Facial Resur facing
of the Male Patient
Samuel O. Poore, MD, PhDa, Liat Shama, MDb,
Benjamin Marcus, MDb,*
KEYWORDS
 Facial aging  Ablative skin resurfacing
 Nonablative skin resurfacing
The most common cosmetic facial plastic proce-
dures sought by men include Botox injections,
hair transplants, filler injections, chemical peels,
rhinoplasty, and microdermabrasion (Fig. 1). The
American Society of Plastic Surgeons (ASPS)
recently reported a 43% increase in nonsurgical
procedures in men over the past 5 years. From
2002 to 2003 the number of minimally invasive
procedures performed on men jumped 41%. The
dramatic increase in the number of nonsurgical
procedures per year, which continues to surpass
surgical procedures, is likely attributable to an
increase in disposable income in the baby-boomer
generation and the increased acceptability of cos-
metic procedures that has led to an increase in
male patients seeking cosmetic procedures.
These statistics clearly reflect that what was
once a field embraced primarily by females has
now become accepted and firmly rooted in the
male demographic.1,2
OVERVIEW OF THE MALE PATIENT
Despite this greater acceptance of men seeking
and obtaining cosmetic surgery, a desire for
discretion plays a significant part in the type of
cosmetic enhancement or surgery that men select.
Men come to cosmetic surgeons and dermatolo-
gists for many of the same issues, concerns, and
problems as women, but cite different reasons.
Women want to ‘‘look less tired’’ or ‘‘look better,’’
whereas men indicate work-related reasons for
seeking cosmetic surgery; they want to ‘‘increase
competitiveness’’ in the workplace.2 When men
a
Division of Plastic and Reconstructive Surgery, University of Wisconsin, 600 Highland Avenue, CSC G5/361,
Madison, Wisconsin, USA
b
Division of Otolaryngology—Head and Neck Surgery, University of Wisconsin, 600 Highland Avenue,
CSC K4/720, Madison, Wisconsin, USA
* Corresponding author.
E-mail address: marcus@surgery.wisc.edu (B. Marcus).
Facial Plast Surg Clin N Am 16 (2008) 357–369
doi:10.1016/j.fsc.2008.04.001
1064-7406/08/$ – see front matter ª 2008 Elsevier Inc. All rights reserved.
present to a cosmetic surgeon, they are usually
less familiar with the medical system and therefore
less comfortable discussing procedures. Addition-
ally, having spent less time in the medical system,
they may not be aware of the downtime that is
associated with the procedure that best
addresses their concerns. Men generally present
for cosmetic procedures at a later age than women
and have usually engaged in behaviors that pre-
dispose them to seeking cosmetic surgery, such
as not wearing sunscreen and smoking.3
Men do not usually wear cosmetics, and there-
fore are more concerned about the postprocedure
downtime, as they may prefer not to have recog-
nizable sequela of healing from a cosmetic proce-
dure.4 This may explain why cosmetic nonsurgical
procedures, including Botox and microdermabra-
sion, have increased among the male demo-
graphic by more than 300% and 400%,
respectively, since 2000. These nonsurgical
procedures have minimal downtime and are
more acceptable to the male demographic.1,3
Additional data from the American Academy of
Facial Plastic and Reconstructive Surgery and
American Society of Aesthetic Plastic Surgery
show an upward trend for men in Botox and hair
restoration with respect to other procedures,
which have remained relatively stable or
decreased. These data indicate that the largely
untapped and growing market for cosmetic
enhancement for men lies in the realm of nonsurgi-
cal procedures. Skin resurfacing encompasses
most nonsurgical procedures.
facialplastic.theclinics.com
358 Poore et al
Top Nonsurgical Cosmetic Procedures
In 2003, 78% of the nearly 8.3 million cosmetic procedures performed in the
USA were nonsurgical. Most popular nonsurgical procedures:
2,272,080 Botox Injection
923,200 Laser Hair Removal
858,312 Microdermabrasion
722,248 Chemical Peel
620,476 Collagen Injection
Source: American Society for Aesthetic Plastic Surgery
THE AGING FACE
A man finds room in a few square inches of his
face for traits of all his ancestors; for the
expression of all his history, and his wants.
—Ralph Waldo Emerson
The aging face presents a complex picture to
facial plastic surgeons because it reflects multifac-
torial and additive causes, including sun exposure,
tobacco use, and a lifetime of facial expression.
There are two types of skin aging. The first is chro-
nologic aging (intrinsic aging), which occurs in all
areas of the skin. The second is photoaging
(extrinsic), which occurs in skin areas including
the neck, face, and hands. Photoaging results in
rough skin, sallow color, uneven pigmentation,
and fine and course wrinkling.5 These intrinsic
and extrinsic factors leads to dyschromias of the
skin, fine wrinkles, loss of collagen, and thinning
of the skin.6 Rhytidosis and skin laxity are the
primary issues surrounding the aging face. Rhyti-
dosis, including fine lines and wrinkles, may be ad-
dressed by several nonsurgical modalities,
including fractional skin resurfacing, plasma skin
resurfacing (PSR), Coblation, dermabrasion, and
chemical peels.
