Aesthetic Dermatology

In most cases, there is little evidence to support delaying cosmetic procedures, such as laser therapy or chemical peels, in patients who have recently been treated with isotretinoin for acne, according to a consensus statement from the American Society of Dermatologic Surgery (ASDS).

An expert panel convened by the ASDS issued specific recommendations that supported safe, early initiation of cosmetic procedures in most cases. It noted that the likelihood of any potential harms from initiating cosmetic procedures after recent isotretinoin treatment is “low to very low” and that such harms have been reported only in case reports and case series.

Notable exceptions included dermabrasion and full-face ablative resurfacing; the experts recommended against having such procedures within 6 months of isotretinoin use because of potentially increased risks of adverse events in some patients.

“Potential benefits of this guideline include early access to scar treatments for many patients who are at the highest risk for scarring and, thereby, potentially improved patient quality of life,” Abigail Waldman, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and her coauthors wrote in the consensus statement (Dermatol Surg. 2017 Oct;43[10]:1249-62). This is the first consensus statement document published by the ASDS to address this topic.

• Dermabrasion. Treating specific facial areas while the patient is on isotretinoin or within 6 months of discontinuation “is not associated with increased risk of scar or delay in wound healing, and there is no evidence in the literature that supports a need to delay treatment,” they wrote. In contrast, they did not recommend full-face or mechanical dermabrasion with rotary devices within the 6-month window because it may be “associated with increased risk of adverse events in selected patients.”
• Lasers and energy devices. Similarly, the panel found no evidence that would justify delaying use of vascular lasers, hair removal lasers and lights, and nonablative or ablative fractional devices among patients recently treated with isotretinoin. However, they said fully ablative treatment of the entire face or regions other than the face should “generally be avoided until 6 months after completion of isotretinoin treatment because of the likely elevated risk of avoidable adverse events.”
• Chemical peels. Patients currently on isotretinoin or who have recently discontinued it can safely undergo superficial chemical peels, according to the panel. For medium or deep chemical peels, there was “insufficient data … to preclude a recommendation in this case,” the panel wrote.
• Other surgeries. Because of the risk of dry eyes, isotretinoin should be discontinued prior to laser eye surgery. For incisional and excisional cutaneous surgery, the data on isotretinoin were insufficient to make any recommendations, the experts concluded, though they acknowledged that in some cases, the surgeries may be “medically necessary.”

Most of these recommendations were based on case series and cohort studies, the panel said, rather than higher-quality, randomized clinical trials, which are “generally impractical and not likely forthcoming in this setting.” Moreover, they cautioned that insufficient evidence to make a recommendation should not be misconstrued as a confirmation of safety or a warning about risk.

Overall, the results of the analysis suggested that “procedural interventions during or soon after isotretinoin treatment can safely and effectively address acne scarring and similar disorders, thus providing relief to patients without the need for protracted waiting,” the authors wrote.

In August, another expert panel’s recommendations were published, which concluded that skin procedures, including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures, can be performed safely on patients who have recently been or are currently being treated with isotretinoin (JAMA Dermatol. 2017 Aug 1;153[8]:802-9).

The authors of the ASDS statement reported no relevant financial conflicts.

[email protected]

In most cases, there is little evidence to support delaying cosmetic procedures, such as laser therapy or chemical peels, in patients who have recently been treated with isotretinoin for acne, according to a consensus statement from the American Society of Dermatologic Surgery (ASDS).

An expert panel convened by the ASDS issued specific recommendations that supported safe, early initiation of cosmetic procedures in most cases. It noted that the likelihood of any potential harms from initiating cosmetic procedures after recent isotretinoin treatment is “low to very low” and that such harms have been reported only in case reports and case series.

Notable exceptions included dermabrasion and full-face ablative resurfacing; the experts recommended against having such procedures within 6 months of isotretinoin use because of potentially increased risks of adverse events in some patients.

“Potential benefits of this guideline include early access to scar treatments for many patients who are at the highest risk for scarring and, thereby, potentially improved patient quality of life,” Abigail Waldman, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and her coauthors wrote in the consensus statement (Dermatol Surg. 2017 Oct;43[10]:1249-62). This is the first consensus statement document published by the ASDS to address this topic.

• Dermabrasion. Treating specific facial areas while the patient is on isotretinoin or within 6 months of discontinuation “is not associated with increased risk of scar or delay in wound healing, and there is no evidence in the literature that supports a need to delay treatment,” they wrote. In contrast, they did not recommend full-face or mechanical dermabrasion with rotary devices within the 6-month window because it may be “associated with increased risk of adverse events in selected patients.”
• Lasers and energy devices. Similarly, the panel found no evidence that would justify delaying use of vascular lasers, hair removal lasers and lights, and nonablative or ablative fractional devices among patients recently treated with isotretinoin. However, they said fully ablative treatment of the entire face or regions other than the face should “generally be avoided until 6 months after completion of isotretinoin treatment because of the likely elevated risk of avoidable adverse events.”
• Chemical peels. Patients currently on isotretinoin or who have recently discontinued it can safely undergo superficial chemical peels, according to the panel. For medium or deep chemical peels, there was “insufficient data … to preclude a recommendation in this case,” the panel wrote.
• Other surgeries. Because of the risk of dry eyes, isotretinoin should be discontinued prior to laser eye surgery. For incisional and excisional cutaneous surgery, the data on isotretinoin were insufficient to make any recommendations, the experts concluded, though they acknowledged that in some cases, the surgeries may be “medically necessary.”

Most of these recommendations were based on case series and cohort studies, the panel said, rather than higher-quality, randomized clinical trials, which are “generally impractical and not likely forthcoming in this setting.” Moreover, they cautioned that insufficient evidence to make a recommendation should not be misconstrued as a confirmation of safety or a warning about risk.

Overall, the results of the analysis suggested that “procedural interventions during or soon after isotretinoin treatment can safely and effectively address acne scarring and similar disorders, thus providing relief to patients without the need for protracted waiting,” the authors wrote.

In August, another expert panel’s recommendations were published, which concluded that skin procedures, including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures, can be performed safely on patients who have recently been or are currently being treated with isotretinoin (JAMA Dermatol. 2017 Aug 1;153[8]:802-9).

The authors of the ASDS statement reported no relevant financial conflicts.

[email protected]

In most cases, there is little evidence to support delaying cosmetic procedures, such as laser therapy or chemical peels, in patients who have recently been treated with isotretinoin for acne, according to a consensus statement from the American Society of Dermatologic Surgery (ASDS).

An expert panel convened by the ASDS issued specific recommendations that supported safe, early initiation of cosmetic procedures in most cases. It noted that the likelihood of any potential harms from initiating cosmetic procedures after recent isotretinoin treatment is “low to very low” and that such harms have been reported only in case reports and case series.

Notable exceptions included dermabrasion and full-face ablative resurfacing; the experts recommended against having such procedures within 6 months of isotretinoin use because of potentially increased risks of adverse events in some patients.

“Potential benefits of this guideline include early access to scar treatments for many patients who are at the highest risk for scarring and, thereby, potentially improved patient quality of life,” Abigail Waldman, MD, of the department of dermatology at Brigham and Women’s Hospital, Boston, and her coauthors wrote in the consensus statement (Dermatol Surg. 2017 Oct;43[10]:1249-62). This is the first consensus statement document published by the ASDS to address this topic.

• Dermabrasion. Treating specific facial areas while the patient is on isotretinoin or within 6 months of discontinuation “is not associated with increased risk of scar or delay in wound healing, and there is no evidence in the literature that supports a need to delay treatment,” they wrote. In contrast, they did not recommend full-face or mechanical dermabrasion with rotary devices within the 6-month window because it may be “associated with increased risk of adverse events in selected patients.”
• Lasers and energy devices. Similarly, the panel found no evidence that would justify delaying use of vascular lasers, hair removal lasers and lights, and nonablative or ablative fractional devices among patients recently treated with isotretinoin. However, they said fully ablative treatment of the entire face or regions other than the face should “generally be avoided until 6 months after completion of isotretinoin treatment because of the likely elevated risk of avoidable adverse events.”
• Chemical peels. Patients currently on isotretinoin or who have recently discontinued it can safely undergo superficial chemical peels, according to the panel. For medium or deep chemical peels, there was “insufficient data … to preclude a recommendation in this case,” the panel wrote.
• Other surgeries. Because of the risk of dry eyes, isotretinoin should be discontinued prior to laser eye surgery. For incisional and excisional cutaneous surgery, the data on isotretinoin were insufficient to make any recommendations, the experts concluded, though they acknowledged that in some cases, the surgeries may be “medically necessary.”

