Advances in Cosmetic Surgery (Volume

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 2019

ADVANCES IN
COSMETIC SURGERY
Gregory H. Branham, MD

Jeffrey S. Dover, MD, FRCPC

Heather J. Furnas, MD, FACS

Marissa M.J. Tenenbaum, MD

Allan E. Wulc, MD, FACS

Director, Continuity Publishing: Taylor Ball
Editor: Jessica McCool
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 ADVANCES IN COSMETIC SURGERY
EDITORS
GREGORY H. BRANHAM, MD
Chief Medical Officer, Barnes-Jewish West County
Hospital, Creve Coeur, Missouri; Professor and Chief,
Facial Plastic and Reconstructive Surgery, Department
of Otolaryngology-HNS, Washington University
School of Medicine, St Louis, Missouri
JEFFREY S. DOVER, MD, FRCPC
Director, SkinCare Physicians, Chestnut Hill,
Massachusetts; Associate Clinical Professor of
Dermatology, Yale University School of Medicine,
New Haven, Connecticut; Adjunct Associate Professor
of Dermatology, Brown Medical School, Providence,
Rhode Island
HEATHER J. FURNAS, MD, FACS
Adjunct Assistant Professor, Division of Plastic and
Reconstructive Surgery, Stanford Medical School,
Stanford, California
MARISSA M.J. TENENBAUM, MD
Associate Professor and Program Director, Division of
Plastic and Reconstructive Surgery, Department of
Surgery, Washington University School of Medicine in
St. Louis, St Louis, Missouri
ALLAN E. WULC, MD, FACS
Associate Clinical Professor, Department of
Ophthalmology, University of Pennsylvania,
Philadelphia, Pennsylvania; Adjunct Associate
Professor, Department of Otolaryngology, Temple
University, Philadelphia, Pennsylvania
iii
 ADVANCES IN COSMETIC SURGERY
CONTRIBUTORS
RACHEL C. BAKER, BS
Research Assistant, Section of Plastic Surgery,
University of Michigan, North Campus Research
Complex (NCRC), Ann Arbor, Michigan, USA
DANIEL J. CALLAGHAN, MD
Mohs Micrographic Surgery Fellow, SkinCare
Physicians, Chestnut Hill, Massachusetts, USA
FRANCISCO L. CANALES, MD
Private Practice, Santa Rosa, California, USA
YUNYOUNG CLAIRE CHANG, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
ANNE CHAPAS, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
JUSTIN COHEN, MD, FACS
Glasgold Group Plastic Surgery, Princeton,
New Jersey, USA
STEVEN M. COUCH, MD, FACS
Associate Professor of Orbital and Oculofacial Plastic
Surgery, Department of Ophthalmology and Visual
Sciences, Washington University in St. Louis, St Louis,
Missouri, USA
JEFFREY S. DOVER, MD, FRCPC
Director, SkinCare Physicians, Chestnut Hill,
Massachusetts; Associate Clinical Professor of
Dermatology, Yale University School of Medicine,
New Haven, Connecticut; Adjunct Associate Professor
of Dermatology, Brown Medical School, Providence,
Rhode Island, USA
GORANA KUKA EPSTEIN, MD
Foundation for Hair Restoration, Miami, Florida, USA
JEFFREY EPSTEIN, MD, FACS
Foundation for Hair Restoration, Miami, Florida,
USA; Assistant Clinical Professor, Department of
Otolaryngology, University of Miami, Coral Gables,
Florida, USA
JILL A. FOSTER, MD, FACS
Plastic Surgery Ohio/Ophthalmic Surgeons and
Consultants of Ohio, Inc, Department of
Ophthalmology, The Ohio State University,
Columbus, Ohio, USA
HEATHER J. FURNAS, MD, FACS
Adjunct Assistant Professor, Division of Plastic and
Reconstructive Surgery, Stanford Medical School,
Stanford, California, USA
ADELE HAIMOVIC, MD
The Ronald O. Perelman Department of Dermatology,
New York University Langone Health, New York City,
New York, USA
ANDREW HARRISON, MD
Department of Ophthalmology and Visual
Neurosciences, University of Minnesota Medical
School, Minneapolis, Minnesota, USA
MORRIS E. HARTSTEIN, MD, FACS
Director, Ophthalmic Plastic Surgery, Assaf Harofeh
Medical Center, Tel Aviv University-Sackler School of
Medicine, Tel Aviv-Yafo, Israel
LARRY KEVIN HEARD, MD
Resident Physician, Department of Dermatology,
University of South Florida, Tampa, Florida, USA
SARA HOGAN, MD, MPH
Cosmetic and Laser Dermatologic Surgery Fellow,
SkinCare Physicians, Chestnut Hill, Massachusetts,
USA
OMER IBRAHIM, MD
Chicago Cosmetic Surgery and Dermatology, Chicago,
Illinois, USA
PRASANTHI KANDULA, MD
Cosmetic and Laser Dermatologic Surgery Fellow,
SkinCare Physicians, Chestnut Hill, Massachusetts,
USA
v
vi CONTRIBUTORS
RYAN C. KELM, BS
Univsersity of Oklahoma College of Medicine,
Oklahoma City, Oklahoma, USA
SHILPI KHETARPAL, MD
Department of Dermatology, Cleveland Clinic
Foundation, Cleveland, Ohio, USA
JENNIFER MACGREGOR, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
KAVITA MARIWALLA, MD
Founder, Mariwalla Dermatology, West Islip,
New York, USA
GUY MASSRY, MD
Beverly Hills Ophthalmic Plastic and Reconstructive
Surgery, Beverly Hills, California, USA; Orbital Center,
Cedars-Sinai Medical Center, Department of
Ophthalmology, Division of Oculoplastic Surgery,
Keck School of Medicine of USC, University of
Southern California, Los Angeles, California, USA
AMY PATEL, MD
Beverly Hills Ophthalmic Plastic and Reconstructive
Surgery, Beverly Hills, California, USA, USA; Orbital
Center, Cedars-Sinai Medical Center, Los Angeles,
California, USA
FORUM PATEL, MD
Physician, Union Square Laser Dermatology,
New York, New York, USA
ALI A. QURESHI, MD
Aesthetic Surgery Fellow, Marina Plastic Surgery,
Marina del Rey, California, USA
SHAWN ROMAN, BS
Bovie Vice President of Research & Development,
Safety Harbor, Florida, USA
PETER M. SCHMID, DO, FAOCOOHNS, FAACS
Private Practice, Longmont, Colorado, USA
LORELEY D. SMITH, MD
Resident Physician, Department of Ophthalmology
and Visual Sciences, Washington University in
St. Louis, St Louis, Missouri, USA
JONATHAN SOH, MD
University of Rochester Medical Center, Rochester,
New York, USA
EMILY A. SPATARO, MD
Assistant Professor, Washington University in St. Louis,
St Louis, Missouri, USA; Division of Facial Plastic and
Reconstructive Surgery, Washington University School
of Medicine, Creve Coeur, Missouri, USA
DANIEL G. STRAKA, MD
Plastic Surgery Ohio/Ophthalmic Surgeons and
Consultants of Ohio, Department of Ophthalmology,
The Ohio State University, Columbus, Ohio, USA
MARISSA M.J. TENENBAUM, MD
Associate Professor and Program Director, Division of
Plastic and Reconstructive Surgery, Department of
Surgery, Washington University School of Medicine in
St. Louis, St Louis, Missouri, USA
SAMANTHA A. THIRY, MSN, FNP-C
Dr. Jennifer Walden, PLLC, Austin, Texas
MARA WEINSTEIN VELEZ, MD
University of Rochester Medical Center, New York,
USA
JENNIFER L. WALDEN, MD, FACS
Clinical Assistant Professor, Department of Plastic
Surgery, The University of Texas Southwestern Medical
Center, Private Practice, Austin, Texas, USA
JENNIFER F. WALJEE, MD, MPH, MS
Associate Professor, Section of Plastic Surgery,
University of Michigan, North Campus Research
Complex (NCRC), Ann Arbor, Michigan, USA
YAO WANG, MD
Department of Ophthalmology and Visual
Neurosciences, University of Minnesota Medical
School, Minneapolis, Minnesota, USA
SUSAN WEINKLE, MD
Assistant Clinical Professor, Department of
Dermatology, University of South Florida, Tampa,
Florida, USA
CHRISTINA WONG, MD
Department of Dermatology, Cleveland Clinic
Foundation, Cleveland, Ohio, USA
JACK ZAMORA, MD
Medical Advisory Board of Bovie, Medical Advisory
Board of Vitro Biopharma, Limitless MD Founder,
Jack Zamora M.D. Cosmetic Surgery & Aesthetics,
Denver, Colorado, USA
 ADVANCES IN COSMETIC SURGERY

CONTENTS VOLUME 2  2019

Editorial Board, iii Surgical Site Infections in Cosmetic

Surgery, 29
Contributors, v By Emily A. Spataro
Introduction, 29
Introduction, xi Background, 29
By Gregory H. Branham, Jeffrey S. Dover, Heather J. Summary of current guidelines, 30
Furnas, Marissa M.J. Tenenbaum, and Allan E. Wulc Surgical site infections in plastic
surgery, 30
Preface, xiii Evidence-based recommendations for the
By Gregory Harris Branham prevention of surgical site infections in
plastic surgery, 31
The Latest in Cosmetic Medicine: Procedure-specific surgical site infection
Supplements, Hormones, and Evidence, 1 prevention, 32
By Samantha A. Thiry and Jennifer L. Walden Breast surgery, 32
Introduction, 1 Abdominoplasty, 32
Age-related diseases, 2 Liposuction, 33
Hormonal changes in men and women Rhytidectomy, 33
associated with age, symptoms, and Blepharoplasty, 33
treatment options, 3 Rhinoplasty, 34
Summary, 9 Facial alloplastic implantation, 34
Skin resurfacing, 34
Sculptural Aesthetic Surface Anatomy of Other dermatologic procedures, 35
the Face, 11 Risk factors, 35
By Peter M. Schmid Summary, 36
Introduction: the sculptor and surgeon, 11
Facial beauty and attractiveness, 11 Pain Control in the Age of an Opioid
Physical examination: facial shape and form, 12 Epidemic, 41
Canons, Proportions, and Shape, 13 By Rachel C. Baker and Jennifer F. Waljee
Facial Structural Platform, 13 Introduction, 41
Facial Soft Tissue Platform, 16 Pain control: opioids, 42
Summary, 19 Opioid prescribing for surgical care, 42
Alternative analgesic treatments, 43
Tricks for Patient Retention for Alternative analgesic treatments: nonsteroidal
Maintenance Care, 23 anti-inflammatory drugs, 43
By Kavita Mariwalla Alternative analgesic treatments:
Nature of the problem, 23 acetaminophen, 43
Discount programs, 25 Alternative analgesic treatments: behavioral
Bundled purchases, 25 techniques, 44
Summary, 27 Summary, 44

vii
viii CONTENTS

Microneedling, 47 Management of vasoocclusion, 74

By Shilpi Khetarpal, Jonathan Soh, Mara Weinstein Authors’ thoughts on fat versus filler, 74
Velez, and Adele Haimovic
Video content accompanies this article at Submental Fat Contouring: A Comparison
http://www.advancesincosmeticsurgery. of Deoxycholic Acid, Cryolipolysis, and
com. Liposuction, 75
Background, 47 By Sara Hogan, Prasanthi Kandula,
Mechanism of action, 47 Daniel J. Callaghan, and Jeffrey S. Dover
Microneedling instruments, 48 Introduction, 75
Procedure, 48 Anatomy of the submental area, 75
Contraindications and treatment Evaluation of the patient with submental
considerations, 48 fullness, 76
Adverse events, 49 Deoxycholic acid, 76
Microneedling and rejuvenation, 49 Deoxycholic acid patient evaluation, 76
Microneedling and scars, 51 Preprocedure, 78
Procedure, 79
New Synergistic Tricks: Fillers D Postprocedure, 79
Neuromodulators D Technology 5 More Adverse effects, 79
than the Sum, 55 Complications, 79
By Ryan C. Kelm and Omer Ibrahim Clinical results, 80
Cryolipolysis, 80
Introduction, 55
Cryolipolysis patient evaluation, 80
Combining soft tissue fillers with
Preprocedure, 80
neuromodulators, 55
Procedure, 82
Soft tissue filler combinations, 56
Postprocedure, 82
Combinations with energy-based devices, 58
Clinical results, 82
Intense pulsed light, 59
Adverse effects, 82
Lasers, 59
Submental liposuction, 82
Nonablative lasers, 59
Submental liposuction patient evaluation, 82
Ablative lasers, 60
Preprocedure, 84
Microfocused ultrasound, 62
Procedure, 84
Radiofrequency, 63
Postprocedural care, 84
Radiofrequency with microneedling, 63
Adverse effects, 84
Soft tissue filler and synthetic deoxycholic
Summary, 84
acid, 63
Summary, 64
Subcutaneous Neck Skin Plasma
Facial Rejuvenation: Fat Transfer Versus Tightening, 89
Fillers, 69 By Jack Zamora and Shawn Roman
By Ali A. Qureshi and Marissa M.J. Tenenbaum Video content accompanies this article at
The aging face, 69 http://www.advancesincosmeticsurgery.com.
Autologous fat injection, 69 Introduction, 89
Surgical technique for fat grafting, 70 Surgical technique, 90
Injection, 71 Preoperative planning, 90
Common side effects, 71 Procedural approach, 90
Filler, 72 Miniincision superficial musculoaponeurotic
Anesthesia and pain management, 73 system/platysma plication, 90
Common side effects, 74 Plasma skin tightening, 91

Treatments for the Aging Lip, 97
By Larry Kevin Heard and Susan Weinkle
Video content accompanies this article at
http://www.advancesincosmeticsurgery.com.
Introduction: Nature of the problem, 97
Surgical technique, 99
Preoperative planning, 99
Preparation and patient positioning, 100
Procedural approach, 101
Injecting fillers, 101
Injecting neurotoxin, 102
Immediate postprocedural care and
rehabilitation, 103
Clinical results in the literature, 103
Potential complications, risks, benefits, and
limits, 103
Summary, 104
Nonsurgical Periorbital Rejuvenation, 107
By Loreley D. Smith and Steven M. Couch
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 107
Periorbital skin resurfacing, 107
Chemical peels, 107
LASER therapy, 109
Neuromodulators, 111
Surgical technique, 112
Dermal fillers, 115
Introduction, 115
Surgical technique, 115
Update on the Treatment of
Postblepharoplasty Lower Eyelid
Retraction, 121
By Daniel G. Straka and Jill A. Foster
Introduction: the nature of the problem, 121
Anatomy, 122
Risk Factors, 123
Transcutaneous or Transconjunctival?, 124
Surgical technique, 126
Preoperative Planning, 126
Preoperative Considerations for Planning
Surgical Technique, 127
Prep and Patient Positioning, 129
Procedural Approach, 130
CONTENTS ix
Immediate Postprocedural Care and
Recovery, 133
Potential complications, 133
Management, 133
Discussion, 133
Update on the Treatment of the
Skeletonized Upper Eyelid, 135
By Morris E. Hartstein
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Defining the Brow Fat Pad: The Brow Fat
Pad Suspension Suture, 143
By Yao Wang, Andrew Harrison, Amy Patel, and
Guy Massry
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 143
Surgical technique, 144
Preoperative planning, 144
Preparation and patient positioning, 144
Procedural approach, 144
Immediate postoperative care, 145
Rehabilitation and recovery, 145
Clinical results in the literature, 145
Potential complications, risks, benefits, and
limitations, 146
Complications, risks, and management, 146
Benefits, 147
Limitations, 147
Summary, 148
Platelet-rich Plasma for Hair Growth, 151
By Christina Wong and Shilpi Khetarpal
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 151
Procedural technique, 152
Preoperative planning, 152
Preparation and Patient Positioning, 157
Procedural Approach, 158
Immediate Postprocedural Care, 158
Rehabilitation and Recovery, 158
Clinical results in the literature, 158
x CONTENTS
Potential complications/risks/benefits/
limits, 159
Summary, 159
Hair Loss in Men and Women: Medical and
Surgical Therapies, 161
By Gorana Kuka Epstein, Jeffrey Epstein, and Justin
Cohen
Video content accompanies this article at
http://www.advancesincosmeticsurgery.
com.
Introduction, 161
Understanding androgenic hair loss, 161
Medical therapies, 163
Addressing underlying conditions
contributing to androgenic alopecia, 163
Minoxidil, 163
Finasteride, 164
Low-level laser light, 164
Platelet-rich plasma, 165
Microneedling, 166
Mesenchymal regenerative cells, stromal
vascular fraction, and adipose tissue
injections, 166
Surgical therapies, 166
Introduction, 166
History of surgeries used to treat androgenic
alopecia, 167
Surgical procedures other than hair
transplants, 167
Hair transplantation, 168
Surgical technique, 169
Preoperative planning, 169
Preparation and patient positioning, 169
Procedural approach, 171
Post procedure care, 173
Future therapies, 175
Subcutaneous Body Skin Tightening, 177
By Forum Patel, Jennifer MacGregor, Yunyoung Claire
Chang, and Anne Chapas
Introduction, 177
Radiofrequency, 177
Micorfocused Ultrasound, 181
Surgical technique, 181
Preoperative planning, 181
Preparation and patient positioning, 181
Procedural approach, 183
Immediate postprocedural care, 185
Rehabilitation and recovery, 185
Potential complications/risks/benefits/
limits, 185
Management, 185
Summary, 185
Hand Rejuvenation, 189
By Prasanthi Kandula, Sara Hogan,
Daniel J. Callaghan, and Jeffrey S. Dover
Introduction, 189
Aging process of the hands, 189
Treatment, 190
Topical Agents, 190
Chemical Peels, 190
Soft-tissue augmentation, 190
Hyaluronic Acid, 190
Calcium Hydroxyapatite, 191
Poly-L-Lactic Acid, 191
Autologous Fat Transfer, 191
Potential Complications, Risks, and
Limitations, 191
Vein treatments, 192
Sclerotherapy, 192
Laser/light sources and energy-based
devices, 192
Intense Pulsed Light, 192
Nonablative Resurfacing Lasers, 192
Ablative Resurfacing Lasers, 192
Q-Switched Devices, 193
Photodynamic Therapy, 193
Pulsed Dye and Pulsed Green Potassium
Titanyl Phosphate Lasers, 193
Summary, 193
Nonsurgical Vaginal Treatments, 195
By Francisco L. Canales and Heather J. Furnas
Introduction, 195
Vaginal health issues, 196
Effect on women’s lives, 196
The rise of nonsurgical options for vaginal
rejuvenation, 196
Vaginal laxity, 197
Radiofrequency devices, 197
Lasers in vaginal rejuvenation, 198
Stress urinary incontinence, 199
Food and drug administration warning, 199
 Advances in Cosmetic Surgery 2 (2019) xi–xii
ADVANCES IN COSMETIC SURGERY
Introduction
Gregory H. Branham, Jeffrey S. Dover, MD, Heather J. Furnas, MD, Marissa M.J.
MD FRCPC FACS
Editors
T
he desire for cosmetic surgery has infiltrated
corners of society never seen before and is
only expected to grow in the years ahead. As
the number of cosmetic surgery procedures continues
to rise throughout the world, so too does the number
of specialists performing these important procedures.
When working with a patient to create their ideal
image, it’s critical to have the most current resources
available to guide your practice and inform your
decisions.
Advances in Cosmetic Surgery, now in its second vol-
ume, aims to highlight the year’s latest advancements
and breakthroughs in the field of cosmetic surgery.
Experts from the four core specialties have come
together to bring you, the reader, the most important
advances in this rapidly evolving field.
Subcutaneous body skin tightening, platelet-rich
plasma for hair growth, microneedling, subcutane-
ous neck plasma skin tightening, facial rejuvenation,
and treatments for the aging lip are just a handful of
topics covered in this issue. High-quality images and
videos accompany many of the articles, helping to
further deepen the reader’s understanding of these
techniques and procedures. Whether you are plan-
ning to perform the procedures discussed here or
learning about them for the first time, we think
https://doi.org/10.1016/j.yacs.2019.02.018
2542-4327/19/ © 2019 Published by Elsevier Inc.
Allan E. Wulc, MD,
Tenenbaum, MD FACS
you will find value in what this exciting series has
to offer.
The editors would like to thank the authors for their
insightful contributions, and all the pioneers in this field
working to bring us better tools, techniques, and ways of
making the seemingly impossible possible for our patients.
We hope you will enjoy reading this issue as much as
we enjoyed putting it together. It is our sincere hope
that the articles presented here will help further break
down barriers between specialties and shed new light
on current cosmetic treatments.
Gregory H. Branham, MD
Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
Washington University School of Medicine
St Louis, MO, USA
Jeffrey S. Dover, MD, FRCPC
SkinCare Physicians
Chestnut Hill, MA, USA
Yale University School of Medicine
New Haven, CT, USA
Brown Medical School
Providence, RI, USA
www.advancesincosmeticsurgery.com
XI
XII Introduction
Heather J. Furnas, MD, FACS
Division of Plastic and Reconstructive Surgery
Stanford Medical School
Stanford, CA, USA
Marissa M.J. Tenenbaum, MD
Plastic and Reconstructive Surgery
Washington University School of Medicine
St Louis, MO, USA
Allan E. Wulc, MD, FACS
Department of Ophthalmology
University of Pennsylvania
Philadelphia, PA, USA
Department of Otolaryngology
Temple University
Philadelphia, PA, USA
E-mail address: branhamg@wustl.edu
 Advances in Cosmetic Surgery 2 (2019) xiii
ADVANCES IN COSMETIC SURGERY
Preface
Gregory H. Branham, MD,
Editor
W
elcome to the second volume of Advances in
Cosmetic Surgery. Our diverse editorial staff
has once again solicited contributions that
will be of interest to all those providing cosmetic sur-
gery and procedures to patients. Whether you are
engaged in a surgically oriented practice or an office-
based or minimally invasive practice, there is something
for everyone in this volume. Our learning is enhanced
immeasurably when we share and compare our tech-
niques and results. To that end, you will see several ap-
proaches to the same problem or issue that you may
encounter in your practice.
In keeping with our commitment to be at the fore-
front of esthetic practice, we have curated an excep-
tional group of topics that will allow the reader to
develop a grasp of what is new and permit the reader
to make sense of what is effective and what is not.
Topics in this volume range from cosmetic medicines
and pain control in the age of the opioid epidemic to
surgical and nonsurgical treatments for correction of
the overoperated patient.
There are so many new products and procedures be-
ing developed, and we are in a time of accelerated devel-
opment of technology and devices. As you read these
articles, please consider how they can be used to inform
https://doi.org/10.1016/j.yacs.2019.03.001
2542-4327/19/ © 2019 Published by Elsevier Inc.
you of what might be useful in your practice and also
what should require caution or at least careful consider-
ation prior to adoption.
Many thanks to all of the contributors who have taken
the time to share their expertise with us and allowed us to
share that with you. We hope that you will find this vol-
ume as engaging and stimulating as our first volume. We
seem to have an endless flow of ideas but would
welcome any suggestions for future topics that you
would like to see included in future volumes.
The editors would also like to thank Jessica McCool
and all the editorial staff at Elsevier who have made this
volume possible. Their commitment to excellence in
this endeavor is evident in the quality of the publica-
tion, and we trust that will be apparent to you as well.
Gregory H. Branham, MD
Facial Plastic and Reconstructive Surgery
Otolaryngology–Head and Neck Surgery
Washington University
1020 North Mason Road
St Louis, MO 63141, USA
E-mail address: branhamg@wustl.edu
www.advancesincosmeticsurgery.com
XIII
 Advances in Cosmetic Surgery 2 (2019) 1–10

