read it and then see them for a second
consultation, most patients will have absorbed everything you
want them to know and you will have obtained proper informed
consent. Just because it is logistically difficult to arrange a
second consultation, it is not an excuse for not arranging one.
I have dealt with over 1000 medical negligence cases, and I
know that at least 200 of these would have never occurred if
there had been a second consultation before the day of surgery.
6   CHAPTER 1 • Informed Consent: Protecting the Patient and the Surgeon
Most hospital consent forms nowadays include reference
to whether an information sheet has been given. This is rec-
ognition that information sheets are important in the consent
process. Although information sheets are not mandatory as
yet, I think they should be because they can contain a lot
more information than is mentioned or highlighted in an
oral consultation. My own policy has always been to write
information sheets as comprehensively as possible so that a
lawyer will have a hard time trying to prove lack of consent.
They can be equivalent to a second consultation and can be
included on your website or sent to a patient in advance of the
first consultation or given to the patient at the time of the first
consultation.
Are tick lists proof of adequate discussion? It is only too
easy for a surgeon in a hurried consultation to speak to a
patient and then at the end of the consultation when the patient
has left to tick all the boxes. A more trustworthy way of using
a tick list is to give the patient a copy of your tick list at the
time of the consultation and invite them to tick the subjects
off and to sign it and hand it back to you as evidence that
these points have been discussed. It is also wise to record the
length of time spent going through this tick list.
It is important to indicate a percentage risk of occurrence
of the various complications you describe. It is also vital to
discuss the potential consequences of the complications rather
than simply giving a list of the name of complications. Thus,
for example, in breast reduction it is sensible to tell a patient
that most infections are of minor consequence but about 1%
to 2% of breast infections after breast reduction can be absolutely
devastating and can ruin the result and cause months of pain
and morbidity.
It is important to establish the financial consequences of
complications. Who will pay for “re-dos”? Some hospitals cover
the costs of complication for 1 month postoperatively. This
must be discussed and explained. Emphasize that you won’t
insure the patient for life. Some patients think they deserve
free correction years after their initial surgery.
It is essential to write down exactly what the patient asked
for in their own words rather than your translation of what
you interpret that they are asking for. The very first record
that you make of the consultation should be what the patient
is actually asking for. It is remarkable how few surgeons actually
do this. I have been involved in lots of medico-legal cases in
which the surgeon has failed to record what the patient actually
requests. If you don’t record it, the patient can come back and
blame the surgeon for doing the wrong operation. They can
say that they never asked for what the surgeon has recom-
mended. Therefore, if their request is ambiguous, then you
must clarify it. “I want nicer fuller breasts” could mean lots
of different things, but it doesn’t necessarily mean breast
augmentation. The patient might subsequently say, “Doctor I
never asked you to make my breasts bigger, I simply asked
you to lift them to make them look fuller.” Having recorded
what the patient is asking for, you should then record the
topics of discussion in relation to this request. It is quite possible
that the patient will change their mind as a result of this discus-
sion and you should then record what their secondary request
is. You must also record what you have recommended and
why and then, separately, what has been agreed.
It is always sensible to show photographs of both good and
bad results so that you can never be accused of showing atypi-
cally perfect results.
If a patient decides to have an operation, but wishes to
delay it for more than a few weeks, it is essential to see them
again for a brief reminder consultation a few days before the
operation. This is to remind you, the surgeon, and also the
patient of what has been agreed and of the risks, and it gives
the patient the chance to ask further questions.
If a patient asks you for a little bit of extra surgery on the
day of the operation, you have the dilemma of causing offense
by refusing or putting yourself in jeopardy if you haven’t sorted
it out properly in advance.
Summary
1. Record the time of the start of the consultation and its
duration.
2. Write down what the patient first asked for, not what you
think might suit them.
3. Write down the options for treatment.
4. Write down what you recommend for them.
5. Write down what you agree to do.
6. Write down the risks and separately the percentage
occurrence of the complications and the consequences of
the complications.
7. Give a comprehensive information sheet.
8. Insist upon a second consultation to run over what has
been discussed already, emphasizing the risks.
9. Discuss the costs of surgery, the financial consequences of
dealing with complications, and who is going to pay for
this.
Reference
1. Montgomery (Appellant) vs. Lanarkshire Health Board (Respondent)
(Scotland) before Lord Neuberger, President, Lady Hale, Deputy
President, Lord Kerr, Lord Clarke, Lord Wilson, Lord Reed, Lord
Hodge. Judgement given on 11 March 2015. Heard on 22 and 23 July
2014.
 Multimodality Nonsurgical Rejuvenation With a Regional Approach 7

2
Aesthetic Medicine: Surgical Pearls

Jaffer Khan MBBS, FRCSI, FRCS (Plast), FACS

Zara Yousufzai MBBS, MS (Plast)
Natasha Jaffer Khan MBBCh, BAO, LRCP, LRCSI

Commercially available botulinum toxin A are:

