Aesthetic Procedures: Nurse Practitioner's Guide to Cosmetic Dermatology [1st ed. 2020] 978-3-030-19947-0, 978-3-030-19948-7

This book is a resource that offers guidance to nurses who are experienced or novice aesthetic practitioners and would l

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Aesthetic Procedures: Nurse Practitioner's Guide to Cosmetic Dermatology [1st ed. 2020]
 978-3-030-19947-0, 978-3-030-19948-7

Table of contents :
Front Matter ....Pages i-xvii
Front Matter ....Pages 1-1
The History of Beauty (Beth Haney)....Pages 3-6
Skin and Facial Anatomy (Beth Haney)....Pages 7-20
The Aging Face (Beth Haney)....Pages 21-32
Psychological Aspects of Aesthetics (Beth Haney)....Pages 33-38
Front Matter ....Pages 39-39
Topical Preparations and Prescription Medications in Aesthetics (Beth Haney)....Pages 41-50
Microdermabrasion (Beth Haney)....Pages 51-58
Permanent and Semi-permanent Micro-Pigment Treatments (Beth Haney)....Pages 59-66
Superficial Chemical Peels (Beth Haney)....Pages 67-72
Acne (Beth Haney)....Pages 73-79
Front Matter ....Pages 81-81
Pharmacology of Neurotoxins: Onabotulinum Toxin (Botox®), Abobotulinum Toxin (Dysport®), Incobotulinum Toxin (Xeomin®), and Prabotulinumtoxin-xvfs (Jeuveau™) (Beth Haney)....Pages 83-89
Reconstitution and Dosing of Neurotoxins (Beth Haney)....Pages 91-97
Indications for Neurotoxin: Upper Face (Beth Haney)....Pages 99-113
Indications for Neurotoxins: Lower Face and Neck (Beth Haney)....Pages 115-123
Neurotoxins: Other Uses and Future Possibilities (Beth Haney)....Pages 125-129
Neurotoxin Adverse Reactions (Beth Haney)....Pages 131-137
Front Matter ....Pages 139-139
Pharmacology of Temporary Dermal Fillers (Beth Haney)....Pages 141-147
Indications and Placement of Temporary Dermal Fillers (Beth Haney)....Pages 149-176
Complications and Corrections of Temporary Dermal Fillers (Beth Haney)....Pages 177-189
Front Matter ....Pages 191-191
Laser and Light-Based Treatments (Beth Haney)....Pages 193-204
Non-surgical Facial Skin Tightening (Beth Haney)....Pages 205-212
Back Matter ....Pages 213-214

Citation preview

Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology Beth Haney

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Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology

Beth Haney

Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology

Beth Haney Former Clinical Assistant Professor University of California Irvine, CA USA

ISBN 978-3-030-19947-0    ISBN 978-3-030-19948-7 (eBook) https://doi.org/10.1007/978-3-030-19948-7 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my mother, Roslyn Brownie, and my late father, Robert Brownie, because without them, this book would not be possible. My love for them knows no bounds. To my beloved husband, Mike, who encourages me to realize my potential and to achieve my lofty goals. I am so grateful we get to live our lives together. We are one.

Preface

The media continues to define unattainable standards of beauty through glossy magazines, movies, and television shows. In addition, the widespread use of filters to enhance and modify images on social media increases the desire for beauty and perfection. Consequently, global demand for aesthetic medical treatments continues to grow at a rapid pace. Many people want to look as young as possible for as long as possible. There is an increase in the number of nurses and other healthcare providers who want to learn about nonsurgical aesthetic treatments and add them into their practice. This textbook was written for providers to learn the pharmacology of aesthetic medications, uses of aesthetic devices, appropriate patient selection, treatment indications, proper techniques, and identification and treatment of complications. Undeniably, aesthetic practice is a broad combination of nursing, medicine, and art. The notion that aesthetics is informal or rudimentary can lead to exaggerated levels of practitioner confidence. Some practitioners delve into aesthetics without proper education or training, and this leads to dissatisfied patients and unsuccessful practices or, worse, legal action. The purpose of this book is to provide practitioners a thorough understanding of aesthetic practice. Nurse practitioners (NP) are advanced practice registered nurses (APRN) and are legally able to diagnose conditions and prescribe medications and treatments for patients in the United States (US). Alternatively, registered nurses (RN) in the United States are not legally able to diagnose conditions or prescribe medications and treatments, and they must have a qualified provider to diagnose and prescribe treatment. Then, after diagnosis and treatment prescription from a qualified provider, in most states, the RN is legally allowed to provide the appropriate aesthetic treatment to the patient. However, nursing laws vary in different countries, and nurses must understand the regulatory mandates that govern their practice to avoid disciplinary measures or legal action. It is vital to understand the legal framework of the country, state, or region where the nurse practices aesthetics. Aesthetic practice consists mainly of enhancement of the appearance, but it also includes other important features such as improvement in confidence and self-­ esteem. Some examples are to help people look younger in a competitive job market, to camouflage disfiguring scars with laser and dermal filler treatment, or to reduce female facial hair. These and other enhancements of appearance can help

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people acquire a job, get a position in the public eye, or even begin a relationship. The benefits of aesthetics are more than simply skin deep. Current evidence along with practical information from the author is included in this book. The readers will obtain knowledge of skin and facial anatomy, pharmacology, and descriptions of aesthetic treatment options and learn common injection techniques. While didactic education is an important tool for the integration of aesthetics into clinical practice, hands-on experience is also required for practitioners to become proficient in aesthetics. Disclaimer: The terms practitioner and provider are used throughout this textbook because they encompass a variety of professionals who perform aesthetic treatments and procedures, but the main focus is on nurse practitioners and nurses who practice aesthetics or would like to learn about aesthetic procedures. However, laws in the United States allow nurse practitioners to perform many more advanced aesthetic procedures than other nurses around the world. It is important to understand local and regional laws governing professional nursing practice. This text is an essential tool for nursing professionals who would like to become skillful in aesthetic dermatology and provide safe and effective treatments to patients. No specific products or treatments are recommended by the author for any patient. This book is not a replacement for hands-on training with an expert aesthetic professional but is intended to provide in-depth didactic information on various treatments and procedures. Safe and effective aesthetic practice is the objective of this book. Irvine, CA, USA

Dr. Beth Haney DNP, FNP-C, FAANP

Acknowledgments

Creating a textbook takes a team of dedicated friends and scholars to transform words into knowledge. It is a great responsibility and privilege to provide education on aesthetic practice to students of different backgrounds and specialties. It is with deep gratitude that I mention the following individuals who supported me during my writing adventure. I truly appreciate the sacrifice of their precious time. Professor Patricia F. Pearce, MPH, PhD, FNP-BC, FAANP, FNAP, who inspired me throughout this project and was instrumental in helping me navigate the complexities of creating this textbook. She provided me insight and guidance that only a true master could impart, and for that, I am deeply grateful. Donald Gardenier, DNP, FNP-BC, FAAN, FAANP, who has a grasp of the English language like no other and enjoys cerebral gifts beyond description. He has mentored me for many years and pushed me into new environments to flourish. Dank je. Professor Judith A. Berg, PhD, RN, WHNP-BC, FNAP, FAANP, FAAN, who is a skillful visionary with the heart of an angel and writing talent matched only by her sense of style. She is a shining star who brings light wherever she travels. I am grateful for her intellect and support. Craig Young, Esq., for his help in the aspects of business and politics. His perspectives add depth to situations that might remain superficial if not for his heart of gold. He is a true friend. Penny Kaye Jensen, DNP, FNP-C, FAAN, FAANP, who is my cherished friend. I thank her for giving her time when there was none to give. Jared D.  Johnson, DNP, ACNP-BC, for his support and his ability to provide excellent feedback in lightning speed. Beyond grateful to you all.

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Contents

Part I Foundations of Aesthetics 1 The History of Beauty��������������������������������������������������������������������������������   3 1.1 History of Cosmetics��������������������������������������������������������������������������   3 1.2 Conclusion������������������������������������������������������������������������������������������   5 References����������������������������������������������������������������������������������������������������   5 2 Skin and Facial Anatomy��������������������������������������������������������������������������   7 2.1 Facial Anatomy ����������������������������������������������������������������������������������   7 2.2 Skin ����������������������������������������������������������������������������������������������������   8 2.2.1 Epidermis��������������������������������������������������������������������������������   8 2.2.2 Dermis������������������������������������������������������������������������������������   8 2.2.3 Subcutaneous Fat��������������������������������������������������������������������   9 2.3 Skin Appendage: Hair ������������������������������������������������������������������������  11 2.4 Fascia��������������������������������������������������������������������������������������������������  12 2.5 Facial Muscles������������������������������������������������������������������������������������  12 2.5.1 Frontalis����������������������������������������������������������������������������������  13 2.5.2 Procerus����������������������������������������������������������������������������������  13 2.5.3 Orbicularis Oculi��������������������������������������������������������������������  14 2.5.4 Corrugator Supercilii��������������������������������������������������������������  14 2.5.5 Lip Elevator Muscles��������������������������������������������������������������  14 2.5.6 Nasalis������������������������������������������������������������������������������������  15 2.5.7 Orbicularis Oris����������������������������������������������������������������������  15 2.5.8 Depressor Anguli Oris������������������������������������������������������������  16 2.5.9 Mentalis����������������������������������������������������������������������������������  16 2.5.10 Platysma����������������������������������������������������������������������������������  16 2.6 Bone����������������������������������������������������������������������������������������������������  17 2.6.1 Upper Facial Bones����������������������������������������������������������������  17 2.6.2 Mid-Face and Lower Facial Bones ����������������������������������������  17 2.7 Conclusion������������������������������������������������������������������������������������������  19 References����������������������������������������������������������������������������������������������������  19

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3 The Aging Face ������������������������������������������������������������������������������������������  21 3.1 Photoaging������������������������������������������������������������������������������������������  21 3.1.1 Lentigines��������������������������������������������������������������������������������  21 3.1.2 Seborrheic Keratosis ��������������������������������������������������������������  21 3.1.3 Actinic Keratosis��������������������������������������������������������������������  23 3.1.4 Lines and Wrinkles ����������������������������������������������������������������  24 3.2 Facial Volume Loss ����������������������������������������������������������������������������  25 3.2.1 Mandible ��������������������������������������������������������������������������������  26 3.2.2 Lips ����������������������������������������������������������������������������������������  27 3.2.3 Cheeks/Malar Area�����������������������������������������������������������������  30 3.2.4 Temples ����������������������������������������������������������������������������������  30 3.3 Conclusion������������������������������������������������������������������������������������������  31 References����������������������������������������������������������������������������������������������������  31 4 Psychological Aspects of Aesthetics����������������������������������������������������������  33 4.1 Unexpected Patient Responses������������������������������������������������������������  33 4.2 Euphoria����������������������������������������������������������������������������������������������  34 4.3 Hostility����������������������������������������������������������������������������������������������  34 4.4 Body Dysmorphic Disorder����������������������������������������������������������������  35 4.5 Decreased Depressive Symptoms ������������������������������������������������������  37 4.6 Conclusion������������������������������������������������������������������������������������������  37 References����������������������������������������������������������������������������������������������������  37 Part II Acne and Non-invasive Treatments 5 Topical Preparations and Prescription Medications in Aesthetics��������  41 5.1 The Skin and Topical Preparation Properties��������������������������������������  41 5.2 Vitamin A/Retinoids����������������������������������������������������������������������������  42 5.3 Skin Lighteners ����������������������������������������������������������������������������������  44 5.3.1 Hydroquinone ������������������������������������������������������������������������  44 5.3.2 Azelaic Acid����������������������������������������������������������������������������  45 5.4 Selected Skin Care Products: Cleansers and Moisturizers ����������������  45 5.4.1 Cleansers ��������������������������������������������������������������������������������  45 5.4.2 Moisturizers and Additives ����������������������������������������������������  47 5.5 Conclusion������������������������������������������������������������������������������������������  49 References����������������������������������������������������������������������������������������������������  49 6 Microdermabrasion ����������������������������������������������������������������������������������  51 6.1 Microdermabrasion ����������������������������������������������������������������������������  51 6.2 Types of Microdermabrasion Devices������������������������������������������������  52 6.3 Considerations of Microdermabrasion������������������������������������������������  53 6.4 The Microdermabrasion Procedure����������������������������������������������������  55 6.5 Conclusion������������������������������������������������������������������������������������������  57 References����������������������������������������������������������������������������������������������������  57

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7 Permanent and Semi-permanent Micro-­Pigment Treatments��������������  59 7.1 Micropigmentation������������������������������������������������������������������������������  59 7.2 Semi-permanent Pigment Treatments ������������������������������������������������  60 7.2.1 Microblading��������������������������������������������������������������������������  60 7.3 Permanent Pigment Treatment������������������������������������������������������������  63 7.4 Conclusion������������������������������������������������������������������������������������������  65 References����������������������������������������������������������������������������������������������������  65 8 Superficial Chemical Peels������������������������������������������������������������������������  67 8.1 Chemical Peels Used in Aesthetics ����������������������������������������������������  67 8.1.1 Salicylic Acid (SA) Peels��������������������������������������������������������  68 8.1.2 Trichloroacetic Acid (TCA) Peels������������������������������������������  68 8.1.3 Lactic Acid (LA) Peels�����������������������������������������������������������  69 8.1.4 Retinoic Acid��������������������������������������������������������������������������  69 8.1.5 Jessner and Modified Jessner Peels����������������������������������������  69 8.1.6 Glycolic Acid and Pyruvic Acid Peels������������������������������������  70 8.1.7 Superficial Peels����������������������������������������������������������������������  70 8.2 Conclusion������������������������������������������������������������������������������������������  71 References����������������������������������������������������������������������������������������������������  71 9 Acne������������������������������������������������������������������������������������������������������������  73 9.1 Acne Pathogenesis and Diagnosis������������������������������������������������������  73 9.1.1 Epidemiology��������������������������������������������������������������������������  73 9.1.2 Etiology and Pathogenesis������������������������������������������������������  73 9.1.3 Psychological Aspects of Acne ����������������������������������������������  75 9.1.4 Treatments������������������������������������������������������������������������������  76 9.2 Conclusion������������������������������������������������������������������������������������������  77 References����������������������������������������������������������������������������������������������������  78 Part III Minimally Invasive Procedures: Neurotoxins 10 Pharmacology of Neurotoxins: Onabotulinum Toxin (Botox®), Abobotulinum Toxin (Dysport®), Incobotulinum Toxin (Xeomin®), and Prabotulinumtoxin-xvfs (Jeuveau™)������������������������������������������������  83 10.1 Botulinum Toxin ������������������������������������������������������������������������������  83 10.1.1 The History ��������������������������������������������������������������������������  83 10.1.2 Types of BoNT/A Used in Aesthetics����������������������������������  84 10.2 Mechanism of Action and Structure of BoNT/A Action������������������  85 10.2.1 Mechanism of Action������������������������������������������������������������  85 10.2.2 Structure��������������������������������������������������������������������������������  86 10.3 Antibody Formation��������������������������������������������������������������������������  86 10.4 Onset, Effect, and Duration of Neurotoxins ������������������������������������  87 10.5 Conclusion����������������������������������������������������������������������������������������  88 References����������������������������������������������������������������������������������������������������  88