ADVANCES IN COSMETIC SURGERY

The Latest in Cosmetic Medicine

Supplements, Hormones, and Evidence
Samantha A. Thiry, MSN, FNP-C*, Jennifer L. Walden, MD, FACS
5656 Bee Caves Road, Suite E201, Austin, TX 78746, USA

KEYWORDS
 Age-related diseases  Antiaging  Supplements  Hormone replacement therapy  Andropause  Menopause

KEY POINTS
 Provider opinions have an effect on the use of hormone replacement therapy (HRT) within practices. It is important for
providers to be educated regarding the evidence behind HRT so they may safely prescribe HRT for specific patients who
understand the risks versus the benefits. A patient-centered approach should be used with this treatment option.
 The true risks versus benefits of HRT and disease processes, such as prostate cancer and breast cancer risks, must be
presented to patients by educated providers without bias. It has been proved that provider attitudes contribute to use of
antiaging medical methods. This can, in turn, negatively affect a patient’s quality of life by not providing them with safe,
monitored, and effective treatment.
 Supplements to help prevent age-related diseases continue to be researched for their true beneficial possibilities.
Evidence exists regarding specific supplements and their chemopreventive and antioxidant properties. Cancer is an age-
related disease and many supplements are aimed at reducing the risk of its occurrence. Supplement use is a patient-
driven demand.
 Providers must become more informed about supplements by receiving appropriate education regarding the evidence so
they can give patients appropriate feed-back when patient inquiries arise.

INTRODUCTION diseases as symptoms of aging. The concept of a foun-

Patients are seeking care to stop the effects of aging not
only from an external standpoint but also from an inter-
nal standpoint. As the demand for antiaging therapy
with hormones and supplements increases, it is imper-
ative that health care providers understand the evidence
supporting proper management and information
regarding alternative treatment options with hormones
and supplements [1].
Age-related diseases continue to be researched for
prevention and optimization [2]. Antiaging specialists
use a medical framework that targets age-associated
tain of youth has been around for centuries but now,
with modern medicine and advancements in technol-
ogy, antiaging practitioners have developed as a
specialty, with the requirements of understanding dis-
eases associated with age and how to physiologically
decrease a patient’s risk of acquiring an age-related dis-
ease. Various dietary and pharmacologic interventions
have been shown to increase lifespan [3]. Also,
although aging is considered a natural life process, opti-
mization of quality of life continues to be a focus. To
meet this demand, an increasingly popular focus has

Disclosure Statement: The authors have nothing to disclose.

*Corresponding author, E-mail address: Samantha.thiry.drwalden@gmail.com

https://doi.org/10.1016/j.yacs.2019.01.001 www.advancesincosmeticsurgery.com
2542-4327/19/ © 2019 Elsevier Inc. All rights reserved. 1
2 Thiry & Walden
been geared toward preventing existing disease pro-
cesses from worsening, as well as treating disease
processes through therapeutic management with hor-
mones or supplementation [3,4].
Patients have shifted the focus of surviving to
thriving throughout their lifetime. Improving a patient’s
quality of life is an important concept in antiaging med-
icine [2]. Hormonal shifts occur during the aging pro-
cess that cause several physiologic changes and clinical
presentation of symptoms. For women, symptoms of
menopause can severely affect overall quality of life as
radical shifts and imbalances of estrogen and testos-
terone hormones occur [5]. Andropause, defined as a
continual decline in testosterone with age, affects both
men and women [5,6]. Hormone therapies are effective
in the treatment of symptoms of age-related hormonal
changes for men and women, which makes it is impor-
tant to understand the evidence regarding risk versus
benefit of the treatment prescribed. It has been proved
that many providers’ opinions on hormone therapies
are not congruent and often misinformed, causing
bias [7]. This tends to cause a lack of credibility with
specific treatment protocols. Patients can end up
suffering with symptoms of hormonal shifts and the
physiologic changes of age due to lack of appropriately
prescribed care and information regarding the true risks
versus benefits of treatment [7,8].
This article examines the multifactorial approach to
antiaging medicine with hormone replacement therapy
(HRT) and treatment using nutraceuticals to help pa-
tients achieve an improved quality of life, as well as
decrease risk for development of disease process by
optimizing their health from a physiologic evidence-
based standpoint. It examines what symptoms of aging
can be improved, as well as how aging is defined, to
improve patients’ overall quality of life. Potential risks
and benefits of HRT, as well as nutraceutical supple-
mentation, are discussed. Assessment of providers’
knowledge and the options of these types of therapies
are examined, as well as appropriate assessment and
treatment in men and in women [4–8].
Age-related diseases
Antiaging medicine is an evolving movement with the
intent to help patients decrease the development of
age-related disease, as well as improve the quality of
the normal aging process [2]. This movement has
been in place for decades but has recently become
much more advanced through research and technology.
One way to define aging is that it is the result of
continuous interaction between an individual’s genetic
makeup and environmental factors, characterized by
lifelong damage accumulation and progressive loss of
tissue and organ functionality [9]. Aging is directly asso-
ciated with an increased risk of disease development.
Common age-related diseases include neurodegenera-
tive disorders, cardiovascular disease, diabetes, osteoar-
thritis, and cancer [9]. Hypertension, high glucose,
cholesterol, and triglyceride levels are age-related risk
factors for morbidity that increase with age. The concept
of targeting age-related diseases through prevention on
a molecular level is important to understanding which
treatment methods will decrease the effects of aging,
not only from a physiologic standpoint but also from
a symptomatic standpoint [9]. Directly targeting the ag-
ing process on a molecular level versus targeting age-
related diseases or symptoms is a viable strategy
[9,10]. To slow the aging process, therapies that are
considered nonstandard, such as blood-based thera-
pies, are being prescribed and tried [9].
As patients continue to seek out ways to diminish or
decrease the effects of aging, it is important for pro-
viders to be up-to-date on current treatment options.
Hormone therapies and supplements are becoming
increasingly popular as treatment and prevention of
age-related conditions. Age-related conditions are the
leading causes of death, not only in the United States
but also worldwide. They are also the leading cause of
health care expenditures [9]. By delaying the aging pro-
cess, the delay of age-related diseases occurs. Delaying
aging, resulting in 2.2 years of additional life expec-
tance, would yield the United States $7 trillion dollars
in savings over 50 years. The target of single pathologic
conditions, such as cancer or heart disease, yields less
savings [9].
Because antiaging science has huge potential finan-
cial benefits, it has tremendous commercial opportu-
nities. Scientific breakthroughs have led to antiaging
science having a more valid reputation [9]. Provider
opinions and approaches are often skewed when it
comes to subjects such as off-label administration of
medication management [7,8]. Therefore, presenting
the evidence behind some HRT and nutraceutical
blood-based approaches of antiaging is important
when creating a patient-centered plan of care [1]. Given
the multiple genes, processes, and pathways associated
with aging, there are many opportunities to develop
pharmaceuticals to target these pathways [9]. To under-
stand the antiaging process, one must first understand
what causes aging and the specific signs and symptoms
of the aging process [2,3]. The description of aging as a
time of decline and suffering is evident because age-
related diseases often cause the physiologic decline of
a patient, in turn causing the patient to suffer [2,3].

Hormonal changes in men and women
associated with age, symptoms, and
treatment options
Age-related hormonal changes in women
A significant age-related hormonal change for women is
menopause. Menopause is used to define the natural,
systemic decrease of endogenous estrogen production
from the ovaries, caused by physiologic depletion of a
woman’s ovarian reserve [11]. This process occurs in
the aging woman and manifests as the cessation of
menses and subsequent end of fertility. In many women,
vasomotor symptoms occur, as well as other physiologic
issues. Vasomotor symptoms commonly experienced
during menopause include vaginal dryness, hot flashes,
and irregular menstrual pattern. Menopausal symptoms
can greatly affect a woman’s overall quality of life and pa-
tients will bring these to a provider’s attention in search
of relief [11,12]. A progressive decline in androgen levels
also occurs as a woman increases in age. Serum concen-
trations of testosterone in women older than the age of
50 years are approximately half of that of women in
aged 20 to 30 years [13,14]. There are several symptoms
of andropause in women, including unexplained fatigue,
low libido, and decreased sense of wellness. Testosterone
therapy has been administered to women for decades to
improve sexual dysfunction [11,15]. Female sexual
dysfunction is an issue for approximately 43% of women
18 to 59 years of age [14].
Menopause is characterized by a decreased produc-
tion of both estrogen and androgen [5,11]. It is impor-
tant to understand the process of aromatization, which
is the conversion of the body’s excess testosterone into
estrogen. Expression of aromatase is important to the
adipose tissue, skin, and bone because it slows the
rate of postmenopausal bone and collagen loss [5].
Testosterone levels decline gradually with age, rather
than showing a precipitous decrease at the menopause
transition [13]. Different typical HRT plans of care are
used in premenopausal, perimenopausal, and post-
menopausal women due to hormone shifts during
each phase of her sexual maturation [11]. Each phase
is assessed differently for risks and benefits associated
with HRT, therefore making it increasingly difficult for
a provider to manage a patient’s symptoms to improve
quality of life through HRT [11].
Female sexual dysfunction and hyposexual desire are
diagnoses that are reviewed as issues that can occur in the
premenopausal, perimenopausal, or postmenopausal
phases [12]. Some studies have shown that up to 50%
of women suffer from female sexual dysfunction. Female
sexual dysfunction is characterized by low sexual desire,
The Latest in Cosmetic Medicine 3
diminished sexual arousal, vaginal dryness, and difficulty
achieving orgasm. Some women enter into menopause
naturally, whereas others enter into menopause via surgi-
cal means such as a hysterectomy [11]. In the United
States, a national survey concluded that nearly half of
women aged 57 to 85 years experience at least 1 sexual
problem, the most common issue being low sexual
desire. There has been a landmark study performed by
Laumann and colleagues [12] that found that 32% of
women ages 30 to 39 years had low sexual desire. There-
fore, it is not only perimenopausal and menopausal
women who are seeking a solution for a decreased qual-
ity of life likely due to hormonal disruption. Understand-
ing the mechanism of action of androgens in relation to
the female body is important when considering the over-
all benefit for patients seeking relief of androgen defi-
ciency symptoms [12].
Androgen deficiency in women
The organs directly responsible for production of testos-
terone in women are the ovaries and adrenal glands,
although testosterone is also converted peripherally
from androstenedione, which is also produced in the
ovaries and adrenals [11]. Androgen deficiency in women
causes decreased lean body mass, increased body fat, thin-
ning or loss of hair, osteopenia, or osteoporosis, which
present as clinical signs. Symptoms of androgen defi-
ciency include low libido, fatigue, lack of a sense of well-
being, orgasmic dysfunction, arousal disorder, vasomotor
symptoms, insomnia, and depression [11,16].
Beta endorphins increase with testosterone levels,
causing mood-enhancing effects [5]. A woman’s quality
of life is greatly affected by a decrease in androgens, not
simply because of sex hormones. Multiple organs rely
on androgens for action such as increasing bone mass,
causing erythropoiesis, augmenting certain cognitive
behaviors, stimulating muscle growth, stimulating kid-
ney growth, and modifying the pattern of adipose tissue
deposit [5]. Interestingly, the thyroid, breast, endome-
trium, colon, lung, skin, and adrenals are all affected
because androgens have a direct effect on the tissue of
each organ [5]. Androgens may affect sexual desire,
bone mineral density, muscle mass, and strength, as
well as adipose tissue. The addition of testosterone ther-
apy in testosterone-deficient women has an effect on es-
trogen production in the brain, bone, and skin
fibroblasts, among other tissues [5].
Assessment of female androgen deficiency
Female androgen deficiency is assessed through subjec-
tive questionnaires and, therefore, a lack of objective in-
formation can cause lack of consistency between
4 Thiry & Walden
provider assessment and the treatment plan. The idea
that androgen deficiency is assessed through subjective
means causes controversy among providers [8,12]. There
have been several tools designed to screen women for
hyposexual desire disorder (HSDD) [12]. The Decreased
Sexual Desire Screener (DSDS) is a validated diagnostic
tool for generalized, acquired HSDD. The DSDS is
meant to be approximately sensitive and specific for
diagnosis of HSDD in women, independent of meno-
pausal status. The Diagnostic and Statistical Manual of
Mental Disorders, 5th edition, lists specific criteria for the
diagnosis of female sexual interest or arousal disorder;
3 out of 6 symptomatic screening assessments must be
answered with a yes for diagnosis [11].
Interpretation of laboratory data associated with
decreased available androgens for women include the
review of free and total testosterone, as well as sex
hormone-binding globulin (SHBG) [13]. Free testos-
terone is biologically available testosterone, whereas
the bioavailability of testosterone for the conversion
into estrogens depends on the levels of SHBG. In a
normal scenario, only 1% to 2% of total testosterone cir-
culates unbound. SHBG binds about 66% of total circu-
lating testosterone. The rest of testosterone circulating is
bound by albumin. It is assumed that the non–SHBG-
bound circulating testosterone is biologically active
[13]. Estrogen and thyroxine increase SHBG. Testos-
terone and glucocorticoids, growth hormone, and insu-
lin suppress SHBG. It is difficult to measure testosterone
levels in women when they are at very low levels [13].
Testosterone therapy in the aging woman
Data from several studies suggest that combined HRT-
androgen therapy may be beneficial to women who
are postmenopausal who complain of low libido
despite estrogen therapy or as monotherapy in women
who are postmenopausal with female sexual dysfunc-
tion. Studies have concluded that no significant increase
of liver enzymes or cardiovascular risk factors occurred
with the administration of testosterone therapy [11].
There are multiple forms of testosterone therapy in
various routes of administration available to women
[5]. Subcutaneous hormone implants; intramuscular
injection; and transdermal, oral, and vaginal adminis-
tration of hormone replacement are among those
offered to women in search of androgen deficiency
symptom relief [5].
Safe administration of hormone replacement
therapy for women
It is extremely important for the patient and prescriber
to understand the risks versus benefits of HRT for
women. Each individual, due to family and personal
history, have variables that are important for a provider
to consider when developing a tailored treatment plan
for the patient’s needs. Women must have an active rela-
tionship with their obstetrician-gynecologist, and docu-
mented history must be reviewed by the treating
physician [11].
Abnormal menses, hirsutism, elevated blood pres-
sure, and mood swings are some of the associated
issues that may occur during androgen therapy for
women [11].
Women, hormone replacement therapy, and
cardiovascular evidence
Notably, estrogen has antiatherosclerotic and antiin-
flammatory properties that may protect women from
cardiovascular disease development through modifica-
tion of the lipid profile [17]. It is noted that women
who are premenopausal have higher high-density lipo-
protein cholesterol and lower low-density lipoprotein
cholesterol levels compared with men, which signifi-
cantly reverses after menopause [17]. Testosterone is
known to be produced by the ovaries and some of the
female body’s testosterone is converted into estrogen,
primarily when androgen levels are higher during the
premenopausal state [5,17]. The converted estrogen
has beneficial effects on vascular endothelium and
smooth muscle tissue. Menopause and the postmeno-
pausal period may be risk factors for developing coro-
nary heart disease. Directly following menopause,
there is a hormonally related risk for the development
of hypertension, coronary artery disease, congestive
heart failure, and cerebrovascular disease, which are
also age-related diseases [2,17]. The Danish Osteopo-
rosis Prevention Study recently noted in a controlled
randomized trial that menopausal hormone therapy
can have the beneficial effect of a reduced rate of coro-
nary artery disease. Hormonal therapy may be harmful
and is not advised in the setting of preexisting coronary
disease, cerebrovascular disease, or a history of throm-
boembolic disease [11]. Hormonal therapy must be
observed for risks and benefits by the administering
provider using a patient-centered approach and individ-
ualized discussion [11,17].
Hormone replacement therapy and breast
cancer concerns
It has been reviewed that there are no valid randomized
or observational clinical studies to provide appropriate
evidence that testosterone has an influence on breast
cancer risk when added to conventional postmeno-
pausal hormone therapy [14]. This is a significant point