The pathogenesis of the aging face includes loss
of the reticular dermis and reduction of overall der-
mal organization. Specifically, Type I collagen, the
most abundant type in the non-aged face, is
replaced with Type III collagen as the dominant
type.7 The hallmark of actinically damaged skin
(damage caused by UVB and UVA rays) consists
of thickened, degraded elastic fibers. Based on
multiple studies there seem to be three types of
wrinkles: (1) animation creases from mimetic mus-
cle insertions, (2) fine, shallow wrinkles caused by
disruption of the elastic structural network, and (3)
coarse, deep, solar wrinkles.5 The clinical and
histologic effects of aging are summarized in
Box 1. Changes in the aging face can be catego-
rized into specific anatomic subunits and facial
Fig. 1. Top nonsurgical cosmetic pro-
cedures performed in 2003 in the
United States. (Courtesy of The
American Society of Aesthetic Plastic
Surgeons, Los Alamitos, CA.)
analysis before any resurfacing procedure should
follow similar partitioning (Box 2). Included in this
is determining each patient’s Fitzpatrick classifica-
tion, which helps guide treatment, predicts side
effects, and helps identify individuals who should
not receive resurfacing at all (Box 3). There are
additional characteristic soft tissue changes in
the face as described by Patipa.8 According to
this author the face should be analyzed by subdi-
viding the face into thirds and noting changes in
each subdivision accordingly (Fig. 2). Complete
facial rejuvenation requires improving volumetric
and cutaneous age-related changes. Skin resur-
facing therefore plays a key role in the facial plastic
surgeon’s armamentarium for male rejuvenation.
Box 1
Clinical and histologic effects of aging
Clinical appearance of photoaging
Fine and coarse wrinkling
Rough texture
Sallowness or yellow color
Uneven pigmentation (lentigines, melasma,
ephelides)
Leathery appearance
Laxity
Histologic effects of photoaging
Epidermal atrophy
Decreased collagen content
Elastosis
Cellular atypia
Preneoplastic dysplasia (actinic keratoses)
Decreased microcirculation
Data from Boswell CB. Skincare science: update on
topical retinoids. Aesthetic Surgery Journal
2006;26:233–9.

Box 2
Skin and soft tissue changes of the face associated
with aging
Perioral changes
Vertical rhytides
Decreased fullness and flattening of the up-
per lip
Downturning of the oral commissures
Deepening of the nasolabial creases (mario-
nette lines)
Cervical changes
Skin laxity and wrinkling
Vertical platysmal bands
More obtuse cervicomental angle
Ptosis of the submandibular glands
Periocular changes
Dermatochalasis: laxity of the skin of the
eyelids
Excessive eyelid edema and pigmentation
Protrusion of the periorbital fat
Ptosis of the lacrimal glands
Facial skeletal changes
Decreased mid and lower facial height
Laxity of support ligaments
Increased chin prominence
Increased prominence of the supraorbital
rim
Increased prominence of the zygomatic arch
Box 3
Fitzpatrick skin types
Type I: White, always burns and never tans
Type II: White, always burns and sometimes tans
Type III: White, sometimes burns and sometimes
tans
Type IV: Light brown, minimal burns and gradu-
ally tans
Type V: Brown, never burns and tans to deep
brown
Type VI: Black, never burns and deeply tans
All patients should receive posttreatment sunscreen.
Type IV requires pre- and posttreatment with retinoic
acid, hydroquinone, and sunscreens to decrease risk
for pigmentary changes. TCA better for types IV and
above. Types V and VI, avoid resurfacing if possible.
Facial Resurfacing of the Male Patient 359
Fig. 2. The three zones of facial aging.
ABLATIVE AND NONABLATIVE SKIN RESURFACING
Techniques in skin resurfacing that address the
aging face, acne, and disorders of vascularity
and pigmentation include ablative and nonablative
modalities. Methods of ablative skin resurfacing
involve superficial penetration of skin with necrosis
of the epidermis leading to removal of the epider-
mis and superficial thermal damage within the
dermis. This dermal damage leads to collagen
denaturation and contraction of the tissue and as
the entire epidermis is vaporized, there is resulting
erythema, which can last several months.6 Hypo-
pigmentation may also occur. Despite the drastic
outcomes of ablative skin resurfacing, its longer
healing process makes it less desirable than non-
ablative skin resurfacing, particularly in patients
who desire improved cosmesis while maintaining
discretion and anonymity. The unwanted side
effects of ablative procedures ultimately lead to
a longer downtime and healing process, and
when the pressures of quickly returning to work
and the desired anonymity of having a cosmetic
procedure are taken into account, ablative tech-
nologies have decreased in popularity among
both male and female patients. This shift in popu-
larity is exemplified by the once gold standard
carbon dioxide laser modality.9
Nonablative skin resurfacing involves deeper
skin penetration with selective thermal damage
to the dermis, effectively sparing the epidermis
with some laser models and minimally affecting
the epidermis with other models.10 Methods of
nonablative skin resurfacing include mid-infrared
lasers, radiofrequency devices, pulsed dye lasers,
360 Poore et al
intense pulsed light, photodynamic therapy,
fractionated laser modalities, and plasma skin
regeneration. There is significant overlap between
indications for these various applications, includ-
ing rhytidosis, actinic keratosis, telangiectasias,
and hyperpigmentation (Fig. 3).11 Some of the
side effects of nonablative resurfacing include
discomfort, sunburnlike erythema, edema, and
flaking. The erythema and flaking may last up to
one week.12
ABLATIVE SKIN RESURFACING
Carbon Dioxide Laser
CO2 laser resurfacing, developed in 1964, has until
recently been regarded as the gold standard of
ablative facial resurfacing.13 Initially used in
a continuous wave, it produces a beam with
a wavelength of 10,600 nm. Water, present mostly
in the epidermis, is its primary chromophore.13 The
first pass ablates the epidermis; subsequent
passes ablate the dermis, which is limited by the
lower water content of the dermis. These subse-
quent passes lead to collagen shrinkage and skin
tightening immediately and over time.14 Clinically,
CO2 laser resurfacing is used to treat photodam-
aged and aging skin and scars. It produces
dramatic and significant changes for photodam-
aged, wrinkled, and scarred skin.15–17
The CO2 laser technology has evolved to an
ultrapulse method, which limits thermal damage
and leads to decreased scar formation. The
Actinic keratosis
Wrinkles
IR, RF devices
PDT
Q-switch
PDL IPL Fraxel
KTP PSR
Telangiectasis Hyperpigmentation
Fig. 3. Treatment applications for multiple nonabla-
tive facial resurfacing modalities. IPL, intense pulsed
light; IR, mid-infrared lasers; KTP, potassium titanyl
phosphate vascular laser; PDL, pulsed dye lasers; PDT,
photodynamic therapy; PSR, portrait plasma skin
regeneration; RF, radiofrequency devices. (From
Ruiz-Rodriguez R, Lopez-Rodriguez L. Non-ablative
skin resurfacing: the role of PDT. J Drugs Dermatol
2006;5:756–62; with permission.)