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11 Reconstitution and Dosing of Neurotoxins����������������������������������������������  91 11.1 Storage����������������������������������������������������������������������������������������������  91 11.2 Preparation����������������������������������������������������������������������������������������  93 11.3 Dosing in Specific Sites��������������������������������������������������������������������  94 References����������������������������������������������������������������������������������������������������  97 12 Indications for Neurotoxin: Upper Face��������������������������������������������������  99 12.1 Patient Selection and Education��������������������������������������������������������  99 12.2 Photographs�������������������������������������������������������������������������������������� 100 12.3 Select Types of Facial Lines ������������������������������������������������������������ 101 12.4 Muscle Memory�������������������������������������������������������������������������������� 103 12.5 Glabella (Procerus, Corrugator Supercilii, Nasalis) ������������������������ 103 12.6 Crow’s Feet (Orbicularis Oculi)�������������������������������������������������������� 105 12.7 Forehead�������������������������������������������������������������������������������������������� 108 12.8 Bunny Lines (Nasalis)���������������������������������������������������������������������� 110 12.9 Lower Eyelids (Inferior Orbicularis Oculi)�������������������������������������� 111 12.10 Conclusion���������������������������������������������������������������������������������������� 112 References���������������������������������������������������������������������������������������������������� 112 13 Indications for Neurotoxins: Lower Face and Neck ������������������������������ 115 13.1 Patient Selection and Expectations �������������������������������������������������� 115 13.2 Gummy Smile ���������������������������������������������������������������������������������� 116 13.3 Chin�������������������������������������������������������������������������������������������������� 117 13.4 Oral Commissures (Down-Turned Corners) ������������������������������������ 118 13.5 Perioral Rhytids (Lip Lines) ������������������������������������������������������������ 119 13.6 Platysmal Bands (Neck Bands)�������������������������������������������������������� 120 13.7 Conclusion���������������������������������������������������������������������������������������� 122 References���������������������������������������������������������������������������������������������������� 122 14 Neurotoxins: Other Uses and Future Possibilities���������������������������������� 125 14.1 Hyperhidrosis������������������������������������������������������������������������������������ 125 14.2 Emerging Features of Botulinum Toxins������������������������������������������ 126 14.3 Acne�������������������������������������������������������������������������������������������������� 126 14.4 Facial Scars �������������������������������������������������������������������������������������� 127 14.5 Conclusion���������������������������������������������������������������������������������������� 129 References���������������������������������������������������������������������������������������������������� 129 15 Neurotoxin Adverse Reactions������������������������������������������������������������������ 131 15.1 Contraindications and Adverse Effects Related to BoNT/A���������������������������������������������������������������������������������������� 131 15.2 Adverse Effect Related to the Penetration of Skin by the Needle������������������������������������������������������������������������������������ 132

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15.3 Adverse Effect Related to Technique������������������������������������������������ 133 15.3.1 Undesired Muscle Impairment���������������������������������������������� 134 15.3.2 Eyelid Ptosis ������������������������������������������������������������������������ 134 15.3.3 Brow Ptosis �������������������������������������������������������������������������� 135 15.3.4 Plateau Smile������������������������������������������������������������������������ 135 15.3.5 Medication Tolerance������������������������������������������������������������ 135 15.3.6 Patient Dissatisfaction���������������������������������������������������������� 136 15.4 Conclusion���������������������������������������������������������������������������������������� 136 References���������������������������������������������������������������������������������������������������� 137 Part IV Minimally Invasive Procedures: Temporary Dermal Fillers 16 Pharmacology of Temporary Dermal Fillers������������������������������������������ 141 16.1 Temporary Dermal Fillers���������������������������������������������������������������� 141 16.2 Hyaluronic Acid (HA) Fillers ���������������������������������������������������������� 141 16.2.1 G-Prime and Particle Size���������������������������������������������������� 142 16.3 Calcium Hydroxyapatite: (Radiesse®)���������������������������������������������� 144 16.4 Poly-l-Lactic Acid: (Sculptra)���������������������������������������������������������� 144 16.5 Conclusion���������������������������������������������������������������������������������������� 146 References���������������������������������������������������������������������������������������������������� 146 17 Indications and Placement of Temporary Dermal Fillers���������������������� 149 17.1 Techniques for Injection of Dermal Filler���������������������������������������� 149 17.1.1 Linear Threading Technique ������������������������������������������������ 152 17.1.2 Cross-Hatch and Fanning Technique������������������������������������ 152 17.1.3 Serial Puncture Technique���������������������������������������������������� 152 17.2 Indications for Dermal Filler������������������������������������������������������������ 153 17.3 Cheek Augmentation������������������������������������������������������������������������ 154 17.3.1 Types of Dermal Fillers for Cheek Augmentation: Temporary ���������������������������������������������������������������������������� 156 17.3.2 Collagen Stimulators������������������������������������������������������������ 157 17.4 Lip Enhancement������������������������������������������������������������������������������ 158 17.5 Peri-oral Area������������������������������������������������������������������������������������ 160 17.6 Policy and Protocol �������������������������������������������������������������������������� 165 17.7 Naso-labial Folds (NLF) ������������������������������������������������������������������ 166 17.8 Glabellar Region ������������������������������������������������������������������������������ 167 17.9 Jawline and Chin������������������������������������������������������������������������������ 168 17.10 Earlobes�������������������������������������������������������������������������������������������� 169 17.11 Hands������������������������������������������������������������������������������������������������ 169 17.12 Infraorbital Area (Tear Trough)�������������������������������������������������������� 173 17.13 Conclusion���������������������������������������������������������������������������������������� 174 References���������������������������������������������������������������������������������������������������� 174

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Contents

18 Complications and Corrections of Temporary Dermal Fillers�������������� 177 18.1 Filler Complications������������������������������������������������������������������������� 177 18.2 Hyaluronidase ���������������������������������������������������������������������������������� 177 18.3 Injection Site Reactions�������������������������������������������������������������������� 178 18.4 Nodule Formation and Tyndall Effect���������������������������������������������� 180 18.4.1 Nodule Formation ���������������������������������������������������������������� 180 18.4.2 Tyndall Effect������������������������������������������������������������������������ 181 18.5 Infection�������������������������������������������������������������������������������������������� 182 18.6 Hypersensitivity and Granuloma Formation������������������������������������ 183 18.7 Vascular Compromise Leading to Tissue Necrosis�������������������������� 183 18.7.1 Emergency Treatment of Vascular Compromise with Hyaluronidase ���������������������������������������������������������������������� 187 18.8 Biofilm���������������������������������������������������������������������������������������������� 187 18.9 Conclusion���������������������������������������������������������������������������������������� 188 References���������������������������������������������������������������������������������������������������� 188 Part V Laser and Light-Based Treatments and Skin Tightening 19 Laser and Light-Based Treatments���������������������������������������������������������� 193 19.1 Normal Skin Aging and Skin Type �������������������������������������������������� 193 19.2 Photodamage������������������������������������������������������������������������������������ 194 19.3 Intense Pulsed Light (IPL)���������������������������������������������������������������� 195 19.4 Lasers in Aesthetics�������������������������������������������������������������������������� 199 19.4.1 Skin Resurfacing������������������������������������������������������������������ 200 19.4.2 Hair Removal������������������������������������������������������������������������ 201 19.5 Conclusion���������������������������������������������������������������������������������������� 202 References���������������������������������������������������������������������������������������������������� 203 20 Non-surgical Facial Skin Tightening�������������������������������������������������������� 205 20.1 Skin Tightening Technology ������������������������������������������������������������ 205 20.1.1 Radiofrequency �������������������������������������������������������������������� 206 20.1.2 Infrared���������������������������������������������������������������������������������� 208 20.1.3 Micro-Focused Ultrasound �������������������������������������������������� 209 20.2 Conclusion���������������������������������������������������������������������������������������� 211 References���������������������������������������������������������������������������������������������������� 211 Index�������������������������������������������������������������������������������������������������������������������� 213

About the Author

Dr.  Beth  Haney, DNP, FNP-C, FAANP  is Past President of the California Association for Nurse Practitioners (CANP) and owns Luxe Aesthetic Center, an aesthetic practice that she founded in 2006. She is the Recipient of the CANP 2018 Nurse Practitioner of Distinction Award for her excellence in furthering the NP role through legislative efforts and is a Former Assistant Clinical Professor at the University of California Irvine (UCI) from 2010 to 2017. She was inducted in 2016 as a Fellow of the American Academy of Nurse Practitioners (FAANP) for her work in policy and education, represents the American Association of Nurse ­ Practitioners (AANP) on the National Primary Care Advisory Board, and serves on the AANP Health Policy Committee. Beth has served over a decade on her local and state NP organization boards and is currently a member of the Dermatology Nurses Association Nurse Practitioner Society Committee. She has written many peer-reviewed articles and is a contributing author of a dermatology nursing textbook. Outside of nursing, she was elected to the Yorba Linda City Council in 2016 for a 4-year term and is currently serving as Mayor Pro Tempore. She was unanimously appointed by the Orange County Board of Supervisors to the Orange County Waste Management and Recycling Commission and works towards ensuring a healthy environment through her work on this commission.

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Part I Foundations of Aesthetics

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The History of Beauty

1.1

History of Cosmetics

Men and women have been enhancing their appearance since 4000 BCE. Egyptian women used a mixture of oxidized copper, ash, lead, burnt almonds, sycamore or cedar sawdust, lizard or bat blood, and certain minerals including iron and lead to add color and definition to their faces (Council TPCP 2018; Murube 2013; Blanco-­ Davila 2000). The most frequently used substance was mesdemet, a black paste commonly used to accentuate the eyes. It consisted of plumbic sulfate or antimony sulfide (Murube 2013). This combination of substances was used on the eyes to give a defined and dramatic look by both men and women. Mesdemet was believed to provide protection from evil spirits and also used as a medical treatment for conjunctivitis (Murube 2013). Fingernails became a popular cosmetic enhancement in early China, around 3000 BCE and Chinese royalty wore gold, silver, black, or red nail polish made of beeswax, gum arabic, and egg. Brightly colored nails were forbidden in lower classes (Council TPCP 2018). Similarly, women in Greece wore white lead face powder or paste, crushed berries for rouge on their faces, and some women used oxen hairs to enhance their eyebrows. Later, clay colored with red iron was used to color their lips. White powder made from rice to whiten the face was popular in Japan and China around 1500 BCE. Other popular cosmetic enhancements of that time included painted teeth, hair stained with henna, and shaved eyebrows (Council TPCP 2018; Murube 2013). Hair color became more popular in Rome around 100 AD. Men lightened their hair while Indians and North Africans used henna to color their hair (Council TPCP 2018). These different approaches to cosmetic enhancement of appearance reflected cultural views of what was beautiful. People in ancient times enhanced their appearance using a variety of substances that we know today are not safe. They used compounds and minerals on their skin in attempt to create a uniform, smooth looking face. In 1400–1500 AD, arsenic was occasionally substituted for lead in facial powders.

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1  The History of Beauty

Later, in the 1700s to 1800s, zinc oxide was used for facial whitening rather than dangerous ingredients of lead and copper. In Britain, laws were passed that expressly prohibited women from using makeup and Queen Victoria claimed makeup as improper and banned its use strictly to actors (Council TPCP 2018). More recently, cosmetics have become safer and more extensively used, in part due to widespread acceptance by most cultures. The evolution of makeup is critical to contemporary views of aesthetics and forms the basis for the birth and widespread growth in the contemporary aesthetics industry. Chemical peels, permanent eyeliner, neurotoxin injections, dermal fillers, and aesthetic surgical procedures to enhance appearance continue to increase in popularity around the world (ASoPS 2017). And, new technologies and procedures emerge with remarkable frequency. Imagination and perception play important roles in makeup and aesthetics (Meskin et al. 2017). For these reasons, it is important to set realistic expectations with patients. Generally, people have a vivid imagination and aesthetic patients often fantasize about how the result of their treatment would look. If the imagination or expectation differs too much from the actual outcome, disappointment prevails. Direct and open communication with patients regarding their individual facial shape, dimensions, and possible options are important to address during the consultation. Therefore, it is crucial that the patient understands the potential outcome of their treatment and expect realistic results. Facial beauty is subjective and can be influenced by local culture as well as certain scientific phenomenon (Hagman 2002). For 3000 years, researchers have been trying to define beauty; is it a geometric equation or a symmetry value? Is it coloring or enhancement of certain features? Some researchers have suggested a specific formula equates to beauty only to have it rebutted in studies where other researchers attempt to define it as “pleasing” or “perfection” (Hagman 2002; Green 1995). Regardless, theories on what constitutes beauty are wide ranging and difficult to measure. Even the famed Golden Section, a mathematical equation, has attempted to define beauty as a scientific calculation based on ratios and symmetry (Luttge and Souza 2018). The Golden Section formula is determined when “the ratios of larger distance to smaller distance equaling whole distance to larger distance are applied to the circumference and sections of a circle” (Luttge and Souza 2018). Symmetry has been hypothesized to represent beauty but asymmetry has been described as charm. The difficulty in assigning a permanent label to the definition of beauty is difficult because beauty is illusive and transcendental (Luttge and Souza 2018). Beauty is impossible to define in the human face through using mathematical equations because of the psychology of perception, and even the Golden Section provides thin evidence of what constitutes beauty (Green 1995; Luttge and Souza 2018). Beauty is a subjective and psychological perception that is as individualized as each human being. Conversely, beauty is also applied to the body. Variations of body types are considered beautiful in different cultures. For example, in some African countries, women with full, thick bodies are considered more attractive than thinner women because heaviness is associated with wealth (Toselli et al. 2016). In other countries, particularly Western countries, thin women are considered more attractive (Toselli

References

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et al. 2016; Schaefer et al. 2018). Unfortunately, the mismatch between body ideals and reality contribute to eating disorders and take a toll on the general health of people in many cultures (Schaefer et al. 2018; Cheng et al. 2019). However, a thorough discussion of eating disorders is outside the scope of this book.

1.2

Conclusion

The concept, definition, and perception of beauty are elusive and encompass not only the face, but the body as well. Beauty ideals plus cultural implications should be considered when treating the aesthetic patient. Consideration of many variables is important when attempting to define beauty and arrive at the mutually satisfying goal of improvement in appearance for the patient. Current aesthetic treatments such as neurotoxins, dermal fillers, and lasers are some of the options to enhance appearance in addition to cosmetics and makeup. Thankfully researchers have made progress in providing data that has identified harmful cosmetic ingredients leading to safer cosmetics and aesthetic options (Salama 2015; Malten 1975; Hepp et al. 2009; Benson 2000). Global education and evidence show certain substances once used in cosmetics were toxic and are now no longer included in cosmetic formulations.

References American Society of Plastic Surgeons (ASoPS). Top five cosmetic plastic surgery procedures. 2017. Available from: https://www.plasticsurgery.org/. Benson HA. Assessment and clinical implications of absorption of sunscreens across skin. Am J Clin Dermatol. 2000;1(4):217–24. Blanco-Davila F.  Beauty and the body: the origins of cosmetics. Plast Reconstr Surg. 2000;105(3):1196–204. Cheng ZH, Perko VL, Fuller-Marashi L, Gau JM, Stice E. Ethnic differences in eating disorder prevalence, risk factors, and predictive effects of risk factors among young women. Eat Behav. 2019;32:23–30. Council TPCP.  Cosmetics in the ancient world Washington DC. 2018. Available from: https:// cosmeticsinfo.org/Ancient-history-cosmetics#cosmetics_in_ancient_world. Green CD. All that glitters: a review of psychological research on the aesthetics of the golden section. Perception. 1995;24(8):937–68. Hagman G. The sense of beauty. Int J Psychoanal. 2002;83(Pt 3):661–74. Hepp NM, Mindak WR, Cheng J. Determination of total lead in lipstick: development and validation of a microwave-assisted digestion, inductively coupled plasma-mass spectrometric method. J Cosmet Sci. 2009;60(4):405–14. Luttge U, Souza GM.  The Golden Section and beauty in nature: the perfection of symmetry and the charm of asymmetry. Prog Biophys Mol Biol. 2018. https://doi.org/10.1016/j. pbiomolbio.2018.12.008. Malten KE.  Cosmetics, the consumer, the factory worker and the occupational physician. Suggestions concerning ways to determine untoward dermatologic effects of cosmetics. Contact Dermatitis. 1975;1(1):16–26. Meskin A, Robson J, Ichino A, Goffin K, Monseré A. Philosophical aesthetics and cognitive science. Wiley Interdiscip Rev Cogn Sci. 2017;9:e1445.