of information to provide to patients inquiring about
HRT [14]. Breast cancer diagnosis represents about
23% of all cancers in women. It is no surprise that it
is an important subject because it is typically an age-
related disease and is a common concern for patients
considering HRT [18]. Breast cancer incidence is
increasing worldwide. Weight gain in adulthood is asso-
ciated with an increased risk of breast cancer in post-
menopausal women. Studies suggest that weight gain
before and around menopausal age may be a
determinant for the development of breast cancer in
postmenopausal women [18]. Increasing a woman’s
testosterone level to a more optimal level has the
benefit of decreasing central visceral fat, increasing
metabolic rate, and decreasing or even treating obesity.
Testosterone also has the benefit of increasing the beta
endorphins responsible for sense of wellbeing [13]. If a
woman is feeling a better sense of wellbeing she is more
likely to be physically and sexually active [13].
Decreasing obesity risk for women before and during
menopause via testosterone therapy decreases a risk fac-
tor for the development of breast cancer [18,19]. Recent
clinical data support a role for testosterone in breast
cancer prevention [19]. Women with symptoms of hor-
mone deficiency who are treated with doses of testos-
terone alone or in combination with anastrazole via
subcutaneous implants have shown a reduced inci-
dence of breast cancer. In addition, testosterone therapy
along with anastrazole has been studied to alleviate
symptoms of hormone-deficient breast cancer survivors
and was not associated recurrent disease [19].
Studies have shown that testosterone and anastra-
zole subcutaneous implants placed in tissue surround-
ing malignant tumors significantly reduces breast
cancer tumor size. Testosterone therapy has been
reviewed and there are several supporting data that
note the direct antiproliferative, protective, and thera-
peutic effects [19].
Provider opinions of hormone replacement
therapy despite evidence
There are differing opinions regarding hormone
replacement therapies that affect not only a physician’s
willingness to prescribe but also a patient’s willingness
to use hormone replacement as a therapy. Part of this
disarray is due to a lack of protocol and continued con-
troversy about normal androgen levels in women. It is
also difficult to assess for androgen deficiency in
women because the symptomology overlaps with
several other medical diagnoses [8,11]. The provider
must rule out other complications that could be pre-
senting as risks to patient’s health. Providers’ opinions
The Latest in Cosmetic Medicine 5
have been observed via survey and it has been noted
that respondents correctly identified the risks of HRT
only 28% of the time, and 67% of providers overesti-
mated the risks and benefits of HRT.
Multiple sources of valid data suggest that combined
HRT-androgen therapy may be beneficial to women
[11]. Providers need to be educated regarding studies
that concluded that no significant increase of liver en-
zymes or cardiovascular risk factors occurred with the
administration of testosterone therapy [16].
Men and testosterone supplementation
Testosterone supplementation in the United States has
increased substantially over the years. Testosterone pre-
scriptions increased by 1700% from 1994 to 2003 and
do not show any signs of decreasing in popularity [4].
As this patient-driven popularity of testosterone supple-
mentation increases, it is important for providers to un-
derstand the signs and symptoms associated with the
decline of testosterone in the male body, as well as
appropriate treatment options and risk factors [4]. To
ignore the increased patient demand for treatment of
the associated symptoms of andropause causes skewed
perspectives regarding the true risks and benefits of HRT
for men throughout the aging process [4].
Men and andropause
Men undergoing the aging process, especially andro-
pause or the progressive decline of testosterone, often
search for symptom relief. Decreased testosterone levels
are also referred to as hypogonadism [20]. Low libido is
the symptom most associated with hypogonadism,
although erectile dysfunction, decreased muscle mass
and strength, increased total body fat, decreased bone
mineral density, anemia, gynecomastia, decreased
mental capacity, and skin and hair alterations also occur
[20]. Decreased quality of life, a diminished sense of
wellbeing, and insomnia are additional symptoms pre-
sent in androgen-deficient men. On clinical presenta-
tion, decreased muscle mass and strength, decrease in
bone mass, osteoporosis, and increased central body
fat may be noted in a patient with testosterone defi-
ciency [20,21]. When assessing for testosterone defi-
ciency, it is important for the provider to use an
approach that considers other age-related diseases by
using objective information, such as laboratory work,
to assess the patient for issues that may be present in
addition to androgen deficiency.
Testosterone deficiency is also associated with
increased cardiometabolic risk. For example, total
testosterone levels are inversely associated with risk of
cardiovascular events. Testosterone deficiency is
6 Thiry & Walden
associated with endothelium damage and testosterone
therapy enhances endothelial repair and function, and
increases synthesis and release of endothelial nitric ox-
ide in the body’s vascular system [20]. Testosterone
deficiency is associated with increased systolic blood
pressure and increased arterial stiffness, which are risk
factors that can lead to further development of age-
related diseases, such as coronary artery disease, hyper-
tension, and hypercholesterolemia [2,4,20].
Diagnosing low testosterone in men
The decline of testosterone for men is about 1% per year
after the age of 30 years and reaches a 30% decline by
the eighth decade of life [4]. The Androgen Deficiency
in the Aging Male (ADAM) questionnaire is an impor-
tant assessment tool when assessing for male androgen
deficiency. Testosterone declines as men age and the
symptoms associated with this decline cause an abun-
dance of unwanted patient symptoms that affect their
overall wellbeing [4]. Assessment regarding the subjec-
tive presence of the most commonly reported androgen
deficiency–associated symptoms must be performed by
a diagnosing provider. The symptoms associated with
this decline cause an abundance of unwanted patient
symptoms, such as fatigue and depression, and a
decreased sense of wellbeing [4]. When assessing for
the reasons for existing symptoms of hypogonadism,
it is important to check patient’s serum total testos-
terone, free testosterone, and SHBG, as well as the total
prostate-specific antigen (PSA) if appropriate for pa-
tient’s age range, when considering prescribing testos-
terone therapy [21].
Testosterone therapy benefits reported
Benefits of testosterone therapy in men include
increased libido, sexual function, bone density, muscle
mass, body composition, mood, erythropoiesis, cogni-
tion, quality of life, and decreased cardiovascular
disease. Improved sexual desire, function, and perfor-
mance are reported by men receiving testosterone
replacement therapy (TRT) [4,6,20].
The cognitive effects of androgen deficiency are asso-
ciated with decline in visual and verbal memory. Men
with higher ratios of testosterone to SHBG show a
decreased risk of Alzheimer disease. This was found in
the Baltimore Longitudinal Study of Aging, a prospec-
tive longitudinal study. It was noted that risk for Alz-
heimer disease was reduced by 26% for each 10 unit
(mmol/mmol) increase in free testosterone at 2, 5,
and 10 years. There are also well-reported data for a
strong correlation between serum levels of testosterone
and cognitive performance in mathematical reasoning
and spatial abilities [6]. Testosterone therapy in hypo-
gonadal men may have some benefit for cognitive per-
formance, especially in older men who are at an
additional risk of developing dementia or Alzheimer
because these are typically age-related diseases [6].
Glycometabolic and cardiometabolic functions, as
well as body compositions, are negatively affected by
testosterone deficiency or hypogonadism [20]. Testos-
terone and its metabolite, 5 alpha-dihydrotestosterone,
regulate energy metabolism, muscle growth, and main-
tenance and inhibit adipogenesis. An inverse relation-
ship between testosterone and insulin resistance has
been postulated and higher physiologic levels of testos-
terone seem to be protective against the development of
type II diabetes mellitus [20,21]. The prevalence of type
II diabetes mellitus and men with hypogonadism is as
high as 33% [21]. It has been shown that TRT causes
an improvement in glycemic control, as well as insulin
resistance, in men with type 2 diabetes [21]. Subcutane-
ous hormone implants, intramuscular injection, trans-
dermal, and sublingual administration of hormone
replacement are among those offered to men in search
of androgen deficiency symptom relief [6].
Safe administration: prostate cancer risk and
other testosterone replacement therapy
considerations
Prostate cancer and the role of testosterone in the disease
often results in confusion. It has not been assessed that
testosterone replacement directly causes prostate cancer,
although its administration in the presence of a carci-
noma can enhance the carcinoma present [4]. Prostate
cancer is a common, androgen-dependent cancer. There-
fore, testosterone administration is absolutely contrain-
dicated in men with clinical prostate cancer. Some men
are diagnosed with prostate cancer less than 4, therefore
establishing a baseline is important [4]. Assessing for
prostate cancer risk is important when assessing the risks
versus benefits of testosterone therapy in symptomatic,
androgen-deficient men. Data have shown that suggest
administration of testosterone in androgen-deficient
men can produce modest incremental increase in serum
PSA levels. These increments should generally be less
than 0.5 ng/mL; increases exceeding 1.0 ng/mL over 3
to 6 months are unusual. Recommendations for moni-
toring prostate-related adverse experiences during TRT
in older men include a baseline evaluation of a digital
rectal examination, serum PSA, and an AUA symptom
score for benign prostatic hypertrophy. Also, follow-up
evaluations should occur at 3, 6, and 12 months, then
annually, with review of the previously mentioned
monitoring tools [4].

Some clinicians practice safe administration of TRT
in men by performing a prostate biopsy when there is
a clinical presentation of prostate cancer risk before pre-
scription of TRT. High-grade prostatic intraepithelial
neoplasia (PIN) has been postulated to be a precancer-
ous condition [21]. An examination of prostates
removed at radical prostatectomy for prostate cancer
revealed high-grade PIN in 86% of cases. It has been
shown that there was no increased risk of prostate can-
cer in hypogonadal men with PIN treated with testos-
terone for 1 year [21]. Continued studies must be
performed for long-term analysis. To date, no study
has definitively shown a relationship between TRT
and prostate cancer. Many providers are hesitant to treat
patients for androgen deficiency owing to fear of
increasing the risk for prostate cancer, whereas evidence
does not support this clinical precaution [21]. There-
fore, prescribers refrain from prescribing TRT to men
who suffer androgen deficiency symptoms and side ef-
fects owing to presumptions that are not evidence-
based [21].
PSA levels increase with age in men regardless of
prostate cancer status, which is why proper thorough ex-
amination and evaluation with established baselines
are such important components when considering
TRT risks versus benefits of therapy [21].
Lack of consistency regarding the prescription of TRT
for men with hypogonadism leads to provider confu-
sion. During the assessment, the provider must under-
stand the process of deciding what specific symptoms
of aging need to be addressed. Androgen deficiency
symptoms commonly affect an individual’s quality of
life and vital physiologic functions [4,6]. To restore
overall wellbeing, balancing these hormones to the
levels of a younger, more youthful, and more well self
is often the goal of HRT [4,6]. It is thought that a consis-
tent decline in testosterone occurs as a direct cause of
age; therefore, restoring testosterone levels to that of a
younger age is thought to help reduce certain age-
related signs and symptoms [4,6,12,20,21]. This has
been evident because patients have had positive physi-
ologic and psychological outcomes associated with TRT.
Because of a recent paradigm shift, it is important for
providers to be educated about the true risks of therapy
and to understand when referral to a gynecologist or
urologist is an appropriate and vital component for
safe administration of TRT [13,22].
Potential risks of TRT must be discussed with the pa-
tient and informed consent of receiving this knowledge
should be documented [13]. TRT can cause erythrocyto-
sis, which in turn can have adverse cardiovascular or
neurologic events. TRT can also cause testicular atrophy
The Latest in Cosmetic Medicine 7
and infertility. Symptoms of BPH may worsen with
therapy, although they could also improve. Acne and
other skin disorders, such as hirsutism, as well as exac-
erbation of sleep apnea, may occur with TRT [20].
Nutraceuticals and antiaging
An extensive amount of research is still required to
explore the profiles and extents of the benefits that nat-
ural compounds provide, although there is increasing
evidence that a nutritional approach provides a tool
to combat age-related diseases. Senescent cells have
been identified as the cause of organismal aging. Both
natural and synthetic compounds have been suggested
to have antisenescence activities, otherwise known as
senolytics [9]. Understanding proinflammatory signals
and prooxidant signals is important to develop man-
agement with antioxidants and antiinflammatory com-
pounds for healthier aging [9]. Polyphenol-rich foods
are one of nature’s antisenescent compounds [9]. Spe-
cific types of polyphenols have properties that not
only promote cell death of aging cells but also delay
the death of healthy tissue. Many supplements use poly-
phenol extract to produce concentrated polyphenol
with the intent of health promotion for the consumer.
Antioxidant and antiinflammatory properties of poly-
phenols reduce the risk of developing age-related dis-
ease [9].
There is evidence that polyphenols contain cardio-
protective and neuroprotective functions such as the
reduction of postprandial hyperlipemia and insulin
resistance. A reduction in glucose uptake in tumor cells
induced by certain polyphenols suggests an anticancer
effect in several human cancers [9]. Although
polyphenol-rich nutrients are a source of chemopreven-
tive, antioxidant, and antiaging properties, there are
other nutrients that have been observed and are viewed
as having similar effects on the human body. The
following descriptions explore popular forms of supple-
mentation widely available and sometimes marketed
with antiaging properties. Chemopreventive and antise-
nescent properties are the focus of properties of each
nutraceutical or supplement described [9].
Curcumin
Curcumin is a polyphenol-rich source often used in the
form of a spice. Curcumin is a root also known as
turmeric or Curcuma longa. It is an ingredient that is
often used in cooking and is one of the ingredients in
curry powder. Curcuminoids are the bioactive compo-
nents of curcumin [1,9,23]. These have been of interest
for years in chemoprevention because they can inhibit
carcinogen activation by way of cytochrome enzymes.
8 Thiry & Walden
Curcuminoids also exhibit antioxidant and antiinflam-
matory properties [1,23]. There is evidence of curcu-
min’s ability to inhibit growth of cancer stem cells;
therefore, this supplement has been hypothesized to
have the potential to act as an adjunct treatment to
conventional cancer treatments, including chemo-
therapy [1].
Curcumin is poorly absorbed by the body, therefore
making therapy a challenge [1]. Much of the available
research on curcumin focuses on the prevention of colo-
rectal cancer. The thought is that because of poor ab-
sorption of curcumin by the body, the spice has direct
mucosal contact with the colorectal tract [1,23]. Curcu-
min treatment has been seen to increase the lifespan in
some animal models. Owing to the obstacle of poor ab-
sorption of its hydrophobicity and poor oral bioavail-
ability, new strategies, such as curcumin-loaded
micelles, are being explored to improve delivery of cur-
cumin to the body [9]. An important study was con-
ducted in 2006 by Cruz-Correa and colleagues in
which participants who had familial adenomatous pol-
yposis received curcumin 480 mg and quercetin 20 mg
orally 3 times a day for 9 months. Participants had an
average decrease of polyp number by 60.4% from base-
line and the mean decrease in polyp size from baseline
with treatment was 50.9%. Additional studies must be
completed to understand the true benefits of curcumin,
although there are evident benefits of supplementation
concluded from prior research [1,9,23].
Probiotics
Probiotics have received increasing popularity for
health benefits and many patients are inquiring how
they may be of benefit. Probiotics are live microorgan-
isms found in fermented foods such as yogurt and kefir.
Probiotics are found in concentrated forms in supple-
ment products [1]. Probiotics may have chemopreven-
tive benefits for the gastrointestinal tract and are of
particular interest in preventing colorectal cancers.
Lactobacillus species are commonly provided in probi-
otic supplement capsules. Bifidobacterium is another
colonized organism that proves to have gut health ben-
efits [1]. Their mechanisms of action, which are thought
to be chemopreventive, are many. Probiotics have the
ability to alter gut microbiota and, as a result, inhibit
or induce colonic enzymes that regulate growth of
harmful bacteria, which in turn benefits immune func-
tion and stimulates active anticancer metabolite pro-
duction. Yogurt is fermented milk that breeds the
organisms used in probiotic supplements. Studies in
women have found an inverse association between con-
sumption of fermented milk and breast cancer risk [1].
The EPIC Italy study followed 45,241 adults for 12 years
and found that yogurt consumption may reduce the risk
of colorectal cancer by up to 35%. This conclusion sug-
gests a promising role for probiotic organisms and the
prevention of colorectal cancer. Trials are ongoing to
research the benefits of probiotics. The chemothera-
peutic effect has also been noted in patients diagnosed
with superficial bladder cancer. Those taking oral sup-
plementation had a higher 3-year recurrence-free sur-
vival rate [1]. Increasing evidence notes that the gut
microbiota is involved in the development of human
diseases such as obesity, metabolic syndrome, diabetes,
cardiovascular disease, cancer, and neurodegenerative
disorders, which are commonly associated with age-
related diseases [1,9].
B vitamins
B vitamins continue to be researched for their necessary
role in a person’s health status and there is evidence that
supports specific physiologic functions of B vitamins. Vi-
tamins B3 (niacin), B6 (pyroxene), B9 (folate), and B12
(cobalamin) work in a synergistic fashion as water-
soluble vitamins with proven vital roles in brain and
nerve function by supporting general metabolic function
as a mechanism of action [1]. Whole grains, dairy prod-
ucts, potatoes, legumes, and bananas, as well as fish, or-
gan meats, and poultry, are commonly consumed food
sources that contain B vitamins [1]. In the United States,
as well as many other countries, B vitamins are included
as an enrichment in flour. There is some observational
evidence that has suggested the protective role of B vita-
mins against some cancers. Vitamin B3 (niacin) protects
DNA from damage when consumed in high doses. There
are also studies that show that daily supplementation of
folic acid and vitamin B12 over 2 years resulted in a
methylation of genes associated with abnormal cell
development and carcinogenesis [1]. Vitamin B9 (folate)
originates mainly in green leafy vegetables, as well as
certain fruits, and is required for DNA synthesis and
DNA methylation. The biological roles of B vitamins
continue to be explored and it is hypothesized that
they could potentially be important in cancer prevention
[18]. The protective role of B vitamins on DNA con-
tinues to be explored, including their role in breast can-
cer because protective effects have been observed in
populations with low folate status. However, more
research is needed to develop more conclusive support
for this hypothesis [18]. A randomized controlled study
completed in New Zealand and Australia showed that
daily supplementation with vitamin B3 was associated
with lower incidence of nonmelanoma skin cancers.
Research regarding B vitamins continues to be

performed and is needed to draw more conclusions
regarding B vitamin benefits to the body’s immunologic
system and their ability to support DNA in prevention of
carcinogenic effects [18].
Diindolylmethane supplement or cruciferous
vegetables
Diindolylmethane (DIM) and indole are major bioactive
molecules of cruciferous plants known to act on enzymes
responsible for the metabolism of estrogen [24]. The
most potent dietary indole is DIM because it is the
most potent estrogen blocker associated with lowering
risk of breast cancer [24]. The cancer preventative po-
tency of DIM is under clinical investigation because of
its important role of blocking estrogen via its ability to
maintain higher levels of 2-hydroxesterolne. Higher
levels of estrogens are associated with breast, uterine,
and cervical dysplasia. DIM’s ability to reduce these spe-
cific estrogens causes a reduction in clinical presentation
of breast, uterine, and cervical dysplasia. Cruciferous veg-
etables have many other physiologic functions that are
chemopreventive. DIM supplements are widely available
and used as a chemopreventive nutraceutical [24].
SUMMARY
Patients are seeking treatment options to reduce the
signs and symptoms associated with age and age-
related diseases [2]. Antiaging medicine must continue
to be explored, streamlined, researched, and better un-
derstood by providers and patients, including
decreasing risk of age-related diseases through hormone
replacement therapies and with supplements that have
proven health benefits, [1,2,10].
As the popularity of hormonal and nutraceutical
supplemental therapies increases, it becomes increas-
ingly important for providers develop better informa-
tion sets for patients and to not allow their opinions
to obscure the facts that present the benefits and risks
of supplementation and HRT. Use of HRT and supple-
ments as a means of physiologically decreasing the ef-
fects of aging must be done with proper knowledge of
the risks versus the benefits when creating an individu-
alized plan. Using a patient-centered approach, the risk
of development of several age-related disease processes
can be reduced [1]. Although much of the research
regarding TRT focuses on treatment of men, women
also substantially benefit from treatment with testos-
terone [5,6,12].
When assessing for risk factors of age-related dis-
eases, it is important to use appropriate assessment
tools and diagnostic procedures to understand when
The Latest in Cosmetic Medicine 9
appropriate referrals must be made [11]. By building
credibility through increased education of providers
regarding evidence of the benefits of dietary and nutra-
ceutical supplements, as well as HRT, patients will start
to receive the treatment of symptoms and health issues
that have a significant impact on their quality of life
[1,13]. This article examines the multifactorial approach
to antiaging medicine with treatment using HRT and
nutraceuticals to help patients achieve an improved
quality of life, as well as decrease the risk for develop-
ment of disease process by optimizing their health
from a physiologic, evidence-based standpoint. Under-
standing signs and symptoms of aging is important
when managing a patient’s quality of life through
HRT and supplementation. Potential risks and benefits
of HRT, as well as nutraceutical supplementation, must
be postulated on a case-by-case basis for the safest, most
effective approach in management by the responsible
provider. Assessment of providers’ knowledge and op-
tions of these types of therapies as appropriate treat-
ment in men and in women must continue be
explored [1,5,6,11].
REFERENCES
[1] Sanders K, Moran Z, Shi Z, et al. Natural products for
cancer prevention: clinical update 2016. Semin Oncol
Nurs 2016;32(3):215–40.
[2] Mykytyn CE. Anti-aging medicine: a patient/practitioner
movement to redefine aging. Soc Sci Med 2006;62(3):
643–53. Available at: http://ezproxy.lib.utexas.edu/
login?url5http://search.ebscohost.com/login.aspx?direct5
true&db5cmedm&AN516040177&site5ehost-live. Ac-
cessed October 30, 2018.
[3] de Magalhães JP, Stevens M, Thornton D. The business of
anti-aging science. Trends Biotechnol 2017;35(11):
1062–73.
[4] Bhasin S, Singh AB, Mac RP, et al. Managing the risks of
prostate disease during testosterone replacement therapy
in older men: recommendations for a standardized
monitoring plan. J Androl 2003;24(3):299–311. Avail-
able at: http://ezproxy.lib.utexas.edu/login?url5http://
search.ebscohost.com/login.aspx?direct5true&db5cmed-
m&AN512721204&site5ehostlive. Accessed September
12, 2018.
[5] Maia H Jr, Casoy J, Valente J. Testosterone replacement
therapy in the climacteric: benefits beyond sexuality. Gy-
necol Endocrinol 2009;25(1):12–20.
[6] Bassil N, Alkaade S, Morley JE. The benefits and risks of
testosterone replacement therapy: a review. Ther Clin Risk
Manag 2009;5(3):427–48. Available at: http://ezproxy.
lib.utexas.edu/login?url5http://search.ebscohost.com/
login.aspx?direct5true&db5cmedm&AN519707253&si-
te5ehost-live. Accessed October 1, 2018.
10 Thiry & Walden
[7] Levens E, Williams RS. Current opinions and un-
derstandings of menopausal women about hormone
replacement therapy (HRT)-the University of Florida expe-
rience. Am J Obstet Gynecol 2004;191(2):641–6. Available
at: http://ezproxy.lib.utexas.edu/login?url5http://search.
ebscohost.com/login.aspx?direct5true&db5cmedm&AN5
15343254&site5ehost-live. Accessed August 29, 2018.
[8] Williams RS, Christie D, Sistrom C. Assessment of the
understanding of the risks and benefits of hormone
replacement therapy (HRT) in primary care physicians.
Am J Obstet Gynecol 2005;193(2):551–6. Available at:
http://ezproxy.lib.utexas.edu/login?url5http://search.
ebscohost.com/login.aspx?direct5true&db5cmedm&AN5
16098892&site5ehost-live. Accessed August 29, 2018.
[9] Gurau F, Baldoni S, Prattichizzo F, et al. Anti-senescence
compounds: a potential nutraceutical approach to
healthy aging. Ageing Res Rev 2018;46(1):14–31.
[10] Janson M. Orthomolecular medicine: the therapeutic use
of dietary supplements for anti-aging. Clin Interv Aging
2006;1(3):261–5. Available at: http://ezproxy.lib.utexas.
edu/login?url5http://search.ebscohost.com/login.aspx?
direct5true&db5cmedm&AN518046879&site5ehost-
live. Accessed September 10, 2018.
[11] Swords KE. Hormone therapy for menopausal women in
the primary care setting. J Nurse Pract 2017;13(8):562–9.
[12] Khera M. Testosterone therapy for female sexual dysfunc-
tion. Sex Med Rev 2015;3(3):137–44.
[13] Davis SR, Tran J. Testosterone influences libido and well-
being in women. Trends Endocrinol Metab 2001;12(1):
33–7. Available at: http://ezproxy.lib.utexas.edu/login?
url5http://search.ebscohost.com/login.aspx?direct5-
true&db5cmedm&AN511137039&site5ehost-live. Ac-
cessed August 28, 2018.
[14] Bitzer J, Kenemans P, Mueck AO. Breast cancer risk in
postmenopausal women using testosterone in combina-
tion with hormone replacement therapy. Maturitas 2008;
59(3):209–18.
[15] Shufelt CL, Braunstein GD. Safety of testosterone use in
women. Maturitas 2009;63(1):63–6.
[16] de Paula FJF, Soares JM Jr, Haidar MA, et al. The benefits
of androgens combined with hormone replacement
therapy regarding to patients with postmenopausal sex-
ual symptoms. Maturitas 2007;56(1):69–77. Available
at: http://ezproxy.lib.utexas.edu/login?url5http://search.
ebscohost.com/login.aspx?direct5true&db5cmedm&AN5
16822626&site5ehost-live. Accessed October 29, 2018.
[17] Svatikova A, Hayes S. Menopause and menopausal hor-
mone therapy in women: cardiovascular benefits and
risks. Revista Colombiana de Cardiología 2018;25(S1):
30–3.
[18] Chajes V, Romieu I. Nutrition and breast cancer. Matur-
itas 2014;77(1):7–11.
[19] Glaser R, Dimitrakakis C. Testosterone and breast cancer
prevention. Maturitas 2015;82(3):291–5.
[20] Traish AM. Benefits and health implications of testos-
terone therapy in men with testosterone deficiency. Sex
Med Rev 2018;6(1):86–105.
[21] Rhoden EL, Morgentaler A. Testosterone replacement
therapy in hypogonadal men at high risk for prostate
cancer: results of 1 year of treatment in men with prostatic
intraepithelial neoplasia. J Urol 2003;170(6 Pt 1):
2348–51. Available at: http://ezproxy.lib.utexas.edu/
login?url5http://search.ebscohost.com/login.aspx?direct5-
true&db5cmedm&AN514634413&site5ehost-live. Ac-
cessed August 30, 2018.
[22] Patrick Selph J, Carson CC. Testosterone replacement
therapy in men with prostate cancer: what is the evi-
dence? Sex Med Rev 2013;1(3):135–42.
[23] Vemuri S, Banala RR, Subbaiah GPV, et al. Anti-cancer
potential of a mix of natural extracts of turmeric, ginger
and garlic: a cell-based study. Egypt J Basic Appl Sci
2017;4(4):332–4.
[24] Manchali S, Kotamballi N, Murthy C, et al. Patil Crucial
facts about health benefits of popular cruciferous vegeta-
bles. J Funct Foods 2012;4(1):94–106.
 Advances in Cosmetic Surgery 2 (2019) 11–21