Most of these recommendations were based on case series and cohort studies, the panel said, rather than higher-quality, randomized clinical trials, which are “generally impractical and not likely forthcoming in this setting.” Moreover, they cautioned that insufficient evidence to make a recommendation should not be misconstrued as a confirmation of safety or a warning about risk.

Overall, the results of the analysis suggested that “procedural interventions during or soon after isotretinoin treatment can safely and effectively address acne scarring and similar disorders, thus providing relief to patients without the need for protracted waiting,” the authors wrote.

In August, another expert panel’s recommendations were published, which concluded that skin procedures, including superficial chemical peels, laser hair removal, minor cutaneous surgery, manual dermabrasion, and fractional ablative and fractional nonablative laser procedures, can be performed safely on patients who have recently been or are currently being treated with isotretinoin (JAMA Dermatol. 2017 Aug 1;153[8]:802-9).

The authors of the ASDS statement reported no relevant financial conflicts.

[email protected]

Novel picosecond-domain 1,064 nm and 532 nm neodymium: yttrium aluminum garnet (Nd:YAG) lasers used with a new holographic beam splitter safely and effectively treated facial acne scars in a prospective study.

Among the 27 participants who completed the study, the mean improvement in acne scarring was 1.4 on a 10-point global aesthetic scale (range –4 to 6 points; 95% confidence interval, 0.85-1.9); these assessments were performed by three blinded physician reviewers 12 weeks after the last treatment. In addition, 23 (85%) of the participants reported that they were satisfied or very satisfied with their treatment, Eric F. Bernstein, MD, who is in private practice in Ardmore, Pa., and his coauthors reported (Lasers Surg Med. 2017 Nov;49[9]:796-802).

The study comprised 27 men and women with Fitzpatrick skin types II-V whose mean age was 45 years. They were treated with four monthly treatments. Of the participants, 19 were treated with the 1,064 nm laser and 8 with the 532 nm laser; both treatments employed a novel holographic hand piece to deliver precise beams of focused laser energy. Blinded physician reviewers evaluated digital images taken both before treatment and 12 weeks after the final treatment.

Based on the averages of scores from the reviewers, 81% of the participants showed some degree of improvement, 48% had a mean improvement of at least 2 points, and 26% had a mean improvement score of at least 3 points.

Participants experienced some side effects immediately after treatment, including mild to moderate erythema (100% of patients for both lasers), mild to moderate edema (95% for 1,064 nm, 97% for 532 nm), mild to moderate petechiae (50%, 38%), and mild purpura (17%, 0%). All these responses cleared within a few hours or a few days after treatments, according to patient reports.

None of the patients experienced pigmentary changes, based on before and after treatment photos. In contrast, the most commonly used laser for treating acne scarring – the nonfractionated CO₂ laser – causes significant hyperpigmentation and even permanent hypopigmentation, the authors pointed out.

No significant difference was seen when comparing mean improvement scores between participants treated with the 1,064 nm lasers and those treated with the 532 nm lasers.

“The use of picosecond-domain pulses delivers clinical benefits at lower fluences and energies than would be required at longer pulse durations and may offer qualitatively different tissue effects than earlier-generation lasers,” Dr. Bernstein and his coauthors wrote. “Future studies investigating combinations of the 1,064 and 532 nm picosecond-domain fractionated wavelengths, as well as larger trials with skin types V and VI, should increase the ways the device is used and the conditions it is used to treat,” they added.

Limitations of the study included the short 3-month follow-up, they noted.

The study was funded by Syneron Candela, the manufacturer of the laser and the holographic beam-splitting optic used in the study; the company loaned the equipment for the study. Dr. Bernstein is a consultant for Syneron Candela. Two of the five authors were employees of Syneron Candela at the time the study was conducted. No other financial disclosures were reported.

Novel picosecond-domain 1,064 nm and 532 nm neodymium: yttrium aluminum garnet (Nd:YAG) lasers used with a new holographic beam splitter safely and effectively treated facial acne scars in a prospective study.

Among the 27 participants who completed the study, the mean improvement in acne scarring was 1.4 on a 10-point global aesthetic scale (range –4 to 6 points; 95% confidence interval, 0.85-1.9); these assessments were performed by three blinded physician reviewers 12 weeks after the last treatment. In addition, 23 (85%) of the participants reported that they were satisfied or very satisfied with their treatment, Eric F. Bernstein, MD, who is in private practice in Ardmore, Pa., and his coauthors reported (Lasers Surg Med. 2017 Nov;49[9]:796-802).

The study comprised 27 men and women with Fitzpatrick skin types II-V whose mean age was 45 years. They were treated with four monthly treatments. Of the participants, 19 were treated with the 1,064 nm laser and 8 with the 532 nm laser; both treatments employed a novel holographic hand piece to deliver precise beams of focused laser energy. Blinded physician reviewers evaluated digital images taken both before treatment and 12 weeks after the final treatment.

Based on the averages of scores from the reviewers, 81% of the participants showed some degree of improvement, 48% had a mean improvement of at least 2 points, and 26% had a mean improvement score of at least 3 points.

Participants experienced some side effects immediately after treatment, including mild to moderate erythema (100% of patients for both lasers), mild to moderate edema (95% for 1,064 nm, 97% for 532 nm), mild to moderate petechiae (50%, 38%), and mild purpura (17%, 0%). All these responses cleared within a few hours or a few days after treatments, according to patient reports.

None of the patients experienced pigmentary changes, based on before and after treatment photos. In contrast, the most commonly used laser for treating acne scarring – the nonfractionated CO₂ laser – causes significant hyperpigmentation and even permanent hypopigmentation, the authors pointed out.

No significant difference was seen when comparing mean improvement scores between participants treated with the 1,064 nm lasers and those treated with the 532 nm lasers.

“The use of picosecond-domain pulses delivers clinical benefits at lower fluences and energies than would be required at longer pulse durations and may offer qualitatively different tissue effects than earlier-generation lasers,” Dr. Bernstein and his coauthors wrote. “Future studies investigating combinations of the 1,064 and 532 nm picosecond-domain fractionated wavelengths, as well as larger trials with skin types V and VI, should increase the ways the device is used and the conditions it is used to treat,” they added.

Limitations of the study included the short 3-month follow-up, they noted.

The study was funded by Syneron Candela, the manufacturer of the laser and the holographic beam-splitting optic used in the study; the company loaned the equipment for the study. Dr. Bernstein is a consultant for Syneron Candela. Two of the five authors were employees of Syneron Candela at the time the study was conducted. No other financial disclosures were reported.

Novel picosecond-domain 1,064 nm and 532 nm neodymium: yttrium aluminum garnet (Nd:YAG) lasers used with a new holographic beam splitter safely and effectively treated facial acne scars in a prospective study.

Among the 27 participants who completed the study, the mean improvement in acne scarring was 1.4 on a 10-point global aesthetic scale (range –4 to 6 points; 95% confidence interval, 0.85-1.9); these assessments were performed by three blinded physician reviewers 12 weeks after the last treatment. In addition, 23 (85%) of the participants reported that they were satisfied or very satisfied with their treatment, Eric F. Bernstein, MD, who is in private practice in Ardmore, Pa., and his coauthors reported (Lasers Surg Med. 2017 Nov;49[9]:796-802).

The study comprised 27 men and women with Fitzpatrick skin types II-V whose mean age was 45 years. They were treated with four monthly treatments. Of the participants, 19 were treated with the 1,064 nm laser and 8 with the 532 nm laser; both treatments employed a novel holographic hand piece to deliver precise beams of focused laser energy. Blinded physician reviewers evaluated digital images taken both before treatment and 12 weeks after the final treatment.

Based on the averages of scores from the reviewers, 81% of the participants showed some degree of improvement, 48% had a mean improvement of at least 2 points, and 26% had a mean improvement score of at least 3 points.