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Murube J. Ocular cosmetics in ancient times. Ocul Surf. 2013;11(1):2–7. Salama AK. Assessment of metals in cosmetics commonly used in Saudi Arabia. Environ Monit Assess. 2015;188(10):553. Schaefer LM, Burke NL, Anderson LM, Thompson JK, Heinberg LJ, Bardone-Cone AM, et al. Comparing internalization of appearance ideals and appearance-related pressures among women from the United States, Italy, England, and Australia. Eat Weight Disord. 2018. https:// doi.org/10.1007/s40519-018-0544-8. Surgeons ASoP.  Top Five Cosmetic Plastic Surgery Procedures 2017. 2017. Available from: https://www.plasticsurgery.org/. Toselli S, Rinaldo N, Gualdi-Russo E. Body image perception of African immigrants in Europe. Glob Health. 2016;12(1):48.

2

Skin and Facial Anatomy

2.1

Facial Anatomy

Facial structure is comprised of skin, subcutaneous fat, fascia, muscle, and bone. The face has 40 muscles and each has a specific function that results in expression (Vigliante 2005). The amount of facial volume contributes to the projection and fullness of the face. Natural appearance, proportioned features, and firm resting tone are attributes of an aesthetically pleasing face. Generally, the aging process begins to change the appearance of the face at approximately 35 years old; however, aging takes place at a relatively constant pace throughout life (Pessa 2000). These changes are a result of bone resorption or thinning, muscle atrophy, and skin changes that happen simultaneously. As the bone begins to recede, flattening and shortening of the face occur, and the tissues soften and begin to fall since they are no longer supported adequately by the bone (Mendelson 2012). It is essential for practitioners to understand facial anatomy and the impact of the aging process, so the practitioner can reproduce the appearance of youth in the aging face. Typically, the face is divided into three parts: the upper face, mid-face, and lower face. The upper face is comprised of the forehead, eyebrows, and eyes; the mid-face is comprised of the nasal area and cheeks; the lower face is comprised of the mouth, chin, and platysma (Vigliante 2005). These three regions should be assessed individually and collectively so that the entire face is balanced. Some important structures lie within the framework of the face. Facial vessels, nerves, ducts, and glands are contained within the face and should be considered (Cohen 2008; DeLorenzi 2014; Scheuer et  al. 2017). Understanding key facial structures is essential to avoid serious complications such as emboli, vascular compromise, or nerve impairment as a result of treatment.

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2.2

2  Skin and Facial Anatomy

Skin

The anatomy of the skin includes the epidermis, dermis, and subcutaneous tissue including fat (Kolarsick et al. 2011; Habif 2016; Nea 2016). The skin is a living, complex organ that protects the underlying tissues from environmental toxins, ultra-­ violet radiation, and injury (Nea 2016). In addition, the skin regulates temperature, fluid loss, homeostasis, and vitamin D production and monitors conditions for immune responses (Nea 2016). It is also the heaviest organ of the body with the dorsal and extensor surfaces being thicker than the ventral and flexor surfaces (Habif 2016).

2.2.1 Epidermis The epidermis is stratified squamous epithelium and is the outermost layer of the skin. Epidermal thickness ranges from approximately 0.05  mm on the eyelids to 1.5 mm on the palms of the hands and soles of the feet (Kolarsick et al. 2011; Habif 2016). There are five layers in the epidermis; stratum corneum, stratum lucidium, stratum granulosum, stratum spinosum, and stratum basale. Each of these layers is on the continuum of the keratinocyte life cycle but not completely separate from each other (Pessa 2000; Vigliante 2005). The basal cells make up the interior most layer of the epidermis and divide to create keratinocytes. The keratinocytes synthesize insoluble proteins, continue to flatten as they move outward, and eventually become the stratum corneum (see Fig. 2.1) (Habif 2016). Several specialized cell types control how the skin responds to the environment: (1) melanocytes synthesize pigment, (2) Langerhans cells are involved in the immune response, and (3) Merkel cell function plays a role in tactile sensation (Kolarsick et al. 2011; Habif 2016). Melanocytes are located deep in the epidermis and account for the varying degrees of pigmentation as a result of sun exposure. The location of the melanocyte in the skin makes it a challenge to cosmetically lighten unsightly dark lesions that result from sun exposure. Patients must be informed that in general, topical medications and treatments will lighten and blend these pigments but may not completely resolve the hyperpigmentation. Langerhans cells phagocytize antigens in the skin and stimulate cell migration in the event of invasion by foreign organisms (Kolarsick et al. 2011). Merkel cells are more numerous in areas of high tactile sensitivity such as the lips, fingertips, and hair follicles. When stimulated, Merkel cells secrete a chemical signal that generates an action potential in the adjacent afferent neuron that relays the signal to the brain (Kolarsick et al. 2011).

2.2.2 Dermis The dermis represents the bulk of the skin and is composed of collagen, elastin, and reticular fibers, and varies in thickness from 0.3 mm on the eyelid to 3.0 mm on the back (Habif 2016). The dermis is made up of two layers: the papillary dermis and

2.2 Skin

9

Fig. 2.1  Epidermal layers (Haggstrom 2010)

the reticular dermis. The papillary dermis is a thin layer whereas the reticular dermis houses collagen, elastin fiber, and reticulum and represents the bulk of the dermis that extends from the lower papillary dermis to the subcutaneous layer (Kolarsick et al. 2011). The reticular dermis is composed of thick collagen fibers and, in addition, houses the mast cells that release histamine and contains macrophages that accumulate melanin and debris from inflammation (Kolarsick et  al. 2011; Habif 2016). The reticular dermis contains the skin appendages of hair follicles and glands (see Fig. 2.2) (Kolarsick et al. 2011).

2.2.3 Subcutaneous Fat The third and deepest layer of the skin is the subcutaneous fat layer. The subcutaneous fat layer contains the bulb and matrix of the hair follicle, larger vessels, dermal collagen, and adipose tissue (lipocytes) (Kolarsick et al. 2011). This layer is of varying thickness depending on the area of the body; for example, increased thickness is

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2  Skin and Facial Anatomy

Epidermis

SC SG SS SB Basement membrane

Dermis

Sebaceous gland

Permanent segment

Arrector pili muscle

Bulge

Outer root sheath

Fibroblasts

Cycling segment

Matrix

Hypodermis

Dermal papilla

Fig. 2.2  Rendering of the epidermal and dermal layers (Wong 2009)

found on the waist and abdomen vs. the eyelid. The function of the subcutaneous layer is to act as a shock absorber, insulation of underlying tissues, provide buoyancy, and store energy (Kolarsick et al. 2011; Nea 2016). In addition, the subcutaneous tissue is considered an endocrine organ because it converts androstenedione into estrone and also produces leptin, a hormone that influences body weight (Kolarsick et al. 2011).

2.3 Skin Appendage: Hair

2.3

11

Skin Appendage: Hair

The hair follicles are referred to as appendages of the skin as are the sweat glands and nails (Kolarsick et  al. 2011). Human beings have all of their hair follicles at birth however, the size changes under the influence of androgens; no hair follicles are formed after birth (Kolarsick et al. 2011; Habif 2016). There are three types of hair as follows. (1) Terminal hairs are thick, heavily pigmented hairs on the head, beard, axillae, and pubic areas. The terminal hair follicles become larger in puberty but shrink during the lifespan at the temporal region. (2) Lanugo hair is fine hair found on the newborn. (3) “Peach fuzz” or vellus hair covers much of the body and is not influenced by androgens as are the terminal hairs (Kolarsick et al. 2011; Habif 2016). Hair growth varies depending on body area. The eyelashes have double or triple rows of few hairs with an average growth phase of 1–6  months. The scalp has approximately 100,000 hairs and has a range in growth phase of 2–6 years, shedding up to 100–150 hairs per day (Habif 2016). This explains why hair on the head can grow to great lengths. Hair on the arms and legs remain in the growth phase for approximately 30–45 days (Habif 2016). Hair diameter is determined by the number of hair cells entering the root sheath of the follicle. The curvature of the root sheath determines the shape or shape of the hair itself. For example, oval follicles create curly hair as in people of African descent whereas round follicles create straight hairs in people of Asian descent (Kolarsick et al. 2011; Habif 2016; Nea 2016; James et al. 2006). Hair color is determined by the amount, size, and distribution of melanosomes interspersed among the matrix cells contained in the hair shaft (Habif 2016). Darker hair has larger melanosomes from an increased number of melanocytes. Conversely, graying hair has fewer melanocytes and produces less or no melanosomes (James et al. 2006). Hair growth cycles are important to understand especially when considering laser hair reduction treatment. Although there are three phases of hair growth, each follicle behaves independently (James et al. 2006). The three stages of hair growth are anagen, catagen, and telogen (Kolarsick et al. 2011). Anagen is the active growth stage where the hair cells are tightly bound and forced out through the skin (Habif 2016). Anagen phase varies depending on the location on the body. For example, the scalp hair follicle has an anagen phase of approximately 2–6 years (James et al. 2006). The hair in the anagen growth phase contains the highest number of melanocytes which absorb high levels of heat (Lin et al. 1998). Laser hair reduction is most effective during the anagen phase because the heat from the laser is absorbed by the melanosomes and this heat is transferred to the hair bulb. Damage occurs to the hair follicle from the absorbed heat and results in impaired production of matrix cells, if matrix cells are produced at all (Lin et al. 1998; Sadick and Prieto 2003). Catagen is the involution phase of the hair follicle when the growth and metabolic processes of hair production regress. Cell division in the matrix ceases, the lower portion of the follicle shrinks and ascends (Habif 2016). This phase lasts about 2–3 weeks in all body areas (Nea 2016).

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2  Skin and Facial Anatomy

Telogen phase describes the resting phase of the hair follicle and the hair ceases to grow any longer. The telogen phase lasts approximately 3–5 months on the scalp whereas other body hair has a longer telogen phase and accounts for the shorter hairs in place for longer periods of time (James et al. 2006). This phase also includes the shedding of the hair from the body called exogen (Nea 2016; James et al. 2006). These phases of hair growth are important to know as it relates to laser hair reduction.

2.4

Fascia

Fascia is defined as loose connective tissue found beneath the subcutaneous layer of the skin that encloses and separates muscles. Fascia covers every structure of the body and provides form to all tissues and organs (Seely et al. 1989). The fascia is able to support and penetrate blood vessels, bone tissue, and meninges and holds the muscle cells in place and serves as a passageway for vessels and nerves to reach muscle cells (Seely et al. 1989; Bordoni and Varacallo 2018). Fascia tissues allow the muscles, nerves, vessels, and joints to glide over one another; so the body can move in real time and into different positions while also having the ability to repair its structure and adapt to mechanical stress (Bordoni and Varacallo 2018). On occasion during BoNT/A injections in the forehead, as the needle passes through levels of skin, fascia can be pierced and create an audible crunch sound that both the patient and practitioner can hear. To avoid alarming the patient, this phenomenon is best explained before injection into a treatment naive patient to prepare them for this sound.

2.5

Facial Muscles

The muscles of the face are different than muscles located in the rest of the body and are associated with the dynamic lines of the face. The facial muscles are generally thin and superficial and insert into or affect the skin (Vigliante 2005). The muscles most relevant to facial aesthetics include the frontalis, procerus, orbicularis oculi, corrugator supercilii, levator labii superioris alaeque nasi, nasalis, levator labii superioris, zygomaticus major, zygomaticus minor, risorius, levator anguli oris, orbicularis oris, depressor anguli oris, mentalis, and platysma. All of these facial muscles can be affected by BoNT/A (Carruthers and Carruthers 2005). When certain muscles are relaxed with BoNT/A, they will naturally be drawn downward, whereas when other muscles are affected, they would naturally be drawn upward—these muscles are classified as depressors or elevators (Carruthers and Carruthers 2005). The effect of BoNT/A on certain muscles requires detailed knowledge of facial musculature and their function and is important when using BoNT/A in aesthetic practice (see Fig. 2.3).

2.5 Facial Muscles

13 Procerus

Frontalis Temporalis Orbicularis oculi Levator labii superioris Zygomaticus

Corrugator supercilii

Nasalis Orbicularis oris Levator labii superioris alaeque nasi Depressor anguli oris Platysma

Buccinator Depressor labii inferioris Mentalis

Risorius

Platysma

Fig. 2.3  Facial muscles relevant in aesthetic practice. Adapted from imotions.com (2016)

2.5.1 Frontalis The frontalis muscle is classified as a brow elevator and has no attachments to the underlying bone. It is wide and thin, and when it contracts, it elevates the eyebrows (Vigliante 2005). The frontalis muscle inserts into the procerus, corrugator, orbicularis oculi, and the skin along the ridge of the nose. The horizontal lines across the forehead are a direct result of the action of the frontalis and raising of the eyebrows (Vigliante 2005). Since the frontalis is a brow elevator, BoNT/A is an effective tool used to smooth these lines but caution should be exercised and lower doses used to avoid brow drop (Carruthers and Carruthers 2006).

2.5.2 Procerus The procerus muscle is classified as a brow depressor and is superficial to the nasal bone (Carruthers and Carruthers 2006). This muscle inserts into the skin between the eyebrows and the root of the nose. The action of this muscle is to draw down the medial brows as part of the concerned, angry, or questioning expression. In some patients, this muscle action causes the small horizontal line(s) across the root of the nose (Prendergast 2012). Although this muscle is small, BoNT/A has a great effect on elevating the medial brows and help soften the glabellar lines in aesthetic patients (Vigliante 2005).

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2.5.3 Orbicularis Oculi The orbicularis oculi is a brow and eyelid depressor, surrounds the orbit of the eye, and acts as a sphincter muscle (Carruthers and Carruthers 2006). This round, flat muscle occupies the eyelids, supraorbital margins, and the superior portion of the cheek. It is divided into three sections: the palpebral, orbital, and lacrimal (Vigliante 2005; Prendergast 2012). The palpebral section encompasses the eyelids and causes the blinking motion. When the palpebral portion acts in conjunction with the tarsal plates it performs as a sphincter and produces a wink. The levator palpebrae superioris is the muscle responsible for keeping the upper eyelid elevated and when this muscle is weakened or injected with BoNT/A, lid ptosis occurs (Vigliante 2005). The orbital section is the largest section of the muscle and encompasses the areas above and below the orbit as well as the nasal portion of the frontal bone. This muscle acts as a depressor of the medial and lateral brow (Vigliante 2005). The lacrimal section of the orbicularis oculi is located near the lacrimal sac and is responsible for compressing the lacrimal sac to express tears into the nasolacrimal duct (Vigliante 2005).