Introduction ■ onabotulinum toxin A (Botox)
Aesthetic medicine comprises all medical procedures that are ■ abobotulinum toxin A (Dysport)
aimed at improving the physical appearance and satisfaction ■ incobotulinum toxin A (Xeomin)
of the patient, using noninvasive to minimally invasive cosmetic Dilution
procedures.
These aesthetic procedures consist of: ■ 1 B.U. = 2.5 s.U
1 vial of Dysport (500 s.U) + 2.5 mL saline = 20 U/0.1 mL
■ injections of neurotoxins (can be rediluted in the syringe with 1 : 1 ratio to create a
■ dermal fillers/fat grafting concentration of 10 s.U/0.1 mL)
■ chemical peels ■ 1 vial of Botox (100 U) + 2.5 mL of saline = 4 U/0.1 mL
■ radiofrequency 30- to 32-gauge needle (a smaller needle is preferred in
■ cryotherapy sensitive patients)
■ lasers and intense pulsed light (IPL) 4 U Botox = 10 U Dysport
■ ultrasound treatment
■ platelet-rich plasma (PRP)
The author used a combination of these procedures for PREPROCEDURE MANAGEMENT OF
nonsurgical rejuvenation. This chapter provides an overview NEUROMODULATORS
of each of these with their clinical implications, recommended
indications, management, advantages, and disadvantages. ■ Conduct an assessment of the patient.
■ Note the location and depth of rhytids.
■ Obtain a history of the patient’s concerns.
• Brow position is important.
Multimodality Nonsurgical • Check for the presence or absence of compensatory
brow elevation.
Rejuvenation With a Regional • Check for blepharochalasis and dermatochalasis.
Approach • Check for collagen depletion.
• Measure the width of the forehead (a wide forehead
would need more neuromodulator/Botox).
Botulinum Toxin (Botox) • Assess strength of frontalis muscle and length of
corrugator.
In aesthetic medicine botulinum toxin (see Table 2.1 and Fig. ■ Take a preoperative photograph.
2.1) is the most commonly used nonsurgical treatment world- ■ Apply a eutectic mixture of local anesthetics (EMLA) 30
wide. In 2014, 4.89 million Botox treatments were done minutes prior to procedure.
worldwide. Its popularity is due to its excellent safety record ■ Give counseling about potential complications.
and predictable outcomes. ■ Obtain consent.

7
8   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls
Table 2.1 Uses of botulinum toxin in aesthetic medicine
Dynamic rhytids • Forehead horizontal lines
• Glabellar vertical lines
• Periocular rhytids (crow’s feet)
• Hyperdynamic orbicularis/pretarsal
orbicularis (under the eyes)
• “Bunny” lines
• Perioral (smoker’s lines)
Diminishing the • Lateral fibers of orbicularis (brow
depressor activity elevation)
of certain muscles • Depressor septi (nasal tip elevation)
• Platysma (Nefertiti lift)
• Mentalis (chin deformity)
• DAO (for marionette lines)
Hypertrophic muscles • Masseter
• Nasalis (alar flare muscle)
• LLSAN (“gummy” smile and alar flare)
• Masseter
• Deltoid
• Medial head of gastrocnemius
DAO, Depressor anguli oris; LLSAN, levator labii superioris alaeque nasi.
POSTOPERATIVE CARE FOR NEUROMODULATORS
■ The lumps on the area injected will go down in 15 to 30
minutes.
■ Do not rub or apply pressure on the area that was
injected with Botox.
■ For 6 hours, avoid bending or stooping down; instead lie
down flat on your back.
■ Do not go to the gym or do any sports until the next day.
■ Follow up after 10 days.
■ Take a postoperative photograph.
Hyaluronic Acid (Fillers)
Adding volume along with short-scar face lift has largely
overtaken surgical correction for midface. The choice of filler
is dependent on the anatomy of each individual and the specific
treatment goals. Injectable soft-tissue fillers are durable, well
tolerated, and potentially reversible in unfavorable clinical
outcomes. Small-particle hyaluronic acid (HA) with lidocaine
(Restylane Silk, Galderma, Uppsala, Sweden) is used for
submucosal implantation for lip augmentation and dermal
implantation for correction of perioral rhytids. Side effects are
generally mild and transient.
PREPROCEDURE MANAGEMENT
■ Conduct a general assessment of the patient.
■ The patient should avoid aspirin (any product containing
acetylsalicylic acid), vitamin E, and other dietary
supplements, including gingko, evening primrose oil,
garlic, feverfew, and ginseng, for 2 weeks.
■ The patient should also avoid blood thinners such as
aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve,
Naprosyn) 1 week before the treatment.
■ Enquire about history of cold sores (or fever blisters)
prior to treatment.
■ Optionally, the patient can start taking an Arnica tablet
for 1 week prior to treatment and 4 days posttreatment.
The standard dosage is three Arnica tablets (30 CH) three
times a day 30 minutes before or after a meal.
■ Enquire about allergy or sensitivity to lidocaine.
■ Mild bruising is common and can last 7 to 14 days.
■ Take a preoperative photograph.
■ Apply EMLA 30 minutes prior to the procedure.
■ Give counseling about potential complications and obtain
consent.
POSTOPERATIVE MANAGEMENT
■ Follow up after 2 weeks for touch-up.
■ Take a postoperative photograph.
■ Counsel the patient that the volume will go down by
approximately 20%.
■ Give Voltarol for pain relief.
■ Massage with Arnica.
■ Avoid hot beverages after the dental block (for lip
augmentation).
■ Avoid cold compression to prevent headache (in the
temporal area).
■ Minimize movement of the treated area.
■ Avoid applying heat to the treated area until bruising or
any swelling has resolved.
■ On the day of treatment, avoid activities that cause facial
flushing including consuming alcohol, hot tub or sauna
use, exercising, hot wax, and tanning. Avoid extreme-cold
activities, like skiing or hiking outdoors.
■ Gently apply a cool compress or wrapped ice pack to the
treated areas for 15 minutes every few hours as needed
to reduce discomfort, swelling, or bruising up to a few
days after treatment. When bruising occurs it typically
resolves within 7 to 14 days.
■ Results last approximately 6 to 12 months.
■ For more than 4 cc of filler used, prednisolone 40 mg
with Nexium 40 mg daily for 2 days after meals may be
considered.
Upper Face
Forehead and Brow Rejuvenation (Fig. 2.2)
ASSESSMENT (TABLE 2.2)
■ Check the brow position (this is important).
■ Check for the presence or absence of compensatory brow
elevation.
■ Check for blepharochalasis or dermatochalasis.
■ Check for collagen depletion.
■ Assess the strength of muscle.
■ Measure the width of the forehead.
TECHNIQUE
■ The brow elevator (frontalis) and depressors (corrugator,
procerus, depressor supercilli [DSC] for the medial brow
and the superolateral fibers of the orbicularis oculi for the
lateral brow) should be treated as a single unit to prevent
brow ptosis.
■ Preventing brow ptosis should be the priority.
 Upper Face 9