Participants experienced some side effects immediately after treatment, including mild to moderate erythema (100% of patients for both lasers), mild to moderate edema (95% for 1,064 nm, 97% for 532 nm), mild to moderate petechiae (50%, 38%), and mild purpura (17%, 0%). All these responses cleared within a few hours or a few days after treatments, according to patient reports.

None of the patients experienced pigmentary changes, based on before and after treatment photos. In contrast, the most commonly used laser for treating acne scarring – the nonfractionated CO₂ laser – causes significant hyperpigmentation and even permanent hypopigmentation, the authors pointed out.

No significant difference was seen when comparing mean improvement scores between participants treated with the 1,064 nm lasers and those treated with the 532 nm lasers.

“The use of picosecond-domain pulses delivers clinical benefits at lower fluences and energies than would be required at longer pulse durations and may offer qualitatively different tissue effects than earlier-generation lasers,” Dr. Bernstein and his coauthors wrote. “Future studies investigating combinations of the 1,064 and 532 nm picosecond-domain fractionated wavelengths, as well as larger trials with skin types V and VI, should increase the ways the device is used and the conditions it is used to treat,” they added.

Limitations of the study included the short 3-month follow-up, they noted.

The study was funded by Syneron Candela, the manufacturer of the laser and the holographic beam-splitting optic used in the study; the company loaned the equipment for the study. Dr. Bernstein is a consultant for Syneron Candela. Two of the five authors were employees of Syneron Candela at the time the study was conducted. No other financial disclosures were reported.

I admit it ... I am a victim too. The hype was real. Offer a service, at a hefty discount, and increase your patient volume. I didn’t need to increase my patient load. But with more overhead, getting the new providers in my practice busy fast was alluring. There are, however, so many inherent risks to discounting. So I offer you this column as my own version of a consumer alert on discount coupon sites.

Getty Images/Thinkstock

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

Sisler J. Discount deals becoming medical rage. CMAJ. 2012 Feb 21;184(3):E167-8.

Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg. 2002 Aug;110(2):614-9.

Atiyeh BS et al. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg. 2008 Nov;32(6):829-39.

Groupon’s Hidden Influence on Reputation. MIT Technology Review. Sept. 12, 2011.

I admit it ... I am a victim too. The hype was real. Offer a service, at a hefty discount, and increase your patient volume. I didn’t need to increase my patient load. But with more overhead, getting the new providers in my practice busy fast was alluring. There are, however, so many inherent risks to discounting. So I offer you this column as my own version of a consumer alert on discount coupon sites.

Getty Images/Thinkstock

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

Sisler J. Discount deals becoming medical rage. CMAJ. 2012 Feb 21;184(3):E167-8.

Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg. 2002 Aug;110(2):614-9.

Atiyeh BS et al. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg. 2008 Nov;32(6):829-39.

Groupon’s Hidden Influence on Reputation. MIT Technology Review. Sept. 12, 2011.

I admit it ... I am a victim too. The hype was real. Offer a service, at a hefty discount, and increase your patient volume. I didn’t need to increase my patient load. But with more overhead, getting the new providers in my practice busy fast was alluring. There are, however, so many inherent risks to discounting. So I offer you this column as my own version of a consumer alert on discount coupon sites.

Getty Images/Thinkstock

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

Sisler J. Discount deals becoming medical rage. CMAJ. 2012 Feb 21;184(3):E167-8.

Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg. 2002 Aug;110(2):614-9.

Atiyeh BS et al. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg. 2008 Nov;32(6):829-39.

Groupon’s Hidden Influence on Reputation. MIT Technology Review. Sept. 12, 2011.

The Food and Drug Administration has approved onabotulinumtoxinA, marketed as Botox Cosmetic by Allergan, for a third indication: the temporary improvement in the appearance of “moderate to severe forehead lines associated with frontalis muscle activity” in adults, according to the manufacturer.

[email protected]

The Food and Drug Administration has approved onabotulinumtoxinA, marketed as Botox Cosmetic by Allergan, for a third indication: the temporary improvement in the appearance of “moderate to severe forehead lines associated with frontalis muscle activity” in adults, according to the manufacturer.

[email protected]

The Food and Drug Administration has approved onabotulinumtoxinA, marketed as Botox Cosmetic by Allergan, for a third indication: the temporary improvement in the appearance of “moderate to severe forehead lines associated with frontalis muscle activity” in adults, according to the manufacturer.

[email protected]

To improve patient care and outcomes, leading dermatologists offered their recommendations on postprocedural makeup. Consideration must be given to:

• Dual Action Redness Relief
  PCA Skin
  “This product is great immediately after laser treatment or filler/botulinum toxin injections to reduce postprocedural redness.”— Gary Goldenberg, MD, New York, New York
   
• Isdinceutics Skin Drops
  ISDIN
  “This product is great to reduce or camouflage postprocedural bruising or redness.”—Gary Goldenberg, MD, New York, New York
   
• Oxygenating Foundation
  Oxygenetix
  “This is my favorite postprocedural makeup. Originally designed for burn victims, this makeup has botanicals, SPF, and is water resistant and soothing.”—Jeannette Graf, MD, Great Neck, New York
   
• Quick-Fix Concealer Stick
  Dermablend
  “This product is customized to match your patient’s skin type. It’s great at covering up purpura postprocedure.”—Shari Lipner, MD, PhD, New York, New York
  
  “I love Dermablend because it can essentially camouflage anything postprocedure, getting patients back to work or their social activities.”— Jerome Potozkin, MD, Danville, California

Cutis invites readers to send us their recommendations. Pigment corrector, lip plumper, moisturizers for men, and wet skin moisturizers will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on postprocedural makeup. Consideration must be given to:

• Dual Action Redness Relief
  PCA Skin
  “This product is great immediately after laser treatment or filler/botulinum toxin injections to reduce postprocedural redness.”— Gary Goldenberg, MD, New York, New York
   
• Isdinceutics Skin Drops
  ISDIN
  “This product is great to reduce or camouflage postprocedural bruising or redness.”—Gary Goldenberg, MD, New York, New York
   
• Oxygenating Foundation
  Oxygenetix
  “This is my favorite postprocedural makeup. Originally designed for burn victims, this makeup has botanicals, SPF, and is water resistant and soothing.”—Jeannette Graf, MD, Great Neck, New York
   
• Quick-Fix Concealer Stick
  Dermablend
  “This product is customized to match your patient’s skin type. It’s great at covering up purpura postprocedure.”—Shari Lipner, MD, PhD, New York, New York
  
  “I love Dermablend because it can essentially camouflage anything postprocedure, getting patients back to work or their social activities.”— Jerome Potozkin, MD, Danville, California

Cutis invites readers to send us their recommendations. Pigment corrector, lip plumper, moisturizers for men, and wet skin moisturizers will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on postprocedural makeup. Consideration must be given to:

• Dual Action Redness Relief
  PCA Skin
  “This product is great immediately after laser treatment or filler/botulinum toxin injections to reduce postprocedural redness.”— Gary Goldenberg, MD, New York, New York
   
• Isdinceutics Skin Drops
  ISDIN
  “This product is great to reduce or camouflage postprocedural bruising or redness.”—Gary Goldenberg, MD, New York, New York
   
• Oxygenating Foundation
  Oxygenetix
  “This is my favorite postprocedural makeup. Originally designed for burn victims, this makeup has botanicals, SPF, and is water resistant and soothing.”—Jeannette Graf, MD, Great Neck, New York
   
• Quick-Fix Concealer Stick
  Dermablend
  “This product is customized to match your patient’s skin type. It’s great at covering up purpura postprocedure.”—Shari Lipner, MD, PhD, New York, New York
  
  “I love Dermablend because it can essentially camouflage anything postprocedure, getting patients back to work or their social activities.”— Jerome Potozkin, MD, Danville, California

Cutis invites readers to send us their recommendations. Pigment corrector, lip plumper, moisturizers for men, and wet skin moisturizers will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

First introduced in 2008 as a surgical treatment of chronic conjunctival injection, cosmetic eye whitening became popularized in South Korea¹ and has been performed in more than 1800 patients in the United States.^1-3 Individuals with healthy eyes who elect to undergo this procedure often present with concerns of hyperemia, undesirable ocular pigmentation, or pingueculas. An initial report from Kim⁴ described 571 patients who underwent regional conjunctivectomy for persistent irreversible hyperemic conjunctiva with a 94.6% postoperative satisfaction rate. In contrast, over the last 5 years, various reported permanent complications raised concerns of the risk-benefit ratio of this cosmetic procedure.