2.5.4 Corrugator Supercilii The medial portion of the corrugator supercilii is located deep, beneath the frontalis and orbicularis oculi muscles in the medial and superior area of the brows near the frontal bone close to the nasofrontal suture line. The lateral portion of the corrugator supercilii muscles insert into the skin of the medial eyebrow (Vigliante 2005; Seely et al. 1989; Prendergast 2012). This is important anatomy to understand since during the BoNT/A injection, needle depth will be more superficial in the lateral areas than in the medial areas where the muscle is deeper. The action of corrugator muscles is to draw the eyebrows down and medially and they work in conjunction with the procerus muscle to produce the frown or negative expression (Carruthers and Carruthers 2005). It is a widely accepted practice to treat both the corrugator and procerus muscles with BoNT/A to create a refreshed, relaxed, and attractive appearance. BoNT/A works by slightly raising the medial brow and preventing the contraction and frown expression of this muscle group.

2.5.5 Lip Elevator Muscles The levator labii superioris alaeque nasi muscle runs vertically on the bilateral area of the nose and is responsible for the elevation of the lip and flare of the nares (Vigliante 2005; Lightoller 1925). Caution should be used when injecting this muscle with BoNT/A because it can cause upper lip ptosis (Carruthers and Carruthers 2005). The levator labii superioris is also a lip elevator and the actions include eversion as well as elevation of the upper lip (Vigliante 2005). Occasionally, a small dose of BoNT/A is used in this muscle to soften the naso-labial folds but inadvertent weakening of this muscle would also produce upper lip ptosis (Vigliante 2005; Carruthers and Carruthers 2005; Mazzuco and Hexsel 2010). The zygomaticus

2.5 Facial Muscles

15

major is a mouth elevator and the principle action is to draw the mouth upward and outward during smiling and laughing. The zygomaticus minor muscles are absent in about 25% of the population and run almost parallel to the zygomaticus major (Vigliante 2005). These muscles are also responsible for eversion and elevation of the upper lip however, they are not considered part of the modiolus or fibromuscular condensation where the eight muscles at the corners of the mouth meet (Vigliante 2005; Seely et al. 1989; Lightoller 1925). The risorius muscle action retracts the angle of the mouth as in grinning (Vigliante 2005). The difference in this muscle from the other facial muscles is that it does not originate from bone (Lightoller 1925). This muscle has its origins in the subcutaneous tissue over the parotid gland, runs across the masseter muscle, and inserts into the skin and mucosa of the corners of the mouth (Vigliante 2005; Lightoller 1925). This muscle is part of the group that forms the naso-labial fold. The levator anguli oris is an elevator of the angle of the mouth, runs deeper than other levator muscles, and originates from the canine fossa directly below the infraorbital foramen (Lightoller 1925). This muscle runs downward and inserts into the corner of the mouth. The action of this muscle is to deepen the naso-labial fold in expressions of disdain or indifference (Vigliante 2005; Lightoller 1925). The levator anguli oris is part of the group that forms the naso-labial fold, and the area is often treated with a dermal filler to soften the appearance of this fold.

2.5.6 Nasalis The nasalis muscles are responsible for dilation and compression of the nares. The nasalis is comprised of two parts, one that resides underneath the nares called the alar nasalis, and the other flat, wider portion that fans over the nose called the transverse nasalis (Vigliante 2005; Seely et al. 1989). In regular breathing, the alar muscles hold the nares open against the pressure in the atmosphere and in heightened emotional states such as crying or anger, cause the nares to flare (Vigliante 2005). The transverse muscles are responsible for depression of the cartilaginous part of the nose and the upward tension of the ala. The transverse part of the nasalis can be treated successfully using small amounts of BoNT/A to address what is commonly known as bunny lines that run obliquely along the sides of the nose (Vigliante 2005; Carruthers and Carruthers 2005). Caution should be used when injecting BoNT/A into these muscles to avoid accidental weakening of the upper lip elevator muscles and causing lip ptosis (Carruthers and Carruthers 2004).

2.5.7 Orbicularis Oris The orbicularis oris is a circular muscle with multiple muscle fibers that include the terminating muscle fibers of 10 pairs of surrounding muscles (Lightoller 1925). Its origin is from the subnasal and inscisor fossae and other nearby muscles and also includes fibers that are intrinsic to the muscle itself (Vigliante 2005; Lightoller 1925; Hur 2017). The action of the orbicularis oculi along with other surrounding

16

2  Skin and Facial Anatomy

muscles draws the lips together, brings the corners inward, purses the lips, and draws the lips against the teeth (Lightoller 1925). These muscle movements contribute to the formation of upper and lower lip lines that are commonly called smoker’s lines and can appear in many people who have never smoked. Aesthetic patients who have never smoked might inquire why they have these unsightly lines. Therefore, it is important to inform these patients that skin damage from sun exposure and normal orbicularis oris muscle activity can contribute to lip line formation. Care should be taken when treating the orbicularis oris with BoNT/A because of the possibility of weakening of muscle fibers that could lead to lip ptosis or dysfunction (Carruthers and Carruthers 2004). Tiny amounts of BoNT/A are used in two to four injection sites using 1 U–2 U (onabotulinumtoxinA or incobotulinumtoxinA) or 2.5 U–5 U (abototulinumtoxinA) maximum (Carruthers and Carruthers 2003).

2.5.8 Depressor Anguli Oris The depressor anguli oris (DAO), originates at the mandible, is continuous with the upper fibers of the platysma, and converge at the commissures of the mouth (Vigliante 2005; Lightoller 1925). The action of this triangular shaped muscle is to draw the corners of the mouth down. Persistent contraction of this muscle gives the mouth a sad or disapproving look and an overall expression of unhappiness. BoNT/A treatment of this muscle relaxes the contraction and provides a neutral position but caution should be used to avoid dysfunction and low doses are recommended (Vigliante 2005; Carruthers and Carruthers 2003, 2004, 2005).

2.5.9 Mentalis The mentalis is a deep muscle and originates from the incisive fossa of the mandible on either side and the two bellies of the muscle pass downward and insert into the skin of the chin (Vigliante 2005). The mentalis does not insert into the orbicularis oris (Vigliante 2005; Lightoller 1925). The action of mentalis muscle creates the deep crease on the chin and raises the center of the lower lip. It is also responsible for the contraction of the chin that results in dimpling, especially when chewing or speaking (Vigliante 2005; Hur 2017; Carruthers and Carruthers 2003). Treatment of the chin with BoNT/A yields a smoothing effect of the dimpling that occurs with contraction however, if a deep horizontal crease is also evident, a small amount of dermal filler may be an appropriate addition to treatment.

2.5.10 Platysma The platysma muscles are wide and flat, originate in the upper chest, clavicle, and acromial areas, and insert at three points: posterior, central, and anterior (Carruthers and Carruthers 2004; Matarasso et al. 1999). The posterior muscle fibers arc forward

2.6 Bone

17

and join into the mentalis, DAO, risorius, and the orbicularis oris muscles at the oral commissures. The central fibers insert into the mandible and the anterior fibers insert into the submental region and are the biggest contributor to the aging neck appearance as the fibers detach from the deeper planes of the muscle as a result of loss of elasticity (Carruthers and Carruthers 2003; Matarasso et al. 1999; Brandt and Boker 2004). The frequently complained about turkey neck appearance occurs from the natural process of aging where the platysma begins to separate in the anterior portions of the muscle (Brandt and Boker 2004; Vistnes and Souther 1979).

2.6

Bone

The facial bones undergo changes throughout life and contribute to the aging appearance of the face (Hellman 1927). Bone loss affects the tissues of the face because bony support diminishes and the ensuing increase in tissue laxity causes the facial appearance to draw downward. The facial bones relevant to aesthetic practice are the bones of the upper face, mid-face, and lower face (see Fig. 2.4).

2.6.1 Upper Facial Bones The frontal bone makes up the entire forehead and relevant to aesthetics, it demonstrates some change as the aging process progresses, although these changes are due mostly to the soft tissues of the forehead (Carruthers et  al. 2013). However, the orbital bones change significantly and in combination with frontal bone changes, the rim of the brow may noticeably protrude in some people. The temporal bone may exhibit more obvious changes as the skeleton ages and is evident by the hollowing appearance of the temporal region (Carruthers et al. 2013). Additionally, the inferior orbital bones tend to widen and lengthen creating a more hollowed look where patients might complain of looking tired (Hellman 1927).

2.6.2 Mid-Face and Lower Facial Bones The bones of the mid-face include the nasalis, zygomatic, and maxilla but the mandible is considered a bone of the lower face (Pessa et al. 2008). The changes that occur in the zygomatic area may be exhibited by flattening of the cheeks along with the deepening of the naso-labial folds as the facial bones change and affect the appearance of the face. The mandible is an area of the lower face that is commonly associated with looking older since the jawline shape is altered as aging occurs (Pessa et  al. 2008). Patients may have difficulty explaining why they feel like they are looking older but will verbalize general dissatisfaction with their lower face. Knowledge of the facial skeleton and the bony changes associated with aging assist the aesthetic practitioner in restoring a more youthful appearance for the patient.

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2  Skin and Facial Anatomy

Bright green: Inferior nasal concha (2) Bright blue: Lacrimal bones (2) Purple: Mandible (1) Yellow: Maxilla (2)

Pink: Nasalis bones (2) Red: Palatine bones (2) Blue: Vomer (1) Dark green: Zygomatic bones (2)

Fig. 2.4  Bones of the face. (Animatography Bd 2015) Animatography Bd. BodyParts3D, © The Database Center for Life Science licensed under CC Attribution-Share Alike 2.1 Japan. 2015. Bright green: Inferior nasal concha (2); Bright blue: Lacrimal bones (2); Purple: Mandible (1); Yellow: Maxilla (2); Pink: Nasalis bones (2); Red: Palatine bones (2); Blue: Vomer (1); Dark green: Zygomatic bones (2)

References

2.7

19

Conclusion

Understanding facial anatomy and muscle function is essential to provide safe and effective aesthetic treatment. Enhanced, natural looking features that give the patient a rejuvenated, attractive appearance is a common goal. Knowledge of age-related volume and bone loss and the effects of muscle contraction will guide the aesthetic practitioner in creating a pleasing result. Proper use of the available options and consideration of the inherent facial shape of the patient will yield the best outcome.

References Animatography Bd. BodyParts3D, © The Database Center for Life Science licensed under CC Attribution-Share Alike 2.1 Japan. 2015. Available from: https://commons.wikimedia.org/ wiki/File:Facial_bones_-_anterior_view03.png. Bordoni B, Varacallo M. Anatomy, Fascia. In: StatPearls [Internet]. Treasure Island: StatPearls Publishing; 2018. Brandt FS, Boker A. Botulinum toxin for the treatment of neck lines and neck bands. Dermatol Clin. 2004;22(2):159–66. Carruthers J, Carruthers A.  Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg. 2003;29(5):468–76. Carruthers J, Carruthers A. Botulinum toxin A in the mid and lower face and neck. Dermatol Clin. 2004;22(2):151–8. Carruthers A, Carruthers J. Procedures in cosmetic dermatology. In: Dover JS, editor. Botulinum toxin. Edinburgh: Elsevier; 2005. Carruthers J, Carruthers A. The use of botulinum toxin type A in the upper face. Facial Plast Surg Clin North Am. 2006;14(3):253–60. Carruthers JC, Carruthers A, Alam M.  In: Dover J, editor. Soft tissue augmentation. 3rd ed. Edinburgh: Elsevier; 2013. Cohen JL. Understanding, avoiding, and managing dermal filler complications. Dermatol Surg. 2008;34(Suppl 1):S92–9. DeLorenzi C. Complications of injectable fillers, part 2: vascular complications. Aesthet Surg J. 2014;34(4):584–600. Habif TP. Clinical dermatology: a Color Guide to diagnosis and therapy. 6th ed. St. Louis, MO: Elsevier; 2016. Haggstrom, Mikael based on work by Wbensmith. Layers of the epidermis. 2010. Available from: https://commons.wikimedia.org/wiki/File:Epidermal_layers.svg. Hellman M. Changes in the human face brought about by development. International Journal of Orthodontia, Oral Surgery and Radiography. 1927;13(6):475–516. Hur MS. Anatomical relationship of the inferior bundle of the incisivus labii inferioris with the depressor labii inferioris and the platysma. J Craniofac Surg. 2017;28(7):1861–4. imotions.com. Facial expression analysis: the complete pocket guide. 2016. Available from: https://imotions.com/blog/facial-expression-pictures/. James WD, Berger TG, Elston DM. Andrews’ diseases of the skin: Clinical dermatology. 10th ed. London: Elsevier; 2006. Kolarsick P, Kolarsick MA, Goodwin C.  Anatomy and physiology of the skin. Journal of the Dermatology Nurses Association. 2011;3(4):203–13. Lightoller GH. Facial muscles: the modiolus and muscles surrounding the rima oris with some remarks about the panniculus adiposus. J Anat. 1925;60(Pt 1):1–85. Lin TY, Manuskiatti W, Dierickx CC, Farinelli WA, Fisher ME, Flotte T, et al. Hair growth cycle affects hair follicle destruction by ruby laser pulses. J Invest Dermatol. 1998;111(1):107–13.

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Matarasso A, Matarasso SL, Brandt FS, Bellman B. Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg. 1999;103(2):645–52; discussion 53–5. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010;63(6):1042–51. Mendelson BW.  C. Changes in the Facial Skeleton With Aging: Implications and Clinical Applications in Facial Rejuvenation. Aesthet Plast Surg. 2012;36:753–60. Nea N. Dermatology nursing essentials: a core curriculum. 3rd ed. Philadelphia: Wolters Kluwer; 2016. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106(2):479–88; discussion 89–90. Pessa JE, Slice DE, Hanz KR, Broadbent TH Jr, Rohrich RJ. Aging and the shape of the mandible. Plast Reconstr Surg. 2008;121(1):196–200. Prendergast P. In: Shiffman MA, editor. Anatomy of the face and neck. Berlin: Springer-Verlag; 2012. Sadick NS, Prieto VG. The use of a new diode laser for hair removal. Dermatol Surg. 2003;29(1):30– 3; discussion 3–4. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman AA, Campbell CF, Rohrich RJ. Facial Danger Zones: Techniques to Maximize Safety during Soft-Tissue Filler Injections. Plast Reconstr Surg. 2017;139(5):1103–8. Seely RR, Stephens TD, Tate P. Anatomy and physiology. Bendigo: Mosby College Publishing; 1989. Vigliante CE. Anatomy and functions of the muscles of facial expression. Oral Maxillofac Surg Clin North Am. 2005;17(1):1–15. Vistnes LM, Souther SG. The anatomical basis for common cosmetic anterior neck deformities. Ann Plast Surg. 1979;2(5):381–8. Wong DJ. Skin tissue engineering. Cambridge: Harvard Stem Cell Institute; 2009.

3

The Aging Face

3.1

Photoaging

A significant effect from sun exposure during the lifetime is the breakdown of components of the skin from ultraviolet radiation. This breakdown includes cellular changes that eventually lead to the development of skin cancers along with the formation of ephelides (freckles), lentigines, seborrheic and actinic keratosis, fine lines, and wrinkles (Nicol 2016; Habif 2016).

3.1.1 Lentigines Lentigines are frequently referred to as “liver spots” and can occur on sun exposed areas such as the face, hands, scalp, arms, and back. Lentigo vary in size from 0.02 to 2.0  cm and becomes more numerous in adults as sun exposure increases. Ephelides, also called freckles, are small light brown or reddish macules that become more apparent with sun exposure and are usually found on the face, arms, and back (Habif 2016). Important differences exist between ephelides and lentigines. The number of ephelides decrease with age and are strongly associated with hair color and skin type where lentigines are associated with sun exposure and increase with aging (see Figs. 3.1 and 3.2) (Habif 2016). Any lesion that develops irregular borders or other signs of neoplasm development should be biopsied.