Ultrapulse CO2 laser (UPCO2, Coherent) is the
most commonly used of the ultrapulse CO2
lasers.18 It maximizes the benefits of CO2 lasers
while minimizing damage to the surrounding struc-
tures. As with other methods of facial resurfacing,
patients are carefully selected for CO2 laser resur-
facing; the ideal candidates for CO2 laser resurfac-
ing are those who have Fitzpatrick I to II skin types
and realistic expectations of the procedure.19,20
Patients who have Fitzpatrick skin types III and
above are at higher risk for pigmentation-related
complications from ablative procedures.19,21,22
CO2 laser resurfacing is performed as an outpa-
tient procedure. Local anesthetic, either topically
or by direct infiltration and nerve blocks, is
commonly used. For full face resurfacing, intrave-
nous sedation is often used also.13,19 The number
of passes performed depends on the desired out-
come. The first pass ablates the epidermis, leading
to an effect profile and recovery period similar to
treatment with multiple passes with the erbium:-
yttrium-aluminum-garnet (erbium:YAG) laser.23
Subsequent passes are carefully applied, with
removal of débrided skin between passes, until
the desired effect is achieved, usually evident
with color changes.13 The resurfacing may be per-
formed in a segmental fashion or over the entire
face. The results from full facial resurfacing have
generally been believed to be more beneficial,
because lines of demarcation with respect to
erythema and texture may be observed with seg-
mental resurfacing. This effect may be especially
prominent in dark-skinned patients.18 Should seg-
mental resurfacing be the best choice for a given
patient, however, feathering techniques may be
applied, either with the laser or with dermabrasion,
to prevent demarcation.13,24 Because men do not
generally use cosmetics to camouflage the skin,
full-face resurfacing is preferable to segmental fa-
cial resurfacing for the male demographic (Fig. 4).
The risks and complications of CO2 laser resur-
facing include edema, erythema, contact dermati-
tis, reactivation of herpetic lesions, infection,
hyperpigmentation, hypopigmentation, and scar-
ring.13,14,19,22 Edema and erythema generally
resolve within a few months. Erythema occurs in
nearly all patients.22 Prophylactic treatment and
early treatment once identified leads to prompt
resolution of contact dermatitis, herpetic infec-
tions, and bacterial infections. Complications
related to pigmentation are more frequent in
patients who have darker skin. Hyperpigmenta-
tion, which is usually temporary, is seen in up to
37% of patients; once recognized, it is effectively
treated with topical bleaching creams and, if an
inflammatory component is present, with steroids
also19,22 Hypopigmentation, observed in less

Fig. 4. Algorithm for the treatment of rosacea and rhinophyma. (From Rohrich RJ, Griffin JR, Adams WP Jr.
Rhinophyma: review and update. Plast Reconstr Surg 2002;110:860–69 [quiz: 870]; with permission.)
than 1% of patients in a large retrospective study,
is a delayed complication that becomes apparent
12 to 18 months after the procedure. It is generally
permanent and occurs more commonly in patients
who have dark skin.19,22 Unfortunately, there is no
effective treatment of this hypopigmentation.19
Scarring is a severe complication of CO2 laser re-
surfacing. Patients who have risk factors, such as
prior cosmetic procedures and isotretinoin use,
are predisposed to scarring. Ectropion has been
reported also.22 These risks and complications
highlight the limitations of CO2 laser resurfacing.
Despite the risks, complications, and limitations,
CO2 laser resurfacing remains an excellent treat-
ment choice for photodamaged, aging, or scarred
skin, provided that the patient is carefully selected
and has reasonable expectations, including
a thorough understanding of the treatment course
and recovery period.
Erbium
Along with CO2 laser, the erbium:YAG laser
system is one of the most frequently used lasers
in skin resurfacing.26 Although CO2 and erbium:
YAG lasers share the same chromophore, water,
the absorption by water of the erbium laser is
Facial Resurfacing of the Male Patient 361
16 times greater than the CO2 laser.27 Because
of this, when compared with CO2 it is particularly
effective in superficial tissue ablation while limiting
adjacent thermal injury. Given the ablative nature
of CO2 and erbium:YAG resurfacing and potential
of postoperative pigment changes, most authors
recommend these modes of therapy for lighter-
skinned individuals (Fitzpatrick I–IV) but agree
that if darker-skinned individuals are to be treated
erbium:YAG is a more appropriate choice than
CO2.28–30 There are short-pulsed and modulated
(short- and long-pulsed) erbium:YAG lasers. Treat-
ments result in less erythema, decreased side
effects, and rapid healing when compared with
CO2 resurfacing, which can result in an extended
period (months) of re-epithelialization with as
many as 20% of patients developing delayed-
onset permanent hypopigmentation.29
Given the decreased amount of thermal injury
seen with the erbium:YAG laser, for some patients
topical anesthesia might be adequate; however,
most authors recommend local infiltration with
lidocaine with epinephrine for small cosmetic
units, although for larger areas regional nerve
blocks with our without intravenous sedation
should be used.29 Postoperatively, the laser-
treated skin must be kept clean and moist using
362 Poore et al
Aquaphor or a petroleum dressing until re-epithe-
lialization occurs, which typically takes 5.5 days for
erbium:YAG and 8.5 days for CO2.31 There is
a reduced incidence of hypopigmentation com-
pared with CO2 laser and shorter recovery times.