ADVANCES IN COSMETIC SURGERY

Sculptural Aesthetic Surface Anatomy

of the Face
Peter M. Schmid, DO, FAOCOOHNS, FAACS
Private Practice, 1308 Sumner Street, Suite 100, Longmont, CO 80501, USA

KEYWORDS
 Aesthetic surgery  Cosmetic surgery  Facial anatomy  Facial aesthetic surgery  Facial cosmetic surgery
 Facial canons  Art and science

KEY POINTS
 Artistic training emphasizes line, shape, and form in human anatomy.
 Sculpting teaches perfect practice.
 Lighting critically discloses nuances of surface form.
 Aesthetic anatomy directs cosmetic therapy.
 Comparative anatomy defines gender differences.

To capture nature, you must see and understand her.
—EDOUARD LANTERI (SCULPTOR)
INTRODUCTION: THE SCULPTOR AND
SURGEON
Cosmetic surgeons are the sculptors of human form. To
surgically alter the human face, best practices require a
profound understanding of anatomic form, function,
structural aesthetics, and harmony (Fig. 1). Complex
by design, outward appearance is fabricated by age, ge-
netics, gender, and ethnicity, which are all continuously
remodeled over time. Although cultures impart unique
biases on iconic beauty, the challenge to aesthetic sur-
gery is to appeal to the patient’s visual and emotional
needs.
An ideal training model for studying aesthetic facial
anatomy is through art education. Sculpting in clay is
a powerful discipline that trains the eye and hones
the surgeon’s visual assessment, dexterity, acumen,
and finesse to optimize one’s surgical results. It allows
the mind to create visual, tactile, and communicative
connections otherwise missed. Such training deepens
the understanding of aesthetic anatomy, its construc-
tion, and nuances of 3-dimensional facial form. It
broadens perspective and perceptions, and from sense
(the ability to recognize shapes) is translated from the
skeleton to the surface of the body. Working from the
live human model and using sculptural principles, the
facial structure is appraised by sculptural ratios, propor-
tion, symmetry, silhouette lines, angles and planes,
mass, shape, volume, form, interrelationships, distinc-
tion, and physical rhythm (Fig. 2).
Albert Einstein once stated that “after a certain level
of technical skill is achieved, science and art tend to coa-
lesce in esthetics, plasticity and form.” As such, the inte-
gration of art into science as the sculptural principles of
facial anatomy follows.
FACIAL BEAUTY AND ATTRACTIVENESS
Humans are hardwired to respond to visual images of
the human face and body, and this response is likely
linked to evolutionary ties [1]. Attractive faces possess

E-mail address: drs@iaprs.com

https://doi.org/10.1016/j.yacs.2019.02.015 www.advancesincosmeticsurgery.com
2542-4327/19/ © 2019 Elsevier Inc. All rights reserved. 11
12 Schmid
FIG. 1 Appraising facial harmony. (Ó 2019 Peter M. Schmid.)
a constellation of mature, neotenous, and expressive
facial features. Aesthetic judgments of facial beauty are
grounded in mathematical averageness, symmetry,
youthfulness, sexual dimorphism, familiarity, sizing-
up, and other specific tangibles [2]. Attractive and
youthful faces exude pleasing harmony through vibrant
skin tone, balanced volumetric fullness, and comple-
mentary features. The tissue shapes are blended into
FIG. 2 Integration of art and science. (Ó 2019 Peter M. Schmid.)
homogenous 3-dimensional curves and arrangements,
precisely layered over skeletal form, resulting in even
reflective highlights, and in some predominant light
and shadow effects portraying volumetric sculptural
aesthetic markers (Box 1).
Beauty is an order to form, a subtle synergistic
composition of geometry, proportion, volumes, and
planes. The more symmetric the face, the more attrac-
tive is its perception in both sexes. Facial beauty, how-
ever, is curiously intriguing for its subtle imperfections
and differences. Asymmetry to a millimeter or degree
creates an interest and unique aesthetic to appearance
in certain individuals.
Woman attractive beauty is outlined by flowing
curvilinear shapes and forms, whereas man attractive-
ness is framed by definition, planes, squareness, and an-
gularity. The surgeon must remain vigilant to discerning
these dimorphic discrepancies of gender-specific anat-
omy or the variations of form that occur in the typical
or the aging patient.
PHYSICAL EXAMINATION: FACIAL SHAPE
AND FORM
Facial appearance is composed of organic shapes
arising from the foundation of the cranial and facial
bones, juxtaposed by soft tissue and complementary
features. Facial characteristics should be studied like
the sculptor, by both visual inspection and soft tissue
palpation. Keen observation discerns the subtleties of
form unique onto the patient, and relevant to gender,
ethnicity, age, or the footprints of previous surgeries.
The face is initially examined as a “whole,” saving
the facial details and subcomponents for last. Facial
shape and form should be appreciated (oval, round,
oblong, heart, triangular square, rectangular diamond,
 Sculptural Aesthetic Surface Anatomy of the Face 13

analysis. The balanced face is divided into equal vertical

BOX 1 halves, by equal vertical facial fifths (note: beyond
Sculptural aesthetic markers width of skull), or by horizontal facial thirds (note:
hairline to the chin) (Fig. 6). The lower facial third
 Lateral orbital rim (f)
can be subdivided into an upper third by gauging the
 Malar eminence (f)
length of the upper lip, with the lower two-thirds
 Lip volume and shape (f) from the stomium to the mentum [3]. Artistic canons
 Temporal plateau (m) serve as objective guidelines to establish conversation
 Submalar plane (f 1 m) with the patient, educating them about their presenting
 Mandible shape and definition (f 1 m) clinical facial findings, whether asymmetries, dispro-
portions, imbalances, or attributes.
Abbreviations: f, female; m, male.
Facial Structural Platform
inverted, pear, peanut, and others) as they relate to the
The bony craniofacial armature suspending the soft tis-
shape of the neck and jawline (Fig. 3).
sues and retaining ligaments of the face imparts exqui-
Under adequate lighting, the seated patient should be
site curvilinear contour and shape. The facial framework
examined in multiperspective views, to study facial shape,
consists of integrated structural platforms, namely, the
asymmetries, apparent or virtual silhouette profile lines,
cranial, midfacial, mandibular, and nasal complexes
and volumetric distributions or imbalances (Fig. 4).
(Fig. 7).
High-contrast lighting should be used to appraise
Unique facial height and dimensions equate to
anatomic landmarks, bony prominences, facial planes,
craniofacial growth influenced by genetics and gender.
dominant reflective highlights and shadows, and under-
The woman skull and facial bones are petite, and the
lying soft tissue deficiencies, depressions, flatness, or
man counterparts are thick and robust. Defining bony
curve distortions. Soft ambient lighting exposes skin
landmarks present in both are the frontal prominence,
qualities, soft tissue discrepancies, and surface irregular-
supraciliary arch, nasal bones, malar eminences, angles
ities secondary to subtle underlying anatomic shapes
of the mandible, and the mental tubercle, each display-
and masses. Facial features are reviewed last (Fig. 5).
ing unique surface form and reflective highlights. The
The facial bones and soft tissues should be delicately
face as a unit is wide posteriorly and tapers anteriorly
palpated to assess position, densities, and deficiencies.
by curvilinear 3-dimensional form. The greatest width
Tissues should be manually repositioned to present
of the skull is at the biparietal eminence, camouflaged
proposals exemplifying restoration of form. Facial ani-
by the scalp.
mation provides insight into soft tissue dispositions,
The upper cranial platform insets within the midfacial
ptosis, and redistributions. A chronologic photo gallery
maxilla-zygomatic complex. The spherical human skull
of the patient’s aging images should be reviewed.
is interfaced with convexities, concavities, ridges, and
Communication via a mirror, computerized digital im-
planes. The woman skull by nature is 70% to 90% the
aging, and sculptural dialogue establishes commensu-
size of the man cranium [4]. The forehead of the
rate objectives and trust.
woman is vertically short and broad spanning, demon-
strating a central frontal roundness with highlights as it
Canons, Proportions, and Shape blends softly into the lateral temporoparietal regions
Canons, proportions, and the golden ratio (phi; and flows downward onto the orbital rims. The mascu-
1:1.618) provide a general reference system for facial line forehead, in comparison, often reflects 5 distinct

FIG. 3 Facial shapes. (Ó 2019 Peter M. Schmid.)

14 Schmid

FIG. 4 Three-dimensional sculptural appraisal. (Ó 2019 Peter M. Schmid.)

angulated forehead planes wrapping horizontally into
the temple zones. The paired temporal crests descend
vertically onto the lateral orbits, creating a visible
squareness contributing to the “chiseled” appearance
of the man upper face.
On profile view, the woman skull demonstrates a
vertically oriented forehead with a 7 inclination,
blending gracefully downward onto soft supraorbital
rims. The man frontal table slopes posteriorly with a
10 inclination [5,6]. Pneumatization of the frontal si-
nuses in the man skull creates a prominent supraorbital
bossing with paired, horizontally oriented highlighted
ridges over the medial lower forehead. This suprabrow
fullness masculinizes the forehead, contributing to the
appearance of a deep-set smaller eye [7]. The nasofron-
tal angle demonstrates subtle concavity in the woman
skull, or an acute angle in the man skull, possessing
larger projecting paired nasal bones.
The midfacial skeletal platform, consisting of the
zygoma and maxillary bones, imparts width and height
to the central face. The malar eminence of the zygoma
fuses with the frontal, maxillary, and temporal bones
and affords shape to the cheek and midface [8]. The
zygomatic arch extending laterally forms a horizontal
buttress interfacing the temporal fossae above and the
submalar zone below. Three paired planes course
around the anterior face from the nasofacial junction
to the preauricular zone. The midfacial bizygomatic

FIG. 5 Multidirectional lighting: underlight, direct, and overlight. (Ó 2019 Peter M. Schmid.)
 Sculptural Aesthetic Surface Anatomy of the Face 15

FIG. 6 (A) Facial halves. (B) Facial horizontal thirds. (C) Facial vertical fifths. (D) Lower facial third subdivided
thirds. (Ó 2019 Peter M. Schmid.)

distance assumes the widest dimension of the face.
Although the midfacial skeleton of the woman face is
structurally smaller than the man face, it appears pro-
portionally more prominent anterolaterally at the malar
eminences, creating a fullness and beauty to the central
face. Man cheekbones by nature appear smaller or even
depressed due to a flatter zygomatic arch and wide
lower face (Fig. 8). The woman orbits relative to the up-
per skull appear rounder, larger, and higher in compar-
ison to the squarer man orbit [8]. The vertical height of
the maxillae and dentition establishes the midfacial
proportions.
The V-shaped mandibular platform supporting the
lower third of the face is structurally the largest bone
of the facial mass. Inset beneath the midfacial platform,
the mandible is confined within to the bimalar width.
The bigonial width of the posterior jaw is narrower
in the woman, thus accentuating the overriding
cheekbone prominences. Structurally wider, the man
bigonial jawbone approximates the bimalar width
and creates a central and lower facial squareness, and
with a vertically longer and thicker ramus with larger
condyles, it lengthens the lower facial third [4].
Although the tapered woman jaw appears curvilinear
and lifted, in the man jaw, it visually imparts a stabiliz-
ing supportive platform. The masculine anterior sym-
physis is square, bulkier, and wider in comparison to
the delicate rounded woman chin [9]. On profile view
in the man, there exists a squareness to the angle of
the jaw, with a gonial angle of 90 in comparison to a
9 to 12 angulation found in the woman mandible
[10,11]. In the attractive woman, the graceful jawline
arches and overrides a distinct submandibular shadow,
serving as an important sculptural aesthetic marker. The
lower jawline edge parallels the inclination of the zygo-
matic arch, creating an aesthetic balance to the lower

FIG. 7 Structural platforms: cranial (C), maxillary (Mx), nasal (N), mandibular (Mn) complexes. (Ó 2019
Peter M. Schmid.)
16 Schmid

FIG. 8 (A) Facial structural analysis cranial view. (B) Biparietal width (black bidirectional arrow) Zygomatic
arches and width (black linear arrows), Skull tapering (oblique faint green arrows). (C) Malar 3-dimensional
projection. (D) Female midfacial. (E) Male midfacial with reduced zygoma projection. (Ó 2019 Peter M. Schmid.)

third of the face. Degrees of mandibular protrusion ef-
fect the visual balance of the face and nasal profile
silhouette lines.
The nasal osseocartilaginous platform is the keystone to
midfacial proportion and balance. Anatomically, this
vertically elongated triangular feature oriented in the
central third of the face influences spatial orientations
both “actual and illusionary” to the appearance of the
intercanthal distance, ocular depth, bimalar width, mid-
facial projection, the chin, and profile aesthetics. The
nose is constructed of subtle shapes and planes and is
individually unique in size, shape, length, and type.
Examined from multiple views, specific appraisals
should include the nasal width, dorsal height, tip pro-
jection and angulation, dorsal-to-tip ratios, and atti-
tude. The quality and thickness of the skin blanket or
express underlying osseocartilaginous form.
The aesthetic nose should be symmetric and straight,
proportionately balanced, and should subtly blend
with the face, bridging the upper and lower facial thirds.
The attractive feminine nose is smaller; the nasal tip is
refined, and the nostrils are soft and round. The nose
should display a structural smoothness with curvilinear
flow from the medial supraorbital rim to the lateral
nasal vault and complement the adjacent the facial fea-
tures. In profile, there is a sweeping profile flatness
often with an elegant soft leading tip, and a flowing S-
shaped curve on profile from the forehead to the chin.
The alar/columella shape is “gull winged” on the frontal
view.
The masculine nose is dominantly large, chiseled,
and angulated, with a fuller nasal tip and thicker skin
reflecting a rounded tip definition. Man nasal profiles
may range from a prominent hump to a straight
dorsum carrying linear reflective dorsal ridge highlights.
Favorably, the nasolabial angle approximates 100 to
110 in the woman profile and 90 in the man profile.
The ideal upper lip-to-tip projection should approxi-
mate a 1:1 ratio [12].
Facial Soft Tissue Platform
Encompassing the skeletal framework is a soft tissue
envelop comprising an interwoven arrangement of
dermal, fatty, glandular, and myofascial tissues each
 Sculptural Aesthetic Surface Anatomy of the Face
unique in consistency, thickness, and disposition.
Youth and beauty are defined by flawless radiant skin
and suspended facial volumes positioned on a healthy
bony framework. The bulk of the facial mass comprises
subcutaneous fat and temporalis and masseter muscle.
Structurally organized into layered deep and superficial
fat “compartments,” facial adipose tissue contributes
significantly to volumetric shape of the entire face
[13]. The woman by nature has abundant subcutaneous
facial fat, creating an even homogenous contour [14].
Retaining ligaments maintain soft tissue shape, vitality,
and support. Understanding compartmental fat distri-
bution guides the eye as to its influence on surface
form (Fig. 9).
Periorbital and temple zones
Orbital aesthetics comprises a framing bony orbit, the
globe, and periorbital soft tissue volumes, interfaced
with a variety of arches and curves. The lateral supraor-
bital rim in women demonstrates a sculptural aesthetic
marker by a sweeping lateral infrabrow fullness, sup-
porting a gracefully tapered and often arched brow.
This volume reflects the contributions of the orbicularis
oculi muscle, retro-orbicularis oculi and periocular fat,
and orbital rim contour [15]. The upper eye is horizon-
tally draped by an angulated upper eyelid skin and
framed above by infrabrow soft tissue fullness, thus
creating a visibly arched or hidden superior palpebral
crease, and degrees of upper eyelid exposure. Similarly,
the lower eyelid drapes the globe from below, sweeping
medially to laterally with an upward inclination
(4.1 mm in the woman and 2.1 mm in the man) as it
inserts into the lateral orbital rim [16]. This angulated
canthal tilt creates an aesthetic “almond shape” to the
woman eye. The aesthetic or youthful lower lid will
often form a vertically short 5- to 12-mm lower lid
crease, and a seamless surface flow inferiorly, blending
FIG. 9 (A) Sculptured facial anatomy, fat pads, and planes. (B) Volumes and highlights in clay. (C) Live model.
green: volumetric facial prominences and highlights. red: malar fad pad projection. (Ó 2019 Peter M. Schmid.)
17
to the lid cheek junction and onto the upper cheek plat-
form. The lower eyelid, cheek, and ogee contour are
maintained by the orbitomalar and zygomaticocutane-
ous ligaments, orbicularis oculi muscle, and lower lid
and cheek fat components [17,18].
The prominent superior orbital rim in the man con-
tributes to anatomically smaller and slitlike masculine
eye appearance. The man infrabrow eyelid skin often
drapes over the upper eyelid as a dominant oblique
linear edge, with an overlying horizontal coarse brow.
The galea fat pad and corrugator/glabellar muscles
contribute to a central fullness at the glabellar zone in
both sexes. Temple fullness, flatness, or depression re-
flects the volumetric status of the temporalis muscles
and the temporal fat pads.
Midface zone
Woman facial beauty emanates from the midfacial
zone. The malar eminences draped by volumetric fat
pads construct a visually inverted “Triangle of Beauty”
tapering downward from the bizygomatic prominences
to the chin (Fig. 10). From oblique frontal views,
healthy cheek contour extends inferiorly as flowing
ogee curves. Attractive woman faces exhibit a conflu-
ence of cheek fullness spanning the midfacial platform
from the nasofacial junction to the preauricular zone.
Cheek contour overriding the malar zones ranges
from elliptical to a crescent-shaped fullness (never
“stuck-on”). As its sweeping form flows around the
zygoma, it tapers laterally and obliquely above the pos-
terior zygomatic arch edge. The prominent cheek 3-
dimensional fullness creates a dominant curving reflec-
tive highlight peaking at the upper anterolateral cheek.
The “high cheekbone” appearance is an extraordinary
sculptural aesthetic marker, genetically found in some
[19,20].
18 Schmid

FIG. 10 Female facial aesthetics with triangles of beauty. (Ó 2019 Peter M. Schmid.)