3.1.2 Seborrheic Keratosis Seborrheic keratosis (SK) lesions are non-cancerous, nor do they become cancerous. SKs do not contain the human papilloma virus (HPV), therefore, they are not warty lesions although they are characteristically referred to as warts by patients (Habif 2016). SKs occur on hair bearing areas of the body including the scalp, face, © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_3

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3  The Aging Face

Fig. 3.1 Ephelides (Beobachter 2017)

Fig. 3.2  Lentigo Photo: B. Haney, DNP, FNP-C, FAANP

arms, trunk, legs, and genitals; they do not appear on the lips, palms of the hands, or soles of the feet (Habif 2016). Although SKs are not necessarily a result of sun exposure, they are mentioned here because they can cause some people to seek treatment for them because of their appearance or location. SKs present as discreet, sharply demarcated lesions that vary in size from 0.2 cm to over 3.0 cm and range in color from tan, brown, and black oftentimes with color variations within the lesion itself. The surface of these lesions can be smooth with tiny round pearls resembling warty appearance, or they may have a dry and cracked surface with a classic “stuck on” appearance (see Fig. 3.3). The SK lesions look as if they can be peeled off the skin however, they should not be picked at or peeled off due to potential pain that would cause. In fact, SKs occur completely in the epidermis and can be removed with little scarring by a trained practitioner (Habif 2016). Alternatively, malignant melanomas have different characteristics than SKs but may look similar because of their variation in color. Therefore, it is critical that all suspicious lesions be promptly referred to a dermatologist.

3.1 Photoaging

23

Fig. 3.3 Seborrheic keratosis. Photo: James Heilman, MD (Heilman n.d.)

Fig. 3.4  Actinic keratosis on the forehead (FamDoc 2014)

3.1.3 Actinic Keratosis Actinic keratosis (AK) is a squamous cell carcinoma lesion that is confined to the epidermis; however, when the cells extend deeper into the papillary or reticular dermis, it is termed squamous cell carcinoma (SCC) (Habif 2016). These superficial lesions need to be closely monitored by a qualified practitioner to ensure they do not progress into SCC.  Most patients would likely become alarmed when the word cancer is mentioned, therefore, AK is the preferred term to use when educating patients. It is also important to inform them of the decreased possibility these lesions can transform into cancers (Habif 2016). Lighter-skinned people are more susceptible to form AKs. Sun exposure is a requisite to the development of these lesions and the judicious use of sunscreen is strongly recommended. Interestingly, organ transplant recipients are 65 times more susceptible to developing AKs so immunosuppression has been determined as a risk factor (Habif 2016). The appearance of AKs range; most lesions are 3 mm–6 mm, but can become larger, and have sharp, adherent scale (see Fig. 3.4). Some lesions will have surrounding color change ranging from pink to red, are usually sensitive, and will bleed if picked or scraped (Habif 2016). Any lesion that becomes inflamed, changes, or begins oozing, a prompt referral to a dermatologist is warranted.

24

3  The Aging Face

Treatment for AK varies depending on the severity of the condition and lesions. Regimens include topical treatment of specific lesions using 0.05% tretinoin for several months, laser treatment with or without photodynamic therapy (PDT), or chemotherapy agents such as 5-fluoroucil or imiquimod (Habif 2016; Le Pillouer-­ Prost and Cartier 2016).

3.1.4 Lines and Wrinkles The aging process begins in the third and fourth decade of life but then progresses quickly throughout the sixth decade (Binder and Azizzadeh 2008). However, fine lines and wrinkles can begin to appear on the skin as early as the second decade of life. Certain factors such as the amount of sun exposure and other lifestyle habits such as smoking, hydration, stress, environmental exposures, chemical exposures, and other factors initiate and accelerate aged appearance. Static lines are visible at rest or without facial muscle motion, and contribute to the appearance of aging (Baumann et  al. 2016). These lines are a source of distress for many aesthetic patients and are a frequent cause for aesthetic consultation. Many patients also complain of fine, crêpey skin under the eyes. The thinness of the skin in the suborbital area lends itself to fine lines, even when the remainder of the facial skin may have few, if any wrinkles. Non-ablative carbon dioxide laser resurfacing treatments have been successful in treating fine lines in the thin skin of the upper and lower eyelids (Tierney et al. 2011). In addition to laser treatments, lower eyelid skin has been shown to respond favorably to topical tretinoin (Hoenig and Hoenig 2013; Manaloto and Alster 1999). Deeper wrinkles and folds are the result of one or more of the following: (1) sun exposure with subsequent collagen breakdown, (2) gravity in association with volume loss from aging or weight loss, (3) facial muscle contraction, (4) genetic influence, (5) bone changes (Hellman 1927; Whitaker and Bartlett 1991; Carruthers et al. 2008; Carruthers and Carruthers 1992; Carruthers et al. 1996). Some of these causes can be prevented or controlled, while some are the result of a natural process or genetic tendencies. Facial changes become more apparent between 35 and 50 years of age (see Figs. 3.1 and 3.2). This age group is the largest portion of the population who seeks aesthetic enhancement (Cosmetic Surgery National Data Bank STATISTICS 2017). Static lines, increased skin laxity, discoloration, changes in bone structure, and softening of tissues that support the face all intensify the appearance of aging (Bitter 2000). Prevention of damage from ultraviolet (UV) radiation from sun exposure is an important aspect in the prevention of pre-mature aging. Protection from the UV rays of the sun can be achieved by using physical block, such as clothing, or chemical block from sunscreens. This is an important strategy recommended for young and old alike. Dermal fillers, botulinumtoxin type A (BoNT/A), laser treatments, topical medications such as tretinoin, intense pulsed light (IPL) treatment, or surgery can be

3.2 Facial Volume Loss

25

reasonable options to address the appearance of aging. The specific issue and condition of the skin will determine which options are appropriate for the patient (Walgrave et al. 2012; Beer 2006; Dreher et al. 2013; Rivas and Pandya 2013; Kotlus 2010). Understanding the aging process and elements that contribute to it, in conjunction with utilizing appropriate treatment options, will guide the practitioner in providing appropriate options for the best outcome.

3.2

Facial Volume Loss

Facial volume changes are due in part to depletion of fat in some areas but deposition of fat in other areas of the face (Coleman and Grover 2006). The reorganization of tissues in the face is a natural progression of aging and contributes to older appearance with advancing age. Patients might complain about deepening naso-­ labial folds (NLF), flattening cheeks, sunken temples, hollowing eyes, and/or the formation of jowls. While the human face generally loses fat as aging progresses, some facial compartments age differently and accumulate fat. For example, the mid-face tends to lose volume, while the submental and/or suborbital areas may accumulate fat (Hellman 1927; Coleman and Grover 2006; Rohrich et  al. 2009). This redistribution of fat leads to many changes, puffiness under the eyes, flattening of the cheeks, hollowing of the eyes and temples, increased fullness of the submental area, formation of jowls, and development of melomental folds. Variations of facial bones during the aging process add to the changes in facial structure (see Fig. 3.5) (Hellman 1927; Rohrich et al. 2009; Pessa et al. 2008; Zadoo and Pessa 2000). Simultaneous fat redistribution and bone resorption occur in the jaw, temporal, and malar areas adding to the aged appearance (Hellman 1927;

a

b

Fig. 3.5  In youth, the piriform (P) lies anterior to the lacrimal crest of the orbital bone (a) but with bone resorption during aging, the piriform falls to the posterior position (b). From: Mendelson, B. & Wong, CH. Aesth Plast Surg (2012) 36: 753–760. https://doi.org/10.1007/s00266-012-9904-3

26

3  The Aging Face

Coleman and Grover 2006; Rohrich et al. 2009). Soft tissues of the face become more lax as the support from the underlying bone decreases. The overall changes in the aging face are somewhat insidious and occur over time. Patients often present complaining about looking tired or sunken, stating these changes seem to have occurred overnight. Familial tendencies also contribute to the appearance of the face and patients often report they are starting to “look like my mother/father.” Knowledge of naturally occurring changes that affect facial structures is essential for practitioners to understand when working with aesthetic patients. This allows the practitioner to provide the patient with appropriate and effective treatment options. Assessment of the patient’s skin and facial structures will guide the practitioner in creating the most suitable treatment plan.

3.2.1 Mandible Facial bones grow and change shape significantly and the changes in the mandible contribute to the appearance of aging (Hellman 1927; Pessa et al. 2008). The aging process has a substantial effect on the appearance of the lower face. Hellman demonstrated that during the aging process, the mandible continues to grow, widen, and flatten (see Figs. 3.6, 3.7, 3.8, 3.9) (Hellman 1927; Pessa et al. 2008). This is in contrast to the perception of youth where the small, convex shape of the mandible is considered youthful (Pessa et al. 2008). This feature of the aging lower face is important for aesthetic practitioners to understand because there are soft tissue dermal fillers that can be implemented into the aesthetic regimen. Dermal fillers can improve the shape of the face and provide a more youthful appearance by reshaping the mandibular area and adding volume and support to the lower face (Moradi et al. 2019; Moradi and Watson 2015). Rejuvenation of the lower face should also include attention to the melomental folds, commonly referred to marionette lines (MLs). The deepness of the ML formation can be due to genetics, age, amount of tissue variation, bone re-structuring, or a combination of these elements (Carruthers et al. 2008). The appearance of the aging lower face is difficult to quantify but recently a system was developed where the ML area can be graded to help the practitioner reach a reasonable goal of lower face restoration (Carruthers et al. 2008). Other areas of the face including the orbital, maxillary, and zygomatic bones change shape during aging and contribute to issues commonly reported by aesthetic patients, e.g., looking tired, deep folds, and/or cheek flattening (Hellman 1927; Rohrich et al. 2009; Pessa et al. 2008; Zadoo and Pessa 2000). The facial fat compartments change shape because of age-related volume loss (Rohrich et  al. 2009). Careful, thorough assessment and appropriate placement of dermal filler to the suborbital and zygomatic areas can improve the appearance of the aesthetic patient by providing a more youthful facial structure and shape. Volumizing the portion of the mandible anterior to the soft protrusion of facial tissue of the ML or “jowl” can create a more rounded, youthful look to the lower face (Carruthers and Carruthers 2013).

3.2 Facial Volume Loss

27

Fig. 3.6  Bone resorption and facial position variations. Nasolabial fold formation and mandibular changes during aging. From: Mendelson, B. & Wong, CH. Aesth Plast Surg (2012) 36: 753–760. https://doi.org/10.1007/s00266-012-9904-3

3.2.2 Lips Full lips are an attribute of the youthful face. However, as people age, the lips typically become thinner. Fine upper and lower lip lines begin to form beyond the vermillion border. Lip line formation can be due to volume loss, sun exposure, and/or orbicularis oris muscle contraction from using straws, smoking, or animation when speaking. The combination of thinning lips and the accompanying lip lines leads to an older looking lower face, especially when the oral commissures, chin, and mandible also exhibit tissue loss (Moradi et  al. 2019; Moradi and Watson 2015; Carruthers and Carruthers 2013).

28 Fig. 3.7  The blackened areas are those of the greatest bone loss and correspond with the areas of decreased skeletal support. From: Mendelson, B. & Wong, CH. Aesth Plast Surg (2012) 36: 753–760. https://doi. org/10.1007/s00266-012-9904-3

Fig. 3.8  The larger arrows show areas of greatest bone loss. The smaller arrows show less bone loss. From: Mendelson, B. & Wong, CH. Aesth Plast Surg (2012) 36: 753–760. https://doi. org/10.1007/s00266-012-9904-3

3  The Aging Face

3.2 Facial Volume Loss

Age 16

29

Age 59

Fig. 3.9  Adapted from Pessa JE, Slice DE, Hanz KR, Broadbent TH, Jr., Rohrich RJ. Aging and the shape of the mandible. Plast Reconstr Surg. 2008;121(1):196–200

Fig. 3.10  From: Mendelson, B. & Wong, CH. Aesth Plast Surg (2012) 36: 753–760. https://doi. org/10.1007/s00266-012-9904-3

Thin lips tend to accentuate the appearance of fine lines and magnify the aspect of volume loss of the lower face. A common procedure to address thinning lips is augmentation with (hyaluronic acid) HA. The appearance of both men and women can improve from subtle and natural looking lip augmentation (Carruthers and Carruthers 2013; Stojanovic and Majdic 2019; Glogau et al. 2012). Assessment of the lips should include consideration of the entire lower face because the lips might be only a portion of the area in need of enhancement (Carruthers and Carruthers 2013). The chin, oral commissures, and MLs should also be considered (Moradi et al. 2019). Simply creating a fuller lip in the presence of sunken lower face may not produce an optimal effect for the patient. For example, the practitioner may note the lips and corners of the mouth have lost volume, and the

30

3  The Aging Face

formation of fine vertical lines around the mouth is noticeable. In addition, the chin has become atrophied and may need volume restoration to provide a pleasing projection of the lower face. In this case, correction of the MLs and chin areas with added filler in addition to the lips would enhance the result of the rejuvenation process and overall patient appearance.

3.2.3 Cheeks/Malar Area The cheeks are a major component of facial structure and full cheeks convey a youthful appearance as well as play an important role in smiling and laughing (Carruthers and Carruthers 2013). The cheeks begin to lose volume during the aging process and, because it is a slow progression, patients do not appreciate the loss until later in life (Binder and Azizzadeh 2008; Rohrich et al. 2009). Patients often notice the NLFs deepening and request those folds be directly addressed. It is important for the practitioner to assess the face and consider the flattened cheeks as a contributing factor to the deep NLFs. The NLFs begin to deepen in part due to the loss of volume in the malar and cheek areas in conjunction with the bone changes of the zygomatic, malar, and infraorbital bones (see Fig. 3.6) (Binder and Azizzadeh 2008; Coleman and Grover 2006; Narurkar et al. 2016). Replacing lost volume in the cheek compartments with dermal filler can soften or alleviate the appearance of prominent NLFs (Figs. 3.7, 3.8, 3.9, and 3.10). Volume loss and redistribution of fat result in a flattening of the cheek area. This leads to a downward positioning of the facial tissue and patients may complain that their “face is falling.” The downward direction of the NLFs, marionette lines, and the occasional crease in the malar area all create corresponding downward directed lines and contribute to the falling appearance of the face. These lines also contribute to a sad appearance (Binder and Azizzadeh 2008; Carruthers and Carruthers 2013). In contrast, when the lines and folds are softened and the cheek volume is replaced, the downward directional lines disappear, fullness is replenished, and the face is more youthful looking.

3.2.4 Temples The temporal area of the face is susceptible to the aging process. The temples are a subtle sign of aging but in severe cases, the appearance of the upper face is notably improved with the use of dermal filler. The temporal layers are made up of temporal muscle, deep temporal fascia, superficial temporal fascia, subcutaneous fat, and skin (Carruthers and Carruthers 2013). As the face ages, the subsequent loss of subcutaneous fat and the increasing protrusion of the temporal vessels cause the area to appear hollow. The loss of support from the underlying tissue can cause changes such as lateral brow ptosis (Coleman and Grover 2006). Although the temporal area loses volume with aging and is improved with dermal filler placement, there are no dermal fillers that are currently FDA approved for

References

31

temporal volume replacement in the USA.  However, the normal aging process involves the hollowing of the temples and this area may be treated by a qualified practitioner. Some of the volume replacement options include hyaluronic acid (HA), poly-l-lactic acid (PLLA), and calcium hydroxyapatite (CaHA).

