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Objectives. Discuss the history of cosmetic facial rejuvenationDiscuss Aging and Photodamage to the skinDiscuss treatment options for adynamic facial conditions and their associated complications. History of Facial Rejuvenation. 3000 BCE EgyptiansManicures, Make-up, Tattoos of the face (1)1500
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1. Nonoperative Facial Rejuvenation Andrew Coughlin M.D.
Raghu Athre M.D.
University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
February 25, 2010
2. Objectives Discuss the history of cosmetic facial rejuvenation
Discuss Aging and Photodamage to the skin
Discuss treatment options for adynamic facial conditions and their associated complications
3. History of Facial Rejuvenation 3000 BCE Egyptians
Manicures, Make-up, Tattoos of the face (1)
1500 BCE Egyptians
Used sandpaper for scars as early form of dermabrasion (2)
100 BCE Roman poet Ovid: The Art of Love
Facial mask of barley, bean, eggs, hartshorn, narcissus bulbs, balsam, Tuscany seed, honey (3)
200 CE Jewish Talmud
Husband must provide 10 dinars for his wifes cosmetic needs
900 CE Arabic Physicians
Crushed rice, seashells, marble, crystal, limes, eggs, beans, ground lentils (dermabrasion)
4. History of Facial Rejuvenation 1905 Kromayer
Mechanical dermabrasion with wheels and rasps (4)
1960s Facial Peels
1990s CO2 Laser Resurfacing
Most recently filler agents have become increasingly popular
**Modern techniques are reminiscent of ancient techniques
5. Layers of the Skin
6. Epidermis Stratum Corneum
Keratinized cells to be sloughed off
Stratum Lucidum
Stratum Granulosum
Stratum Spinosum
Stratum Basale
Basal regenerative cells and melanocytes
Regeneration every 12-14 days (1)
7. Epidermis
8. Dermal Layers Papillary Dermis
Meshwork of fine type III collagen fibers
Anchors epidermis down to dermis
Reticular Dermis
Thick type I collagen bundles
Elastic fibers for resiliency
Glycosaminoglycans (GAGs)
Ground substance between fibers
Can hold up to 1000x their weight in water (5)
Hair, sebaceous/sweat glands, nerve receptors and blood vessels
9. Papillary and Reticular Dermis
10. Hypodermis Connects skin and underlying bone/muscle
Loose connective tissue and elastin
Predominant Cells
Fibroblasts
Macrophages
Adipocytes
11. Damage to the Dermis Age
Decreased ratio of Type I : Type III collagen
Photodamage and Tobacco Smoke (6)
Increase tissue collagenases and gelatinases
Further decrease collagen in the dermis
Decrease capillary and blood flow to skin
Decreased skin integrity
**Ultimately leads to decreased skin turgor and elasticity forming wrinkles and sagging skin (7)
12. Initial Evaluation Patient selection is key
Unrealistic
Psychiatric history or multiple physician visits
Smokers have 12 times increased skin sloughing and scarring
Must perform proper:
Education
Counselling
Consistent procedural skills
13. Physical Exam Are rhytids dynamic vs adynamic
Traction of skin in antagonistic direction
Hypo- or Hyperpigmented skin
Associated skin conditions
Active infection
Thickness of skin
Glogau System
14. Glogau System (8) Stratifies patients based on amount of aging and skin damage
Category I
Photoaging down to stratum granulosum or papillary dermis with minimal wrinkles
Dermabrasion or superficial chemical peeling
Category II
Photodamage down to upper reticular dermis and wrinkles with facial gestures
Medium depth chemical peeling
Category III
Photodamage down to upper reticular dermis and wrinkles at rest
Medium depth peels
Category IV
Photodamage to mid reticular dermis, wrinkles, skin discoloration
Deep peel required
15. Treatment Options Dermabrasion
Laser Resurfacing
Chemical Peels
Facial Fillers
16. Dermabrasion Purpose is to level the skin and promote re-epithelialization with new collagen deposition.
Used for:
Scar revision
Acne scarring
Rhinophyma
Facial rhytids
Contraindicated for Keloids and Hypertrophic Scars
Must only injure only the papillary dermis
Preserves adnexal structures for re-epithelialization
Damage through the reticular dermis (Fat visualized) leads to adverse scarring
17. Dermabrasion Performed with high speed diamond fraise or wire brush.
Local anesthesia +/- IV sedation
Broad surfaces are frozen to maintain rigid tissue (malar region)
Brush strokes are made at right angles to the brush rotation to avoid loss of control and damage to normal tissue
Feathering: Edges are slightly brushed for blending
18. Dermabrasion Upper layers of skin are removed resulting in partial thickness wounds
Small pinpoint bleeding of the wound
Heal by re-epithelialization in 7-10 days
Recovery is 2-3 weeks
19. Microdermabrasion Alternative to dermabrasion that attacks just the upper layer of skin
Disadvantages
Only good for early photodamage and superficial wrinkles
Not useful for dermal pathology
Uses Aluminum oxide microcrystals
Advantages
Repeated at short intervals
Painless requiring no anesthesia
Minimal erythema and side effects
20. Microdermabrasion Freedman 2001 (9)
10 patients treated with 6 treatments
Physical exam and tissue biopsy
Thickened epidermis and dermis with newly deposited collagen
Karimipour 2010 PRSJ (10)
Very good for skin contour irregularities such as rhytids
Less effective with dyschromias than glycolic acid peels
No RCT to evaluate uses in acne but decision should be based on patients expectations
21. Picture of Debridment Instrument
22. Dermabrasion Results
23. LaserResurfacing
24. Laser Resurfacing Works by targeting chromophores
Each laser has a different chromophore:
Water, oxyhemoglobin, melanin, etc.
Chromophore absorbs the laser heat destroys cells harboring that chromophore
Amount of chromophore in a cell is proportional to absorption/destruction
Lasers have opened the door for treatment of periocular skin where dermabrasion cannot reach
25. Ablative Lasers Carbon Dioxide (10,600nm)
Used with the same indications as dermabrasion
Wavelength selectively targets water in soft tissue
More collagen production and prolonged redness due to dispersed thermal injury
Other advantages
Hemostatic properties
Depth of treatment is more precise with laser
Skin tightening is immediate
Skin irregularities are improved immediately
26. Ablative Lasers Erbium:YAG (2,940nm)
Reduced thermal damage
Less post-therapy redness
Less collagen production
Newman et al. 1999 (11)
Compared Er:YAG and CO2 laser
21 patients with half the upper lip treated by each laser
Er:YAG had less days of crusting 3.4 compared to 7.7
63% vs 54% improvement at 2 months favoring CO2
27. Other Lasers Nd:YAG Laser (1,064nm)
Infrared, invisible, oxyhemaglobin, deep penetration
Good for port-wine stains, telangiectasias, hemangiomas
KTP (532nm)
Visible, oxyhemaglobin absorption
Good for cutaneous lesions
Argon (193nm)
Visible, broad blue band, oxyhemaglobin
Penetrates between CO2 and Nd:YAG
Same indications as Nd:YAG
Flashlamp Excited Pulsed Dye (595 nm)
Visible, yellow light, vascular sensitive
Less scarring and hypopigmentation than Nd:YAG & Argon
Cutaneous vascular lesions
28. Effectiveness of Lasers Bisson in 2002 evaluated 31 patients (12)
At 6 weeks wrinkle depth reduction of 91%
At 2 years wrinkle depth reduction of 87%
2001 Lasers are falling out of favor (13)
88% of patients considered post-therapy results very good.
77% would not be willing to have procedure again.
**Several studies have shown equivalent results of CO2 lasers compared to dermabrasion (14-16)
29. Laser Resurfacing Results
30. Complications of Dermabrasion/Laser Resurfacing Infection (17)
Bacterial infection rates 4.3 to 12%
Fungal infection rates 1.8 to 2.2%
Hypo/Hyperpigmentary mismatches
Dark Skinned Patients
Melasma or Cholasma associated with OCPs
Photosensitivity post-procedure should be prevented with UV blocking lotions for 2 months (18-19)
Scarring Risk
Must stop 13-cis-retinoic acid (Accutane) for 6-12 months prior to therapy (20)
Milia Formation
Small epidermal cysts common after dermabrasion
Can be prevented with occlusive ointments or dressings for 1-2 weeks
Can be treated with abrasive cleansers or scalpel
Herpes Simplex Risk
Roberts et al 1997 (21)
Studied 907 patients with CO2 laser treatment and found that HSV infection of 3% was reduced to 1% with acyclovir prophylaxis
Therefore patients treated with antivirals for 2-3 days prior and 7-10 days post procedure
31. Laser Resurfacing Redness
32. Melasma/Chloasma
33. Milia
34. Chemoexfoliation Controlled wounding of skin to induce regeneration and a more youthful appearance
Most commonly used for photodamage that leads to
Thickened Stratum Corneum
Thinned Stratum Spinosum
Disorganized maturation and elastin
Decreased dermal collagen and GAGs
Irregular melanin dispersion
Skin is rough, wrinkled and mottled
35. Damaging Levels Stratum Corneum
Skin feels smoother
Epidermal Basement Membrane
Melanocytes live here
Lighter and evenly pigmented
Upper Reticular Dermis
Smoother and lighter skin
Deposition of new collagen, elastin, GAGs
Subsequent reduction of fine wrinkles
Middle Reticular Dermis
More collagen production with reduction of deeper wrinkles
Deep Reticular Dermis
Collagen production can produce a scar
36. Factors that increase solution penetration Solution Concentration
Condition of Skin
Pre-treatment tretinoin, electrolysis, surgery, waxing.