In the attractive man with chiseled features, there ex-
ists inverted facial Trapezoids of Masculinity. Notably,
such shape spans from the bimalar width angulating
inferio-obliquely into the lateral paramental squareness
of the chin (Fig. 11). The cheek pad is broad-based su-
periorly and positioned anteromedially, with a tapering
caudal soft tissue apex that extends downward into the
lower midface. Underprojection of the man cheek cre-
ates a flatness to the malar zone. Often, the shape of
the malar complex appears skeletonized and tapers
posterolateral as a well-defined triangular form over-
lying the outline of the zygomatic arch. The man cheek
pad at times appears “stuck on,” especially with aging.
Expanding downward from the horizontal zygomatic
arch to the mandibular edge are submalar facial planes.
Within this region the densities of the parotid gland,
the masseter muscle, and deep facial fat pads exist. The
parotid glands provide volume to the preauricular zone
overlying the ascending ramus and angle of the
mandible. The masseter muscle creates an oblique sur-
face form in many, because it originates off the inferior
zygomatic arch and maxillary process and inserts inferi-
orly into the angle and lower ramus of the mandible.
This powerful contractile muscle in the man (and in
select lean women) may render a chiseled linear shadow
off its anterior muscular edge and add bulk to the bigo-
nial mandibular width. The zygomatic major muscle
extending from the malar eminence to the modiolus of
the mouth defines an oblique aesthetic line to the ante-
rior submalar zone. The buccal fat pad of Bichat

FIG. 11 Male facial aesthetics and Trapezoids of Masculinity. (Ó 2019 Peter M. Schmid.)
 Sculptural Aesthetic Surface Anatomy of the Face 19

contributes to premasseteric submalar fullness [21]. may reflect a sensual sculptural aesthetic marker of high
There is a visual aesthetic tension by the juxtaposed regard.
curvilinear shape of the midface with the chiseled angu- The chin presents in various shapes and forms,
larity of the mandibular platform. whether average, overprojected, retrognathic, square,
tapered, rounded, cleft, witchlike, or dimpled. Ideally,
Perioral complex: mouth and chin the chin should be delicate and round in the woman
Mouth appearance is a synthesis of form and function and strong and chiseled in the man. Strong chins are
unique in size, shape, and volume. The mound of the aesthetically pleasing in the man, whereas slight under-
mouth is arched, contouring the maxillary and mandib- projection and vertically aligned with the upper in profile
ular alveolar ridges and dentition. Woman lips are view are favorable in the woman. The shape of the chin
anatomically shorter and full, with length often the dis- creates a central reflective mass, the “chin pad,” anatomi-
tance between the medial limbus of the iris. In the man, cally situated as a projecting fleshy prominence at the
the upper lip is thinner and longer, with horizontal front of the chin rather than off the lower edge of the
length approximating the width of the midpupillary mandible. It typically overrides the labiomental crease,
distance. Youthful mouths maintain a lower facial which is set back 4 mm from chin profile [25]. The chin
inverted triangle of beauty from the bicommissure pad may be characteristically dimpled or cleft in some.
labial width to the chin. In contrast, the masculine
mouth reveals a masculine trapezoid lip-to-chin rela-
tionship, based ona square-shaped chin. SUMMARY
The upper lip is M-shaped and conforms to a shorter Human facial appearances are distinct complex physical
underlying W-shaped lower lip. The upper lip becomes arrangements of structural anatomy, features, and form.
aesthetically appealing by its raised and curvilinear With sculptural training, the cosmetic surgeon can
vermillion edge, which blends medially into Cupid’s advance observational skills, form sense, aesthetic judg-
bow. The upper white lip consists of 2 lateral planes ment, and intellect for 3-dimensional facial aesthetics
meeting centrally at a U-shaped concavity named the and form (Fig. 12). An artistic directive promotes per-
philtrum or “love charm.” Philtral columns extend fect practice and productive refinements in perfor-
from the base of the nose to the vermillion border as mance, applicable through the various stages of
inverted V-shaped linear ridges varying in definition analysis, planning, and delivery of cosmetic surgical
[22]. The philtral columns intersect Cupid’s bow at
the Glogau-Klein points, the 2 sites of greatest promi-
nence and a highlight point to the upper lip [23].
The vermillion edges and tubercles of the mouth
create distinct aesthetic reflective highlights and forms
of expression. The pink upper lip vermillion structurally
consists of 3 tubercles, and the lower lip consists of 2 tu-
bercles. Anatomically, the central upper lip tubercle,
bounded by the 2 lateral tubercle masses, interlocks
with the 2 horizontal tubercles of the lower lip, overpro-
jecting the lower lip by 1 to 3 mm on profile view [24].
The lower lip tubercles fused centrally as cylindrical
forms and taper laterally to rest on a lower lip shelf,
as it blends into the concavity of the oral commissures.
Two oblique soft tissue pillars formed by the depressor
muscles support the lateral lower lip, and centrally a
sublabial plane and shadow course downwards to the
mental crease. The contemporary ideal vertical upper-
to-lower lip height ratio is defined as 1 to 1.618, with
side-to-side symmetry following the same ratio. Cul-
tural beauty defies this dictum, as variable lip ratios
may reflect heightened beauty. Excessive elongation or
flatness to the upper lip is unappealing in the woman. FIG. 12 Sculpting and form sense: serenity in bronze.
Contingent upon volume, shape, and size, the mouth (Ó 2019 Peter M. Schmid.)
20 Schmid

FIG. 13 (A) Connections and translations from artistic sculpting in clay to cosmetic surgery. (B) Artistic planning
and multiperspective analysis. (C) Deliberate volumetric AFT replacement, jawline suture reshaping, and
lipectomy and lipocontouring to selectively sculpt and shape surface form. AFT, autologous fat transfer. (Ó 2019
Peter M. Schmid.)

technique. This heightened tool set can achieve the ulti-
mate goal: natural-looking results and highly satisfied
patients (Fig. 13).
Video: https://vimeo.com/293594371 Full HD:
https://vimeo.com/292786654.
REFERENCES
[1] Rhodes G. The evolutionary psychology of facial beauty.
Annu Rev Psychol 2006;57:199–226.
[2] Thornhill R, Gangestad S. Facial attractiveness. Trends
Cogn Sci 1999;3(12):452–60.
[3] Powell N, Humphreys B. Proportions of the aesthetic face.
New York: Thieme Medical Publishers; 1984. p. 15–39.
[4] Krogman W. Sexing skeletal remains. In: The human
skeleton in forensic medicine. Springfield (IL): Charles
C. Thomas; 1973. p. 112.
[5] Farkas L. Anthropometry of the head and face in medi-
cine. New York: Elsevier; 1981.
[6] Bartlett S, Wornom I, Whitaker L. Evaluation of facial
skeletal aesthetics and surgical planning. Clin Plast Surg
1991;18(1):1–9.
[7] Habal M. Aesthetics of feminizing the male face by
craniofacial contouring of the facial bones. Aesthetic
Plast Surg 1990;14(2):143–50.
[8] Hage J, Becking AG, de Graaf FH, et al. Gender-confirming
facial surgery: considerations on the masculinity and femi-
ninity of faces. Plast Reconstr Surg 1997;99(7):1799–807.
 Sculptural Aesthetic Surface Anatomy of the Face
[9] Stewart T. Attributions of sex. In: Stewart TD, editor. Es-
sentials of forensic anthropology. Springfield (IL):
Charles C. Thomas; 1979. p. 85–92.
[10] Horowitz H, Thompson R. Variations of the craniofacial
skeleton in postadolescent males and females. Angle Or-
thod 1964;34:97.
[11] Liew S. Contemporary beauty. UBM Medica e-newsletter,
Modern Medical Network; 2009. p. 84–5.
[12] Simons R. Nasal tip projection, ptosis, and supratip
thickening. Ear Nose Throat J 1982;61(8):452–5.
[13] Rohrich R, Pessa J. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119(7):2219–27.
[14] De Greef S, Claes P, Vandermeulen D, et al. Large-scale
in-vivo Caucasian facial soft tissue thickness database
for craniofacial reconstruction. Forensic Sci Int 2006;
159(1):S126–46.
[15] Codner M. Adipose compartments of the upper eyelid:
anatomy applied to blepharoplasty. Plast Reconstr Surg
2004;113(1):379–80.
[16] Whitaker L. Selective alterations of palpebral fissure form
by lateral canthopexy. Plast Reconstr Surg 1984;74:611.
[17] Nahai F. The art of aesthetic surgery: principles and tech-
niques. St. Loius (MO): Quality Medical Publishing Inc;
2005.
21
[18] Rohrich R, Arbique GM, Wong C, et al. The
anatomy of suborbicularis fat: implications for perior-
bital rejuvenation. Plast Reconstr Surg 2009;124(3):
946–51.
[19] Swift A, Remington K. Beautification: a global approach
to facial beauty. Clin Plast Surg 2011;38(3):347–77.
[20] Hinderer U. Malar implants for improvement of the
facial appearance. Plast Reconstr Surg 1975;56(2):
157–65.
[21] Stuzin J, Wagstrom L, Kawamoto HK, et al. The anatomy
and clinical applications of the buccal fat pad. Plast Re-
constr Surg 1990;85(1):29–37.
[22] Sarnoff D, Gotkin R. Six steps to the “perfect” lip. J Drugs
Dermatol 2012;11(9):1081–8.
[23] Goodman G. Duckless lips: how to rejuvenate the older
lip naturally and appropriately. Cosmet Dermatol 2012;
25(6):276–83.
[24] Ricketts R. Esthetics, environment, and the law of lip
relation. Am J Orthod 1968;54(4):272–89.
[25] Iblher N, Kloepper J, Penna V, et al. Changes in the ag-
ing upper lip-a photomorphometric and MRI-based
study (on a quest to find the right rejuvenation
approach). J Plast Reconstr Aesthet Surg 2008;61(10):
1170–6.
 Advances in Cosmetic Surgery 2 (2019) 23–27

ADVANCES IN COSMETIC SURGERY

Tricks for Patient Retention for

Maintenance Care
Kavita Mariwalla, MD
Mariwalla Dermatology, 1253 Montauk Highway, West Islip, NY 11795, USA

KEYWORDS
 Patient retention tactics  Loyalty programs  Discount programs  Patient communication strategies

KEY POINTS
 Patient retention is the key to the success of an aesthetic practice.
 Encouraging patients to continue maintenance treatments can be more difficult than it seems.
 There are some common strategies that have proven themselves over time, namely, loyalty programs, bundling
procedures, and discount events.
 Not all patient retention needs to involve a decreased dollar value off services.
 Consistent communication, aesthetic ambassadors, and creating a welcoming environment can also make patients want
to return.

NATURE OF THE PROBLEM appointments come from existing patients. The

It is widely known that for a procedure such as botuli-
num toxin injections, patients return on average 1.4
times per year [1]. Understanding that the toxin typi-
cally has a duration of action of 90 days, that leaves a
gap in the 4 treatments per year expectation. It begs
the question, what is preventing these patients from
coming back? Or to change the reference, what can a
practice do to encourage their return? The underlying
issue most aesthetic practices face is how to retain and
encourage patients to continue maintenance care. This
becomes more complicated when the procedure done
has a longer duration of action. However, there are
ways to continue to pique patients’ interest and
encourage them to return to the office not just for repeat
treatments but also to explore new treatments as they
age.
Acquiring leads is the start to building any
aesthetic practice; however, failure to retain existing
patients can be devastating. According to practice-
builders.com [2], studies have shown that 68% of
same website cites that 12% to 15% of patients
who are faithful to a single practice represent 55%
to 70% of appointments. Losing a patient wastes 7
times the resources used in converting a lead to a
patient.
If the goal is to encourage patient loyalty,
one must remember that the key to loyalty is patient
satisfaction. According to the Technical Assistant
Research Programs, if 1 customer is satisfied, the in-
formation reaches 4 others. If 1 customer is alienated,
it spreads to 10 customers, or even more if the prob-
lem is serious. Therefore, if 1 customer is annoyed, 3
other patients will need to be satisfied just to stay
even.
Assuming the results of any procedure performed
met expectations, the next step to patient satisfaction
is making the person feel valued. One way to demon-
strate this is through appreciation or tokens of gratitude
for being loyal which can, in turn, engender repeat
visits. There are many ways to accomplish this. Loyalty

E-mail address: kavita.mariwalla@gmail.com

https://doi.org/10.1016/j.yacs.2019.02.014 www.advancesincosmeticsurgery.com
2542-4327/19/ © 2019 Elsevier Inc. All rights reserved. 23
24 Mariwalla
programs, discount programs, and bundled purchases
are easy-to-implement ways to enhance patient reten-
tion for maintenance care. In this article, the author re-
views these options as well as the pros and cons for
each.
 Loyalty programs
 Loyalty programs are the most common method
used by practices and even cosmetic companies
to drive repeat business.
- In this model, patients receive points or have
to spend a certain amount of money in order
to get a discount.
- There are some national programs that prac-
tices should participate in because patients
may ask for them by name, and more impor-
tantly, these programs are at no cost to the
practitioner.
 Two such programs are Brilliant Distinc-
tions, which encourages patients to stay
within the Allergan suite of injectables,
and ASPIRE, which promotes Galderma
products.
 How they work: Depending on what the
patient buys, they are eligible for points,
which they can use for future discounts
on products in that suite of offerings. For
example, $500 in Botox can result in $15
in discounts for a repeat Botox or any Juve-
derm injection if using Brilliant Distinc-
tions. This discount is then reimbursed to
the practice.
 The disadvantage to these programs is that
they are somewhat cumbersome to admin-
ister because often times patients register
for them with an e-mail address they do
not remember. Also someone is needed
who can register the patient for these re-
wards and then remember to ensure that
rebate checks for discounts passed to pa-
tients are recouped by the practice from
the company (which is why this is no
cost to the practice). This can be time
consuming, and if trying to register a new
patient to the program, the checkout pro-
cess for other patients can get backed up.
- The practitioner can offer their own loyalty
program, which can take several forms, as
follows:
 A card, which results in an automatic dol-
lar value discount after a certain amount is
spent.
 This card can be printed in house on
thick paper stock or even as a “credit
card” printed on plastic.
- Several companies print such
customized plastic membership
cards, which can be branded to the
practice.
 A standard discount that is given to
anyone who spends over a certain amount
per year
 The cautionary tale here is that if pro-
cedures are discounted outright for
repeat customers, the practitioner runs
the risk of eventually driving down
their own price permanently.
 A discount for a person for a repeat pro-
cedure if they bring in a friend for a similar
procedure (thus potentially getting an
additional patient)
 An alternate option to a broad loyalty program is to
consider procedure-specific targeting.
 For example, if patients do not return 3 to 4 times
per year for toxin injections (most do not),
consider an “Early Buyer’s Club.” In other words,
the patient pays in advance for 3 treatments to be
performed in a year and the last treatment will be
30% off. The result is that the net discount is 10%
per treatment, but the advantage is a doubling of
the average repeat rate for treatment (average is
1.4 treatments per year).
 For large procedures, instead of a discount, offer
an additional less expensive treatment at
6 months after the procedure is completed that
is in line with what they have already spent. For
example:
- If a patient completes a series of laser hair
removal treatments, offer a chemical peel
6 months later at no cost.
 The net cost to the practitioner will be
minimal, but it will entice the patient to re-
turn for their “free treatment” and will give
the practitioner another touch point to
introduce them to a different service the
practice offers.
- If a patient has done a radiofrequency tight-
ening treatment, at the 1-year mark, offer a
20% discount on a toxin treatment. Although
this may seem like a deep discount, remember
that this patient has already spent a consider-
able amount in the practice and therefore may
be willing to spend money on additional,
 Tricks for Patient Retention for Maintenance Care
more expensive treatments once introduced
to them.
 Loyalty programs can also be combined with ser-
vices from other local health and wellness vendors.
 For example, if there is a popular gym or fitness
class center in the area, it may be worthwhile to
offer a small discount on services for anyone
who is a member of that gym or center.
 Alternately, approach a local gym or fitness center
and ask if they will offer a sample class or free 1-
month membership to a patient who has done a
body-contouring service (most fitness centers are
also always looking to attract new clients).
 Similarly, if there is a popular bridal salon in
town or event planner, it may be beneficial to
offer a discount to mothers of the bride or the
brides themselves as a way to attract new patients
and create a loyal referral source for the practice.
- As part of this package, offer the bride a free
service for a certain dollar value on their wed-
ding anniversary for the first 3 years.
DISCOUNT PROGRAMS
 The most common discount program is “Friends
and Family,” whereby a standard discount is given
to all family members of employees.
 Depending on the size of the practice, this can be
a sizable expense; however, there are ways to
administer this. One can limit the definition of
family to nuclear family (so no cousin’s cousin).
Another option is to limit the time of year these
discounts can be used so the discounted proced-
ures do not take up time slots during busy times
of year.
 Offer employees a “golden ticket” on a yearly ba-
sis. They can give this ticket, which is for a specific
procedure or carries a specific dollar value, to 1
person of their choosing.
 This kind of program does improve employee
morale but also engenders loyalty among their
family members, who can in turn encourage
others to visit the practice because of their good
results.
 Live-learning programs
 A monthly or quarterly educational program
featuring the physician is a good way to teach pa-
tients about procedures, especially lasers, and can
be an avenue to encourage patients to return to
the practice for learning without feeling pressure.
- At this information session, discounts can be
offered if patients treat more than 1 area or
25
book more than 1 treatment at the time of
the meeting.
- Consider offering a passport program that re-
wards patients for returning to these live
learning sessions with a giveaway after
attending a certain number of them.
 Seasonal specials
 Seasonal specials are quite popular; however, if
seasonal specials occur at regular intervals, the
practice can end up cannibalizing their own pa-
tients because the patient will just wait until the
next promotion before booking a service, which
can result in consistently discounted procedures.
 If the practice chooses to go with seasonal spe-
cials, the specials should be very specific. In other
words, instead of a standard percent discount off
a procedure, offer a discount on lip filler around
Valentine’s Day if toxin is purchased in the
month of December.
 Milestone events
 A simple birthday coupon for patients offering a
standard dollar amount off of cosmetic proced-
ures is also an excellent way to keep patients com-
ing back.
- An e-mail program tied to the patient data-
base can be configured to send out these
birthday wishes the day before the start of
every month, and patients have that particular
month to redeem the coupon.
- Be aware of aesthetic patients who may be
celebrating a milestone event, such as a 50th
birthday; consider a free birthday gift with
purchase in addition to the standard coupon.
 Consider a month-long bridal skin boot camp or
even a mother-of-the-bride boot camp.
- Map the timeline out visually and post this in
the waiting area or even create a beautiful
album showcasing brides from the practice
so that patients can be reminded that, when
they reach such a milestone, the practice is
available to help them look their best.
BUNDLED PURCHASES
 Bundling purchases is a good way to ensure patients
not only maintain results but also continue to return
for additional services.
 Ideally, bundling occurs with 2 “like” services.
 Summer is typically a slower month for laser proced-
ures; however, summer may be the ideal time to
offer maintenance treatments at a discount if a laser
procedure is done in the fall.
26 Mariwalla
 In other words, if an intense pulsed light is
performed in the fall, offer a spring refresher
facial or a discount on sunscreen for the summer.
Not only will this keep patients in a routine but
also could potentially improve their results.
 If a body-sculpting treatment is done in the fall, consider
a discount for laser hair removal for a small area, such as
armpits, to make sure they are “summer ready”.
 Create a communication platform to reach out to pa-
tients at a specific interval after a procedure is done.
 For example, a year after Ultherapy, reach out to pa-
tients to make sure they are still satisfied with their
results and discuss a repeat treatment at a discount.
Do not think of maintenance as simply procedure
based. Consider skincare as well. For example, if dur-
ing a consultation a patient is given a sample of
product, offer them a 10% discount if they return
the empty sample and decide to buy that product.
It gives them incentive to actually try the sample
and to return. Obviously, limit the samples!
 Depending on how much a patient purchases, include
a gift with purchase, which can be a lip plumper (which
you do not necessarily have to have as part of your
normal inventory) or a bag (often available from the
cosmeceutical companies themselves).
 Organize a once a year cosmeceutical discount event.
Do not do this at regular intervals; otherwise, all
products are permanently discounted. At this once
a year event, offer a substantial discount, like 20%
on all products purchased.
- If this becomes an annual event, patients will
look forward to it and plan on buying accord-
ingly and will return to the practice for their
purchases.
- Limit the number of any 1 product a person can
buy to avoid someone buying 20 of 1 thing and
then reselling them later online.
 Consider a box-style subscription program. For a fixed
dollar amount over a 12-month period, patients can
come in and pick up products appropriate for each
season. For example, for $X, patients can stop in after
March 21 for a specific moisturizer; after June 21, for a
specific sunscreen; after September 21, for a retinol;
and after December 21, for an antiaging product. By
coming in seasonally, patients can then be exposed
to appropriate materials, highlighting procedures
that are particularly useful for that time of year.
Although this article so far has focused on dis-
counts, bundling, and loyalty programs, there are
ways to maintain patient loyalty without decreasing
the dollar value of any service offered. This involves
communication, as follows:
 Intake questionnaire
 The cosmetic questionnaire can be as cumber-
some or as streamlined as the office wants.
 Regardless of how many questions are in this
questionnaire, there are data that may not be
considered part of their treatment.
- Consider the inclusion of soft data that will
help you target your marketing efforts.
 For example, make sure to collect zip codes of
patients to help with targeted e-mailing via
online social media apps like Facebook (not
just home zip codes but also work zip codes).
 Ask patients about their occupation and
consider events such as nurse appreciation
events or teacher appreciation events if you
find you have a critical number of patients
in this demographic.
 Ask patients if they belong to any “mom
groups” on Facebook.
 Many of these groups will allow adver-
tising of a business on certain days of
the week, which can help you target
your patient demographic.
 Follow-up communications
 After any cosmetic service, patients should be
contacted 3 days later and again 10 days later.
 Patients should not receive more than 12 e-mail
communications per year from the office because
this can be overwhelming.
 According to practicebuilders.com, practices that
communicate with their patients 10 times per
year have 300% more profit than those that lost
contact with patients.
 Schedule follow-up visits
 In a study by White and colleagues [1], patients
who did not have a mandatory follow-up visit af-
ter neurotoxin injection had a 55% retention rate.
Once a mandatory 2-week follow-up posttreat-
ment evaluation visit was instituted, that reten-
tion rate went up to 67%.
 Create a welcoming environment
 By cultivating a clean and aesthetically pleasing
office environment, patients will want to return,
having gained trust in the totality of their treat-
ment experience.
 This welcoming environment can include a small
bottle of water at check-in along with a practice-
branded napkin.
 Tricks for Patient Retention for Maintenance Care
 Healthy snacks can be offered for patients who
are waiting for their appointment more than
15 minutes.
 Cosmetic ambassadors can be hired, whose job it
is to remember patients and look through charts
the day before to make notes on the day sheet so
at checkout the receptionist is cued to ask friendly
questions.
- For example, how is your son XXX, or
how was the college reunion? The key of
course is to keep such notes in the patient
chart.
SUMMARY
Ultimately, patient retention tactics are not just helpful
to grow an aesthetic practice but are critical for practice
success. Implementing ways to retain patients for main-
27
tenance care can involve the creation of programs that
reward dollars spent, loyalty for repeat treatments, and
bundling of packages. However, in addition to tangible
surprises like these for patients, low-cost strategies like
e-mails and a concerted communication campaign can
help. Losing an existing patient not only wastes the effort
spent in converting a lead to a patient but also can erode
the foundation a practice is built on.
REFERENCES
[1] White L, Tanzi EL, Alster TS. Improving patient retention
after botulinum toxin type A treatment. Dermatol Surg
2006;32(2):212–5.
[2] Available at: https://www.practicebuilders.com/blog/8-
proven-patient-rentention-strategies-that-work/. Accessed
January 12, 2019.
 Advances in Cosmetic Surgery 2 (2019) 29–40

ADVANCES IN COSMETIC SURGERY

Surgical Site Infections in Cosmetic

Surgery
Emily A. Spataro, MD
Division of Facial Plastic and Reconstructive Surgery, Washington University School of Medicine, 1020 North Mason Road, Building 3, Suite
205, Creve Coeur, MO 63141, USA

KEYWORDS
 Surgical site infection  Cosmetic surgery  Plastic surgery  Evidenced-based medicine  Wound complications

KEY POINTS
 Surgical site infections occur at a lower rate in cosmetic surgery than in general surgery; however, surgical site infections
can still be a major source of morbidity for patients.
 Prevention of surgical site infections includes identifying factors that place patients at risk for infection, as well as
implementing evidence-based guidelines shown to decrease the incidence of surgical site infection.
 Owing to the heterogeneity of cosmetic surgery procedures, cosmetic surgeons should be familiar with the current
literature and clinical practice guidelines for each procedure they routinely perform.