3.3

Conclusion

As the human face ages, tissue and bone changes affect appearance. Volume loss, tissue redistribution, and gravity contribute to the components of the aging facial structure. Symmetrical and proportioned projections of facial features are crucial for excellent results. Consideration of the entire face during patient assessment is an important part of aesthetic practice. Holistic assessment and treatment using appropriate modalities will result in a youthful, symmetrical appearance.

References Baumann L, Dayan S, Connolly S, Silverberg N, Lei X, Drinkwater A, et al. Duration of clinical efficacy of onabotulinumtoxinA in crow’s feet lines: results from two multicenter, randomized, controlled trials. Dermatol Surg. 2016;42(5):598–607. Beer KR. Comparative evaluation of the safety and efficacy of botulinum toxin type a and topical creams for treating moderate-to-severe glabellar rhytids. Dermatol Surg. 2006;32(2):184–97. Beobachter S. Shoulder. 2017. Available from: https://commons.wikimedia.org/wiki/File:Shoulder_-_ Flickr_-_Stiller_Beobachter.jpg. Binder WJ, Azizzadeh B. Malar and submalar augmentation. Facial Plast Surg Clin North Am. 2008;16(1):11–32. Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg. 2000;26(9):835–42; discussion 43. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-a exotoxin. J Dermatol Surg Oncol. 1992;18(1):17–21. Carruthers JC, Carruthers A.  In: Dover J, editor. Soft tissue augmentation. 3rd ed. Edinburgh: Elsevier; 2013. Carruthers A, Kiene K, Carruthers J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol. 1996;34(5 Pt 1):788–97. Carruthers A, Carruthers J, Hardas B, Kaur M, Goertelmeyer R, Jones D, et al. A validated grading scale for marionette lines. Dermatol Surg. 2008;34(Suppl 2):S167–72. Coleman SR, Grover R. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J. 2006;26(1S):S4–9. Cosmetic Surgery National Data Bank STATISTICS [Internet]. 2017. Available from: https:// www.surgery.org/sites/default/files/ASAPS-Stats2017.pdf Dreher F, Draelos ZD, Gold MH, Goldman MP, Fabi SG, Puissegur Lupo ML.  Efficacy of hydroquinone-­free skin-lightening cream for photoaging. J Cosmet Dermatol. 2013;12(1):12–7. FamDoc F. Actinic keratoses on forehead. 2014. Available from: https://commons.wikimedia.org/ wiki/File:Actinic_keratoses_on_forehead.JPG. Glogau RG, Bank D, Brandt F, Cox SE, Donofrio L, Dover J, et  al. A randomized, evaluator-­ blinded, controlled study of the effectiveness and safety of small gel particle hyaluronic acid for lip augmentation. Dermatol Surg. 2012;38(7 Pt 2):1180–92.

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Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. St. Louis: Elsevier; 2016. Heilman J. (n.d). Many seborrheic keratosis on the back of a person with Leser–Trélat sign due to colon cancer. Available from: https://commons.wikimedia.org/wiki/File:Seborrheic_keratosis_on_human_back.jpg. Hellman M. Changes in the human face brought about by development. Int J Orthod Oral Surg Radiogr. 1927;13(6):475–516. Hoenig J, Hoenig D.  Minimally invasive periorbital rejuvenation. Facial Plast Surg. 2013;29(4):295–309. Kotlus BS.  Dual-depth fractional carbon dioxide laser resurfacing for periocular rhytidosis. Dermatol Surg. 2010;36(5):623–8. Le Pillouer-Prost A, Cartier H.  Photodynamic photorejuvenation: a review. Dermatol Surg. 2016;42(1):21–30. Manaloto RM, Alster TS. Periorbital rejuvenation: a review of dermatologic treatments. Dermatol Surg. 1999;25(1):1–9. Moradi A, Watson J.  Current concepts in filler injection. Facial Plast Surg Clin North Am. 2015;23(4):489–94. Moradi A, Shirazi A, David R. Nonsurgical chin and jawline augmentation using calcium hydroxylapatite and hyaluronic acid fillers. Facial Plast Surg. 2019;35(2):140–8. Narurkar VA, Cohen JL, Dayan S, Kaminer MS, Rivkin A, Shamban A, et al. A comprehensive approach to multimodal facial aesthetic treatment: injection techniques and treatment characteristics from the HARMONY study. Dermatol Surg. 2016;42(Suppl 2):S177–91. Nicol NH.  Anatomy and physiology of the integumentary system. In: Nicol NH, editor. Dermatologic nursing essentials: a core curriculum. 3rd ed. Pitman: Dermatology Nurses Association; 2016. Pessa JE, Slice DE, Hanz KR, Broadbent TH Jr, Rohrich RJ. Aging and the shape of the mandible. Plast Reconstr Surg. 2008;121(1):196–200. Rivas S, Pandya AG. Treatment of melasma with topical agents, peels and lasers: an evidence-­ based review. Am J Clin Dermatol. 2013;14(5):359–76. Rohrich RJ, Arbique GM, Wong C, Brown S, Pessa JE. The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg. 2009;124(3):946–51. Stojanovic L, Majdic N. Effectiveness and safety of hyaluronic acid fillers used to enhance overall lip fullness: a systematic review of clinical studies. J Cosmet Dermatol. 2019;18(2):436–43. Tierney EP, Hanke CW, Watkins L. Treatment of lower eyelid rhytids and laxity with ablative fractionated carbon-dioxide laser resurfacing: case series and review of the literature. J Am Acad Dermatol. 2011;64(4):730–40. Walgrave SE, Kist DA, Noyaner-Turley A, Zelickson BD. Minimally ablative resurfacing with the confluent 2,790 nm erbium:YSGG laser: a pilot study on safety and efficacy. Lasers Surg Med. 2012;44(2):103–11. Whitaker LA, Bartlett SP. Skeletal alterations as a basis for facial rejuvenation. Clin Plast Surg. 1991;18(1):197–203. Zadoo VP, Pessa JE. Biological arches and changes to the curvilinear form of the aging maxilla. Plast Reconstr Surg. 2000;106(2):460–6; discussion 7–8.

4

Psychological Aspects of Aesthetics

4.1

Unexpected Patient Responses

Reputations can be elevated from beautiful aesthetic procedure results, or harmed from poor outcomes. Patient perception and subsequent satisfaction have the greatest impact on the success of the outcome. Although rare, an unexpected patient response to aesthetic treatment can occur. Aesthetic practice is highly subjective for both the patient and practitioner and an unexpected response due to unrealized expectations can be particularly emotional. Although comprehensive and detailed consultations are provided, and the patient is initially agreeable, there can be an unexpected patient response. For example, disappointment, anger, or hostility may occur, to the surprise of the practitioner. The most effective way to avoid medical-legal issues is through prevention (Raveesh et al. 2016). The prudent practitioner provides a thorough and direct consultation by the actual treatment provider rather than through an assistant or technician. Providing the opportunity for the patient to ask questions and relay expectations directly to the practitioner who will perform the treatment will avoid potential miscommunication (Huycke and Huycke 1994). The reasons patients may pursue legal recourse include (1) feeling like not enough information was provided regarding the condition or options available, (2) the practitioner not being available, (3) poor relationship with the practitioner, and (4) not being referred appropriately (Raveesh et al. 2016; Huycke and Huycke 1994). Practitioners should supply realistic and understandable information about appropriate procedures and thoroughly explain side effects, risks, and benefits to every patient. The patient’s level of understanding and expectations of treatment must be established by asking direct questions and allowing time for discussion (Raveesh et al. 2016; Huycke and Huycke 1994). In the case of any adverse event, prompt follow-up is essential to ensure the patient is evaluated and appropriately treated, or referred to a qualified provider (Huycke and Huycke 1994). Pictures, diagrams, drawings, and other teaching materials are tools that can be used to illustrate outcomes to the patient and provide realistic visual information. © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_4

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4  Psychological Aspects of Aesthetics

Discussion using teaching tools allows for potential inconsistencies to be realized and misconceptions clarified. As an example, many patients confuse the muscle weakening actions of botulinumtoxin type A (BoNT/A) with the volume replacement action of dermal filler. While the actions and outcomes of these treatment modalities are understood by practitioners, oftentimes a comprehensive consultation and assessment reveal misunderstandings by the patient. Detailed explanation and direct communication of available aesthetic options appropriate for the individual patient result in an excellent outcome.

4.2

Euphoria

Unexpected patient responses can include exaggerated euphoria. Unusually euphoric patients are infrequent and, although can be initially pleasant, extreme euphoria is not expected and may be indicative of psychological disturbance. Repeat visits to the practitioner for multiple, additional treatments or fixes have been reported (Scharschmidt et al. 2018; Phillips et al. 2019a). Unfortunately, patients with psychological disturbances respond poorly to cosmetic treatments and the attempt by the practitioner to modify the result may worsen the situation (Rankin and Borah 1997; Phillips et al. 2019b). Multiple, repeat visits for a previously resolved issue can lead to loss of revenue for the practice because of decreased availability to care for additional patients due to scheduling issues. The extremely euphoric patient who continuously invades the practice under the guise of delight but routinely requests touch-ups or re-treatments is a challenge for the practitioner. This is not to say patients are not invited to be thrilled with their treatment, but careful consideration of a patient with extreme euphoria is advised. Direct communication and thorough documentation of the consultation at each visit are essential; however, in some cases referral to a psychologist may be warranted.

4.3

Hostility

Hostility is an unexpected and unpleasant patient response in any clinical practice. A compassionate and direct consultation that outlines realistic expectations and limitations of treatment or medication prior to initiation of the procedure can help alleviate the potential for an angry patient. Detailed review of the consent form should include realistic outcomes and possible side effects to help ensure the patient has clear understanding of the limitations of treatment. In addition, the practitioner should have a selection of referral options to offer the patient in the event either the patient or the practitioner is compelled to seek outside assistance. Many patients have some level of anxiety before or during aesthetic treatments. Some patients may not divulge true expectations and this makes it difficult to identify patients who are at increased risk of hostility (Rankin and Borah 1997). However, some aesthetic patients may not only bring the normal anxious component into the situation but some may have escalating or intense anxiety. Coupled with unrealistic expectations, this can predispose the patient to the unfavorable response of hostility (Scharschmidt et al. 2018; Rankin and Borah 1997).

4.4 Body Dysmorphic Disorder

35

Nevertheless, if a patient becomes hostile after treatment, whether it is immediate or weeks or months after treatment, a conversation in a sympathetic and calm demeanor along with reiteration of options should be reviewed with the patient (Raveesh et  al. 2016; Huycke and Huycke 1994). Understanding the reason for hostility through conversation can shed light on this atypical response and calm the patient. When patients believe the practitioner has their best interest in mind, they are more receptive to options and may ultimately become satisfied (Huycke and Huycke 1994). However, in some cases, referral to psychiatry or to a psychologist may be justified (Rankin and Borah 1997).

4.4

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is a psychological condition that is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria (American Psychiatric Association 2013). This condition is characterized by an intense preoccupation of hardly noticeable or non-existent defects in the person’s appearance that is upsetting to them in ways where they believe they are ugly or deformed when in reality, they appear normal (Phillips et al. 2019a). This obsessive preoccupation can lead to repetitive behaviors such as continually checking their image in mirrors, windows, or other reflective objects (Phillips et  al. 2019b). Interestingly, this behavior is not easily controlled by the patient and they do not enjoy having to constantly confirm their appearance. BDD is more common than practitioners may realize and is associated with suicidal ideation and behavior. According to research, most patients seek help with their perceived defects through plastic surgery or cosmetic dermatology (Phillips et  al. 2019b). This is risky for the practitioner because the patient who suffers with BDD will not likely be satisfied with the outcome of the procedure and might focus on the result or discover another defect. The diagnosis of BDD includes the following (American Psychiatric Association 2013): • Preoccupation with one or more non-existent or extremely slight defect, thinking about it for at least 1 h per day • Concerns about appearance that lead to repetitive actions such as mirror checking or skin picking or mental acts such as comparing their appearance to others • Clinically significant distress or interruption of social behaviors that result from appearance concerns • Psychosocial impairment • The patient preoccupation is not better explained by concerns of body fat/weight in an individual who meets diagnostic criteria for an eating disorder There is a short screening assessment tool available that can be of great value in determining who may not be an appropriate aesthetic candidate or who may require psychological referral (Phillips et al. 2019b). Patients who suffer with BDD may welcome the suggestion for psychological referral however, this is not always the case and the practitioner should be prepared to handle this sensitive situation. It is advised to avoid providing aesthetic treatments to a person who might have BDD until a psychological evaluation can be performed. Referral to a qualified provider for treatment is essential for the optimal health of a patient suffering with

36

4  Psychological Aspects of Aesthetics

BDD.  Treatment for BDD can include pharmacotherapy and/or cognitive behavioral therapy and many patients find relief using medications or cognitive behavioral therapy provided by a qualified provider (Phillips et al. 2019b). Some BDD screening tools are available to assess the patient prior to treatment (Phillips et al. 2019c). A practice policy that requires every new patient to complete a BDD screening questionnaire can assist in the screening process. If the patient responses indicate the possibility of BDD, referral to a mental health provider is strongly recommended. The following is a sample questionnaire that utilizes available screening questions to determine the possibility of BDD in a person who presents for cosmetic treatment (not intended for use in clinic): Sample BDD Questionnaire Patient Name:

Date:

Are you very concerned about the appearance of some part of your body, which you consider especially unattractive? (Please circle one) Yes No If you answered no, thank you for your time and attention. You are finished with this questionnaire. ***************************************************************************************** If yes, do these concerns preoccupy you? That is, you think about them a lot and they’re hard to stop thinking about? (Please circle one)

Yes

No

What are these concerns? What specifically bothers you about the appearance of these body parts?

What effect has your preoccupation with your appearance had on your life?

Has your defect often caused you a lot of distress, torment or pain? How much? (circle best answer) 1

2

3

4

5

No distress

Mild and not too disturbing

Moderate and disturbing but still manageable

Severe and very disturbing

Extreme and disabling

Has your defect caused you impairment in social, occupational or other important areas of functioning? How much? (circle best answer) 1

2

3

4

5

No limitation

Mild interface but overall performance not impaired

Moderate, definite interference, but still manageable

Severe, causes substantial impairment

Extreme, incapacitating

Has your defect often significantly interfered with you social life?

Yes

No

If yes, how?

Has your defect often significantly interfered with your school work, your job, or your ability to function in your role? Yes No Are there things you avoid because of your defect?

Yes

No

References

4.5

37

Decreased Depressive Symptoms

There is mounting evidence that suggest neuromodulator treatment with BoNT/A in the glabella can lead to decreased feelings of depression and improved quality of life. The increasing number of potential indications for BoNT/A treatment are spilling over into other fields of medicine including psychiatry because of findings other than cosmetic outcomes in patients receiving treatment (Kruger and Wollmer 2015). A growing field of study is the connection of mood and BoNT/A treatment and the noted improvement in mood. A single glabellar treatment with BoNT/A demonstrated improvement in major depressive disorder (MDD) when provided by a qualified practitioner (Scharschmidt et al. 2018; Kruger and Wollmer 2015; Magid et al. 2014, 2015a; Baumeister et al. 2016). There have been several hypotheses on the effect of BoNT/A on depression which include, (1) patients felt better about themselves because of the decreased appearance of their frown lines, (2) because patients treated with BoNT/A appear happier or more relaxed, they are perceived and treated more favorably, and therefore enjoy an elevated mood, and (3) the facial muscles send feedback to the brain and when treated with BoNT/A, the muscles decrease the activity in the amygdala (Magid et al. 2014). The amygdala is the area of the brain that regulates emotion and several studies show the connection between facial expression and emotion (Reichenberg et al. 2016; Hennenlotter et al. 2009; Magid et al. 2015b; Kim et al. 2014). One study demonstrated the positive effects of BoNT/A versus placebo on MDD in patients lasted 24 weeks which is interesting since the cosmetic effect of BoNT/A endures approximately 12–16  weeks (Magid et  al. 2014). This suggests that the mood elevating effects of BoNT/A lasts longer than the cosmetic effects of treatment and highlights the potential for additional uses of BoNT/A in patients by qualified providers for reasons other than cosmetic indications (Kruger and Wollmer 2015; Magid et al. 2015a).