Before After

A B
Before After

C D

FIGURE 2.1 Combination treatment of hyaluronic acid to periocular midface and marionette areas with botulinum toxin to glabellar forehead and periocular area.

■ This can be achieved by full treatment to the corrugator, ■ For the technique, see Video 2.1.
procerus, and DSC, a conservative dose to the frontalis, ■ Injections placed above the midpupillary line for the
and a later touch-up to the frontalis if required in 10 days. corrugator should be at least 1 cm above the bony orbital
■ Treatment of the superolateral fibers of the orbicularis rim to help prevent lid ptosis caused by diffusion of
oculi will also help to maintain an elevated brow Botox to levator muscles.
position. ■ Some return for a touch-up in 10 days.
■ Assess the activity of DSC. If DSC overactivity is missed,
the patient may come back with descent of the medial COMPLICATIONS
brow (an angry look).
■ If there is previous history of heaviness of brow after ■ Lid ptosis
treatment, inject only in the central forehead. ■ Brow ptosis
10   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Before After

A B
Before After

C D

FIGURE 2.2 (A,B) Botulinum toxin to corrugator, depressor supercilli, and procerus muscle complex. (C,D) Botulinum toxin to frontalis muscle.

Table 2.2 Management of forehead and brow rejuvenation

Indication/patient’s
perspective Muscle Plane Treatment
Glabellar frown lines Corrugator Subdermal 4–8 injections in females
Glabellar frown lines Procerus Deep subdermal 6-10 injections in males
10 s.U in each injection
Glabellar frown lines Depressor supercilli Deep subdermal
Dynamic lines on the forehead Frontalis Subdermal One injection centrally and two laterally on forehead.
(between 10 and 30 s.U in divided doses)
To maintain the brow position Orbicularis oculi (superior Subdermal As a prophylactic measure, 10 s.U on each side to
To prevent lateral brow ptosis lateral fibers) be given under the tail of the brow to inactivate
the depressor action
 Hints and Tips 11

Periocular Rejuvenation (see Table 2.3, 4. Avoid the supraorbital bundle and the infraorbital
bundle.
Fig. 2.3, Video 2.2 and Video 2.5) 5. Avoid injecting above the orbital rim.
6. Inject slowly and don’t inject a large bolus.

☛ Hints and Tips

Temporal Area: Temple Augmentation
1. Plunger should be withdrawn three times to avoid (Fig. 2.4)
intravascular placement.
2. If oozing, hold for 2 minutes. Management of hollowness of the temporal area is aimed at
3. Always keep hyaluronidase handy. volumization.