The procedure involves performing a localized conjunctivectomy with or without removal of the Tenon capsule.⁴ Brimonidine tartrate is given for vascular constriction. When conjunctivectomy is performed in the right eye, the medial conjunctiva is incised from the 2-o’clock to 5-o’clock positions and the lateral conjunctiva is incised from the 10-o’clock to 7-o’clock positions. After the conjunctiva and Tenon capsule are excised, hemostasis is achieved with electrocauterization. Postoperative management may consist of topical mitomycin C (MMC) 0.02% 4 times daily for 2 to 5 days along with topical steroids. The addition of bevacizumab 1.25 mg/mL also has been described.⁵

In this report, we provide a comprehensive review of the complications of cosmetic eye whitening based on a review of the literature. Clinicians in both aesthetic practice and ophthalmology should be aware of the potential complications to accurately educate their patients about the possible risks and benefits of this procedure.

Methods

A review of PubMed articles indexed for MEDLINE (January 2009 to July 2017) using the search terms cosmetic eye whitening, cosmetic wide conjunctivectomy, I-Brite, and chronic hyperemic conjuctiva was conducted to evaluate the number of reports of complications from cosmetic eye whitening. A total of 10 articles were included in the study based on a review of abstracts. Non–English-language abstracts were not reviewed.

Results

Based on a review of 10 articles commenting on the complications of cosmetic eye whitening, a total of 2400 patients had undergone a cosmetic conjunctivectomy with various postoperative complications and recurrences (Table).^4-13 The most commonly recurring complications based on the reported frequencies in the articles included chronic conjunctival epithelial defects, scleral thinning, calcific plaques, dry eye syndrome, diplopia (sometimes requiring strabismus surgery), and elevated intraocular pressure.

Kim⁴ was the first to report this surgical technique for irreversible hyperemic conjunctiva (N=1815). The reported success rate in South Korea was overwhelmingly high at 94.6%. In a mean (SD) follow-up time of 12.9 (7.8) months (range, 2–27 months), less than 20% of patients required surgical revision. During this time, the most common postoperative complications included elevation in intraocular pressure (17.2%), conjunctival granuloma (8.4%), transient vision decrease (7.5%), pigment deposition (5.3%), scleral calcifications (3.9%), and diplopia secondary to conjunctival adhesions (1.6%). No permanent defects were reported, and complications improved with surgical and medical management.⁴

Contrary to the findings of Kim,⁴ a large number of complications were seen; thus, on March 4, 2011, the Korean Ministry of Health & Welfare issued a declaration to discontinue the procedure under Article 49 of the Medical Service Act. Medical records from the single clinic in Korea from November 2007 to May 2010 were reviewed.⁵ One of the largest reviews of cosmetic eye whitening complications reviewed 1713 patients who underwent conjunctivectomy plus topical MMC with or without bevacizumab injection. Pterygium and chronic conjunctival hyperemia were the most common diagnoses that prompted patients to undergo treatment. Over an average follow-up period of 10.9 months, the overall complication rate was 82.9%, with severe complications being fibrovascular conjunctival proliferation (43.8%), recurrent hyperemic conjunctiva (28.1%), intraocular pressure (13.1%), scleral thinning with calcified plaques (6.2%), scleral thinning (4.4%), and diplopia (3.6%). A total of 56.9% of patients reported being satisfied with the cosmetic outcome of the surgery.⁵

In some of the smaller case series and case reports we reviewed, more vision-threatening complications have been described. Infectious endophthalmitis, infectious scleritis, and necrotizing scleritis have all been reported as complications of cosmetic eye whitening.^8,10

Comment

The pathophysiology of the complications of cosmetic eye whitening stem from the disruption of the normal conjunctiva, destruction of the vascularization to the sclera, and loss of limbal stem cells. Mitomycin C is a topical antimetabolite antibiotic agent that inhibits DNA synthesis. This relatively safe and inexpensive product has decreased the recurrence rate in pterygium surgery as early as 1963.^14,15 Complications of MMC in pterygium surgery include infectious scleritis, necrotizing scleritis, calcium formation, and even scleromalacia, occurring at incidence rates as low as 1.4%.¹⁶ These risks are balanced against the medical necessity of using MMC. Given the elective nature of cosmetic eye whitening, these complications in a cosmetic setting may not be justified.

The debate of the use of this procedure continues to occur in ophthalmologic societies. Both the Korean Ministry of Health & Welfare and the American Society of Cataract Refractive Surgery do not condone the use of regional conjunctivectomy for cosmetic eye whitening.^5,17 Evidence shows that complications from cosmetic conjunctivectomy can be devastating and unnecessary given its elective nature. Although some complications (eg, dry eye syndrome, pain, discomfort) may be considered mild, the number of potentially serious complications brings the usefulness of the procedure into question.

This review is a launchpad to inform the medical community of the potential downside to conjunctivectomy for cosmetic eye whitening with the hope that it can initiate meaningful risk-benefit discussions between providers and physicians.

First introduced in 2008 as a surgical treatment of chronic conjunctival injection, cosmetic eye whitening became popularized in South Korea¹ and has been performed in more than 1800 patients in the United States.^1-3 Individuals with healthy eyes who elect to undergo this procedure often present with concerns of hyperemia, undesirable ocular pigmentation, or pingueculas. An initial report from Kim⁴ described 571 patients who underwent regional conjunctivectomy for persistent irreversible hyperemic conjunctiva with a 94.6% postoperative satisfaction rate. In contrast, over the last 5 years, various reported permanent complications raised concerns of the risk-benefit ratio of this cosmetic procedure.

The procedure involves performing a localized conjunctivectomy with or without removal of the Tenon capsule.⁴ Brimonidine tartrate is given for vascular constriction. When conjunctivectomy is performed in the right eye, the medial conjunctiva is incised from the 2-o’clock to 5-o’clock positions and the lateral conjunctiva is incised from the 10-o’clock to 7-o’clock positions. After the conjunctiva and Tenon capsule are excised, hemostasis is achieved with electrocauterization. Postoperative management may consist of topical mitomycin C (MMC) 0.02% 4 times daily for 2 to 5 days along with topical steroids. The addition of bevacizumab 1.25 mg/mL also has been described.⁵

In this report, we provide a comprehensive review of the complications of cosmetic eye whitening based on a review of the literature. Clinicians in both aesthetic practice and ophthalmology should be aware of the potential complications to accurately educate their patients about the possible risks and benefits of this procedure.

Methods

A review of PubMed articles indexed for MEDLINE (January 2009 to July 2017) using the search terms cosmetic eye whitening, cosmetic wide conjunctivectomy, I-Brite, and chronic hyperemic conjuctiva was conducted to evaluate the number of reports of complications from cosmetic eye whitening. A total of 10 articles were included in the study based on a review of abstracts. Non–English-language abstracts were not reviewed.

Results

Based on a review of 10 articles commenting on the complications of cosmetic eye whitening, a total of 2400 patients had undergone a cosmetic conjunctivectomy with various postoperative complications and recurrences (Table).^4-13 The most commonly recurring complications based on the reported frequencies in the articles included chronic conjunctival epithelial defects, scleral thinning, calcific plaques, dry eye syndrome, diplopia (sometimes requiring strabismus surgery), and elevated intraocular pressure.