4.6

Conclusion

The vast majority of patients are satisfied with treatments and report increased confidence and/or positive effect on mood. Aesthetics practice can be rewarding however, there are psychological aspects to consider. Astute evaluation and screening for BDD and other mental health issues are important parts of providing holistic care. Patient safety and well-being are priorities and can be accomplished through careful assessment and compassionate and thoughtful communication.

References American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5). Arlington: American Psychiatric Association; 2013. Baumeister JC, Papa G, Foroni F. Deeper than skin deep - the effect of botulinum toxin-a on emotion processing. Toxicon. 2016;118:86–90.

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Hennenlotter A, Dresel C, Castrop F, Ceballos-Baumann AO, Wohlschlager AM, Haslinger B. The link between facial feedback and neural activity within central circuitries of emotion-new insights from botulinum toxin-induced denervation of frown muscles. Cereb Cortex. 2009;19(3):537–42. Huycke LI, Huycke MM.  Characteristics of potential plaintiffs in malpractice litigation. Ann Intern Med. 1994;120(9):792–8. Kim MJ, Neta M, Davis FC, Ruberry EJ, Dinescu D, Heatherton TF, et al. Botulinum toxin-induced facial muscle paralysis affects amygdala responses to the perception of emotional expressions: preliminary findings from an A-B-A design. Biol Mood Anxiety Disord. 2014;4:11. Kruger TH, Wollmer MA.  Depression--an emerging indication for botulinum toxin treatment. Toxicon. 2015;107(Pt A):154–7. Magid M, Reichenberg JS, Poth PE, Robertson HT, LaViolette AK, Kruger TH, et al. Treatment of major depressive disorder using botulinum toxin a: a 24-week randomized, double-blind, placebo-controlled study. J Clin Psychiatry. 2014;75(8):837–44. Magid M, Keeling BH, Reichenberg JS. Neurotoxins: expanding uses of neuromodulators in medicine--major depressive disorder. Plast Reconstr Surg. 2015a;136(5 Suppl):111S–9S. Magid M, Finzi E, Kruger TH, Robertson HT, Keeling BH, Jung S, et  al. Treating depression with botulinum toxin: a pooled analysis of randomized controlled trials. Pharmacopsychiatry. 2015b;48(6):205–10. Phillips KA, Dimsdale J, Solomon D. Body dysmorphic disorder: choosing treatment and prognosis [Internet]. Up to Date, Inc. 2019a [cited 02-13-2019]. Available from: https://www.uptodate.com/contents/body-dysmorphic-disorder-choosing-treatment-and-prognosis. Phillips KA, Dimsdale J, Solomon D. Body dysmorphic disorder: general principles of treatment [Internet]. Up to Date, Inc. 2019b [cited 02-10-2019]. Available from: https://www.uptodate .com/contents/body-dysmorphic-disorder-general-principles-of-treatment. Phillips KA, Dimsdale J, Solomon D.  Body dysmorphic disorder: assessment, diagnosis, and differential diagnosis [Internet]. Up to Date Inc. 2019c [cited 04-17-19]. Available from: https://www.uptodate.com/contents/ body-dysmorphic-disorder-assessment-diagnosis-and-differential-diagnosis. Rankin M, Borah GL. Anxiety disorders in plastic surgery. Plast Reconstr Surg. 1997;100(2):535–42. Raveesh BN, Nayak RB, Kumbar SF.  Preventing medico-legal issues in clinical practice. Ann Indian Acad Neurol. 2016;19(Suppl 1):S15–20. Reichenberg JS, Hauptman AJ, Robertson HT, Finzi E, Kruger TH, Wollmer MA, et  al. Botulinum toxin for depression: does patient appearance matter? J Am Acad Dermatol. 2016;74(1):171–3 e1. Scharschmidt D, Mirastschijski U, Preiss S, Brahler E, Fischer T, Borkenhagen A. Body image, personality traits, and quality of life in botulinum toxin a and dermal filler patients. Aesthet Plast Surg. 2018;42(4):1119–25.

Part II Acne and Non-invasive Treatments

5

Topical Preparations and Prescription Medications in Aesthetics

5.1

The Skin and Topical Preparation Properties

The skin is the largest and heaviest organ of the body. It averages 20 square feet and weighs about 9 lbs (Jablonski 2006). The skin has many functions including regulating body temperature, providing protection from environmental toxins and harmful ultraviolet radiation, acting as a barrier to prevent water loss, inhibiting invasion of foreign substances, and providing an immune defense from potential threats (Nicol 2016; Habif 2016). The goal of topical preparations is to maintain and restore the highest level functions of the skin barrier. Functions of aesthetic practice are to rejuvenate the skin, repair damage that has occurred from UV radiation, prevent damage from environmental forces, and treat acne. The goal of aesthetic practice is to assist the patient in achieving their desired appearance and the healthiest skin possible. Healthy, intact skin regulates percutaneous absorption. Any insult that removes the protective components such as lipids, water, or protein from the epidermis can compromise this protective function (Habif 2016). For example, alkaline soaps affect the stratum corneum layer of the skin by changing the normal skin pH of 5.4–5.9 and alteration of the acid mantle can decrease bacterial resistance (see Fig. 5.1) (Haney 2016). The decrease in bacterial resistance can increase chances of infection so most people benefit from acidic cleansers. Absorption rates of topical preparations also vary depending on anatomic site. Skin thickness and composition vary according to the area of the body. For example, eyelids and mucous membranes have faster absorption rates compared to palms of the hands or soles of the feet (Habif 2016). The skin on the palms of the hands and the soles of the feet have a thicker stratum granulosum layer of the epidermis than other areas of the body and this accounts for the difference in appearance and absorption rate (Nicol 2016). For a more detailed description of the anatomy of the skin, please see Chap. 2. The characteristics of the skin on different body areas will influence not only absorption rates but the efficiency, effectiveness, and possible side effects of © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_5

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5  Topical Preparations and Prescription Medications in Aesthetics

Fig. 5.1  Epidermal layers. https://commons. wikimedia.org/wiki/ File:Epidermal_layers.png

topical preparations. The absorption rate of transdermal medications is affected by the thickness of the stratum corneum and this can vary on different areas of the body (Brown and Langer 1988). For example, tretinoin, a prescription topical medication for acne, is available in strengths of 0.025–0.1% and can be used on areas including the face, chest, back. However, the skin on the face compared to the chest can have different thicknesses (Nicol 2016; Habif 2016; Brown and Langer 1988). The face can have a thicker stratum corneum than the chest on certain individuals and the use of 0.1% strength tretinoin on the chest could cause more intense side effects than if the same strength was used on the face. Thus, providers must consider application site and intention of application for each individual and provide individualized dose and duration of the topical prescribed.

5.2

Vitamin A/Retinoids

Vitamin A/retinoids (tretinoin) and their derivatives are frequently used in treating acne, photoaging, hyperpigmentation, actinic keratosis, wrinkles, and to enhance percutaneous absorption of other topical agents such as hydroquinone (Habif 2016; Marson and Baldwin 2019; Leyden et al. 2017; Thielitz et al. 2008). Tretinoin has

5.2 Vitamin A/Retinoids

43

multiple trade names, i.e., Retin-A®, and is available in cream, lotion, and gel and is used as a treatment for wrinkles, rough skin, and hyperpigmentation (Topical tretinoin 2019). The onset of action of tretinoin for acne treatment is 2–8 weeks (Habif 2016). Fine lines and wrinkles typically respond within several months with consistent tretinoin use (Topical tretinoin 2019). Some additional benefits of tretinoin are improved skin turgor, improvement of all major components of the skin, and improved skin color due to improved skin circulation (Haney 2016; Thielitz et al. 2008; Duteil et al. 2017). Additionally, patients who have more severe photodamage have been shown to have superior results compared to those with minimal photodamage (Kligman et al. 1986). More importantly, abnormal skin cells, such as actinic keratosis, have been shown to proliferate toward becoming normal cells with consistent use of tretinoin (Kligman et al. 1986). This finding supports the notion that reversal of actinic keratosis, potentially cancerous cells, and sun damaged skin is attainable with tretinoin use. The mechanism of action of tretinoin is not well understood but it has been shown to initiate increased cell turnover in normal follicles and comedones (Thielitz et al. 2008). This action benefits acne sufferers because it reduces cohesion between keratinized cells and prevents the build-up of trapped skin cells under the skin. These trapped cells lead to the inflammatory response of acne lesion formation (Habif 2016). In addition, tretinoin appears to disrupt the surface epithelium and allow better penetration of other substances such as hydroquinone or benzyl peroxide (Fulton et al. 1974). For these reasons, tretinoin is often combined with various other topical preparations. Side effects of tretinoin include erythema, skin peeling, dryness, edema, stinging sensation, extrusion of comedones, and the prevention of new comedone formation (Habif 2016; Haney 2016; Thielitz et al. 2008). There is also an increased risk of sunburn due to the thinning of the stratum corneum while using tretinoin (Habif 2016). Patients may experience increased stinging or sensitivity to some previously used topical preparations after they start using tretinoin (Habif 2016). These patients should be advised to avoid using any products that increase stinging such as products with preservatives or fragrance. Patients should also be instructed to avoid applying tretinoin around the lateral and medial canthi of the eyes, oral commissures, angles of the nose, and mucous membranes because it may cause epidermal injury (Habif 2016). Some tips patients can try at home if they are having side effects include (Habif 2016): 1. Dryness—the application of non-irritating moisturizer 30 minutes after application of the retinoid at night and continually applying moisturizer throughout the following day if desired 2. Irritation—start with a weaker dose of the medication and apply every other night or twice a week for a 2–4 weeks until tolerance has improved, then increase until application occurs every night 3. Redness/stinging—sun avoidance is strongly advised. Application of sunscreen of 30–50 SPF and the use of physical UV blocks such as a hat, sunglasses, and clothing are necessary to decrease the extent of sun exposure and side effect 4. Chemical or physical scrubs increase the chance of irritation and are not recommended while using stronger versions of prescription tretinoin

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5  Topical Preparations and Prescription Medications in Aesthetics

An important role of the aesthetic practitioner is to educate the patient on risks, benefits, and side effects of medications, including topical preparations. Management of patient expectations regarding treatment results and the time necessary to notice improvement in the skin condition is also important. Providing thorough explanation and the opportunity for the patient to ask questions ensures best outcomes and adherence to the prescribed regimen (Habif 2016).

5.3

Skin Lighteners

5.3.1 Hydroquinone Hydroquinone is a commonly used ingredient in creams and lotions to lighten the skin, decrease pigments from sun exposure, and treat melasma (Nordlund et  al. 2006). Currently, it remains the gold standard for treating hyperpigmentation and melasma (Tse 2010; Draelos 2007a). Controversies in hydroquinone use arose when a study using rats demonstrated that large amounts of ingested hydroquinone were associated with development of tumors. However, there are no reports of tumor formation in humans when used as a topical preparation (Nordlund et  al. 2006; Vanaman Wilson et  al. 2017; Levitt 2007). Consequently, some regulatory agencies previously raised concern over its use but it is now considered safe and effective for topical human use in approved doses (Levitt 2007; Torok 2006). Hydroquinone works by blocking the tyrosinase catalyzed conversion of tyrosine into melanin. Tyrosinase is the enzyme involved in the early stages of melanin formation (Palumbo et  al. 1991). Further, the use of tretinoin in combination with hydroquinone provides a more efficacious and tolerable effect than either drug used alone (Draelos 2007a; Hsieh et al. 2017). The results for the patient include lighter brown spots, fewer hyperpigmented areas, improvement in photodamage, and smoother looking skin (Vanaman Wilson et al. 2017). Most prescription skin lightening regimens include daily application of hydroquinone either alone or in combination with other medications or substances to be used for a specified amount of time. Practitioners who prescribe skin lightening medications often recommend a drug holiday although the literature does not confirm or refute this practice. Side effects of hydroquinone are mild for most people and include dryness, irritation, peeling, erythema, and/or stinging or burning (Vanaman Wilson et al. 2017). Sun avoidance is crucial when using hydroquinone for hyperpigmentation because the effects of sun exposure contribute to the darkening of pigments. Implications of UV rays and infra-red exposure from sunlight should be communicated to the patient and discussed during the initial consultation for treatment (Duteil et  al. 2017). Patients might report they spend time outdoors or enjoy activities where sun exposure is virtually guaranteed and they are resistant to avoiding sun exposure. Commitment to sun avoidance is an important component of the skin lightening regimen and should be emphasized to the patient. Sun exposure while attempting to reverse hyperpigmentation caused from UV and infra-red influence is counter-­ productive and may worsen the side effects of prescribed medications (Habif 2016).

5.4 Selected Skin Care Products: Cleansers and Moisturizers

45

Patient commitment, skin condition, and level of side effect tolerability can be useful to guide practice and recommend appropriate regimens for patients.

5.3.2 Azelaic Acid Azelaic acid (AA) is a dicarboxylic acid synthesized by the fungus, Malassezia furfur, and AA is commonly used to treat melasma, rosacea, and acne (Fitton and Goa 1991; Ball Arefiev and Hantash 2012). Malassezia furfur is associated with the hypopigmented macules seen in tinea versicolor (Ball Arefiev and Hantash 2012). Azelaic acid has been increasingly used as a skin lightener because of concern over the side effect profile of hydroquinone and tretinoin; AA causes less skin irritation than hydroquinone and tretinoin (Draelos 2007a, 2009). However, AA has slightly less efficacy in the treatment of hyperpigmentation than hydroquinone but can be better tolerated in patients with sensitive skin because there is only a short lived stinging sensation (Draelos 2007a). Azelaic acid can also safely be used in combination with other skin lightening preparations for additional pigment improvement (Fitton and Goa 1991). Azelaic acid has a similar mechanism of action as hydroquinone as it interferes with tyrosinase activity, but in addition, AA appears to interfere with DNA synthesis because of a specificity for abnormal melanocytes (Draelos 2007a). Due to this affinity for abnormal melanocytes, AA has been used to suppress the progression of lentigo maligna to lentigo maligna melanoma (Fitton and Goa 1991). Azelaic acid has an excellent safety profile and can be a viable option to hydroquinone or tretinoin for skin lightening (Draelos 2007a).