For superficial resurfacing 3 to 4 days are usually
required, whereas with deeper resurfacing, 6 to
10 days are usually required. In male patients, in
whom increased autonomy and less downtime
are particularly important factors when consider-
ing resurfacing, the erbium:YAG laser holds a dis-
tinct advantage over CO2 resurfacing.
Dermabrasion
Dermabrasion, a technique of skin resurfacing that
involves mechanical removal of the epidermis and
parts of the dermis, has a longer history in facial
resurfacing than most other modalities. The first
use of controlled abrasion of the skin using rasps
and burrs with rotation to treat acne scars, kerato-
sis, and areas of hyperpigmentation was reported
by Kromeyer in 1905. More contemporary equip-
ment, such as a wire-brush dermabrasion
machine, were used in the 1950s.9 The equipment
and techniques have been refined over the years.
Small, portable dermabraders are most popular
today and use various end pieces, including wire
brushes, diamond fraises, and serrated wheels.
These tools mechanically abrade the epidermis
and dermis in succession, leading to the regener-
ation of the epidermis. Postoperative wound care
involves either an open or a closed dressing sys-
tem. Moist wounds allow for faster healing. Re-ep-
ithelialization takes approximately 1 week, with up
to 4 weeks of residual erythema.
The goal of dermabrasion is to rejuvenate the
skin by removing a controlled thickness of dam-
aged skin, thereby stimulating normal wound
healing and skin rejuvenation. Dermabrasion me-
chanically removes the epidermis and parts of
the dermis while leaving the deep epidermal
appendages located deep in the dermis. It is
from these appendages that the epidermis regen-
erates. Unlike laser resurfacing, dermabrasion
does not affect melanocytes, so disorders of pig-
mentation following treatment are less of a prob-
lem than in laser resurfacing. Clinical indications
for dermabrasion include: surgical and traumatic
scarring, acne pits and scars, rhinophyma, and
facial rhytides. Typically, this is performed using
local blocks in combination with refrigerant topical
anesthesia, which helps freeze and stiffen the skin
before dermabrading. Several authors advocate
dermabrading the forehead first followed by the
cheeks, chin, upper lip, and then the nose, while
being particularly careful to feather the edges of
each anatomic unit to avoid potential lines of
demarcation.
Although the skin re-epithelializes in 5 to 7 days,
some erythema may persist for up to 4 weeks.
Adverse effects associated with dermabrasion
include postinflammatory hyper- and hypopig-
mentation, persistent erythema, hypertrophic
scarring, herpes simplex virus, and bacterial skin
infection. Postoperatively, most authors advocate
keeping the wound moist using an antibiotic oint-
ment, Vaseline gauze, or another type of hydrocol-
loid dressing. These should be changed daily for at
least 5 days.
One particular area in which dermabrasion is
effective is in the treatment of perioral rhytides.
Although dermabrasion was once one of the
first-line treatments, and is a relatively inexpensive
mode of therapy, it is technically difficult to master
and in the hands of an inexperienced user the re-
sults can be varied. Because lasers are easier to
technically master concerning depth of tissue
injury, modalities such as CO2 resurfacing have
largely supplanted dermabrasion. Dermabrasion
and laser resurfacing have specific advantages
and disadvantages. There are several controlled
studies directly comparing the efficacy of derm-
abrasion and CO2 lasers for the treatment of perio-
ral rhytides. Holmkvist and Rogers32 compared
dermabrasion to CO2 laser by treating one half of
the perioral area with dermabrasion and the other
half with superpulsed CO2 laser. They found no
statistical differences between the two groups.
In a similar study, Gin and colleagues33 compared
the 950-millisecond dwell time CO2 laser to man-
ual tumescent dermabrasion and found both
modalities equally effective. Kitzmiller and col-
leagues 34–37 compared the effectiveness of derm-
abrasion and CO2 laser and found that there was
slightly better outcome in those treated with CO2
laser. Despite the slight clinical difference patients
were evenly split in which technique they would
recommend to a friend. The authors argue that
both techniques are essentially equally effective
in the treatment of perioral rhytides.
Chemical Peels
Chemical peels, also known as chemexfoliation or
dermapeeling, have been used for more than 100
years. They are used to target the signs of photo-
aging and acne scars and precancerous lesions.