Before After

A B
Before After

C D

FIGURE 2.3 Tear trough and lateral orbital rim enhancement with hyaluronic acid.
12   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Table 2.3 Management of periocular rejuvenation

Patient characteristics Management
Dark circles • Mesotherapy
• Carboxytherapy
• Platelet-rich plasma
• Volumization
• Patient in upright position or semirecumbent position
• Low–G prime HA, Teosyal Redensity is my choice of product
• I prefer using a 30-gauge needle or a 25-gauge cannula, which gives accuracy of placement and less
likelihood of irregularity
• Patient is instructed to gently close eyes or open in forward gaze to assess the depth
• Inject deep below the orbicularis. Delivery of small aliquots of low G prime HA subdermally is also possible
• Always withdraw plunger three times with slow delivery and do not overfill
• Inform the patients about upper eyelid heaviness because filler has some lidocaine and causes
infraorbital anesthesia
Prominent eye bags • In minimal extraocular fat, volumize between the periocular and cheek fat just under the orbital rim to
decrease the disparity
• Volumizing may improve the look but the amount of volume required in the cheek to match the periocular
area would result in swollen eyes
• If periocular fat is normal but looks excessive due to inadequate cheek volume and a disharmonious lid
cheek junction then volumization would give a good effect
Prominent eyes • Volumize the lateral orbital rim below the rim to create a harmonious lid cheek junction
• For patients who don’t have bulging eyes, volumization would make their eyes look smaller
• Volumization in the lateral orbital rim area gives the effect of higher cheek bones, but eyes become small;
hence for bulging eyes, filling this area gives good results
• Test to assess extraorbital fat
• With the eyes closed, applying digital pressure on the globe would result in bulging of the periocular fat
Sleep lines • Fractional laser (CO2 laser)
• Volumize with low–G prime HA
Upper lid hollowness • Small amount of local anesthetic is injected at two points:
and brow position • 1 cm below the tail of brow, avoiding any superficial veins
• at midbrow area just above the orbital rim
• I use 27-gauge cannula 1.5 inch needle
• Enter into the subgaleal slide plane
• You will hear a pop as you enter
• I use a retrograde threading technique with very small amounts of volume placed above the orbital rim into
and above the eyebrow. No more than 0.5 cc per eye
• Second access point tends to use a smaller 30-gauge cannula
• Product of choice is low–G prime HA
• Massage well
Periocular rhytids • HA
• CO2 laser
• Botox for dynamic lines (Table 2.4)
• Assessment of extent and depth of rhytids (into cheek or under the eyes)
• Laxity and excess of periocular skin particularly in the infraorbital area
• Avoid injecting too low over the zygoma to prevent diffusion to zygomaticus major, as it would inactivate
cheek elevation upon smiling (masklike smile)
• Patients with excess lower eyelid skin, injections in the lower lid area can lead to descent of skin,
causing a malar crescent at the level of the lateral orbital rim
• Treating the periocular area can result in exaggeration of bunny lines, which may be treated on
subsequent treatment
• While treating the bunny lines, injection placed deep and low on the nasal sidewall can diffuse to LLSAN
may lead to an asymmetric smile
• Complication
• Blurred vision
• Double vision
• Diffusion to the zygomaticus major leading to a asymmetric smile
• Bunny line exaggeration
• In redundant skin injection to the pretarsal area can lead to descent of the skin resulting an arc at the lid
cheek junction
HA, Hyaluronic acid; LLSAN, levator labii superioris alaeque nasi.
Another random document with
no related content on Scribd:
trabajo que en esto tomares te
será galardonado.
Amintas.—A mí me place de muy
buena voluntad; por aquí
podremos ir mejor, y en bajando
aquel valle hallaréis un camino
abierto y ancho; por él os iréis sin
tomar á una parte ni á otra, que
no lo podréis errar; y porque dexo
el ganado solo no voy hasta allá;
por tanto, perdonadme y Dios
vaya con vosotros os guíe.
Florián.—Ese quede contigo y te
haga bienaventurado.

Finis.
 COLLOQUIO

Que trata de la desorden que en

este tiempo se tiene en el
mundo, y principalmente en la
cristiandad, en el comer y
beber: con los daños que dello
se siguen, y cuán necesario
sería poner remedio en ello.

INTERLOCUTORES

Licenciado Velázquez.—Salazar.
Quiñones.—Ruiz.