Kim⁴ was the first to report this surgical technique for irreversible hyperemic conjunctiva (N=1815). The reported success rate in South Korea was overwhelmingly high at 94.6%. In a mean (SD) follow-up time of 12.9 (7.8) months (range, 2–27 months), less than 20% of patients required surgical revision. During this time, the most common postoperative complications included elevation in intraocular pressure (17.2%), conjunctival granuloma (8.4%), transient vision decrease (7.5%), pigment deposition (5.3%), scleral calcifications (3.9%), and diplopia secondary to conjunctival adhesions (1.6%). No permanent defects were reported, and complications improved with surgical and medical management.⁴

Contrary to the findings of Kim,⁴ a large number of complications were seen; thus, on March 4, 2011, the Korean Ministry of Health & Welfare issued a declaration to discontinue the procedure under Article 49 of the Medical Service Act. Medical records from the single clinic in Korea from November 2007 to May 2010 were reviewed.⁵ One of the largest reviews of cosmetic eye whitening complications reviewed 1713 patients who underwent conjunctivectomy plus topical MMC with or without bevacizumab injection. Pterygium and chronic conjunctival hyperemia were the most common diagnoses that prompted patients to undergo treatment. Over an average follow-up period of 10.9 months, the overall complication rate was 82.9%, with severe complications being fibrovascular conjunctival proliferation (43.8%), recurrent hyperemic conjunctiva (28.1%), intraocular pressure (13.1%), scleral thinning with calcified plaques (6.2%), scleral thinning (4.4%), and diplopia (3.6%). A total of 56.9% of patients reported being satisfied with the cosmetic outcome of the surgery.⁵

In some of the smaller case series and case reports we reviewed, more vision-threatening complications have been described. Infectious endophthalmitis, infectious scleritis, and necrotizing scleritis have all been reported as complications of cosmetic eye whitening.^8,10

Comment

The pathophysiology of the complications of cosmetic eye whitening stem from the disruption of the normal conjunctiva, destruction of the vascularization to the sclera, and loss of limbal stem cells. Mitomycin C is a topical antimetabolite antibiotic agent that inhibits DNA synthesis. This relatively safe and inexpensive product has decreased the recurrence rate in pterygium surgery as early as 1963.^14,15 Complications of MMC in pterygium surgery include infectious scleritis, necrotizing scleritis, calcium formation, and even scleromalacia, occurring at incidence rates as low as 1.4%.¹⁶ These risks are balanced against the medical necessity of using MMC. Given the elective nature of cosmetic eye whitening, these complications in a cosmetic setting may not be justified.

The debate of the use of this procedure continues to occur in ophthalmologic societies. Both the Korean Ministry of Health & Welfare and the American Society of Cataract Refractive Surgery do not condone the use of regional conjunctivectomy for cosmetic eye whitening.^5,17 Evidence shows that complications from cosmetic conjunctivectomy can be devastating and unnecessary given its elective nature. Although some complications (eg, dry eye syndrome, pain, discomfort) may be considered mild, the number of potentially serious complications brings the usefulness of the procedure into question.

This review is a launchpad to inform the medical community of the potential downside to conjunctivectomy for cosmetic eye whitening with the hope that it can initiate meaningful risk-benefit discussions between providers and physicians.

First introduced in 2008 as a surgical treatment of chronic conjunctival injection, cosmetic eye whitening became popularized in South Korea¹ and has been performed in more than 1800 patients in the United States.^1-3 Individuals with healthy eyes who elect to undergo this procedure often present with concerns of hyperemia, undesirable ocular pigmentation, or pingueculas. An initial report from Kim⁴ described 571 patients who underwent regional conjunctivectomy for persistent irreversible hyperemic conjunctiva with a 94.6% postoperative satisfaction rate. In contrast, over the last 5 years, various reported permanent complications raised concerns of the risk-benefit ratio of this cosmetic procedure.

The procedure involves performing a localized conjunctivectomy with or without removal of the Tenon capsule.⁴ Brimonidine tartrate is given for vascular constriction. When conjunctivectomy is performed in the right eye, the medial conjunctiva is incised from the 2-o’clock to 5-o’clock positions and the lateral conjunctiva is incised from the 10-o’clock to 7-o’clock positions. After the conjunctiva and Tenon capsule are excised, hemostasis is achieved with electrocauterization. Postoperative management may consist of topical mitomycin C (MMC) 0.02% 4 times daily for 2 to 5 days along with topical steroids. The addition of bevacizumab 1.25 mg/mL also has been described.⁵

In this report, we provide a comprehensive review of the complications of cosmetic eye whitening based on a review of the literature. Clinicians in both aesthetic practice and ophthalmology should be aware of the potential complications to accurately educate their patients about the possible risks and benefits of this procedure.

Methods

A review of PubMed articles indexed for MEDLINE (January 2009 to July 2017) using the search terms cosmetic eye whitening, cosmetic wide conjunctivectomy, I-Brite, and chronic hyperemic conjuctiva was conducted to evaluate the number of reports of complications from cosmetic eye whitening. A total of 10 articles were included in the study based on a review of abstracts. Non–English-language abstracts were not reviewed.

Results

Based on a review of 10 articles commenting on the complications of cosmetic eye whitening, a total of 2400 patients had undergone a cosmetic conjunctivectomy with various postoperative complications and recurrences (Table).^4-13 The most commonly recurring complications based on the reported frequencies in the articles included chronic conjunctival epithelial defects, scleral thinning, calcific plaques, dry eye syndrome, diplopia (sometimes requiring strabismus surgery), and elevated intraocular pressure.

Kim⁴ was the first to report this surgical technique for irreversible hyperemic conjunctiva (N=1815). The reported success rate in South Korea was overwhelmingly high at 94.6%. In a mean (SD) follow-up time of 12.9 (7.8) months (range, 2–27 months), less than 20% of patients required surgical revision. During this time, the most common postoperative complications included elevation in intraocular pressure (17.2%), conjunctival granuloma (8.4%), transient vision decrease (7.5%), pigment deposition (5.3%), scleral calcifications (3.9%), and diplopia secondary to conjunctival adhesions (1.6%). No permanent defects were reported, and complications improved with surgical and medical management.⁴

Contrary to the findings of Kim,⁴ a large number of complications were seen; thus, on March 4, 2011, the Korean Ministry of Health & Welfare issued a declaration to discontinue the procedure under Article 49 of the Medical Service Act. Medical records from the single clinic in Korea from November 2007 to May 2010 were reviewed.⁵ One of the largest reviews of cosmetic eye whitening complications reviewed 1713 patients who underwent conjunctivectomy plus topical MMC with or without bevacizumab injection. Pterygium and chronic conjunctival hyperemia were the most common diagnoses that prompted patients to undergo treatment. Over an average follow-up period of 10.9 months, the overall complication rate was 82.9%, with severe complications being fibrovascular conjunctival proliferation (43.8%), recurrent hyperemic conjunctiva (28.1%), intraocular pressure (13.1%), scleral thinning with calcified plaques (6.2%), scleral thinning (4.4%), and diplopia (3.6%). A total of 56.9% of patients reported being satisfied with the cosmetic outcome of the surgery.⁵

In some of the smaller case series and case reports we reviewed, more vision-threatening complications have been described. Infectious endophthalmitis, infectious scleritis, and necrotizing scleritis have all been reported as complications of cosmetic eye whitening.^8,10

Comment

The pathophysiology of the complications of cosmetic eye whitening stem from the disruption of the normal conjunctiva, destruction of the vascularization to the sclera, and loss of limbal stem cells. Mitomycin C is a topical antimetabolite antibiotic agent that inhibits DNA synthesis. This relatively safe and inexpensive product has decreased the recurrence rate in pterygium surgery as early as 1963.^14,15 Complications of MMC in pterygium surgery include infectious scleritis, necrotizing scleritis, calcium formation, and even scleromalacia, occurring at incidence rates as low as 1.4%.¹⁶ These risks are balanced against the medical necessity of using MMC. Given the elective nature of cosmetic eye whitening, these complications in a cosmetic setting may not be justified.

The debate of the use of this procedure continues to occur in ophthalmologic societies. Both the Korean Ministry of Health & Welfare and the American Society of Cataract Refractive Surgery do not condone the use of regional conjunctivectomy for cosmetic eye whitening.^5,17 Evidence shows that complications from cosmetic conjunctivectomy can be devastating and unnecessary given its elective nature. Although some complications (eg, dry eye syndrome, pain, discomfort) may be considered mild, the number of potentially serious complications brings the usefulness of the procedure into question.

This review is a launchpad to inform the medical community of the potential downside to conjunctivectomy for cosmetic eye whitening with the hope that it can initiate meaningful risk-benefit discussions between providers and physicians.

Several concepts of ideal aesthetic measurements can be traced back to ancient Greek and European Renaissance art. In examining canons of beauty, these classical ideals often are compared to modern-day standards, allowing clinicians to delineate the parameters of an attractive facial appearance and facilitate the planning of cosmetic procedures.