They are made up of superficial, medium-depth,
and deep chemical peels. Medium-depth and
deep chemical peels are the types used to target
the photdamaged skin and rhytides.38 The best
results are observed with deep chemical peels,
which also have the longest recovery time and
 Facial Resurfacing of the Male Patient 363

a higher risk for adverse effects, including cardiac NONABLATIVE RESURFACING

and renal complications. Skin Care and Retinoids
Medium-depth peels use trichloroacetic acid
Retinoids, which include retinol, retinal, retinyl
35% to 50% alone or 35% combined with Jess-
palmitate, retinyl acetate, and retinoic acid, all
ner solution (resorcinol, salicylic acid, ethanol,
derivatives of Vitamin A, can be the most effective
and lactic acid), glycolic acid 70%, or solid car-
component to reverse photoaging. In fact, given
bon dioxide. Medium-depth peels combined
their effectiveness and simplicity of use, the lowest
with other agents use a lower concentration of
rungs of the facial plastic surgeon’s skin resurfac-
trichloroacetic acid and avoid complications
ing treatment ladder must be occupied by the use
associated with the higher concentrations, such
of retinoids. Of all the retinoids, trans-retinoic acid
as scarring. This technique penetrates to the
(tretinoin) is the most bioactive form. When applied
papillary dermis and upper reticular dermis. After
to the skin it primarily causes thinning of the stra-
approximately 1 week there is coagulative necro-
tum corneum, leading to a smoother skin texture.
sis of the epidermis and collagen necrosis of the
It has also been shown to disperse melanin gran-
papillary and upper reticular dermis, which leads
ules leading to the reduction of hyperpigmentation
to edema of the dermis and homogenization of
in treated areas. It also treats fine lines and rhyti-
the mid-reticular dermis.38
des by increasing glycosaminoglycan deposition
The complications associated with medium-
in the dermis and increases collagen production.
depth chemical peels include hypopigmentation,
The use of tretinoin is not without side effects
hyperpigmentation, erythema, hypertrophic and
and retinoid dermatitis, characterized by dry skin,
keloid scars, and infections. These reflect the
burning sensations, peeling, and itching, is
normal wound healing process. Hyperpigmenta-
a well-documented sequela of tretinoin use. Also,
tion is usually temporary and resolves with
because tretinoin thins the stratum corneum, its
wound care. Hypopigmentation, observed more
use makes the skin much more sensitive to
frequently with deep chemical peels, does not
sunlight and sun block should be used at all times.
have a good solution, aside from cosmetics,
Tretinoin is available in multiple formulations and
which would not be well-received among the
concentrations, including a cream, solution,
male demographic. Erythema is observed 1 to
microspheres, and an emollient (eg, Renova).
2 weeks after treatment and may persist for up
Tretinoin is most commonly applied at night be-
to several months. Scars are observed with high-
cause it is degraded by sunlight and patients are
er concentration in medium-depth peels and
usually started on a low concentration (0.025%)
deep chemical peels. Infections result from
on an every-other-day schedule. Once tolerated,
poor wound care and are easily treatable with
daily application a higher doses can be used.
topical antibiotics.
Tretinoin should not be used in isolation but should
Deep chemical peels use phenol 50% to 88% in
rather be incorporated into a consistent and com-
combination with distilled water, hexachlorophene
prehensive skin care regimen, such as the one
soap, and croton oil, known as Baker and Gor-
described by Boswell.5
don’s formula. Diluting the phenol and combining
it with water allows for deeper skin penetration.
The soap reduces surface tension and the croton
Fractional Skin Resurfacing
oil acts a vesicant, allowing the phenol to reach
a deeper layer of the skin. This peel reaches the Fractional resurfacing, fractional technology, or
mid-reticular dermis, leading to epidermal necro- fractional thermolysis involves skin rejuvenation
sis and dermal edema and homogenization of in a specific thermal damage pattern. It produces
the dermis. This mechanism is the same as seen microthermal treatment zones, which are discrete
in medium-depth peels.38 Given the deep penetra- columns of thermal damage at specific depths in
tion of the agents, however, there is a higher a repeated skip pattern.10,12 The surrounding tis-
potential for adverse events and toxicity. These sue is spared, which leads to rapid epidermal
adverse events include cardiac arrhythmias, regeneration and repair. Because the process of
hypertrophic scars, prolonged erythema, pigment collagen remodeling and new collagen formation
changes, atrophy, laryngeal edema, and toxic occurs in the dermis and affects the epidermis
shock syndrome. These can be avoided with care- also, fractional resurfacing is ideal for the improve-
ful application and methodology with deep chem- ment of rhytides and scars.12 The result is
ical peels. Hypertrophic scars result from smoother skin with improved tone and texture.10
penetration of the deeper layers of the dermis. Fractional resurfacing may be ablative or nonabla-
They can be treated with steroids if recognized tive, targeting deep or superficial wrinkles,
early.38,39 respectively.
364 Poore et al
Fractional resurfacing has been shown clinically
and histologically to require less time for healing
than ablative technologies, such as CO2 lasers.12
Nonablative fractional resurfacing has predictable
side effects, including edema and erythema, that
last up to 1 week, which is far less than the
reported downtime with CO2 lasers.40 Generally,
three to five treatments are administered 1 to
4 weeks apart. Because darker-skinned patients
are at a higher risk for postinflammatory hyperpig-
mentation, longer intervals between treatments
are recommended.12
Because fractional thermolysis is relatively new,
the most commonly studied system is the first one
introduced, the Fraxel SR laser (Reliant Technolo-
gies).12 It is an erbium-based system and is gener-
ally used in a nonablative manner. This technique
usually requires local anesthesia applied approxi-
mately 1 hour before the procedure, because
discomfort during the procedure is common.