Ruiz.—¿A dónde bueno, señor

Quiñones?
Quiñones.—Hacia el monasterio
de San Jerónimo, á gozar un rato
del fresco de la tarde y de la
buena conversación del
licenciado Velázquez; porque él y
Salazar ha poco que iban para
allá cabalgando, y yo mandé
luego aderezar mi caballo para
salir á buscarlos.
Ruiz.—Si vuesa merced me lo
paga, acompañarle he yo, porque
no vaya solo.
Quiñones.—Antes merezco que
se me pague á mí el buen aviso,
que no veo adonde mejor se
pueda pasar el día.
Ruiz.—En fin, lo habré de hacer
aunque pensaba dar una vuelta
por cierta parte que me convenía.
Quiñones.—Tiempo habrá para
todo, que agora no está para
perderse la frescura del campo.
Por este camino creo que iremos
más ciertos de encontrar con
ellos.
Ruiz.—Antes me parece que son
aquéllos que vienen entre las
viñas; aquí podremos esperarlos
si vuesa merced manda.
Quiñones.—Bien será, porque
nos vamos paseando hacia la
ribera del río.
Licenciado.—Paréceme, señor
Quiñones, que por cumplir vuesa
merced mejor su palabra, ha
traído al señor Ruiz en su
compañía.
Quiñones.—De temor lo he
hecho; como vuestras mercedes
eran dos, pudieran estar de
concierto contra mí, y he querido
traer quien me ayude si quisiesen
acometerme.
Salazar.—Sea por lo que fuere,
que á lo menos tendremos una
hora ó dos de buena recreación
paseándonos por este campo,
que la tarde hace aparejada para
ello.
Quiñones.—Y aun es bien
menester para ir á cenar de
buena gana, que yo, como el
conde tuvo huéspedes, quedéme
á comer en palacio, y fueron
tantos los platos que se sirvieron
y de tan buenos manjares, que
traigo el estómago estragado de
lo mucho que he comido.
Licenciado.—El mayor yerro que
pueden hacer los hombres es
comer más de aquello que puede
gastar la virtud y calor natural;
porque, según doctrina de todos
los médicos, la indigestión y
corrución de los manjares que
della se sigue es origen de todas
las enfermedades, y assí dice el
Sabio en el capítulo xxxvii del
Eclesiástico: No quieras ser
deseoso en las comidas que
hicieres, ni comas de todos los
manjares, porque en la
muchedumbre dellos hay siempre
enfermedad.
Salazar.—Pues en verdad que lo
que en nuestros tiempos más se
usa es no tener atención á ningún
daño que del mucho comer puede
seguir, sino al gusto que dello se
recibe.
Licenciado.—¿Y pareceos, señor
Salazar, que es pequeño mal
esse? Yo os digo que si los
hombres que aman su salud y
desean alargar la vida
conociessen y entendiesen los
inconvenientes que del mucho
comer tienen por contrarios, que
por ventura ayunarían muchas
veces, aunque no fuese para
servir á Dios, sino para su solo
provecho.
Salazar.—Yo creo que hay
muchas personas que, aunque lo
entienden, no dexan por eso de
comer á su voluntad, porque el
aparejo les da ocasión á querer
cumplir tanto con el apetito como
con la salud, y si no dígame
vuesa merced ¿qué había de
hacer el señor Quiñones si puesto
á la mesa le servían tantos y tan
diversos platos? ¿No fuera
necedad dexar de comer de
todos, siquiera para saber si eran
buenos ó malos y hacer lo que
todos los otros que allí estaban
hacían?
Licenciado.—Antes fuera muy
gran discreción tener sufrimiento
para que el aparejo de la gula no
le diera causa de vencerse della.
Salazar.—Pues si eso es assí,
¿para qué se hacen y aderezan
tantos y tan diferentes manjares
en las casas de los grandes
señores y aun en las que no lo
son, sino para que los que sientan
á sus mesas los coman y se
harten con ellos, pues que para
este propósito se aparejaron?
Licenciado.—Así es la verdad;
pero lo mejor sería que no los
aparejasen ni los hubiesen.
Ruiz.—Contraria opinión es esta
de la común, porque todos los
hombres generalmente querrían
comer y beber lo mejor que
pudiesen.
Licenciado.—Si comiendo bien,
digo de buenas cosas, no
comiesen más de aquello que les
basta para sustentarse, no es
muy mala opinión la que decís;
pero por la mayor parte nacen
della la desorden y vienen los
hombres con el aparejo á comer
más de lo necesario, sin sentirlo,
y assí sin sentirse se recrece
dello el daño, y cuando ya se
siente, muchas veces no puede
remediarse, y aun algunas cuesta
tan caro, que suele perderse por
ello la vida.
Salazar.—Pues lo que con todas
essas condiciones el día de hoy
más se usa en esta tierra es
comer y beber sin temor, y
después venga lo que viniere.
Licenciado.—También se usa
morirse las gentes muy más
presto de lo que solían en otros
tiempos.
Salazar.—¿Y es por ventura el
comer la causa?
Licenciado.—Sí, por la mayor
parte, y si queréis escuchar la
razón, yo os la diré para que lo
entendáis notoriamente. En los
tiempos antiguos que los hombres
vivían con mayor simplicidad que
agora, y contentándose con lo
que la naturaleza les aparejaba
para su mantenimiento, sin andar
buscando otras nuevas formas de
composiciones en los manjares
que comían, vivían los hombres
muy largos tiempos, como á todos
es notorio la larga vida de Adán,
nuestro primero padre, de
Matusalén y de otros muchos, los