Given the growing number of available cosmetic interventions, dermatologists have a powerful ability to modify facial proportions; however, changes to individual structures should be made with a mindful approach to improving overall facial harmony. This article reviews the established parameters of facial beauty to assist the clinician in enhancing cosmetic outcomes.

Canons of Facial Aesthetics

Horizontal Thirds
In his writings on human anatomy, Leonardo da Vinci described dividing the face into equal thirds (Figure 1). The upper third measures from the trichion (the midline point of the normal hairline) to the glabella (the smooth prominence between the eyebrows). The middle third measures from the glabella to the subnasale (the midline point where the nasal septum meets the upper lip). The lower third measures from the subnasale to the menton (the most inferior point of the chin).¹

Although the validity of the canon is intended to apply across race and gender, these proportions may vary by ethnicity (Table). In white individuals, the middle third of the face tends to be shorter than the upper and lower thirds.² This same relationship has been observed in black males.³ In Chinese females, the upper third commonly is shorter than the middle and lower thirds, correlating with a less prominent forehead. In contrast, black females tend to have a relatively longer upper third.⁴

The relationship between modern perceptions of attractiveness and the neoclassical norm of equal thirds remains a topic of interest. Milutinovic et al¹ examined facial thirds in white female celebrities from beauty and fashion magazines and compared them to a group of anonymous white females from the general population. The group of anonymous females showed statistically significant (P<.05) differences between the sizes of the 3 facial segments, whereas the group of celebrity faces demonstrated uniformity between the facial thirds.¹

The lower face can itself be divided into thirds, with the upper third measured from the subnasale to the stomion (the midline point of the oral fissure when the lips are closed), and the lower two-thirds measured from the stomion to the menton (Figure 1). Mommaerts and Moerenhout⁵ examined photographs of 105 attractive celebrity faces and compared their proportions to those of classical sculptures of gods and goddesses (antique faces). The authors identified an upper one-third to lower two-thirds ratio of 69.8% in celebrity females and 69.1% in celebrity males; these ratios were not significantly different from the 72.4% seen in antique females and 73.1% in antique males. The authors concluded that a 30% upper lip to 70% lower lip-chin proportion may be the most appropriate to describe contemporary standards.⁵

Vertical Fifths
In the vertical dimension, the neoclassical canon of facial proportions divides the face into equal fifths (Figure 2).⁶ The 2 most lateral fifths are measured from the lateral helix of each ear to the exocanthus of each eye. The eye fissure lengths (measured between the endocanthion and exocanthion of each eye) represent one-fifth. The middle fifth is measured between the medial canthi of both eyes (endocanthion to endocanthion). This distance is equal to the width of the nose, as measured between both alae. Finally, the width of the mouth represents 1.5-times the width of the nose. These ratios of the vertical fifths apply to both males and females.⁶

Anthropometric studies have examined deviations from the neoclassical canon according to ethnicity. Wang et al⁷ compared the measurements of North American white and Han Chinese patients to these standards. White patients demonstrated a greater ratio of mouth width to nose width relative to the canon. In contrast, Han Chinese patients demonstrated a relatively wider nose and narrower mouth.⁷

In black individuals, it has been observed that the dimensions of most facial segments correspond to the neoclassical standards; however, nose width is relatively wider in black individuals relative to the canon as well as relative to white individuals.⁸

Milutinovic et al¹ also compared vertical fifths between white celebrities and anonymous females. In the anonymous female group, statistically significant (P<.05) variations were found between the sizes of the different facial components. In contrast, the celebrity female group showed balance between the widths of vertical fifths.¹

Lips
In the lower facial third, the lips represent a key element of attractiveness. Recently, lip augmentation, aimed at creating fuller and plumper lips, has dominated the popular culture and social media landscape.⁹ Although the aesthetic ideal of lips continues to evolve over time, recent studies have aimed at quantifying modern notions of attractive lip appearance.

Popenko et al¹⁰ examined lip measurements using computer-generated images of white women with different variations of lip sizes and lower face proportions. Computer-generated faces were graded on attractiveness by more than 400 individuals from focus groups. An upper lip to lower lip ratio of 1:2 was judged to be the most attractive, while a ratio of 2:1 was judged to be the least attractive. Results also showed that the surface area of the most attractive lips comprised roughly 10% of the lower third of the face.¹⁰

Penna et al¹¹ analyzed various parameters of the lips and lower facial third using photographs of 176 white males and females that were judged on attractiveness by 250 volunteer evaluators. Faces were graded on a scale from 1 (absolutely attractive) to 7 (absolutely unattractive). Attractive males and females (grades 1 and 2) both demonstrated an average ratio of upper vermilion height to nose-mouth distance (measured from the subnasalae to the lower edge of the upper vermilion border) of 0.28, which was significantly greater than the average ratio observed in less attractive individuals (grades 6 or 7)(P<.05). In addition, attractive males and females demonstrated a ratio of upper vermilion height to nose-chin distance (measured from the subnasalae to the menton) of 0.09, which again was larger than the average ratio seen in less attractive individuals. Figure 3 demonstrates an aesthetic ideal of the lips derived from these 2 studies, though consideration should be given to the fact that these studies were based in white populations.

Golden Ratio
The golden ratio, also known as Phi, can be observed in nature, art, and architecture. Approximately equal to 1.618, the golden ratio also has been identified as a possible marker of beauty in the human face and has garnered attention in the lay press. The ratio has been applied to several proportions and structures in the face, such as the ratio of mouth width to nose width or the ratio of tooth height to tooth width, with investigation providing varying levels of validation about whether these ratios truly correlate with perceptions of beauty.¹² Swift and Remington¹³ advocated for application of the golden ratio toward a comprehensive set of facial proportions. Marquardt¹⁴ used the golden ratio to create a 3-dimensional representation of an idealized face, known as the golden decagon mask. Although the golden ratio and the golden decagon mask have been proposed as analytic tools, their utility in clinical practice may be limited. Firstly, due to its popularity in the lay press, the golden ratio has been inconsistently applied to a wide range of facial ratios, which may undermine confidence in its representation as truth rather than coincidence. Secondly, although some authors have found validity of the golden decagon mask in representing unified ratios of attractiveness, others have asserted that it characterizes a masculinized white female and fails to account for ethnic differences.^15-19

Age-Related Changes

In addition to the facial proportions guided by genetics, several changes occur with increased age. Over the course of a lifetime, predictable patterns emerge in the dimensions of the skin, soft tissue, and bone. These alterations in structural proportions may ultimately lead to an unevenness in facial aesthetics.

In skeletal structure, gradual bone resorption and expansion causes a reduction in facial height as well as an increase in facial width and depth.²⁰ Fat atrophy and hypertrophy affect soft tissue proportions, visualized as hollowing at the temples, cheeks, and around the eyes, along with fullness in the submental region and jowls.²¹ Finally, decreases in skin elasticity and collagen exacerbate the appearance of rhytides and sagging. In older patients who desire a more youthful appearance, various applications of dermal fillers, fat grafting, liposuction, and skin tightening techniques can help to mitigate these changes.

Conclusion

Improving facial aesthetics relies on an understanding of the norms of facial proportions. Although cosmetic interventions commonly are advertised or described based on a single anatomical unit, it is important to appreciate the relationships between facial structures. Most notably, clinicians should be mindful of facial ratios when considering the introduction of filler materials or implants. Augmentation procedures at the temples, zygomatic arch, jaw, chin, and lips all have the possibility to alter facial ratios. Changes should therefore be considered in the context of improving overall facial harmony, with the clinician remaining cognizant of the ideal vertical and horizontal divisions of the face. Understanding such concepts and communicating them to patients can help in appropriately addressing all target areas, thereby leading to greater patient satisfaction.

Several concepts of ideal aesthetic measurements can be traced back to ancient Greek and European Renaissance art. In examining canons of beauty, these classical ideals often are compared to modern-day standards, allowing clinicians to delineate the parameters of an attractive facial appearance and facilitate the planning of cosmetic procedures.

Given the growing number of available cosmetic interventions, dermatologists have a powerful ability to modify facial proportions; however, changes to individual structures should be made with a mindful approach to improving overall facial harmony. This article reviews the established parameters of facial beauty to assist the clinician in enhancing cosmetic outcomes.