A cooling device is generally applied. Benzodiaze-
pines and narcotics may be used to relieve anxiety
and pain in sensitive patients.6 The number of
passes is tailored to the treatment level for each
patient. The treatment energies range from 6 mJ
to 12 mJ for superficial lesions including melasma
and dyschromasia. Higher energy levels from
10 mJ to 20 mJ target wrinkles. Deep wrinkles
and scar may require 25 mJ to 40 mJ, used with
great care. Each treatment usually involves 8 to
10 passes.6,41
Postoperative care is similar to other laser pro-
cedures and includes careful hygiene and the
use of sun protection. Patients may return to
work the day after surgery. They can expect
some erythema and edema, which usually resolve
in less than 1 week, so downtime is minimal. The
main risks include laser nicks, blistering and crust-
ing, reactivation of herpes infection, postinflam-
matory hyperpigmentation, and hypertrophic
scarring.12,39 Postinflammatory hyperpigmenta-
tion is more common in darker-skinned patients
and may be transient.6
Fractional thermolysis has been shown to treat
melasma with good efficacy and a low incidence
of side effects, such as postinflammatory hyper-
pigmentation and hypopigmentation.39 Compari-
son with the gold standard of CO2 lasers is
limited to comparisons rather than head-to-head
studies. The available data demonstrate that frac-
tional thermolysis works well for some lesions with
decreased side effects, but does not provide the
dramatic, reliable results seen with CO2
lasers.10,41 CO2 lasers have approximately 4
weeks of downtime, as compared with 1 week
for fractional thermolysis.10 CO2 lasers carry
a higher risk than fractional thermolysis, including
delayed healing and scarring and delayed
hypopigmentation.10,41
Plasma Skin Resurfacing
PSR uses radiofrequency energy to convert nitro-
gen gas into plasma, which leads to rapid and pre-
cise heating of the skin tissue with minimal thermal
injury to the surrounding tissues.42 Unlike carbon
dioxide lasers, PSR is not chromophore depen-
dent, allowing for even delivery of energy to the
skin.42 PSR leads to zones of effect. The zone of
thermal damage is characterized by nonviable
cells as a consequence of vaporization of the
tissue. A new epidermal layer forms 2 to 3 days
after treatment. The zone of thermal modification
contains viable, although modified, tissue. Fibro-
blast activity in this zone leads to new collagen
and elastin formation.42 The stratum corneum
and the epidermis are left intact.
PSR is performed at an energy setting adjusted
for the target tissue, ranging from 1 to 4 J with non-
overlapping pulses, with the effects dependent on
the energy level. Fitzpatrick and colleagues (2005)
found that collagen remodeling depended on the
energy setting used in a study examining the
effects of PSR on rhytides.
Histologic evaluation of the effect of PSR on
collagen regeneration was performed as part of
a clinical study by Kilmer and colleagues.42 Skin
samples, taken pretreatment and 90 days after
treatment, were sent for histologic evaluation
examining markers of collagen formation and elas-
tic properties of skin. The investigation showed
complete, intact epidermis in all specimens. The
dermis showed normal architecture and de-
creased solar elastosis. Scarring and incomplete
healing with disorganized dermal architecture
were not observed. Neocollagenesis was ob-
served with variability.42 Other studies have
included histologic evaluation and have shown
collagen remodeling with less variability.43 Scar-
ring and dyspigmentation resulting from PSR
were not observed at the histologic level.42
Clinical studies on PSR have not shown scarring
or dyspigmentation after the procedures. Mild
erythema and desquamation were noted at low
settings and increased at higher settings. Hyper-
pigmentation resulting from PSR was not ob-
served. Patients who had hyperpigmentation
before treatment had improvement in hyperpig-
mentation after treatment with single-pass, high-
energy (3–4 J) PSR.42 The lack of posttreatment
hyperpigmentation and scarring makes PSR ideal
for patients who are more likely to develop these
sequelae, such as dark-skinned patients.22 Dys-
chromias and scarring are the primary reasons

for which treatment is sought in dark-skinned
patients. (Jackson 2003/Jackson 2003) It is the
melanin content of dark skin that makes it resistant
to many of the signs of photoaging and makes it
more susceptible to dyschromia secondary to
trauma and inflammation. (Jackson 2003/grimes
2000) Although most studies examining PSR and
other skin resurfacing modalities have few partici-
pants who are Fitzpatrick skin types IV through VI,
the lack of side effects, which are more prevalent
in this demographic, make PSR a natural and ideal
choice for dark-skinned patients.
Generally, this type of nonsurgical cosmetic
enhancement is well tolerated by patients and
results in improved skin texture, tone, fine lines,
dyschromia, and rhytides with minimal side
effects.42 These characteristics make PSR a likely
choice for men who desire subtle enhancement of
their appearance with minimal side effects. The
effects of PSR on the skin of the neck have been
examined and shown to reduce the signs of photo-
damage with the similar low side-effect profile
seen in the use of PSR on facial skin. Although fur-
ther studies are needed to elucidate the most
effective treatment protocol, the use of PSR on
the skin of the neck is promising.44
Coblation
Coblation, or cool ablation, is a bipolar radiofre-
quency technology that uses two electrodes set
close to each other, with a gap filled by tissue
and fluid, usually saline. When voltage is applied
to the electrodes, tissue is vaporized that ulti-
mately leads to tissue exfoliation with subsequent
re-epithelialization. This technology prevents col-
lateral damage to surrounding tissues, because
the ions lose energy quickly. Each pass achieves
more ablation, beginning with the dermis and
extending to the epidermis with subsequent
passes. Although re-epithelialization is achieved
in approximately 1 week, leading to less downtime
than traditional carbon dioxide laser resurfacing,
the dermal damage leads to a mild erythema that
lasts for several weeks.45 For the male demo-
graphic, this would likely be preferable to ablative
carbon dioxide and erbium:YAG laser resurfacing
with improvement in fine and deep wrinkles and
lentiginies.29 As with other forms of ablative tech-
nology, the potential for deep thermal penetration
and the damage to melanocytes is high and the
resultant hypopigmentation can be significant.