INTRODUCTION or within 90 days if prosthetic material is implanted [3].

It is estimated that more than 1.5 million cosmetic sur-
geries were performed in the United States in 2017, and
this number is far larger worldwide [1]. Surgical site
infections (SSIs), although occurring with a lower
incidence in cosmetic surgery patients than in general
surgery inpatients, can still be a major source of
morbidity and even mortality in this patient popula-
tion. This argument is especially true because most of
these patients are healthy, and infection is considered
by some as a catastrophic consequence in the cosmetic
surgery population [2]. Therefore, the prevention of this
complication includes identifying factors that place pa-
tients at risk for SSIs, as well as implementing evidence-
based guidelines shown to decrease the incidence of SSI.
Background
SSIs are defined by the Centers for Disease Control and
Prevention (CDC) as infections at or near the surgical
site occurring within 30 days of an operative procedure,
Currently, the rate of SSI for inpatient procedures is esti-
mated between 2% and 5%, and up to 60% of SSIs have
been estimated to be preventable through implementa-
tion of evidence-based guidelines [3]. The incidence of
SSIs are monitored by the CDC’s National Healthcare
Safety Network as well as the National Surgical Quality
Improvement Program [4]. Additionally, the Centers for
Medicare and Medicaid Services require hospitals to re-
ports SSI rates, which are then publicly available on
their web site [4]. Risk factors for SSI include both pa-
tient and procedural factors, such as age, tobacco use,
diabetes, body mass index (BMI), emergency surgery,
duration of the procedure, and wound class [3].
Although some of these factors cannot be changed,
SSIs can be reduced by targeting modifiable factors
through the implementation of evidence-based guide-
lines. This goal is accomplished by implementing SSI
data tracking and providing feedback, improving the
safety culture of institutions, and developing checklists

Financial Disclosure: The author has nothing to disclose.

E-mail address: emily.spataro@wustl.edu

https://doi.org/10.1016/j.yacs.2019.02.010 www.advancesincosmeticsurgery.com
2542-4327/19/ © 2019 Elsevier Inc. All rights reserved. 29
30 Spataro
or guidelines shown to reduce infection rates. For
instance, the Agency for Healthcare Research and Qual-
ity designed an intervention that systematically incor-
porated the World Health Organization surgical
checklist, as well as methods to improve the safety cul-
ture of participating institutes, and were able to reduce
the SSI rate by 16% between 2010 and 2015 [4].
SUMMARY OF CURRENT GUIDELINES
Both the CDC and World Health Organization have
recently updated their evidence-based recommenda-
tions and guidelines regarding SSI prevention [5,6]. A
summary of these findings include that patients should
shower or bathe with soap (either plain or antimicro-
bial) or an antiseptic agent at least the night before
the operation; however, there is no evidence to support
chlorhexidine gluconate wash as being superior in pre-
venting SSI. Decolonization for Staphylococcus aureus
with mupirocin is only recommended for cardiotho-
racic and orthopedic operations, but may be considered
for other procedures. Antibiotic prophylaxis should be
given when indicated based on published clinical prac-
tice guidelines and timed such that the bactericidal con-
centration is established in the tissues before making an
incision. Hair removal should be done with clippers
only, because shaving is strongly discouraged at all
times, whether preoperatively or in the operating
room. Skin preparation should be done with an
alcohol-based agent unless contraindicated, and there
is a recommendation against using antimicrobial seal-
ants after surgical site skin preparation. Preoperative
hand scrubbing can either be performed with antimi-
crobial soap or an alcohol-based hand scrub. For clean
and clean-contaminated procedures, additional pro-
phylactic antimicrobial agent doses should not be
administered after the surgical incision is closed in the
operating room, even in the presence of a drain. There
is no evidence regarding whether different types of ster-
ile drapes/gowns are better at preventing SSI, and there
is insufficient evidence for saline wound irrigation.
However, iodine irrigation may help, and antibiotic irri-
gation was shown not to help decrease SSIs. Negative
pressure dressings do help to decrease SSI in high-risk
wounds. No recommendations could be made
regarding changing surgical gloves or instruments dur-
ing the procedure. Finally, there was a recommendation
against the use of topical antibiotic agents applied to
surgical incisions [5,6].
Additionally, there is a recommendation to admin-
ister nutrient-enhanced formulas for underweight pa-
tients undergoing major operations and to not
discontinue immunosuppressive medications. During
surgery, glycemic control should target blood glucose
to less than 200 mg/dL, normothermia should be main-
tained, and an increased fraction of inspired oxygen
should be delivered, both during the procedure as
well as in the immediate postoperative period in pa-
tients with normal pulmonary function. Last, the trans-
fusion of blood products should not be withheld to
prevent SSI [5,6].
SURGICAL SITE INFECTIONS IN PLASTIC
SURGERY
SSI rates tend to be lower in cosmetic surgery proced-
ures than for the general surgery inpatient procedures
owing to a lesser number of comorbidities in these pa-
tients, as well as the outpatient nature of these proced-
ures [4]. However, reported SSI rates of various cosmetic
surgery procedures vary widely within the literature,
depending both on procedure type, as well as method
of recording incidence of SSI, such as institutional chart
review or database use. For instance, 1 study of SSI in
breast surgery and abdominoplasty used 2 different da-
tabases: the Tracking Operations and Outcomes for
Plastic Surgeons (TOPS) database and the CosmetAs-
sure database [7]. The TOPS database is a self-reported
plastic surgery database that captures SSI treated in the
office, compared with the CosmetAssure database,
which is based on insurance claims for cosmetic proced-
ures and only captures infections requiring hospital or
emergency readmission, or a subsequent procedure,
thus, including only major SSIs. Therefore, SSI rates
were not only different between the 2 procedures, but
also between the 2 databases used: for abdominoplasty,
a 3.5% SSI rate was found in the TOPS database and a
0.7% SSI rate was found in the CosmetAssure database;
for breast surgery, a 0.3% SSI rate was found in the
TOPS database, and a 0.1% SSI rate was found in the
CosmetAssure database. Thus, the infection rate was
greater not only for abdominoplasty, but also with
use of the TOPS database, because it captured more mi-
nor infections [7].
As demonstrated, the incidence of SSI in the litera-
ture varies significantly by procedure. The literature
regarding breast augmentation has reported SSI rates
between 0.001% and 7.000%; breast reduction between
0.11% and 22.00%; abdominoplasty between 0.16%
and 32.60%; and body lift between 3% and 25% [8–
31]. Rates of SSI using the CosmetAssure database for
these same procedures were 0.2%, 0.5%, 1.0%, and
1.9%, respectively [32]. There were also very low infec-
tion rates for liposuction and facelift, both occurring at

a rate of 0.1%, which is comparable with the literature
reporting an incidence of less than 0.3% for both pro-
cedures [31–36].
Factors contributing to wound infection include pa-
tient factors, anesthetic factors, and surgical factors [37].
Patient factors include diabetes, tobacco use, malnutri-
tion, chronic renal failure, alcohol use, jaundice,
obesity, age, poor physical condition, medication, and
chemotherapy or radiation exposure. Anesthetic factors
include tissue perfusion, volume status, body tempera-
ture, blood oxygen tension, pain, and blood transfu-
sion. Surgical factors include wound classification,
skin preparation, surgical site, procedure duration, pro-
cedure complexity, suture material, the presence of a
foreign body or implant, suturing quality, preexisting
infection, antibiotic prophylaxis, occurrence of hema-
toma, and mechanical stress on the wound [37]. These
factors may lead to decreased collagen synthesis (gener-
ally patient factors), increased vasoconstriction (both
patient and anesthetic factors), and increased immuno-
suppression (all factors), which then causes decreased
wound tensile strength, as well as decreased neutrophil
bactericidal activity and lowered tissue oxygenation, all
contributing to wound infection [37]. Large, multi-
center studies established factors affecting SSI rates in
clean surgery to be age, BMI, preoperative shaving, sur-
gical drains, perioperative antibiotics, preoperative skin
decolonization, perioperative hypothermia, and nico-
tine use [38,39]. Likewise, risk factors associated with
SSI using the CosmetAssure database analyzing
129,007 patients found an increased risk of SSI with
advanced age, female gender, BMI, smoking, a hospital
or ambulatory surgery setting, and trunk and extremity
procedures, as well as combined procedures after multi-
variable analysis [32].
In addition to determining rates of SSI and associ-
ated risk factors, the usefulness of systemic antibiotic
prophylaxis in plastic surgery has also been investi-
gated. A systematic review regarding the use of anti-
biotic prophylaxis to prevent SSI in plastic and
reconstructive surgeries concluded that systemic anti-
biotic prophylaxis was recommended for clean breast
surgery and contaminated surgery of the hand or head
and neck, but not recommended to reduce infection
in clean surgical cases in hand, skin, head and neck,
or abdominoplasty [40]. Additionally, there was hetero-
geneity regarding types and doses of antibiotics used, so
recommendations could not be made regarding
optimal antibiotic type or dose, because each study
included a single dose of antibiotic preoperatively, but
all had variable antibiotic durations postoperatively
[40]. Many referenced studies showed no benefit from
Surgical Site Infections in Cosmetic Surgery 31
longer term antibiotic prophylaxis [41–45]. This
finding was also reflected in another systematic review
of antibiotic prophylaxis in plastic and reconstructive
surgery procedures, with evidence supporting that anti-
biotic prophylaxis decrease postoperative SSI in clean
plastic surgeries with high-risk factors and clean-
contaminated plastic surgeries only. A short course
administration regimen was adequate; however, there
remains a need for more high-quality prospective trials
on larger scales to further confirm these findings [46].
EVIDENCE-BASED RECOMMENDATIONS
FOR THE PREVENTION OF SURGICAL SITE
INFECTIONS IN PLASTIC SURGERY
A 2015 systematic review by Dauwe and colleagues
[37], regarding SSI prevention recommendations for
facelift surgery, used data from studies of clean surgery
owing to a lack of studies pertaining specifically to face-
lift. Because these recommendations were drawn from
clean surgeries, and most cosmetic surgeries fall into
this category, most recommendations can be applied
to cosmetic surgery procedures in general. Decoloniza-
tion recommendations include routine presurgical
showering; however, the use of chlorhexidine or iodine
was not shown to decrease SSI risk. Although an
alcohol-based chlorhexidine surgical preparation is
generally recommended, this study recommends para-
chlorometaxylenol for facial surgical preparation to
avoid the ocular toxicity and ototoxicity of chlorhexi-
dine; however, ophthalmic iodine paint can also be
safely used to avoid toxicity [37]. Patients should be
screened preoperatively with nasal swabs for S aureus
colonization, and S aureus carriers should be treated
with preoperative intranasal mupirocin to reduce risk
of S aureus SSI [37]. Antibiotic recommendations
include a single dose of preoperative antibiotic admin-
istered within 1 hour of surgical incision (or 2 hours for
vancomycin or a fluoroquinolone), with cefazolin as
the first-line agent for all clean procedures (clindamycin
for patients with a beta-lactam allergy) and vancomycin
for those with methicillin-resistant S aureus risk factors,
and to discontinue prophylactic antibiotics within
24 hours of surgery [37].
Additionally, perioperative hypothermia should be
prevented to reduce risk the of postoperative SSI, and
surgeons should consider not operating on patients
who cannot abstain from nicotine use, because all nico-
tine products should be stopped 4 weeks before and
continued abstinence should extend to 4 weeks after
surgery. The use of a preoperative urine nicotine test
may be used to assess compliance with smoking
32 Spataro
abstinence [37]. Postoperative monitoring recommen-
dations include a thorough examination of all inci-
sions, even in the late postoperative period, because
delayed atypical infections have been described. Imme-
diate initiation of antibiotic therapy should occur with
the observation of erythema or other signs of infection,
and treatment with empiric antibiotics should cover
skin flora, especially methicillin-resistant S aureus,
even in patients without risk factors. Finally,
wounds should be surgically drained and debrided of
infected or devitalized tissue, and fluid or tissue
removed from the wound cultured for directed anti-
biotic treatment [37].
PROCEDURE-SPECIFIC SURGICAL SITE
INFECTION PREVENTION
As stated, the incidence of SSI in the literature varies
both by study methodology, as well as type of proced-
ure performed. Understanding the presentation, risk
factors, and prevention recommendations for SSI in
each surgical procedure is important toward reducing
their incidence. Herein, the literature regarding SSI for
each of these procedures is discussed individually.
Breast surgery
Breast surgery includes both cosmetic breast reduction
and augmentation, as well as reconstruction after mas-
tectomy. SSIs associated with breast surgery may occur
either in the acute postoperative period or much later,
and most infections are caused by gram-positive organ-
isms [47]. Acute infections are usually associated with
fever, breast pain, erythema, and drainage, whereas
late onset infections may present with chronic pain,
persistent drainage, failed healing of the incision site,
or migration of the implant [47]. In 1 study, the rates
of early and late onset SSI was 1.7% and 0.8%, respec-
tively, and more recent studies show a similar distribu-
tion of early and late onset infections, but with slightly
lower percentages [48–50]. Diagnosing SSI is usually
clinical and, when suspected, patients should be started
on empiric intravenous or oral antibiotics depending
on infection severity and closely monitored for signs
of improvement, followed by culture-directed therapy
[47]. However, implant removal is often necessary,
especially in patients worsening on empiric antibiotics,
showing signs of systemic toxicity, or who have
cultures showing atypical mycobacteria or fungal
infections [47].
Postmastectomy implants are associated with a
higher risk of infection compared with cosmetic breast
augmentation implants [47]. Studies have shown that,
for breast reconstruction after mastectomy, axillary
node dissection, and chemotherapy or radiation, pa-
tients are at up to 10 times higher risk of SSI than for
cosmetic breast surgery [10,51–54]. Infection was
shown to be less likely to occur with delayed implant
placement (2-stage surgery) [48,55]. Other risk factors
include obesity, diabetes, renal failure, active skin disor-
ders, and tobacco use [56,57]. The assessment of surgi-
cal factors have shown no difference between silicone
and saline implants, but the use of acellular dermal ma-
trix is associated with higher infection rates compared
with submuscular reconstruction, and the use of
drains have variable results on SSI rates [11,58,59].
Late onset SSI is thought to occur from seeding of
implants from remote sources [47]. Treatment generally
requires implant removal, antibiotics for 10 to 14 days,
and some advocate delayed reimplantation by 4 to
6 months [47].
A literature review regarding SSI prevention in breast
implant surgery shows there is support for the use of
perioperative antibiotics in implant-based breast recon-
struction, with extended coverage for high-risk patients
[60]. In a metaanalysis of randomized, controlled trials,
the use of antibiotics in clean breast surgery compared
with no antibiotics showed an odds ratio for SSI of
0.16 (95% confidence interval, 0.04–0.61), or 94 fewer
infections per 1000 patients [40]. Regarding the postop-
erative use of antibiotics, a retrospective review of 353
patients undergoing breast surgeries received either pre-
operative antibiotics, or both preoperative and postop-
erative antibiotics, reported a 7.8% overall rate of SSI,
with no difference in SSI rate per group. Therefore, the
use of postoperative antibiotics for non–high-risk pa-
tients was not advocated [61].
Other methods to decrease SSI in breast surgery
include laminar air flow in the operating room, mini-
mizing operating room traffic, shorter duration of oper-
ative time, washing the implant pocket before
placement, double gloving, and conductive warming
of the patient [60]. There is no evidence that implant
type, surgeon experience, or incision site affects the
SSI rate [60]. Additionally, there are varied results
regarding S aureus screening and treatment, but because
this is the most common pathogen cultured from these
infections, a recommendation was made for S aureus
screening with appropriate treatment of carriers preop-
eratively [60].
Abdominoplasty
The infection rates for abdominoplasty have been
shown to vary between 0.16% and 32.6% [25–27]. A
study of SSI in abdominoplasty from a self-reported