Pre-peel degreasing with alcohol or acetone
Application (brush, swab, sponge)
Rubbing
Time of contact
Occlusion with tape or petroleum jelly
37. Individual Results Some argue that test patching is important because each person reacts so differently to each type of peel
Depth of penetration
Wrinkling response
Scarring
Post-therapy care should include ointment to promote healing, sun avoidance, and proper wound care to prevent infection
38. Patient Selection Post-therapy appearance can be frightening
Make sure patients are:
Psychologically stable
Compliant with post-therapy care
Willing to stay out of the sun
Willing to wear makeup
Be sure to perform proper informed consent and document it appropriately
39. Topical Retin-A First line therapy
Advantages
Reverses all the previously discussed findings of sun damage
Also decreases fine wrinkles, evens pigmentary differences, smoothes the skin
Disadvantages
Photosensitivity
Dries the skin out making moisturizers necessary
Class C pregnancy media
Can be combined with alpha hydroxy acids which are less effective but potentiate tretinoin preparations
40. Process of Skin Peeling Cleansing
Septisol and acetone to decrease oil and scaliness of the skin
Jessners or 70% glycolic solution can be used first to break initial barriers and allow TCA to penetrate deeper (8)
Application
Superficial? blotchy white and red frost
Medium? white frost with surrounding erythema
Deep? solid white with no erythema
Healing
Cool saline presses to decrease inflammation
Vinegar soaks Q2 hours while awake for 5-7 days
Regular follow up to look for infection
41. Superficial Peels Glycolic Acid
Trichloroacetic Acid 10%
Jessner Solution (lactate+salicylate+resorcinol+ethanol)
Apply for a few minutes then rinse with water or neutralize with bicarbonate solution
Stinging sensation and slight flush
Smooth glowing skin with no activity restrictions
Repeated doses Q week/2 weeks/4 weeks
If you want to peels down to the basement membrane
Slightly stronger concentration of solution
desquamation for 2-3 days
42. Superficial Peel Results
43. Medium Depth Peel Amount of collagen depends on depth of peel and individual variations
Scarring occurs with any subepidermal wound but is unpredictable
TCA >50% have higher incidence of scarring (22-24)
TCA 35% in combo with Jessner or glycolic solution first help with penetration
Post treatment
Skin turns dark brown
Exfoliates for 4-7 days
Socially incapacitated for 7 days
New skin is very pink
44. Medium Peel Results
45. Deep Peels Baker-Gordon Peel
Formulation
3cc 88% phenol
2cc water
8 drops of septisol
3 drops croton oil
Treatment
Agitate solution prior to usage
Cotton tip application to 1 section of face at a time
Slow application to regional subunits
Prevents systemic absorption and arrhythmias
Post Treatment
Frosting of skin is immediate
Swelling intense and release of epithelium over 1-2 days
Re-epithelialization takes over 1 week
Constant serous exudate hourly
Very red skin for months
Hypopigmentation expected
Results
Robust collagen formation is long-lasting
Fine and deep wrinkles respond well
46. Bakers Peel Progression
47. Complications Landau 2007 (23)
181 patients with full face peels
10-15 minutes between each face section
6.6% arrhythmias
Increased with Diabetes, HTN, depression
Prevention
Sedation
IV hydration
EKG, LFTs, Kidney function prior to therapy
Monitoring with close follow up
48. Complications Infection
Usually result of poor post-procedural care
Bacterial, Fungal, or Herpetic
Prophylactic antivirals
Post-procedure antibiotics
Vinegar washes very important
Culture any non-healing wounds
49. Complications Hyperpigmentation
Dark skin, OCPs and pregnancy
Prophylaxis with hydroquinone
Treatment with Tretinoin, alpha hydroxy acid, and steroid cream
Sun avoidance before and after treatment plus sunscreen
Repeeling is an option if poor results occur