Coblation is not recommended for individuals
who have Fitzpatrick skin types IV and higher.
The most commonly studied electrosurgical
system is the Visage Cosmetic Surgery System
(ArthroCare Corporation). Several studies have
Facial Resurfacing of the Male Patient 365
been performed examining the clinical and histo-
logic effects of Coblation. Histologic evaluation
of 15 subjects in one study revealed new upper
papillary dermis collagen formation after cobla-
tion.46 The clinical results in the study, decreased
perioral and periorbital rhytides with complete re-
epithelialization within 7 days, reinforced the histo-
logic finding.46 Scarring has also been shown to be
safely treated with the Visage system.47
A prospective, multicenter study demonstrated
efficacy of Coblation for periorbital and perioral
rhytides in patients who have Fitzpatrick type I to
III skin.48 This study, as with most studies of
Coblation, focused on patients who had Fitzpa-
trick type I to III skin, because hyperpigmentation
is a known side effect of many ablative skin resur-
facing modalities. The number of passes and volt-
age correlated positively with improvement in
rhytides in 95 patients. Transient hypopigmenta-
tion and scarring have been observed, but are
rarely permanent, usually resolving within
6 months.47,48
Overall, bipolar radiofrequency has been shown
to be efficacious for rhytides with several weeks of
posttreatment erythema and edema. Although this
is less than other ablative methods of skin resur-
facing, it is longer than with some of the newer
nonablative methods of skin resurfacing.
As such, bipolar radiofrequency has been com-
bined with nonablative optical technologies to
achieve the benefits of each type of technology
while maximizing the limited side effects. The
Aurora applicator combines the radiofrequency
and intense pulsed light. ReFirme ST combines
radiofrequency and infrared light. Polaris WR com-
bines radiofrequency and diode laser. The Aurora
SR is recommended for treatment of telangiecta-
sias, rosacea, and other lesions with symptom-
atology in the epidermis and superficial dermis.
Polaris WR and ReFirme ST target rhytides and
skin laxity. A study of 100 patients using the Aurora
SR used three to five treatments of one to three
passes with optical fluencies ranging from 28 to
34 J/cm2 and a radiofrequency of 20 J/cm2 to
examine its efficacy on dyschromias and rhytides.
The Aurora SR reduced dyschromias, telangiecta-
sias, and rhytides with minimal side effects.49,50
Acne
Puberty, and the concomitant increase in the con-
centration of circulating androgens, is the herald-
ing event in the development of acne vulgaris
and therefore its development is universally
unavoidable. In fact 95% to 100% of 16- to
17-year-old boys and 83% to 85% of 16- to 17-
year-old girls develop acne vulgaris.51 Although
366 Poore et al
the condition usually remits spontaneously by age
25, approximately 95% of individuals display
some degree of post-acne scarring. The develop-
ment of post-acne scarring is a complex interplay
of the inhibited outflow of sebum from sebaceous
glands to the skin surface followed by the develop-
ment of either open or closed comedones and the
possible differentiation into an inflamed acne
lesion caused primarily by the obligate anaerobe
Propionibacterium acnes in the context of the
anaerobic conditions of a closed comedo.52,53
Although techniques in facial resurfacing have
proved beneficial in the treatment of post-acne
scarring, including chemical peels, microdermab-
rasion, dermabrasion, plasma, and multiple laser
and light treatments, there is now an increasing
body of literature on the treatment of active acne
vulgaris with various light and laser therapies,
including blue/blue red light combinations,
1450-nm diode laser, and intense pulsed light
(IPL) with or without aminolevulinic acid (Levulan)
enhancement. Although a full description of these
therapies is beyond the scope of this article, one
emerging and promising technology worthy of dis-
cussion is Levulan-enhanced IPL. In a split-face
study, Alster and colleagues53 evaluated the effec-
tiveness of Levulan-enhanced IPL therapy com-
pared with IPL alone. They demonstrated higher
clinical improvement scores on the side of the
face treated with a combination of Levulan and
IPL compared with IPL alone. A similar split-face
study was conducted by Santos and colleagues,54
who demonstrated similar conclusions. For a thor-
ough review of the other techniques the reader is
referred to reviews by Ortiz and colleagues,
Taub, and Goodman and Baron.55–57
Acne scars occur as a function of the extent of
inflammation, abscess formation, and fistulous
tract development. Overall, acne scars are most
often atrophic resulting from inflammation deep
in the tissues and subsequent scarring with ulti-
mate contracture resulting in indentation and atro-
phy. In certain individuals acne scars become
thickened, resulting in hypertrophic or keloid scar-
ring. This scarring usually occurs in those who
have a family history of hypertrophic or keloid
scarring.
Ablative and nonablative technologies have
been used for the treatment of atrophic scars.
Although ablative technologies, including CO2
and erbium lasers, have proved effective in the
treatment of atrophic scars, the collateral thermal
damage can lead to significant downtime and
potential side effects.28,58,59 Recently, Alster and
colleagues59 reported success with fractional pho-
tothermolysis in a group of 53 patients who had
mild to moderate atrophic facial acne scars. They
used a 1550-nm erbium-doped fiber laser (Fraxel,
Reliant) applied to the scarred regions in 8 to
10 passes after the application of 30% lidocaine
solution for 60 minutes. This treatment was per-
formed on all patients at monthly intervals for
3 months with the ultimate conclusion that when
compared with CO2 resurfacing there were similar
clinical improvements with less downtime and
fewer side effects.