cuales se contentaban con comer
solas las frutas silvestras, y
principalmente debían de ser
bellotas y castañas, y otras desta
manera, porque después del
diluvio de Noé que ya habían
pasado muy largos tiempos, las
gentes comían esto mesmo y se
sustentaban con ello,
principalmente los de la provincia
de Arcadia. Los atenienses su
mantenimiento eran higos secos.
El de los caramanos, dátiles. El
de los meotides, mijo. El de los
persas, mastuerzo. Los de Tirinto
comían peras silvestres, y assí
otras naciones se mantenían de
otras diferentes frutas y raíces, de
las cuales dicen que era la
principal la de una hierba que
llamamos grama, hasta que vino
aquella mujer llamada Ceres, que
andando buscando las simientes
de las hierbas que eran buenas
para comer, halló la simiente del
trigo y la manera que había de
tener para hacerse pan della, y
por esta causa fue adorada por
diosa entre los gentiles. Y cuando
los antiguos comían algunas
carnes no andaban buscando que
fuesen sabrosas ni delicadas, ni
buscaban de darles otro nuevo
sabor con las salsas y aparejos
que agora se les hacen. Y así
cuenta Homero que Alcinoo, rey
de los feaces, teniendo por
huésped á Ulises y por
convidados á todos los principales
de su reino, para el banquete que
les hizo mandó matar doce ovejas
y ocho puercos y dos bueyes, que
estonces debían ser los más
preciados manjares que se
usaban; y en este tiempo también
tenían los hombres muy larga la
vida, y como comenzaron á
inventar manjares nuevos y
compuestos, así comenzaron á
debilitar y enflaquecer con ellos
los estómagos, porque la
diversidad de los sabores que
hallaban en ellos les hacía comer
más de lo que podían gastar los
estómagos. Y así dice Galeno
que del tiempo de Hipócrates
hasta el suyo, la naturaleza
estaba debilitada en los hombres,
y el tiempo de Galeno acá
también lo deben de estar mucho
más, pues siempre vemos que
van en disminución de los años
de la vida, y que viven agora
menos que solían; pero la culpa
que ponemos á la naturaleza no
es suya, sino de nuestra
desorden, porque si tuviéssemos
mayor concierto y templanza en el
comer y beber, nuestra vida
generalmente sería muy más
larga. Y así lo dice Hipócrates en
el libro sexto de Las
enfermedades populares: El
concierto de nuestra salud en
esto consiste que comamos con
tanta templanza que nunca nos
hartemos de los manjares; y si en
algún tiempo hubo desorden y
desconcierto es en el de agora,
que cuando me pongo á pensarlo
de ver las invenciones que las
gentes han procurado, todo en
daño de sus vidas, como si las
tuviesen por enemigas y su
intención no fuese otra sino de
acabarlas muy presto.
Quiñones.—No es mala materia
ni poco provechosa lo que se
trata, si el señor licenciado la lleva
adelante así como la ha
comenzado.
Licenciado.—Si vuestras
mercedes huelgan de oirla, yo me
iré declarando más
particularmente, aunque no
aproveche para más de que
entendamos el yerro que
hacemos, porque
verdaderamente es muy grande, y
tan grande, que yo no he visto
mayor desatino que el que agora
se ha introducido en el mundo, á
lo menos en la christiandad, que
en las otras naciones de gentes
son más templadas y viven más
moderadamente. Solían en
nuestra España comer las
personas ricas y los caballeros un
poco de carnero assado y cocido,
y cuando comían una gallina ó
una perdiz era por muy gran
fiesta. Los señores y grandes
comían una ave cocida y otra
assada, y si querían con esto
comer otras cosas, eran frutas y
manjares simples. Agora ya no se
entiende en sus casas de los
señores sino en hacer provisión
de cosas exquisitas, y si con esto
se contentasen, no habría tanto
de qué maravillarnos; pero es
cosa de ver los platillos, los
potajes, las frutas de sartén, las
tortadas en que van mezcladas
cien cosas tan diferentes las unas
de las otras, que la diversidad y
contrariedad dellas las hace que
en nuestro estómago estén
peleando para la digestión. Y es
tanto lo que en esto se gasta, que
á mi juicio ha encarecido las
especias, la manteca, la miel y la
azúcar, porque todo va cargado
dello, y como comen á la
flamenca, con cada servicio que
llevan va un plato destos para los
hombres golosos, y con no
tocarse algunas veces en ellos,
tienen mayor costa que toda la
comida. Y comer de todos estos
manjares diferentes (aunque cada
uno dellos sea simple) sería muy
dañoso, cuanto más siendo los
más dellos compuestos, que
muchos hay dellos que llevan
encorporadas diez y doce y veinte
cosas juntas, no mirando lo que
Plinio dice contra ello en el
undécimo capítulo de la Natural
Historia, cuyas palabras son: El
manjar simple para los hombres
es muy provechoso, y el
ayuntamiento de manjares es
pestilencia, y más dañoso que
pestilencia cuando los manjares
son adobados. Y lo peor de todo
es que, muchos, cuando se
sientan á la mesa y aun casi
todos, como es cosa natural,
luego procuran satisfacer á la
hambre que llevan y comen hasta
hartarse de lo primero que les
ponen delante, y pudiéndose