50. Complications Scarring
Post-therapy infection
Use of oral accutane
Healing is by re-epithelialization from pilosebaceous units
Accutane destroys sebaceous units
Recently radiated skin
Recently operated skin (undermining)
History of keloids
51. Complications Hypopigmentation
Occurs after deep peeling
More apparent in very dark or very light skin
Feathering of the peel with dermabrasion can camouflage the edges
52. Soft Tissue Augmentation
53. Soft-Tissue Augmentation History Began in 1893 Neuber harvested arm fat and injected it into the patients facial defects (24)
Fillers now used for
Scars from trauma and acne
Static or dynamic rhytids
Lip augmentations
Melolabial fold augmentation
1900s paraffin injection used but fell out of favor due to paraffinomas (granulomatous reactions)
40-50s Silicone introduced
Granulomatous reactions and scarring limited its use
1970s Stanford used human and animal collagen
Still in use today in bovine form (25)
54. Modern Injectable Fillers Research is huge in this area for the ideal filler
Inert, long lasting, abundant, low cost, no allergy, not carcinogenic, fixable
Patient demand high
Outpatient injection
No surgery
Minimal recovery 48-72 hours
Lower short term cost
Dermis is the #1 place of injection
Fibroblasts that produce type 1 collagen are most abundant in this region
55. Types of Fillers Xenografts
Homografts
Autografts
Synthetics
56. Xenografts Bovine Collagen
Most widely used and is the Gold Standard
All are dissolved in saline and lidocaine and Pepsin proteolysis to decrease antigenicity
Zyderm I (35mg/mL)
Injected into upper dermis
Poor long term effect because of low concentration
Overcorrection necessary 100% (26)
Zyderm II (65mg/mL)
Injected into mid dermis
Longer effect with higher concentration
Overcorrection necessary 50% (26)
Zyplast (35mg/mL)
Cross linked with glutaraldehyde to decrease degredation
Injected into reticular dermis for longer duration/less resorption
No overcorrection recommended
57. Bovine Collagen Complications Hypersensitivity reaction
Tenderness
Induration
Erythema
Pruritis
Skin testing before definitive use
3-4% with positive skin test (27,28)
20 to 30% may show delayed reaction
Must examine skin test site in 4 to 6 weeks prior to initiating therapy
Some argue that second skin test necessary as reactions can occur with repeated injections
Other complications
Tissue necrosis (29)
Foreign body reaction
Headache/Nausea/Arthralgias (30)
58. Homografts Cosmoderm and Cosmoplast
Bioengineered collagen from fibroblasts
No antigenicity so no skin testing required
Packaged and concentrated analogously to Zyderm I and Zyplast respectively
Cosmoderm for superficial wrinkles
Cosmoplast for deeper scars and grooves
On average they last 3-6 months but duration is less than bovine equivalents (26)
59. Homografts Alloderm (Cymetra = injectable form)
Acellular dermal graft from cadaveric skin
Freeze drying process removes cells but leaves collagen IV, VII, proteoglycans and elastin
Requires reconstitution with lidocaine prior to injection
No skin testing required
Duration of 3 to 6 months (31)
60. Xenografts Hyaluronic Acid
A Glycosaminoglycans (GAG)
Can hold 1000x its weight in water leading to increased skin turgor
Overcorrection not required
Identical in all species leading to minimal immunogenicity
<1% chance of hypersensitivity
Correction achieved for 6-9 months with HA (32)
Hylaform (500 micron, 5.5mg/mL)
Purified from rooster combs
Few reports of local or systemic reactions from avian protein
Shortened lifespan due to lower concentration (33)
Restylane (400 micron, 20mg/mL)
Bacterial cultures of Equine steptococci
Cross linked with epoxides
Also has Fine Lines and Perlane formulations with diffent particle sizes
Isovolumetric contraction where matrix does not disperse water until all hyaluronic acid particles are degraded leading to prolonged effects (34)