plastic surgery database, the TOPS database, showed a
3.5% rate of SSI [7]. In another study using the Cosme-
tAssure database, postabdominoplasty infection
occurred at a rate of 1.1% [62]. Risk factors for compli-
cations included male sex, age greater than 55 years,
BMI greater than 30, multiple procedures, or hospital/
surgical center location compared with an office-based
procedure [62]. Other studies have also shown
increased rates of complications for abdominoplasty
in obese patients, in particular wound complications,
seromas, and venous thromboembolism [63–65].
Smoking has been shown to increase wound complica-
tion and infection rates in abdominoplasty as well. One
study evaluating 132 abdominoplasty patients, of
whom 53.8% smoked, found a 48.9% wound compli-
cation rate in smokers compared with a 14.8% rate in
nonsmokers [26]. Likewise, Araco and colleagues [66],
found a 12-fold increase in infectious complications
in smokers undergoing abdominoplasty. Other poten-
tial risk factors for increased SSI rate in abdominoplasty
such as age, sex, and diabetes, have shown more vari-
able results in the literature [62].
Liposuction
Infection rates in liposuction are generally very low,
occurring in less than 1% of cases, especially when
not combined with other procedures [33,67–69]. It is
thought that the most common cause of SSI is the pres-
ence of a hematoma in the subcutaneous tissue, result-
ing in secondary bacterial contamination [68]. The
most common bacteria cultured in liposuction SSIs
are S aureus, Group A Streptococcus, and S pyogenes
[70–72]. Postliposuction infections are often difficult
to diagnose because they often have an indolent course,
but localized wound infections can progress to necro-
tizing fasciitis with very serious outcomes [71–77].
Thus, if an infection is suspected, antibiotic therapy
against these pathogens should be initiated. When
analyzing risk factors for major complications after
liposuction, higher rates were found with combined
procedures (greatest risk factor), age, BMI, and perfor-
mance in a hospital setting [78]. Infection occurred at
a rate of 0.1% in this study, and only an increased
BMI was associated with SSIs specifically [78]. BMI
was also found to be an independent risk factor for
SSI in cosmetic surgical procedures in another study
[32]. Several studies have shown obesity to increase
the rate of infections, seromas, wound related complica-
tions and venous thromboembolism after surgery
[12,14,16,17,63–65]. Other studies have found associa-
tion of SSI after liposuction with age greater than 50,
diabetes, alcohol abuse, drug use, peripheral vascular
Surgical Site Infections in Cosmetic Surgery 33
disease, gastrointestinal malignancy, immunosuppres-
sion, and malnutrition [76]. No difference in post-
liposuction SSI incidence was found when assessing
the amount of fat aspirated during the procedure [33].
Rhytidectomy
Owing to the extensive vascularity of the face, infection
is rare in rhytidectomy, with reported rates of less than
1% [79,80]. In general, complications in facial cosmetic
surgery are infrequent, with reported rates ranging be-
tween 0.003% and 0.600% [79,81,82]. Despite the
low infection rates, in a survey of cosmetic surgeons,
68% prescribe some combination of preoperative and
postoperative antibiotics for rhytidectomy, because
infection is considered a catastrophic consequence in
cosmetic patients [2]. No clinical trials could be found
investigating infection rates with and without antibiotic
use in facelift specifically but, owing to the low infec-
tion rate, antibiotics are unlikely to show benefit [83].
A literature review with recommendations for facelift
based on the evidence from studies of clean surgeries
was summarized previously [37]. The main weaknesses
of these recommendations are the lack of studies
applying directly to facelift surgery and the inclusion
of expert opinion [37]. Therefore, risk factors for SSI af-
ter rhytidectomy are drawn from those for clean surgery
such as age, BMI, preoperative shaving, surgical drains,
hypothermia, and nicotine use [38,39].
Blepharoplasty
As with other facial surgeries, the infection rate in
blepharoplasty is very low, occurring in less than 1%
of cases owing to the clean wound classification and
rich vascularity of the orbit [84,85]. When infections
occur, patients present with tender, erythematous, and
edematous eyelids [86]. The most common organisms
cultured are Staphylococcus and Streptococcus species
[86]. However, although rare, infections from blepharo-
plasty can lead to preseptal or orbital cellulitis, and the
progression to orbital cellulitis is considered a vision-
threatening complication [87]. Despite this fact, case re-
ports of even serious infections resolve when treated
early with antibiotics [88–91]. In a retrospective review
of 1627 blepharoplasties, all patients were treated with
topical antibiotics, and only 11 were treated with oral
antibiotics for prosthetic joints or heart valves, resulting
in an infection rate of 0.2%. All infections resolved with
a course of oral antibiotics [84]. Thus, it was concluded
that topical antibiotic use is sufficient for blepharo-
plasties, but not 100% effective in preventing SSI [84].
Surveys of cosmetic surgeons found that the anti-
biotic prescribing practices for routine eyelid surgeries
34 Spataro
vary widely throughout the world, but use has increased
significantly over the last 25 years, despite there being
no standard of care requiring the routine use of postop-
erative antibiotics [92–94]. Because systemic antibiotics
have not been proven necessary, and given the potential
for compilations with systemic use, topical antibiotics
are prescribed more commonly [95,96].
Rhinoplasty
The incidence of SSI in rhinoplasty and septoplasty sur-
gery has been reported between 0% and 18% [97,98].
Although infections are uncommon owing to the high
local vascularity and generally healthy patient popula-
tion, infections can occur at the skin–soft tissue enve-
lope, at sites of sutures, in the implanted cartilage or
alloplastic implants, or result from other complications
such as septal hematoma [99]. As with most facial infec-
tions, the most common pathogens are Staphylococcus
and Streptococcus species [100,101]. The sequelae of an
infection include unacceptable cosmetic results and
scar formation including synechia, nasal tip drop, septal
perforation, and saddle nose deformity [102]. Indica-
tions for postoperative antibiotic use in septorhino-
plasty include the prevention of septicemia in patients
with valvular heart disease or immunocompromise, as
well as complex revisions with extensive cartilage graft-
ing [103,104]. One study assessing antibiotic use in rhi-
noplasty showed a decrease complication rate with
antibiotic use for revision rhinoplasties only [105]. In
studies comparing the use of preoperative antibiotics
in septorhinoplasty compared with both preoperative
and postoperative antibiotics, there was found to be
no added benefit from the addition of postoperative an-
tibiotics [98,106,107]. In addition, SSI rates have been
reported at less than 1% in studies where no prophylac-
tic antibiotics were used [103,108,109]. Furthermore,
patients undergoing endonasal septorhinoplasty with
autologous cartilage were shown not to benefit from
prophylactic antibiotic use [107]. In case reports of rhi-
noplasty patients with SSI, culture-driven antibiotic reg-
imens resulted in the resolution of the infection and
minimal long-term functional or cosmetic conse-
quences [110,111]. As a result, the most recent rhino-
plasty clinical practice guidelines recommended
against the use of postoperative antibiotics in rhino-
plasty [112].
Facial alloplastic implantation
Facial alloplastic implants are most often used to
augment the chin, nose, and malar area. Various types
of implant material are available, including silicone,
polytetrafluoroethylene (with the trade names Teflon,
Gore-Tex, and Proplast), and high-density polyethylene
(trade name Medpor) [113]. Infections usually occur
from the transfer of intraoral flora during the placement
of the malar or chin augmentation transorally, and are
more common if the implant is not well-fixated, with
some authors advocating either fixation of the implant
with screws or suture and some advocating
precise pocket formation without the need for fixation
[114–117]. Additional techniques include the use of
perioperative and postoperative antibiotics, as well as
soaking the implant and irrigating the pocket with an
antibiotic solution [114,118]. One case report
described infection of malar and chin implants owing
to poor oral hygiene of the adjacent teeth as well as non-
fixation of implants several years after placement [115].
Infection rates for alloplastic chin implants have been
reported to be between 5% and 7% [119], another
study found rates of 0.7% for silicone chin implants
and 7.6% infection rate for Proplast chin implants
[120]. Malar implants have a reported infection rate
that varies from 2.3% to 14.6% [120,121]. A metaanal-
ysis of rhinoplasty implants reported infection rates of
between 0% and 10% [122]. Higher SSI rates were
found in patients with revision rhinoplasty, diabetes,
septal perforation, and more porous implants [83].
Signs of infection include pain, drainage, skin ery-
thema, or fistula [114]. Although generally the implant
requires removal when infected, reports of implant
salvage have been described with oral antibiotics and
irrigation of the cavity with an antibiotic solution [114].
Skin resurfacing
Most data regarding infections after skin resurfacing
arises from literature for laser resurfacing, and specif-
ically ablative CO2 laser resurfacing. Infection rates
vary greatly, reported at between 0.0% and 8.3%
[123–127]. In a large study of patients who under-
went CO2 laser resurfacing, acne occurred at a rate
of 15%, milia at a rate of 11%, contact dermatitis at
a rate of 10%, and herpes simplex virus infection
occurred in 7.4% of patients, regardless of
prior herpes simplex virus history [128]. General
methods of infection prevention include sterile tech-
nique, appropriate skin preparation, and diligent
postoperative wound care [123–127]. Higher rates
of infection have been associated with closed dress-
ings methods, with open techniques reporting a 0%
to 1% infection rate [126,128]. It is thought that
occlusive dressings promotes the growth of bacteria
and fungi [125].
Regarding topical antibiotic use, a systematic review
of randomized, controlled trials comparing
Another random document with
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 III.
Royaume de Kiev.

Kiev, situé sur une hauteur, qui domine le Dniéper, un peu en

aval de son confluent avec la Desna, avait une situation très
favorable au commerce dans un temps où les rivières étaient les
principales voies de communication. Son importance en tant que
centre commercial, politique et militaire devait dater de très loin,
puisque lorsque ses chroniqueurs se mirent à y rassembler des
renseignements sur les débuts de sa vie politique et de sa dynastie,
ils ne purent guère recueillir que de simples légendes. Ils racontent
que Kiev tirerait son origine d’un bac établi à cet endroit sur le
Dniéper et dont le passeur aurait porté le nom de Kyï ; d’autres récits
prétendent que Kyï était un prince de la tribu des Polianes établis
dans cette contrée, qui y aurait bâti le premier un château fort.
Les premiers princes de la dynastie de Kiev, sur lesquels des
informations certaines nous soient parvenues, vivaient dans la
première moitié du Xe siècle : c’étaient le prince Igor et son épouse
Olga, qui avait reçu le baptême au milieu du IXe siècle. De leur
mariage naquit le prince Sviatoslav, dont le fils Vladimir christianisa
le pays, organisa l’église et donna l’élan à la vie intellectuelle et par
conséquent à la littérature. Il y avait eu avant Igor un prince Oleg, qui
a gardé dans la littérature un renom de prince sage et tant soit peu
magicien (dans les « bylines » il est appelé « Volga », nom analogue
à celui de la princesse Olga « princesse sage »). Mais on ne sait
quels étaient ses liens avec la dynastie. Probablement nous nous
trouvons là en face d’une pure conjecture émise par l’un des
rédacteurs de la chronique de Kiev, qui prétend que le prince Igor
était fils du Varègue Rurik, prince de Novogorod : Igor avec son
oncle Oleg seraient venus à Kiev avec des Varègues-Russes et
auraient conquis le pays. Des traités passés par Oleg et Igor avec
Byzance, en 907, 911 et 944, qui sont tombés sous les yeux d’un
des rédacteurs postérieurs de la chronique de Kiev, confirment en
effet que ces princes étaient bien souverains à Kiev, qu’ils se
faisaient appeler « princes russes » et que dans leur entourage on
trouvait beaucoup de noms scandinaves. C’est évidemment ce qui a
donné au chroniqueur l’idée d’attribuer aux Russes et à la dynastie
de Kiev une origine scandinave, et comme le nom de Russe n’était
connu ni en Suède, ni en Scandinavie en général, le chroniqueur
s’est vu obligé d’affirmer que Rurik, en se rendant chez les Slaves,
avait emmené avec lui « tous les Russes ».
Quelle que soit l’origine de cette appellation, elle désignait aux
IXe et Xe siècles cette caste militaire en même temps que
commerçante, qui dominait à Kiev, qui assujettissait peu à peu les
pays slaves voisins, trafiquait des esclaves et des produits qu’elle
percevait en qualité de tributs sur les contrées qui lui étaient
soumises. C’est à Kiev et à ses environs, le pays des Polianes, que
l’on donnait le nom de Russie. C’est là un fait bien établi, qu’on
explique cette dénomination comme on voudra, qu’elle ait été
importée par des étrangers appelés russes ou qu’elle fût une
appellation locale adoptée par les troupes des Varègues.
Naturellement à mesure que les princes de Kiev étendaient leurs
conquêtes sur les Slaves méridionaux — que nous considérons
aujourd’hui comme Ukrainiens — et sur les Slaves septentrionaux —
Ruthènes blancs et Moscovites — le nom de Russie était adopté par
les pays conquis, qui le considéraient comme une appellation
politique et jusqu’à un certain point nationale. Mais au sens restreint
elle s’appliquait exclusivement, entre le XIe et le XIIIe siècles, à la
contrée de Kiev [3] .
 [3] Une remarque caractéristique c’est que le
chroniqueur nous présente le pays de Novogorod comme
la première base de l’expansion des Russes scandinaves
dans le monde slave. Mais pour les gens du pays de
Novogorod la « Russie » c’était Kiev et l’Ukraine, par
opposition à leur propre contrée. Ceci rend l’hypothèse
du chroniqueur bien chancelante.

Les Russes sont mentionnés pour la première fois dans les

documents grecs du commencement du IXe siècle, à l’occasion des
expéditions militaires qu’ils entreprirent, soit pour se procurer du
butin, soit pour entamer des relations commerciales, vers les cités
byzantines du littoral de la Mer Noire. Il est probable que c’est à
cause de ces expéditions que l’empereur grec se vit forcé dans les
environs de 835 d’entamer des négociations avec les princes
russes. Les annales carolingiennes nous disent en passant qu’en
l’année 839 l’empereur de Byzance envoya des ambassadeurs
russes à Louis le Débonnaire, afin qu’ils pussent retourner chez eux
en faisant ce détour, parce que la route directe leur était barrée par
quelque horde hostile. Mais peu de temps après, les expéditions
russes se renouvellent et, en 860, Constantinople elle-même faillit
tomber entre leurs mains. Le gouvernement grec dut se mettre en
frais pour établir des relations amicales avec les Russes : on leur
envoya des ambassadeurs munis de riches présents et des
missionnaires, conduits par un évêque, qui en baptisèrent un grand
nombre.
L’expédition de 860 est le premier fait historique, touchant la
Russie, que les compilateurs de Kiev du XIe siècle aient trouvé dans
les sources byzantines. Ils notèrent que c’était à partir de ce moment
que « les pays russes » furent connus et sans hésiter donnèrent pour
chef à cette expédition les princes de Kiev, Ascold et Dir, dont les
tombeaux gardaient encore vivant le souvenir. Il est curieux que le
chroniqueur n’eût pas la moindre idée d’un autre centre russe. De
même il faut noter qu’Ascold s’étant fait connaître par ses vertus
chrétiennes, on éleva une église sur son tombeau. Ceci évoque à la
mémoire le succès des missionnaires byzantins de 860, auquel on
rattache la mission chez les Khozares de Constantin-Cyrille, l’apôtre
des Slaves [4] .
[4] Un détail curieux permet de situer avec certitude
l’état « russe » du IXe siècle en Ukraine : le prince des
russes en 839 s’attribue le titre de Khakan (autre forme
de Kahan) qui est le titre des souverains Khozares.
Hilarion, dans le panégyrique qu’il a fait de Vladimir le
Grand, lui donnera plus tard cette qualification, que
porteront dans les documents postérieurs les divers
princes de l’Ukraine. C’est là un témoignage de
l’influence des Khozares sur l’Ukraine et sur le pouvoir
des princes russes qui se développait dans un pays où
leur action se faisait sentir.

Les sources étrangères — grecques, latines, arabes,

arméniennes, hébraïques — font surtout mention de ces Russes à
propos des expéditions qu’ils entreprirent en Crimée, en Asie
mineure, sur le littoral de la Caspienne, en quête de butin. Les
chroniqueurs de Kiev prêtent particulièrement leur attention à
l’expansion du pouvoir et de l’influence de leurs princes sur les
Slaves et autres tribus voisines. Mais les débuts de ce mouvement
dataient déjà de trop loin pour qu’ils pussent nous en donner des
renseignements précis dans son stade primitif.
Il est hors de doute que, déjà au IXe siècle, les princes de Kiev
étaient maîtres du Dniéper et de ses ramifications vers le nord, qu’ils
appelaient « route de chez les Varègues jusque chez les Grecs ». Et
cette dénomination était exacte, en fait, depuis la fin du Xe siècle et
le fut surtout au XIe siècle, alors que les troupes Varègues prenaient
habituellement ce chemin, pour se rendre à Byzance, où elles
s’engageaient dans la garde impériale, dont elles formaient le plus
fort contingent. D’après les chroniqueurs, c’est le prince légendaire
Oleg, qui se serait rendu maître de la voie du Dniéper, ce qui prouve
qu’ils n’en savaient rien de certain. De son temps les princes de Kiev
commandaient les voies terrestres et fluviales, qui menaient à l’est à
travers les contrées habitées par les Slaves et les Finnois jusqu’à la
Volga ; là se trouvaient dans les villes du pays les gens d’Oleg. Les
traités que ce dernier conclut avec Byzance font mention des « très
hauts et sérénissimes princes » et des « puissants boïards » qui sont
soumis à sa domination. Un traité d’Igor en énumère une vingtaine.
C’était donc une organisation politique assez importante, assez
lâche, peu centralisée, dont l’union était maintenue par les garnisons
« russes » et par les visites périodiques des princes, mais qui, traitée
avec énergie, pouvait fournir au pouvoir central des armées et des
moyens matériels considérables.
Le traité byzantin sur l’administration de l’empire, qui porte le
nom de Constantin Porphyrogénète, nous donne des informations
sur la pratique administrative du royaume de Kiev, aux environs de
940, l’époque d’Igor. Au mois de novembre, les princes à la tête de
tous les russes, sortent de Kiev et se rendent « en poludie » pour
percevoir les tributs annuels, que doivent leur payer les contrées
slaves de Novogorod, les Derevlianes, les Dregovitches, les
Krivitches (les Ruthènes blancs d’aujourd’hui), les Siverianes et
autres peuplades, qui leur sont soumises. Ils y établissent leurs
quartiers d’hiver, et au mois d’avril, quand le Dniéper dégèle, ils
rentrent à Kiev. De là ils expédient en bateaux par le fleuve et la Mer
Noire sur le marché de Constantinople les marchandises et esclaves
recueillis. Les Russes de Kiev, leur boïards et leurs princes sont en
même temps des guerriers et des commerçants. Ce sont les intérêts
de leur commerce qui gouvernent leur politique : les voies fluviales
de l’Europe orientale, gardées par leurs garnisons, constituent la
charpente de leur domination, dont les résultats se traduisent en un
substantiel profit commercial.
 IV.
Le Christianisme.

L’histoire du royaume de Kiev au Xe siècle n’est qu’une série de

changements périodiques vers la consolidation ou l’affaiblissement
de l’état. Réunies par le système des garnisons, les tribus
ancestrales de ceux que nous appelons aujourd’hui les Ukrainiens,
les Ruthènes blancs, les Grands Russes, les Finnois et
probablement aussi les Lithuaniens, ne pouvaient être maintenues
dans cet état de sujétion que par les armes. Or les Russes de Kiev
n’étaient pas assez nombreux pour contrôler efficacement la vie
locale de toutes ces contrées ; leurs tendances visaient surtout à
s’étendre, à s’emparer de riches territoires et de centres
commerciaux importants.
Le règne de Sviatoslav, fils d’Igor (de 960 à 970) marque une
période d’expansion énergique. Ce fut l’époque de nombreuses
expéditions vers la Volga et sur le littoral de la Caspienne, de vastes
aspirations sur la Bulgarie et même sur Constantinople. Sviatoslav
reprenait à son compte le projet d’un empire gréco-slave, qui avait
déjà tenté le roi bulgare Siméon. L’habile politique de Byzance fit
échouer ses desseins. L’un de ses fils, Vladimir, après avoir réuni de
nouveau sous sa domination les contrées soumises à son père,
suivit une autre politique, qui marque le commencement d’une ère
nouvelle pour les nations slaves et l’Europe orientale en général. Il
chercha à établir un système de gouvernement plus solide dans le
royaume de Kiev, il s’efforça de consolider le pouvoir du prince, de
lui donner un fondement moral en relevant son prestige, au lieu de
ne lui laisser que la force comme unique soutien. Et de même que
beaucoup d’illustres souverains du moyen-âge s’étaient servis dans
ce but des traditions laissées en Europe par l’empire romain, il
s’adressa à Byzance.
D’abord il fait la paix avec elle, lui prête son assistance dans les
luttes intestines qui la déchiraient et en obtient en revanche des
titres, des insignes et l’appui de son église et de sa civilisation. Il ne
rêve plus comme son père de conquérir Constantinople, mais il tient
à devenir le beau-frère de l’empereur grec, à rentrer de quelque
façon dans la famille impériale, qui lui prêtera quelque chose de son
éclat. Ce n’était d’ailleurs pas une nouveauté : dans le traité
d’administration mentionné plus haut, nous lisons, que les princes
« khozares, magyares, russes et autres » en échange de services
rendus, demandaient à recevoir des mains de l’empereur la
couronne et les insignes impériaux. Ils avaient à cœur d’obtenir la
main d’une princesse byzantine, ou de donner en mariage une de
leurs princesses à un membre de la famille impériale pour relever
par là le prestige de leurs dynasties. Les efforts de Vladimir furent
couronnés de succès, et cette fois les conséquences en furent
considérables, parce qu’elles faisaient partie d’un plan habilement
conçu et poursuivi avec beaucoup d’énergie.
Pour lui avoir prêté secours, Vladimir demanda à l’empereur de
lui accorder sa sœur en mariage et, probablement aussi, de lui
envoyer la couronne et les insignes. C’est là, vraisemblablement,
l’origine des récits qui coururent plus tard au sujet des insignes
royaux apportés en Russie et dans lesquels un des souverains
postérieurs du même nom, Vladimir Monomaque, joue le principal
rôle. Une fois sauvé du péril, il fallut que Vladimir le frappât à
l’endroit sensible : il marcha vers la Crimée, s’empara de la
Chersonèse, de sorte que l’empereur dut céder. La princesse Anna
fut envoyée en Russie, Vladimir reçut le baptême et, comme il avait
pris avec lui de la Chersonèse le clergé ainsi que divers objets du
culte chrétien et de l’art grec, il se mit à implanter chez lui, à Kiev et
à propager dans les autres parties de son royaume la civilisation
slavo-byzantine.
Ni le christianisme, ni la civilisation byzantine n’étaient chose
nouvelle pour le pays : nous avons déjà mentionné le succès des
missionnaires de Byzance en 860 et le baptême d’Olga. De plus,
des fouilles récentes entreprises à Kiev, aux environs de l’ancienne
demeure des princes, ont mis à jour un cimetière chrétien, qui date
sûrement d’une époque plus ancienne que celle de Vladimir. Dans
les vieilles sépultures, tant à Kiev, que dans tout le bassin du
Dniéper, nous trouvons un amalgame caractéristique d’influences
byzantines et orientales — irano-arabes venant du Turkestan et du
Califat — que l’on remarque non seulement dans les objets
importés, comme tissus, pièces de céramique ou d’orfèvrerie, mais
encore dans les produits de l’industrie locale. (L’art de Byzance lui-
même était à cette époque fortement imprégné de goût oriental par
l’influence de la Syrie, de l’Arménie et de la Perse.) L’importance de
l’œuvre de Vladimir consista surtout à donner la prédominance à
l’influence byzantine sur celle de l’orient, en lui ouvrant plus
largement la voie qu’on ne l’avait fait jusque-là. Par dessus tout,
l’organisation d’une église chrétienne sur le modèle de celle de
Constantinople était grosse de conséquences : devenue, dès
l’époque de Vladimir, religion d’état, l’église se répand par les
canaux de l’appareil administratif et fait sentir partout son action
civilisatrice.
Les historiens de Kiev nous disent ouvertement, que
l’acceptation du christianisme avait été tout aussi forcée que
spontanée. Vladimir avait ordonné non seulement de détruire les
objets du culte païen, mais de baptiser de force les gens de Kiev et
des autres grandes villes. D’un autre côté, le paganisme chez les
Slaves orientaux n’avait pas de formes bien arrêtées, point de caste
sacerdotale, point de temples ou de sanctuaires nationaux ; c’était
plutôt un état d’esprit qu’un culte. C’est pourquoi il céda sans
résistance devant le christianisme, s’amalgamant en partie avec lui
pour former ce qui est resté dans la littérature chrétienne sous le
nom de « religion à double tradition ». Le petit nombre des
missionnaires empêcha la nouvelle religion de se répandre
facilement dans le fond des provinces, mais parmi les classes
dirigeantes, concentrées dans les villes, elle gagna rapidement du
terrain, grâce au soutien que lui accordait le pouvoir, grâce à son
excellente organisation, à sa hiérarchie, aux formes éclatantes de
ses cérémonies et enfin grâce aux arts et aux lettres, qu’elle avait
pris à son service.
Les églises et les monastères de bois ou de pierre s’élèvent de
toutes parts. De la Bulgarie et des villes grecques accourent avec le
clergé des architectes, des maçons, des artisans, des mosaïstes,
des joailliers, puis des peintres, des maîtres de chant, des scribes.
Les élèves se recrutent dans la population locale ; on les initie dans
le secret des arts. Vladimir enlève les jeunes gens aux familles les
plus distinguées et les donne aux prêtres étrangers « pour être
instruits dans les lettres ». A l’instar de Byzance, il bat monnaie ;
nous y voyons son effigie parée des insignes d’un basileus byzantin.
Modes, vêtements, parures viennent de Byzance, les classes
supérieures s’en emparent, puis les font pénétrer dans les couches
plus profondes de la population. Les clichés décoratifs, les sujets
littéraires byzantins viennent se combiner avec les dessins et les
fables slaves et orientales. Le royaume de Kiev, et avant tout le
triangle ukrainien, formé par les trois grosses villes de Kiev,
Tchernyhiv et Pereïaslav, devient le foyer, d’où la civilisation gréco-
romaine, sous son enveloppe slavo-byzantine, va se répandre dans
toute l’Europe orientale.
 V.
Développement de la vie sociale et
nationale sur de nouveaux principes.