levantar y sustentar con ello
conservando su salud y vida,
como después vienen otras cosas
nuevas y que despiertan en la
golosina el apetito, aunque no
hagan sino probar de cada uno un
bocado, hacen tan gran replición
en el estómago, que no pueden
gastarse, y desasosiegan y dan
trabajo al que las ha comido. Y
esto es lo que dice Galeno en el
tercer libro de Régimen: Que la
diversidad de las cosas que se
comen, cuando no son
semejantes en sus virtudes,
hacen en el estómago
desasosiego. Y en otra parte: Las
cosas compuestas de muchas
sustancias son de muy más fácil
corrupción que las simples y
compuestas de pocas; pero todo
esto no basta para que las gentes
se concierten en el comer, porque
con ver los hombres plebeyos la
desorden que los que pueden y
tienen mayores haciendas y más
aparejo hacen, toman argumento
para comer y gastar más de lo
que tienen, y en esto está tan
estragada la razón y tan perdida
la buena regla, que hay muchos
que, no teniendo sino dos reales,
aquello dan por una trucha ó por
una gallina, que comen aquel día
sin mirar á lo de adelante, y todo
cuanto ganan lo echan en comer,
sin guardar un maravedí, y,
después, si caen enfermos ó se
han de morir de hambre ó han de
hacer que pidan por Dios para
ellos, y esto tienen en menos que
dejar de probar todas cuantas
cosas buenas y preciosas vienen
á venderse, cuesten lo que
costaren.
Ruiz.—No se puede negar todo lo
que vuestra merced dice ser assí;
pero muchas cosas hay que,
aunque se conozca en ellas el
yerro, no hay orden para que
pueda remediarse, como es esto
del comer desordenado de la
gente común, porque no se les
puede ir á la mano en ello, sino
que han de hacer lo que
quisieren, como coman de sus
haciendas y no de las ajenas.
Licenciado.—Bien se parece que
no ha leído vuestra merced
algunos autores que tratan de una
ley que los romanos hicieron y se
guardó mucho tiempo en Roma, y
principalmente lo cuenta Macrobio
en el tercero libro de las
Saturnales.
Ruiz.—¿Y qué ley era essa?
Licenciado.—Una ley que
mandaba por ella que todos
comiesen públicamente en los
portales de sus casas y que
hubiesse por los barrios repetidos
veedores que andaban de casa
en casa mirando si alguno comía
más curiosamente ó
suntuosamente de lo que
convenía á su estado, y luego
eran castigados por esto, y si por
acaso lo querían comer en
ascondido, no podían, porque no
osaban comprarlo, temiendo ser
acusados de quien lo viese, y aun
por ventura de quien lo vendía; y
como estonces se cumplía esta
ley, también se podía hacer
agora, y aun en algunas partes se
guarda alguna cosa della, porque
dicen que en Francia los villanos
no pueden comer gallina ninguna,
ni los perniles de los tocinos, si no
fuesse con mucha necesidad.
Quiñones.—Bien lejos estamos
de que en España se hagan
essas leyes ni se guarden
tampoco, y hablar en ello es
predicar en desierto.
Licenciado.—Yo no lo digo
porque se ha de hacer, sino
porque sería justo que se hiciese;
y lo que más principalmente
convendría es que los caballeros
y señores y grandes se
moderasen en sus gastos
excesivos, y que ellos mismos,
juntándose, hiciesen entre sí
mesmos una ley, ó que nuestro
emperador lo hiciese, de que en
ningún banquete ni comida
suntuosa se sirviesen sino tantos
platos tasados; porque después
que un hombre come de cuatro
manjares ó cinco, el estómago
está satisfecho y todo lo lo demás
es superfluo, que no aprovecha
para otra cosa sino para estragar
los estómagos y disminuir la salud
y las haciendas, y tan
disminuídas, que de aquí viene
que solían hacer más los señores
y mantenerse más gentes y
criados con cuatro cuentos de
renta que agora con doce, y
entonces ahorraban dineros para
sus necesidades, y estaban ricos
y prósperos, y agora siempre
andan empeñados y alcanzados,
y todo esto se gasta en comer y
en beber, principalmente si tienen
huéspedes, si andan en corte,
que han de hacer plato, porque
entonces tienen por mayor
grandeza lo que sobra y se pierde
y se gasta bien gastado. Y
verdaderamente esta es la
principal causa de sus
necesidades, que de andar los
señores ó un caballero en la corte
un año ó dos haciendo estos
gastos vienen á ponerse en
necesidad, que con estar otros
cuatro en sus casas ahorrando y
estrechándose no pueden salir
della y muchas veces en su vida.
Y el mayor daño de todos es que
lo mesmo quiere hacer un señor
de dos cuentos de renta que de
quince, y también quiere que
sirvan á su mesa veinte y treinta
platos diferentes, como si no
gastasen en ello dineros.
Quiñones.—Poco es para lo que
agora se usa, que ya en un
banquete no se sufre dar de
ochenta ó cien platos abajo, y aun
averiguado es y notorio que ha
poco tiempo que en un banquete
que hizo un señor eclesiástico se
sirvieron setecientos platos, y si
no fuera tan público, no osara
decirlo por parecer cosa fuera de
término.
Ruiz.—Mal cumple ese y todos
los otros señores eclesiásticos lo
que son obligados conforme
aquel decreto que dice que los