61. HA Pitfalls Must inject intradermally
Injection too deep
Decreased duration of action
Injection too superficial
Unappealing bumps
**Undesirable injections can be corrected with hyaluronidase injection.
62. Autografts Fat
Very abundant
No antigenic potential
Requires additional procedure for harvesting
Liposuction
Questions regarding how much is reabsorbed
Adynamic melolabial folds have prolonged duration of action compared to dynamic glabella (26)
63. Autografts Isolagen (Fibroblasts)
Postauricular punch biopsy of patients skin
Cultured in vitro with growth factors for 4-6 weeks
Overnight delivery for injection the following day
Several Treatments required for desired outcome
Cost and time considerations make it impractial
6 month histologic evaluation showed integration of fibroblasts but is on hold by FDA due to growth factors and further studies (35)
64. Synthetic Material Silicone
Been used for over 50 years
Requires multiple microdroplet injections over 4 weeks
Injections performed into deep dermis 1 to 3mm apart
No overcorrection because innate reaction to the product was part of the process
Webster studied 235 pts over 2800 injections (36)
Good results and few complications
Others have shown extensive reactions (37-39)
Chronic inflammation
Migration
Extrusion ulceration
Skin necrosis
Granulomatous hepatitis
Pulmonary emboli
Silicosis (pneumonitis)
FDA declared it illegal in 1991 but recent use for retinal detachment is bringing off label use back
American Academy of Dermatology (1993) (7)
There is a wealth of clinical experience in dermatology with the use of liquid injectable silicone by the micro-droplet technique which shows its efficacy and safety in many individuals over many years.
65. Synthetic Material ArteFill
Combined 20% polymethylmethacrylate and 80% bovine collagen
Skin testing required
As collagen is degraded (4 months) the PMMA is encapsulated to maintain augmentation
Injected into the subdermis to prevent persistent painful nodule
Individual results are unpredictable so multiple injections are required over 3-4 months with 50 to 75% permanent correction (25)
Overcorrection not recommended because each result is different
Lemperle (Bailey37) showed good results with minimal complications
Others report granulomatous reactions and scarring (Bailey38).
Not approved in US but Europe has shown long term correction of >10 years (7)
66. Synthetic Material Radiesse (25 to 45 micron size)
35% synthetic hydroxyapatite particles in water, glycerin, and sodium carboxymethylcellulose
Injeted into deep dermis or subdermally due to viscosity
Massage is necessary to contour product
Produces augmentation in 2 ways
Collagen ingrowth by fibroblasts
Encapsulation of crystals by fibroblasts to prevent degredation
Radiographic evidence of implant for up to 6 years (40)
Pitfalls
Injection into lips can produce painful nodules
Palpable implant for 2 to3 months until the product is replaced by collagen
Tzikas studied 90 patients and found 88% patient satisfaction at 6 months (41)
67. Post-therapy Findings Post-injection pain
Redness
Ecchymosis
Swelling
Nodularity
Palpability
**Should be transient and resolve over 1-2 days
68. Complications: 0-2 days Overcorrection
Know the properties of the injectable filler and whether to overcorrect or not
Implant visibility
HA can produce bluish nodule
Other fillers cause white nodule
Massage can help
Hyaluronidase or mechanical deroofing of nodule
Vascular compromise
Arterial: Immediate skin blanching with necrosis (glabella)
Aspiration, massage, warm compress, 2% nitropaste
+/- hyperbaric oxygen for impending necrosis
Venous: violaceous discoloration with dull ache
Nitropaste and warm compresses
**Skin breakdown treated with Abx and gentle debridment
69. Venous Injury
70. Complications: 3-14 days Noninflammatory Nodules
Observation, gentle massage, reassurance
Early Inflammatory Nodules
Treat with antibiotics for 4-6 weeks
Macrolide and Tetracycline
I&D plus culture if fluctuance is observed
Close f/u visit at 48 hours
If no response to therapy get tissue culture
71. Tissue Infection
72. Complications: >14 days Hypersensitivity
Bovine collagen 3-4% + skin test
HA <1%
Nodules
Saline injection and vigorous massage
Inflammatory nodules
Evaluate for infection and treat as necessary
No infection but no response at 7-10 days?add intralesional steroid injection to avoid resistant granuloma
Still no response?biopsy and culture
True Granulomas (0.01-1%)
Massage and Intralesional steroids
73. Summary There are a variety of treatment options available
Proper knowledge of the product or procedure is necessary to avoid complications
Patient expectations, informed consent, and proper patient selection is paramount
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