Canons of Facial Aesthetics

Horizontal Thirds
In his writings on human anatomy, Leonardo da Vinci described dividing the face into equal thirds (Figure 1). The upper third measures from the trichion (the midline point of the normal hairline) to the glabella (the smooth prominence between the eyebrows). The middle third measures from the glabella to the subnasale (the midline point where the nasal septum meets the upper lip). The lower third measures from the subnasale to the menton (the most inferior point of the chin).¹

Although the validity of the canon is intended to apply across race and gender, these proportions may vary by ethnicity (Table). In white individuals, the middle third of the face tends to be shorter than the upper and lower thirds.² This same relationship has been observed in black males.³ In Chinese females, the upper third commonly is shorter than the middle and lower thirds, correlating with a less prominent forehead. In contrast, black females tend to have a relatively longer upper third.⁴

The relationship between modern perceptions of attractiveness and the neoclassical norm of equal thirds remains a topic of interest. Milutinovic et al¹ examined facial thirds in white female celebrities from beauty and fashion magazines and compared them to a group of anonymous white females from the general population. The group of anonymous females showed statistically significant (P<.05) differences between the sizes of the 3 facial segments, whereas the group of celebrity faces demonstrated uniformity between the facial thirds.¹

The lower face can itself be divided into thirds, with the upper third measured from the subnasale to the stomion (the midline point of the oral fissure when the lips are closed), and the lower two-thirds measured from the stomion to the menton (Figure 1). Mommaerts and Moerenhout⁵ examined photographs of 105 attractive celebrity faces and compared their proportions to those of classical sculptures of gods and goddesses (antique faces). The authors identified an upper one-third to lower two-thirds ratio of 69.8% in celebrity females and 69.1% in celebrity males; these ratios were not significantly different from the 72.4% seen in antique females and 73.1% in antique males. The authors concluded that a 30% upper lip to 70% lower lip-chin proportion may be the most appropriate to describe contemporary standards.⁵

Vertical Fifths
In the vertical dimension, the neoclassical canon of facial proportions divides the face into equal fifths (Figure 2).⁶ The 2 most lateral fifths are measured from the lateral helix of each ear to the exocanthus of each eye. The eye fissure lengths (measured between the endocanthion and exocanthion of each eye) represent one-fifth. The middle fifth is measured between the medial canthi of both eyes (endocanthion to endocanthion). This distance is equal to the width of the nose, as measured between both alae. Finally, the width of the mouth represents 1.5-times the width of the nose. These ratios of the vertical fifths apply to both males and females.⁶

Anthropometric studies have examined deviations from the neoclassical canon according to ethnicity. Wang et al⁷ compared the measurements of North American white and Han Chinese patients to these standards. White patients demonstrated a greater ratio of mouth width to nose width relative to the canon. In contrast, Han Chinese patients demonstrated a relatively wider nose and narrower mouth.⁷

In black individuals, it has been observed that the dimensions of most facial segments correspond to the neoclassical standards; however, nose width is relatively wider in black individuals relative to the canon as well as relative to white individuals.⁸

Milutinovic et al¹ also compared vertical fifths between white celebrities and anonymous females. In the anonymous female group, statistically significant (P<.05) variations were found between the sizes of the different facial components. In contrast, the celebrity female group showed balance between the widths of vertical fifths.¹

Lips
In the lower facial third, the lips represent a key element of attractiveness. Recently, lip augmentation, aimed at creating fuller and plumper lips, has dominated the popular culture and social media landscape.⁹ Although the aesthetic ideal of lips continues to evolve over time, recent studies have aimed at quantifying modern notions of attractive lip appearance.

Popenko et al¹⁰ examined lip measurements using computer-generated images of white women with different variations of lip sizes and lower face proportions. Computer-generated faces were graded on attractiveness by more than 400 individuals from focus groups. An upper lip to lower lip ratio of 1:2 was judged to be the most attractive, while a ratio of 2:1 was judged to be the least attractive. Results also showed that the surface area of the most attractive lips comprised roughly 10% of the lower third of the face.¹⁰

Penna et al¹¹ analyzed various parameters of the lips and lower facial third using photographs of 176 white males and females that were judged on attractiveness by 250 volunteer evaluators. Faces were graded on a scale from 1 (absolutely attractive) to 7 (absolutely unattractive). Attractive males and females (grades 1 and 2) both demonstrated an average ratio of upper vermilion height to nose-mouth distance (measured from the subnasalae to the lower edge of the upper vermilion border) of 0.28, which was significantly greater than the average ratio observed in less attractive individuals (grades 6 or 7)(P<.05). In addition, attractive males and females demonstrated a ratio of upper vermilion height to nose-chin distance (measured from the subnasalae to the menton) of 0.09, which again was larger than the average ratio seen in less attractive individuals. Figure 3 demonstrates an aesthetic ideal of the lips derived from these 2 studies, though consideration should be given to the fact that these studies were based in white populations.

Golden Ratio
The golden ratio, also known as Phi, can be observed in nature, art, and architecture. Approximately equal to 1.618, the golden ratio also has been identified as a possible marker of beauty in the human face and has garnered attention in the lay press. The ratio has been applied to several proportions and structures in the face, such as the ratio of mouth width to nose width or the ratio of tooth height to tooth width, with investigation providing varying levels of validation about whether these ratios truly correlate with perceptions of beauty.¹² Swift and Remington¹³ advocated for application of the golden ratio toward a comprehensive set of facial proportions. Marquardt¹⁴ used the golden ratio to create a 3-dimensional representation of an idealized face, known as the golden decagon mask. Although the golden ratio and the golden decagon mask have been proposed as analytic tools, their utility in clinical practice may be limited. Firstly, due to its popularity in the lay press, the golden ratio has been inconsistently applied to a wide range of facial ratios, which may undermine confidence in its representation as truth rather than coincidence. Secondly, although some authors have found validity of the golden decagon mask in representing unified ratios of attractiveness, others have asserted that it characterizes a masculinized white female and fails to account for ethnic differences.^15-19

Age-Related Changes

In addition to the facial proportions guided by genetics, several changes occur with increased age. Over the course of a lifetime, predictable patterns emerge in the dimensions of the skin, soft tissue, and bone. These alterations in structural proportions may ultimately lead to an unevenness in facial aesthetics.

In skeletal structure, gradual bone resorption and expansion causes a reduction in facial height as well as an increase in facial width and depth.²⁰ Fat atrophy and hypertrophy affect soft tissue proportions, visualized as hollowing at the temples, cheeks, and around the eyes, along with fullness in the submental region and jowls.²¹ Finally, decreases in skin elasticity and collagen exacerbate the appearance of rhytides and sagging. In older patients who desire a more youthful appearance, various applications of dermal fillers, fat grafting, liposuction, and skin tightening techniques can help to mitigate these changes.

Conclusion

Improving facial aesthetics relies on an understanding of the norms of facial proportions. Although cosmetic interventions commonly are advertised or described based on a single anatomical unit, it is important to appreciate the relationships between facial structures. Most notably, clinicians should be mindful of facial ratios when considering the introduction of filler materials or implants. Augmentation procedures at the temples, zygomatic arch, jaw, chin, and lips all have the possibility to alter facial ratios. Changes should therefore be considered in the context of improving overall facial harmony, with the clinician remaining cognizant of the ideal vertical and horizontal divisions of the face. Understanding such concepts and communicating them to patients can help in appropriately addressing all target areas, thereby leading to greater patient satisfaction.

Several concepts of ideal aesthetic measurements can be traced back to ancient Greek and European Renaissance art. In examining canons of beauty, these classical ideals often are compared to modern-day standards, allowing clinicians to delineate the parameters of an attractive facial appearance and facilitate the planning of cosmetic procedures.

Given the growing number of available cosmetic interventions, dermatologists have a powerful ability to modify facial proportions; however, changes to individual structures should be made with a mindful approach to improving overall facial harmony. This article reviews the established parameters of facial beauty to assist the clinician in enhancing cosmetic outcomes.