bienes de los clérigos son bienes
de los pobres, porque después de
gastado lo necesario para sí y
para su familia, todo lo demás
tiene obligación de gastarlo con
ellos, so pena de ir al infierno
como quien hurta hacienda ajena,
pues hacen esos banquetes á los
ricos, y sin necesidad, quitándolo
á la gente pobre y necesitada.
Pero todos me parece que van
igualmente desordenados, sin
tener atención ninguna sino á
comer y beber á su voluntad.
Licenciado.—Bien conforma
esso con lo que Valerio Máximo
dice de la costumbre que se solía
tener en el comer antiguamente,
lo cual trata por estas palabras en
el segundo libro de Las
instituciones antiguas: Hubo en
los tiempos pasados, en los
antiguos, grandísima sencilleza y
templanza en el comer, lo cual es
demostración muy cierta de su
moderación y continencia, porque
no comían manjares los cuales
por su demasía hubiesen
vergüenza de que todos los
viesen. Estaban en tanta manera
los hombres de mayor autoridad
en sus pueblos continientes, que
lo que más ordinariamente
comían eran poleadas ó puchas,
y con ellas se contentaban. Y en
el mismo capítulo y libro torna á
decir: La templanza en el comer y
beber era como verdadera madre
de su salud, y enemiga de los
manjares superfinos y apartada
de toda abundancia de vinos y de
todo uso demasiado de
destemplanza. Agora me parece
que todo es ya al contrario de lo
que Valerio ha dicho, como si toda
la bienaventuranza de la vida
consistiese en el comer y beber
destempladamente, y muy pocos
hay que no pecan en este vicio si
no son los que no tienen ni
pueden más, que destos Dios
sabe su buena voluntad. Y deste
comer mucho y beber demasiado
se siguen grandes daños é
inconvenientes que todos ayudan
á destruir y desconcertar la vida,
como lo trata Hipócrates en el
libro De afectionibus, Acaccio
Antiocheno en el tercero libro
Tetrablibii, y esto procede de que
no puede el estómago con los
muchos manjares, ni con la
diversidad ni abundancia dellos
para gastarlos y digirirlos. Y así
dice el filósofo en el quinto
capítulo del tercero libro De
partibus animalium: Es verdad
que el calor natural no gasta ni
digiere lo que se come
demasiado, no porque él sea
pequeño, sino porque comemos
más de lo que es necesario para
sustentarnos; pero nosotros no
tenemos atención á esto, sino á
ser unos epicuros, teniendo este
vicio por suma felicidad; y es la
desorden tan grande, que si hoy
hubiese quien tornase á sustentar
esta opinión epicúrea de nuevo,
no faltaran gentes que con muy
gran afición y voluntad la
siguiessen. Y dejando lo del
comer, qué destemplanza tan
grande es la del vino, que ya que
en muchos no se muestra la
beodez y desatinos que del
demasiado beber proceden, á lo
menos veremos la curiosidad en
buscar vinos de olor y sabor
exquisitos, no teniendo en nada la
costa que se hace por estar
proveídos dellos, aunque éste no
le tengo por gran vicio cuando la
templanza anda de por medio, de
manera que no beban demasiado
ni reciban daño en su salud por lo
que bebieren.
Salazar.—Paréceme que el
señor licenciado de teólogo se ha
vuelto médico; pero bien es que
los hombres sean estudiosos, de
manera que puedan hablar en
todas las materias que se
propusiesen, que quien lo viere
alegar tantas autoridades á su
popósito, parecerle ha que no ha
estudiado más teología que
medicina, y con todo esto no
quiero que se vaya alabando que
no halla contradicción en todos
nosotros para lo que ha dicho,
porque yo quiero agora decir que
no hará poco cuando le hubiera
dado buena salida.
Licenciado.—Haré lo que
pudiere, pues que hasta agora no
me ha obligado á más que á esto.
Salazar.—Ni yo quiero más
tampoco, y para que mejor nos
entendamos, lo principal que
vuesa merced ha dado y sobre lo
que más ha fundado su intención
es la templanza de los antiguos
en el comer y beber, y hay tantas
cosas que alegar contra esto, que
creo que algunas se ofreceran á
mi memoria. Y la primera es la
destemplanza del gran Alejandro
en los convites, que con ella vino
á matar á Clito, su familiar y muy
privado, y después en Babilonia
se estaban haciendo banquetes y
fiestas cuando le dieron la
ponzoña con que le mataron. Sin
esto, á todos es notorio cuán
destemplado fué el emperador
Nerón, que muchas veces
duraban los banquetes desde un
día á la hora que él y sus
convidados se sentaban á la
mesa hasta otro día á la mesma
hora. De Heliogábalo todos saben
los grandes y excesivos gastos
que hacía en procurar manjares
preciosos y delicados y costosos,
tanto que algunos quieren decir
que hacía buscar papagallos que
de los sesos dellos pudiesen
hacer salsa que bastara para
muchos convidados que con él
comían. No es menos lo que se
dice del emperador Galba, y de
Joviniano escribe Bautista Ignacio
que, comió tanto en una cena,
que por no gastarlo se murió. Otro
tanto dice Eufesio de Domicio
Afro, y el banquete que Marco
Antonio hizo á Cleopatra todos lo
saben, y el que ella le tornó á
hacer, que porque fuese más
costoso deshizo en vinagre una