Le long règne de Vladimir (979–1015), suivi d’une courte

contestation entre ses fils, qui un moment se partagèrent son
royaume, puis le règne non moins long de son fils Iaroslav (1019–
1054) remplissent la période, où la réorganisation de l’état de Kiev
se poursuit, sur les bases jetées par Vladimir. Le chroniqueur de
Kiev caractérise cette époque de développement du christianisme
de la manière suivante : « Vladimir avait préparé le sol en éclairant le
pays par le baptême ; Iaroslav a semé la bonne parole au milieu des
fidèles, et nous (la troisième génération), nous en recueillons les
fruits en tirant profit des sciences. » Nous pourrions appliquer aussi
bien cette caractéristique aux autres domaines de l’édification
sociale. De même que les événements politiques de cette époque
nous rappellent, tantôt les grands rois barbares de l’occident, tantôt
l’âge de Charlemagne.
Les anciens écrivains de Kiev notent le changement brusque qui
survint dans la façon d’agir de Vladimir dès qu’il eut reçu le baptême.
Rude, sanguinaire, despote auparavant, il s’adoucit, devient
compatissant envers le peuple et se soucie beaucoup plus de faire
régner la paix dans le pays que d’agrandir ses domaines. Il s’entoure
non seulement de chefs militaires, mais aussi d’évêques ; il appelle à
sa cour les « anciens », les citoyens distingués à qui il « demande
conseil en tout ce qui touche l’ordre et l’organisation de l’état ». Par
exemple le chroniqueur cite les lois sur le meurtre, que Vladimir
modifia et promulgua après en avoir délibéré en conseil. Tous les
jours des tables somptueuses étaient dressées à la cour, que le
prince fût présent à Kiev ou qu’il n’y fût pas, pour les antrustions, les
fonctionnaires du palais et les citoyens de qualité. Les fêtes étaient
l’occasion de fastueux banquets publics, qui duraient plusieurs jours.
On préparait des centaines de jarres d’hydromel, on distribuait de
l’argent aux pauvres et l’on portait à domicile une part du festin aux
malades et aux infirmes.
Les anciens auteurs citent tous ces faits pour montrer l’influence
exercée sur Vladimir par le christianisme, qui avait transformé un
guerrier rude et sauvage en un prince plein de vertus et canonisé
plus tard par l’église. Mais on ne peut douter que ce ne fût là un
programme politique soigneusement suivi, qui atteignit
complètement son but : rapprocher la classe guerrière du reste de la
population, donner au pouvoir un solide fondement moral et en
général unifier l’état. Nous en trouvons la preuve dans la tradition,
qui a survécu à toutes les catastrophes politiques, passant dans la
poésie populaire, inspirant même les chansons épiques de l’extrême
nord, d’Archangel, et d’Olonets, nous parlant encore du « gracieux
prince Vladimir, beau comme le soleil » et de ses festins journaliers.
Le principe d’un état patrimonial, introduit par Vladimir et qui
s’affermit sous Iaroslav et ses descendants, apporta un autre appui
moral à l’organisation de l’état. Avant Vladimir, les membres de la
famille régnante étaient peu nombreux et l’on n’attachait pas grande
importance au principe dynastique. Vladimir, que la légende nous
représente comme très adonné aux femmes, eut un grand nombre
de fils, entre lesquels il distribua ses domaines, déjà de son vivant,
pour qu’ils les gouvernassent, remplaçant ainsi l’ancien système de
la vice-royauté par le régime patrimonial. Les débuts n’en furent pas
bien encourageants : à sa mort, ses fils commencèrent aussitôt à
s’entretuer pour s’emparer de l’héritage, tout comme l’avaient fait les
fils de Sviatoslav, y compris Vladimir lui-même. Mais le clergé,
soutenu par la nouvelle littérature ecclésiastique, tenait beaucoup à
ce système, qui imposait aux princes le devoir de se laisser guider
dans leurs relations mutuelles par l’amour fraternel et l’esprit de
famille. Le peuple aussi se rangeait à cette façon de voir, qui
semblait lui donner des garanties contre les discordes des princes,
dont il avait tant à souffrir. Ainsi au cours des temps, parallèlement
avec l’expansion de la morale chrétienne dans les classes
supérieures, l’idée finit par s’établir que le royaume de Kiev était le
patrimoine de la dynastie du « vieux Vladimir », une propriété dans
laquelle chaque membre de la famille princière avait droit à son
domaine particulier, à charge de veiller, tous ensemble, à ce
qu’aucune partie de ce territoire ne tombât entre des mains
étrangères. Le trône de Kiev devait appartenir à l’aîné, qui, dans ses
rapports avec ses frères puînés, avait le devoir de les traiter
« véritablement en frères », tandis que ces derniers étaient obligés
de le « considérer comme un père » et d’obéir à ses volontés. Cela
va sans dire, cette constitution patriarcale ne fut pas toujours
strictement observée en pratique, mais elle donnait en tous cas une
idée directrice et nous en verrons les conséquences importantes
dans la suite.
Cet ensemble de principautés était régi par les lois et décisions
prises par le prince aîné de Kiev « dans la douma » ou conseil
comprenant, outre les autres princes du sang et boïards, les
évêques et les anciens de la population. Nous en avons déjà
rencontré un exemple. Le plus ancien recueil d’arrêts et décisions
est connu sous le nom de « Droit russe de Iaroslav ». C’est un
compendium analogue aux leges barbarorum de l’Europe
occidentale ; il s’agit surtout de lois pénales, de mesures protectrices
en faveur du prince et de ses gens. La première partie porte un tel
caractère d’ancienneté qu’il faut l’attribuer à l’époque de Iaroslav ou
de Vladimir. C’est aussi à Iaroslav qu’appartient la fixation du taux
d’une contribution, que l’agent du prince ou ses aides ont le droit de
lever sur la population au cours de leurs tournées périodiques. Il
fallait défendre les sujets contre les agents du fisc dont la rapacité
était déjà un thème favori de la littérature de l’époque. A cette partie
primitive ont été faites de nouvelles additions provenant évidemment
des fils et petit-fils de Iaroslav et de la pratique judiciaire postérieure.
Ces lois et arrêtés de Kiev furent considérés comme les règles
de la procédure judiciaire dans les autres parties du royaume : les
historiens du droit reconnaissent aussi dans les monuments
législatifs et les arrêtés judiciaires des contrées de la Russie blanche
et de la Moscovie les mêmes principes, qui se trouvaient déjà dans
les compilateurs anonymes de la législation de Kiev des XIIe et XIIIe
siècles, qui conserve toujours le nom de « Droit russe ». Ainsi Kiev
donna des lois à toute l’Europe orientale, et cela pendant une longue
suite de siècles.
Mais ce fut surtout l’église qui constitua le plus ferme pilier de la
domination de Kiev et dont l’action contribua le plus à cimenter les
diverses parties du royaume. Iaroslav s’était appliqué à doter le
mieux possible l’archevêché de Kiev : il bâtit dans sa capitale la
cathédrale de Sainte Sophie (vers 1035), un monument de l’art
byzantin des plus précieux, qui, avec ses mosaïques, ses fresques
et ses sculptures, nous a été conservé jusqu’à aujourd’hui. Le
métropolite restera pendant trois siècles le chef spirituel du royaume,
c’est-à-dire de toute l’Europe orientale, ne dépendant de
Constantinople qu’au point de vue strictement canonique.
Indépendamment du clergé séculier, se fonde à Kiev, vers le milieu
du XIe siècle, le monastère devenu célèbre plus tard sous le nom de
monastère des cavernes (Petcherska Lavra), qui sera une pépinière
pour le clergé régulier et où se recrutera la hiérarchie de toute
l’Europe orientale. Après s’être concerté avec le métropolite, le
prince nommait aux évêchés vacants dans les provinces et les
« hégoumènes » (abbés) de Kiev conservaient ainsi dans la
hiérarchie l’influence du clergé de la capitale, de même que l’unité
de la dynastie et de l’aristocratie boïarde maintenait l’unité dans
l’administration civile. Ayant importé de Byzance le principe d’une
étroite union entre l’église et l’état, dans laquelle, en échange de son
patronat, l’église offrait au souverain ses services, le clergé
s’évertuait à relever le prestige de son patron immédiat, le prince
local et celui du souverain de Kiev, travaillant ainsi à
l’affermissement du système et à la consolidation de l’unité
nationale.
Pendant ce temps l’élément scandinave avait cessé de jouer un
rôle dans la formation de l’état. Au XIe siècle nous ne rencontrons
plus que quelques émigrants du nord isolés, qui se fondent bientôt
dans l’élément slave. En général il est difficile de savoir quelle a été
l’influence exacte de l’élément scandinave sur la civilisation de Kiev.
Les savants qui se sont occupés de cette question sont portés à
croire qu’elle n’a été ni profonde, ni persistante. En tous cas, à
l’époque de Vladimir et de Iaroslav, c’était bien l’élément slave qui
créait la civilisation de Kiev et organisait le royaume d’après la
tradition politique, venue de Byzance.
Et il s’agissait bien là avant tout de ces populations que nous
appelons aujourd’hui ukrainiennes. Le peuple ukrainien moderne est
sorti, sans aucun doute, par une évolution continue, des unités
ethnographiques, qui peuplaient aussi le triangle formé par les trois
capitales d’alors : Kiev — Pereïaslav — Tchernihiv. L’hypothèse
émise par quelques savants que l’ancienne population de ce
territoire aurait émigré vers le nord aux XIIIe et XIVe siècle, par suite
de revers subis dans la steppe et que le bassin du Dniéper aurait été
à nouveau colonisé par des émigrés venant de l’Ukraine occidentale
(Galicie actuelle), ne repose sur aucun fondement. L’élément
indigène, s’appuyant sur la zone boisée, y est resté fermement
implanté et la frontière septentrionale actuelle des dialectes
ukrainiens nous démontre clairement cette stabilité et cette
perpétuité de la colonisation ukrainienne. L’organisation de l’état de
Kiev et sa civilisation furent donc avant tout l’œuvre des tribus
ukrainiennes. Mais elles s’étendaient bien au delà du territoire de
ces tribus.
En fait, sous Vladimir, le royaume de Kiev était très étendu. Un
document de la chancellerie pontificale en trace les frontières ainsi
qu’il suit : au nord-ouest elles sont voisines de la Prusse, au sud-
ouest elles passent « près de Cracovie ». Au nord Novogorod,
Rostov et Mourome sont les capitales des apanages des fils de
Vladimir ; au sud-est elles embrassent Tmoutorokhan ou
Tamatarque, l’ancienne Phanagorie. Les tribus des slaves orientaux
ne s’étant pas encore beaucoup différenciées entre elles, toutes
s’accommodent aisément aux usages de Kiev et participent à
l’expansion de sa civilisation. Elles se considèrent comme faisant
partie de la Russie au sens large, elles en adoptent non seulement
les lois mais la langue et la littérature. Cela leur fait une conscience
commune, tout ainsi bien aux Ukrainiens, qu’aux Ruthènes blancs et
qu’aux Grands Russes. Mais les gens de Kiev exercent une
influence souveraine sur tout le système, ce sont eux les promoteurs
de la civilisation et ils seraient bien étonnés, s’ils pouvaient prévoir
qu’un jour les colons slaves de Novogorod et de Rostov
contesteraient à leurs descendants le droit de se considérer comme
les héritiers de la tradition kiévienne.
 VI.
La vie intellectuelle.

Ces trois facteurs principaux : la dynastie de Kiev, la classe

militaire dirigeante russe, et la hiérarchie ecclésiastique et
administrative de la nouvelle métropole de la « Russie » [5] , avaient
puissamment contribué à étouffer l’ancien particularisme ethnique et
local des peuplades slaves et des tribus affiliées, d’où sont sorties
les trois grandes branches des slaves orientaux : les Ukrainiens, les
Ruthènes blancs et les Grands Russes.
[5] La forme slave de ce mot est Russǐ (nom collectif ;
Russin désigne l’individu ; l’adjectif est russǐski ou rusǐki).
La forme grecque était Rhos pour le peuple, Rhosia pour
le pays. La capitale du royaume de Kiev était désignée
dans les documents grecs sous le nom de métropole de
la Russie (Rhosias). Plus tard cette forme a été
également adoptée par la terminologie slave.

Les princes puînés, tout autant que les boïards Kiéviens, qui
allaient assumer des fonctions dans les provinces, avaient tout
intérêt à ne point être regardés comme des étrangers, mais à se
trouver partout comme chez eux. Il en était de même du clergé
métropolitain qui recueillait les prébendes provinciales, avec l’espoir
d’être rappelé à Kiev pour y remplir de plus hautes fonctions.
 Aussi la nouvelle littérature, qui naît dans les monastères de la
métropole, se met-elle au service de ces tendances. Elle s’attache à
des thèmes d’un intérêt général, elle met en avant la notion du
« bien des pays russes », entendant par là les intérêts et les
aspirations du royaume entier, écartant toute manifestation du
particularisme.
La littérature laïque, cultivée à la cour du prince et chez les plus
puissants boïards, soutenait évidemment les mêmes principes. Nous
en trouvons la preuve un siècle et demi plus tard dans la chanson
d’Igor, œuvre anonyme, composée par un poète de la cour aux
environs de 1186. C’est l’intérêt des « pays russes », qui l’inspire,
elle fait entendre des admonitions aux princes, qui négligent la vieille
tradition de Kiev. Sans doute l’auteur ne fait que suivre les traces
des anciens poètes de la cour, dont il fait mention à plusieurs
reprises.
Après l’établissement du métropolite à Kiev, les premiers groupes
de personnes versées dans les lettres se réunirent sous son
influence et un des premiers essais littéraires fut le commencement
de la chronique de Kiev.
Jusqu’à la fin de cette période, toute la production littéraire du
royaume vient de Kiev. C’est là que se forme une langue littéraire
commune (κοινή). D’abord ce travail d’unification se trouvait facilité
par la présence à Kiev, aussi bien dans les monastères que dans les
rangs du clergé séculier, de personnes lettrées attirées à dessein de
toutes les parties du royaume et qui, dans ce nouveau milieu,
apportaient pour les polir et les fondre ensemble, leurs particularités
dialectiques provinciales. En outre, on s’appliquait sciemment à cette
uniformisation en s’attachant à imiter le plus fidèlement possible les
modèles fournis par la Bulgarie. C’est pourquoi les monuments écrits
de Kiev se distinguent nettement de ceux de Novogorod par
exemple, en ce qu’ils n’offrent guère de particularités dialectiques [6]
et qu’ils manifestent une tendance à demeurer toujours sur le terrain
commun des intérêts généraux de la « terre russe ». Ceci leur assura
une large pénétration dans les provinces. Ce qui nous en reste
aujourd’hui a été préservé presque exclusivement dans les pays du
nord, qui ont été moins éprouvés par les catastrophes postérieures
qui désolèrent l’Ukraine.
[6] C’est justement ce qui a fait naître l’hypothèse
mentionnée plus haut, d’après laquelle la population de
Kiev aux XIe et XIIe siècles, aurait eu un tout autre
caractère ethnographique, bien plus ressemblant à celui
des Grands-Russiens d’aujourd’hui, et qu’elle aurait été
remplacée plus tard par une émigration ukrainienne
venant de l’ouest. Nous l’avons dit, cette hypothèse ne
résiste pas à une critique sérieuse.

La chronique de Kiev, qui malgré les nombreux remaniements

postérieurs a toujours conservé le même titre : Povesti vremenych
let, se propose de « raconter chronologiquement d’où est sortie la
terre Russe ; qui fut le premier prince à Kiev et comment s’est
formée la terre Russe ». Dans sa première rédaction, qui date
probablement de l’époque de Iaroslav entre 1030 et 1040, le terme
« terre Russe » est pris dans le sens étroit, comme s’appliquant
strictement aux pays de Kiev et il ne s’agit que de l’histoire de cette
contrée. Mais déjà à une époque très ancienne, l’un des rédacteurs
élargit la matière de sa chronique, en incorporant aux récits de Kiev
ceux de Novogorod, lui donnant ainsi l’ampleur d’un ouvrage
« russe » dans le sens le plus large du mot. A partir de ce moment le
travail littéraire ne s’interrompra plus à Kiev. On y crée une histoire
nationale de tous les pays russes, où le particularisme n’apparaît
plus et où sont enregistrées, sans distinction de provenance,
principalement les traditions locales du christianisme, qui surtout
paraissaient dignes d’être transmises à la postérité. Le premier
groupe des rédactions s’arrête vers le commencement du XIIe
siècle ; elles sont suivies d’une vaste compilation de matériaux
historiques et littéraires variés, embrassant tout le siècle. Grâce à la
chronique de Kiev une foule de renseignements précieux et
d’anciens fragments littéraires ont pu être conservés jusqu’à nos
jours.
Du reste, il n’existait pas à cette époque de centre intellectuel qui
eût pu rivaliser avec Kiev. Au point de vue politique et commercial
seulement, on lui opposa au début Novogorod, la grande ville du
Nord en antagonisme avec celle du Midi. Les traditions historiques
des premiers siècles sont pleines des rivalités politiques entre ces
deux grands centres, l’un s’appuyant sur la Mer Noire et restant en
contact avec Byzance, l’autre sur la Baltique, entretenant des
relations avec les « Varègues ». Tantôt les princes de Kiev
s’assujettissent Novogorod, tantôt les boïards de Novogorod
soutiennent leurs princes issus de la dynastie régnante dans leurs
prétentions au trône, et obtiennent en échange des privilèges ou des
droits de souveraineté plus étendus sur leurs domaines provinciaux.
Mais depuis Vladimir et Iaroslav la prépondérance intellectuelle de
Kiev est assurée.
Autant ses chroniques dès le début du XIe siècle sont
abondantes, riches d’idées, estimables pour leur style, autant les
annales de Novogorod sont pauvres et maigres. Déjà sous Iaroslav
nous rencontrons un brillant rhéteur comme le métropolite Hilarion.
Le monastère des cavernes nous fournit les sermons de Théodose,
les hagiographies de Nestor et de bien d’autres anonymes, qui
malgré leur simplicité de style, révèlent des talents de narrateurs qui
nous attirent et nous fascinent. C’est encore à Kiev que sont écrits
de nombreux ouvrages historiques, dont malheureusement seule
une faible part nous est parvenue, comme l’histoire de la guerre de
Volhynie, écrite par un certain Basile. Puis ce sont des sermons,
point du tout dépourvus de talent, que divers recueils nous ont
conservés. De son côté, la chanson d’Igor, par ses allusions, ses
citations, son allure, évoque devant nos yeux toute une poésie
profane, s’épanouissant à la cour.
Quel est le centre provincial qui pourrait nous offrir rien de
semblable ? Où trouverions nous, soit dans les pays des Ruthènes
blancs (chez les Krivitches, les Drehovitches et les Radimitches),
soit dans les contrées des Grands Russiens, un foyer d’élite comme
celui-ci ?
Il ne manque pas de témoignages qui prouvent que, dans les
pays que nous venons de nommer, on regardait Kiev et la Russie du
midi comme une contrée bien distincte des autres territoires. Aller en
« Russie » signifiait à Novogorod se rendre en Ukraine. Dans le pays
de Rostov-Souzdal, nous voyons la population s’insurger contre les
fonctionnaires « russes », venus des villes du midi, c’est-à-dire de
l’Ukraine. Mais l’hégémonie de Kiev se fait tellement sentir dans la
politique et surtout dans la vie intellectuelle qu’elle dérobe à nos
yeux les différences qui existaient entre les trois principales
branches des Slaves orientaux.