Microdermabrasion was originally used as
a treatment of acne and scarring and remains pop-
ular despite the arrival of newer treatments.
Limited evidence investigating the use of micro-
dermabrasion for acne demonstrates good effi-
cacy.60 It is well-tolerated by patients, with few
side effects. Erythema is the main side effect,
which resolves within 24 hours. Investigation of
the clinical histologic effects of microdermabra-
sion demonstrates moderate improvement with
acne scarring, usually requiring deeper treatment.
The usefulness of microdermabrasion for acne is
as an adjunct to other procedures, such as photo-
dynamic therapy.56 Removal of acne scars
requires penetration to the superficial papillary
dermis. Of note, microdermabrasion may exacer-
bate telangiectasia and erythema so patients
who have acne rosacea should not be offered
microdermabrasion.61 Superficial chemical peels,
including alpha-hydroxy acids, such as glycolic
acid, and salicylic acid, have shown efficacy pri-
marily in the treatment of acne. The glycolic peels
led to improvement in active acne and in the post-
inflammatory changes observed with acne
scarring. Salicylic acid peels have shown improve-
ment in acne in several studies. There were few
side effects, including erythema, dryness, and
crusting. Superficial chemical peels work well as
an adjunct to systemic and topical therapies for
the inflammatory stages of acne.56
Rhinophyma
‘‘I take inordinate pride in my nose. Indeed,
I have treatment done on it every day.’’ (At
this point, Fields is handed a glass and lifts
it.) ‘‘My daily treatment.’’
—From W.C. Fields: A Life on Film
Contrary to popular belief, rhinophyma, charac-
terized by an erythematous, discolored, hypertro-
phied, and inflamed nose, is not the result of
chronic alcoholism; it is the fourth and most severe
stage of rosacea. The first three stages are classi-
fied as prerosacea (frequent facial flushing), vas-
cular rosacea (thickened skin, telangiectasis,
facial erythema, and erythrosis), and inflammatory
rosacea (erythematous pustules and papules of

the face, forehead and nose). Although rosacea is
more common in women, the progression to full-
blown rhinophyma is more common in men, which
may be attributable to androgenic influence. An in-
fectious cause has also been postulated because
plugged sebaceous glands are typically colonized
with bacteria. It remains unclear, however, if bac-
terial colonization is a primary or secondary com-
ponent of the disease process. Rhinophyma is
classified on severity of the deformity and
includes:
Early vascular type
Diffuse enlargement (moderate)
Localized tumor (early)
Diffuse enlargement (extensive)
Diffuse enlargement (extensive and localized
tumor)
A full exploration in the treatment of rosacea
and rhinophyma is beyond the scope of this article
and for a full analysis the reader is referred to Roh-
rich and colleagues.25 Various skin resurfacing
modalities play a significant role in treatment.
For simple rosacea, topical and oral antibiotics
are the mainstay of treatment. For more advanced
forms surgical therapy includes dermabrasion,
cryosurgery, loop cautery, and CO2 lasers. An
algorithm from Rohrich and colleagues25 is pre-
sented in Fig. 4.
Multiple modalities have been described in the
treatment of rhinophyma, including sharp excision,
CO2 laser, loop electrocautery, dermabrasion,
ultrasonic scalpel, and a combination of these
techniques.62–64
There have been multiple cases of rhinophyma
presenting concomitantly with skin cancer and
cases of skin cancer mimicking rhinophyma;
therefore all surgical specimens should be sent
for pathologic analysis.65,66 {{4747 Moran, A.M.
2006;}} Rohrich and colleagues25 discourage the
use of ablative techniques (laser and so forth) for
primary therapy because this precludes adequate
tissue being sent for pathology.
Simo and Scharma62 describe the use of
CO2 laser in the treatment of three cases of
rhinophyma. Their protocol uses a Zeiss Opmilas
CO2 25 using an initial beam of 5 W focused to 1
mm to delineate the area to be corrected. They
then increase the power to 15 W and defocus to
a size of 3 mm, which penetrates to approximately
0.5 mm and allows sculpting of the hypertrophied
area in progressive layers until the desired shape is
achieved. Postoperatively they use paraffin gauze
for 24 hours because of serous discharge. They
then let an eschar form, which disappears over
a 6-week period. They report excellent results.
Facial Resurfacing of the Male Patient 367
Rohrich and colleagues25 use a combination of
cold excision with a scalpel followed by dermabra-
sion for fine sculpting. They also use electrocau-
tery for hemostasis and either erbium or CO2
laser for hemostasis only when electrocautery is
not sufficient. Postoperatively they use a combina-
tion of Xeroform gauze antibiotics for 4 days twice
daily starting on postoperative day one. They do
not use ointment for more than 3 days to prevent
maceration but do continue with Xeroform gauze
until re-epithelialization occurs and the nose is
healed (usually 4 weeks).
Fincher and Gladstone64 described the tech-
nique of dual-mode erbium:YAG laser for correc-
tion of rhinophyma in six patients with excellent
results. The authors use a dual-mode erbium:YAG
laser with a scanning laser hand piece set of 3 mm
spot, 100 mm of ablation, and 50 of coagulation.
They perform an average of four passes. Postop-
eratively they use an occlusive dressing for
3 days and the Aquaphor for 2 weeks. They con-
clude that using this technique provides excellent
hemostasis and less nonspecific thermal damage,
and anecdotally report more rapid re-epitheliza-
tion than with CO2 laser even though there are
no specific studies comparing the two
modalities.64
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