Canons of Facial Aesthetics

Horizontal Thirds
In his writings on human anatomy, Leonardo da Vinci described dividing the face into equal thirds (Figure 1). The upper third measures from the trichion (the midline point of the normal hairline) to the glabella (the smooth prominence between the eyebrows). The middle third measures from the glabella to the subnasale (the midline point where the nasal septum meets the upper lip). The lower third measures from the subnasale to the menton (the most inferior point of the chin).¹

Although the validity of the canon is intended to apply across race and gender, these proportions may vary by ethnicity (Table). In white individuals, the middle third of the face tends to be shorter than the upper and lower thirds.² This same relationship has been observed in black males.³ In Chinese females, the upper third commonly is shorter than the middle and lower thirds, correlating with a less prominent forehead. In contrast, black females tend to have a relatively longer upper third.⁴

The relationship between modern perceptions of attractiveness and the neoclassical norm of equal thirds remains a topic of interest. Milutinovic et al¹ examined facial thirds in white female celebrities from beauty and fashion magazines and compared them to a group of anonymous white females from the general population. The group of anonymous females showed statistically significant (P<.05) differences between the sizes of the 3 facial segments, whereas the group of celebrity faces demonstrated uniformity between the facial thirds.¹

The lower face can itself be divided into thirds, with the upper third measured from the subnasale to the stomion (the midline point of the oral fissure when the lips are closed), and the lower two-thirds measured from the stomion to the menton (Figure 1). Mommaerts and Moerenhout⁵ examined photographs of 105 attractive celebrity faces and compared their proportions to those of classical sculptures of gods and goddesses (antique faces). The authors identified an upper one-third to lower two-thirds ratio of 69.8% in celebrity females and 69.1% in celebrity males; these ratios were not significantly different from the 72.4% seen in antique females and 73.1% in antique males. The authors concluded that a 30% upper lip to 70% lower lip-chin proportion may be the most appropriate to describe contemporary standards.⁵

Vertical Fifths
In the vertical dimension, the neoclassical canon of facial proportions divides the face into equal fifths (Figure 2).⁶ The 2 most lateral fifths are measured from the lateral helix of each ear to the exocanthus of each eye. The eye fissure lengths (measured between the endocanthion and exocanthion of each eye) represent one-fifth. The middle fifth is measured between the medial canthi of both eyes (endocanthion to endocanthion). This distance is equal to the width of the nose, as measured between both alae. Finally, the width of the mouth represents 1.5-times the width of the nose. These ratios of the vertical fifths apply to both males and females.⁶

Anthropometric studies have examined deviations from the neoclassical canon according to ethnicity. Wang et al⁷ compared the measurements of North American white and Han Chinese patients to these standards. White patients demonstrated a greater ratio of mouth width to nose width relative to the canon. In contrast, Han Chinese patients demonstrated a relatively wider nose and narrower mouth.⁷

In black individuals, it has been observed that the dimensions of most facial segments correspond to the neoclassical standards; however, nose width is relatively wider in black individuals relative to the canon as well as relative to white individuals.⁸

Milutinovic et al¹ also compared vertical fifths between white celebrities and anonymous females. In the anonymous female group, statistically significant (P<.05) variations were found between the sizes of the different facial components. In contrast, the celebrity female group showed balance between the widths of vertical fifths.¹

Lips
In the lower facial third, the lips represent a key element of attractiveness. Recently, lip augmentation, aimed at creating fuller and plumper lips, has dominated the popular culture and social media landscape.⁹ Although the aesthetic ideal of lips continues to evolve over time, recent studies have aimed at quantifying modern notions of attractive lip appearance.

Popenko et al¹⁰ examined lip measurements using computer-generated images of white women with different variations of lip sizes and lower face proportions. Computer-generated faces were graded on attractiveness by more than 400 individuals from focus groups. An upper lip to lower lip ratio of 1:2 was judged to be the most attractive, while a ratio of 2:1 was judged to be the least attractive. Results also showed that the surface area of the most attractive lips comprised roughly 10% of the lower third of the face.¹⁰

Penna et al¹¹ analyzed various parameters of the lips and lower facial third using photographs of 176 white males and females that were judged on attractiveness by 250 volunteer evaluators. Faces were graded on a scale from 1 (absolutely attractive) to 7 (absolutely unattractive). Attractive males and females (grades 1 and 2) both demonstrated an average ratio of upper vermilion height to nose-mouth distance (measured from the subnasalae to the lower edge of the upper vermilion border) of 0.28, which was significantly greater than the average ratio observed in less attractive individuals (grades 6 or 7)(P<.05). In addition, attractive males and females demonstrated a ratio of upper vermilion height to nose-chin distance (measured from the subnasalae to the menton) of 0.09, which again was larger than the average ratio seen in less attractive individuals. Figure 3 demonstrates an aesthetic ideal of the lips derived from these 2 studies, though consideration should be given to the fact that these studies were based in white populations.

Golden Ratio
The golden ratio, also known as Phi, can be observed in nature, art, and architecture. Approximately equal to 1.618, the golden ratio also has been identified as a possible marker of beauty in the human face and has garnered attention in the lay press. The ratio has been applied to several proportions and structures in the face, such as the ratio of mouth width to nose width or the ratio of tooth height to tooth width, with investigation providing varying levels of validation about whether these ratios truly correlate with perceptions of beauty.¹² Swift and Remington¹³ advocated for application of the golden ratio toward a comprehensive set of facial proportions. Marquardt¹⁴ used the golden ratio to create a 3-dimensional representation of an idealized face, known as the golden decagon mask. Although the golden ratio and the golden decagon mask have been proposed as analytic tools, their utility in clinical practice may be limited. Firstly, due to its popularity in the lay press, the golden ratio has been inconsistently applied to a wide range of facial ratios, which may undermine confidence in its representation as truth rather than coincidence. Secondly, although some authors have found validity of the golden decagon mask in representing unified ratios of attractiveness, others have asserted that it characterizes a masculinized white female and fails to account for ethnic differences.^15-19

Age-Related Changes

In addition to the facial proportions guided by genetics, several changes occur with increased age. Over the course of a lifetime, predictable patterns emerge in the dimensions of the skin, soft tissue, and bone. These alterations in structural proportions may ultimately lead to an unevenness in facial aesthetics.

In skeletal structure, gradual bone resorption and expansion causes a reduction in facial height as well as an increase in facial width and depth.²⁰ Fat atrophy and hypertrophy affect soft tissue proportions, visualized as hollowing at the temples, cheeks, and around the eyes, along with fullness in the submental region and jowls.²¹ Finally, decreases in skin elasticity and collagen exacerbate the appearance of rhytides and sagging. In older patients who desire a more youthful appearance, various applications of dermal fillers, fat grafting, liposuction, and skin tightening techniques can help to mitigate these changes.

Conclusion

Improving facial aesthetics relies on an understanding of the norms of facial proportions. Although cosmetic interventions commonly are advertised or described based on a single anatomical unit, it is important to appreciate the relationships between facial structures. Most notably, clinicians should be mindful of facial ratios when considering the introduction of filler materials or implants. Augmentation procedures at the temples, zygomatic arch, jaw, chin, and lips all have the possibility to alter facial ratios. Changes should therefore be considered in the context of improving overall facial harmony, with the clinician remaining cognizant of the ideal vertical and horizontal divisions of the face. Understanding such concepts and communicating them to patients can help in appropriately addressing all target areas, thereby leading to greater patient satisfaction.

SAN DIEGO – When counseling patients about laser tattoo removal, resist the temptation to promise clearance in a certain number of treatments.

“You will regret it,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “If you say, ‘This looks like this is going to take 6-8 treatments, this looks very simple to me,’ you’ll find that you’ll have someone who requires 15-18 treatments. Further, partial clearing may be cosmetically inferior than nontreatment.”

SAN DIEGO – When counseling patients about laser tattoo removal, resist the temptation to promise clearance in a certain number of treatments.

“You will regret it,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “If you say, ‘This looks like this is going to take 6-8 treatments, this looks very simple to me,’ you’ll find that you’ll have someone who requires 15-18 treatments. Further, partial clearing may be cosmetically inferior than nontreatment.”

SAN DIEGO – When counseling patients about laser tattoo removal, resist the temptation to promise clearance in a certain number of treatments.

“You will regret it,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium. “If you say, ‘This looks like this is going to take 6-8 treatments, this looks very simple to me,’ you’ll find that you’ll have someone who requires 15-18 treatments. Further, partial clearing may be cosmetically inferior than nontreatment.”