5.4

Selected Skin Care Products: Cleansers and Moisturizers

5.4.1 Cleansers Soap has been used for thousands of years and is the oldest surfactant. Surfactants are defined as the alkali salt of fatty acids with a pH of 9.5–10 (Friedman and Wolf 1996; Draelos 2018a). Synthetic soaps vary in composition, surfactant types, and pH. Cleansers emulsify dirt, oil, environmental debris, and microorganisms on the skin surface. During cleansing, the interaction between the cleanser, the moisture skin barrier, and skin pH plays a role in removing these elements (Kuehl et al. 2003). The most common cleanser formulations are composed of synthetic detergents, known as syndets, which is a combination of the words synthetic and detergent (Draelos 2018a). These cleansers possess a neutral to slightly alkaline pH resulting in less removal of the protective skin barrier because the related pH of syndets more closely resembles the pH of the skin. Soaps typically have a pH of 9–10, while syndets have a pH of 5.5–7, closer to natural skin pH (Korting and Braun-Falco 1996). Cleansers are an important part of the skin care regimen because they remove superficial debris and, therefore, can help prevent comedones and large pores. The pH

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5  Topical Preparations and Prescription Medications in Aesthetics

of the skin is considered to range from 4.2 and 5.9 and it is generally believed most people benefit from using acidic cleansers (Kuehl et  al. 2003; Korting and BraunFalco 1996). Cleansers contain ingredients that work in different ways. Depending on the skincare concern, patients choose cleansers based on their skin care goals, thus one patient might choose ingredients for oily skin, and others for dry skin. Ingredients of skin cleansers consist of the following (Kuehl et al. 2003): Water Surfactants Moisturizers Binders Lather enhancing substances Preservatives Fragrance Dyes or pigments

Break up debris found on the skin (emollients and humectants)—Added to cleansers to mitigate the effect of the acidity and to maintain skin barrier Stabilize the product To provide foam All cleansers must contain preservatives to prevent the growth of microorganisms Can be a source of irritation or reaction in some patients Can be found in some products, gives color

Cleansers can be categorized according to action and skin type. Cleansers that emulsify superficial sebum effectively can be used for oil-prone skin. Other cleansers may contain oils or glycerin for sensitive or dry skin types. Cleansers that contain active ingredients such as benzyl peroxide or salicylic acid are effective for acne-prone skin (Habif 2016; Draelos 2018a). Cleansers with a higher fat/oil percentage do not have as much capability to remove the moisture skin barrier so they are classified as more mild or for sensitive skin (Draelos 2018a). The various cleansers are comprised of liquid cleansers and bar soap and are included in the following table: Oil-free Gentle Acne washes Dry skin Dry skin Normal to combination skin Sensitive and dry skin

Recommended for acne-prone or oily skin (Matthews 2016) Sensitive skin Recommended for acne, contains active ingredients such as benzyl peroxide or salicylic acid Cleansers containing emollients or humectants (Kuehl et al. 2003) Cold cream (Draelos 2018a) Cleansing milks (thinner than cold cream) (Draelos 2018a) Micellar water cleanser (Draelos 2018a)

Skin cleansers lower the surface tension on the skin and remove dirt, sebum, microorganisms, and exfoliated stratum corneum cells (Kuehl et al. 2003). Ideally, cleansers should clean the skin without irritating, damaging, or disrupting the skin or the skin barrier. Interestingly, water alone removes approximately 65% of oil and debris, but is not as effective at removing cosmetic oils or some environmental residues (Kuehl et al. 2003). Water, soap, or a liquid cleanser will affect the moisture skin barrier and lead to dryness of the skin unless a moisturizer is added (Draelos 2018a; Kuehl et al. 2003).

5.4 Selected Skin Care Products: Cleansers and Moisturizers

47

Soap will bring about the greatest changes to the skin barrier and dryness because of the inherent properties of the soap e.g. higher pH and the stripping of the natural moisture barrier of the skin (Kuehl et al. 2003). Liquid facial cleansers are generally gentler because they cause less disruption of the skin moisture barrier and cause minimal change to skin pH. In addition, liquid cleansers are formulated as a combination of surfactants, moisturizers, and an acidic pH and these properties help to minimize disruption to the skin barrier (Kuehl et al. 2003). Emollients are substances added to cleansers that create a barrier on the skin that impedes skin water loss by forming a protective barrier to keep moisture from evaporating. Examples of common emollients added to skin care products are silicone, dimethicone, oils, butters, stearyl alcohol, cetyl alcohol, and petroleum derivatives (Draelos 2018b). Humectants, on the other hand, attract and bind water, and draw it up from the dermis into the epidermis (Kuehl et al. 2003; Draelos 2000). Humectants work by attracting water from the deeper layers of skin and drawing the water toward superficial layers of skin (Draelos 2018b). Examples of humectants include sorbitol, hyaluronic acid, alpha hydroxyl acids, amino acids, honey, propylene glycol, and butylene glycol (Purnamawati et al. 2017). Glycerin is one of the more typical and effective water binding agents and is an effective humectant (Alber et  al. 2014; Christman et al. 2012).

5.4.2 Moisturizers and Additives Moisturizers are essential components of the skin care regimen and act as emollients on the skin, promote skin hydration, and create a layer of protection after cleansing. Moisturizers may also include humectants that work by drawing water up from the dermis into the epidermis, thereby increasing hydration at the more superficial layers of skin (Draelos 2000, 2018b). Emollients are used to soften and smooth the loose or shedding cells of the stratum corneum of the skin, and help reduce rough, flaky skin. They are also occlusive agents which are substances that provide a layer of protection by acting as a barrier that helps prevent water loss from the skin (Draelos 2000, 2018b). A function of a good moisturizer is to keep the skin younger looking by decreasing the appearance of fine lines that may be accentuated by dryness. Moisturizers can have a plumping effect when the humectant in the product draws water from deeper areas into the superficial, deflated areas of dryness (Draelos 2018b). In addition, reflection of light helps to create a more luminous appearance and moisturizers often include an ingredient such as iron oxide, mica, or fish scale that promotes this attribute (Draelos 2018b). Some moisturizers claim to have reparative or rejuvenating properties but often, the manufacturer has added sunscreen to substantiate this claim (Draelos 2018b). Products that are marketed as tinted moisturizers or tinted sunscreens can be substituted for makeup and provide moisture, sun protection, and cosmetic blending of the skin (Draelos 2010, 2018b). The combination of moisture and sun protection in a cosmetic product adds convenience to the routine.

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5  Topical Preparations and Prescription Medications in Aesthetics

Moisturizer Formulations (Haney 2016; Draelos 2018b). Cream Lotion Ointment Solution/ suspension Gel Serum Stick

Mixture of oil and water; higher viscosity, thicker than lotion Greater water content than cream; lower viscosity than cream Primarily greases such as petroleum or dimethicone, little to no water Powder or particles suspended in liquid; may contain more alcohol and water Non-greasy, thick until rubbed into skin; contains water, acrylic polymers, propylene glycol, gums, cellulose thickeners Thin liquid; evaporates quickly, non-greasy, acts as a medium to deliver ingredients to skin. Not a good moisturizer Waxy solid; used on lips, no water, melts at body temperature

Moisturizer properties range from simply replacing a new skin barrier that has been removed through cleansing to skin lightening and anti-aging benefits. There are numerous additives in the form of vitamins, minerals, exfoliants, antioxidants, and botanicals that are routinely added into moisturizers (Gonzalez and Perez 2016). Antioxidants modulate oxidative damage from free radicals that lead to signs of aging in the skin (Chiu and Kimball 2003; Thiele et al. 2001). Some of the benefits of these additives have been substantiated through research, while others have not. Following is a list of common non-prescription additives (Draelos 2007b, 2018b): Skin lighteners  • Arbutin: Derived from the leaves of the lingonberry plant (Vaccinium vitis-idaea)a  • Kojic acid: Derived from fungusb  • Liquiritin: Licorice extract containing flavonoids  • Aleosin: Aloe vera derived glycoprotein known as hydroxymethylchromone and inhibits tyrosinase  • Vitamin C: L-ascorbic acid Peptides  • Carrier peptides: Glycine, histidyl, lysine linked to copper—facilitates wound healing  • Signal peptides: Lysine, threonine, threonine, lysine, serine linked to palmitic acid— stimulates collagen synthesis Vitamins  • Vitamin A: (Retinoids) Retinyl palmitate, retinol, retinyl esters—stimulates collagen, fights fine lines, acne  • Vitamin E: Alpha-tocopherol oil-soluble—antioxidant  • Niacin: Vitamin B3—anti-inflammatory, epidermal lipid increase  • Panthenol: Vitamin B5—humectant able to hold water  • Essential fatty acids: Unsaturated linoleic, linolenic, and arachidonic acid Botanicals  • Soy—phytoestrogens functioning as antioxidants  • Curcumin—antioxidant  • Silymarin—antioxidant  • Pycnogenol—antioxidant  • Ginkgo—antioxidant Exfoliants  • Alpha hydroxy acid (AHA): Glycolic acid, water-soluble—keratolytic  • Beta hydroxy acid (BHA): Salicylic acid, oil-soluble—keratolytic, desmolytic a

Most effective OTC skin lightening ingredient (Draelos 2007a) Second most effective OTC skin lightening ingredient (Draelos 2007a)

b

References

5.5

49

Conclusion

The number of available skin products is staggering and patients frequently seek advice on which preparations are most appropriate for their particular skin type. Skin lighteners and acne products are commonly requested and practitioners who are knowledgeable in their use can provide effective skin care. In addition to skin care treatments, cleansers are an important part of the skin care regimen, especially for people who use cosmetics (Draelos 2018a). Cleansers emulsify dirt, oil, and microorganisms on the skin surface so they can be washed away (Korting and Braun-Falco 1996). Liquid facial cleansers are gentler to the skin than bar soaps and minimize disruption to the skin moisture barrier (Draelos 2018b). Moisturizers are an additional component to the skin care routine and include emollients and humectants. Moisturizers are important because they replace the protective moisture barrier that is disrupted during cleansing.

References Alber C, Buraczewska-Norin I, Kocherbitov V, Saleem S, Loden M, Engblom J. Effects of water activity and low molecular weight humectants on skin permeability and hydration dynamics - a double-blind, randomized and controlled study. Int J Cosmet Sci. 2014;36(5):412–8. Ball Arefiev KL, Hantash BM. Advances in the treatment of melasma: a review of the recent literature. Dermatol Surg. 2012;38(7 Pt 1):971–84. Brown L, Langer R. Transdermal delivery of drugs. Annu Rev Med. 1988;39:221–9. Chiu A, Kimball AB. Topical vitamins, minerals and botanical ingredients as modulators of environmental and chronological skin damage. Br J Dermatol. 2003;149(4):681–91. Christman JC, Fix DK, Lucus SC, Watson D, Desmier E, Wilkerson RJ, et al. Two randomized, controlled, comparative studies of the stratum corneum integrity benefits of two cosmetic niacinamide/glycerin body moisturizers vs. conventional body moisturizers. J Drugs Dermatol. 2012;11(1):22–9. Draelos ZD. Therapeutic moisturizers. Dermatol Clin. 2000;18(4):597–607. Draelos ZD.  Skin lightening preparations and the hydroquinone controversy. Dermatol Ther. 2007a;20(5):308–13. Draelos ZD. Cosmeceuticals. In: Goldberg DJ, editor. Facial rejuvenation. Berlin: Springer; 2007b. Draelos ZD. An evaluation of prescription device moisturizers. J Cosmet Dermatol. 2009;8(1):40–3. Draelos ZD. Active agents in common skin care products. Plast Reconstr Surg. 2010;125(2):719–24. Draelos ZD. The science behind skin care: cleansers. J Cosmet Dermatol. 2018a;17(1):8–14. Draelos ZD. The science behind skin care: moisturizers. J Cosmet Dermatol. 2018b;17(2):138–44. Duteil L, Esdaile J, Maubert Y, Cathelineau AC, Bouloc A, Queille-Roussel C, et al. A method to assess the protective efficacy of sunscreens against visible light-induced pigmentation. Photodermatol Photoimmunol Photomed. 2017;33(5):260–6. Fitton A, Goa KL. Azelaic acid. A review of its pharmacological properties and therapeutic efficacy in acne and hyperpigmentary skin disorders. Drugs. 1991;41(5):780–98. Friedman M, Wolf R. Chemistry of soaps and detergents: various types of commercial products and their ingredients. Clin Dermatol. 1996;14(1):7–13. Fulton JE Jr, Farzad-Bakshandeh A, Bradley S. Studies on the mechanism of action to topical benzoyl peroxide and vitamin a acid in acne vulgaris. J Cutan Pathol. 1974;1(5):191–200. Gonzalez N, Perez M. Natural cosmeceutical ingredients for hyperpigmentation. J Drugs Dermatol. 2016;15(1):26–34. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. St. Louis: Elsevier; 2016.

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Haney B. Therapeutic/treatment modalities. In: Nicols N, editor. Dermatology nursing essentials: a core curriculum. 3rd ed. Philadelphia: Wolters Kluwer; 2016. Hsieh PW, Hung CF, Lin CH, Huang CW, Fang JY. Anti-melasma codrug of retinoic acid assists cutaneous absorption with attenuated skin irritation. Eur J Pharm Biopharm. 2017;114:154–63. Jablonski NG. Skin: a natural history. 1st ed. Berkeley: University of California Press; 2006. Kligman AM, Grove GL, Hirose R, Leyden JJ. Topical tretinoin for photoaged skin. J Am Acad Dermatol. 1986;15(4 Pt 2):836–59. Korting HC, Braun-Falco O.  The effect of detergents on skin pH and its consequences. Clin Dermatol. 1996;14(1):23–7. Kuehl BL, Fyfe KS, Shear NH.  Cutaneous cleansers. Skin Ther Lett. 2003;8(3):1–4. Available from: http://www.skintherapyletter.com/cosmetic-dermatology/cutaneous-cleansers/. Levitt J. The safety of hydroquinone: a dermatologist’s response to the 2006 Federal Register. J Am Acad Dermatol. 2007;57(5):854–72. Leyden J, Stein-Gold L, Weiss J. Why topical retinoids are mainstay of therapy for acne. Dermatol Ther (Heidelb). 2017;7(3):293–304. Marson JW, Baldwin HE.  New concepts, concerns, and creations in acne. Dermatol Clin. 2019;37(1):1–9. Matthews SWN. In: Nicol NH, editor. Acne and other disorders of the skin. 3rd ed. Alphen aan den Rijn: Wolters Kluwer; 2016. Nicol NH.  Anatomy and physiology of the integumentary system. In: Nicol NH, editor. Dermatologic nursing essentials: a core curriculum. 3rd ed. Philadelphia: Dermatology Nurses Association; 2016. Nordlund J, Grimes P, Ortonne JP.  The safety of hydroquinone. J Cosmet Dermatol. 2006;5(2):168–9. Palumbo A, d’Ischia M, Misuraca G, Prota G.  Mechanism of inhibition of melanogenesis by hydroquinone. Biochim Biophys Acta. 1991;1073(1):85–90. Purnamawati S, Indrastuti N, Danarti R, Saefudin T. The role of moisturizers in addressing various kinds of dermatitis: a review. Clin Med Res. 2017;15(3–4):75–87. Thiele JJ, Schroeter C, Hsieh SN, Podda M, Packer L.  The antioxidant network of the stratum corneum. Curr Probl Dermatol. 2001;29:26–42. Thielitz A, Abdel-Naser MB, Fluhr JW, Zouboulis CC, Gollnick H. Topical retinoids in acne--an evidence-based overview. J Dtsch Dermatol Ges. 2008;6(12):1023–31. Topical tretinoin (topical all-trans retinoic acid): Drug information [Internet]. Up to Date. 2019. Available from: https://www.uptodate.com/contents/ topical-tretinoin-topical-all-trans-retinoic-acid-drug-information. Torok HM. A comprehensive review of the long-term and short-term treatment of melasma with a triple combination cream. Am J Clin Dermatol. 2006;7(4):223–30. Tse TW. Hydroquinone for skin lightening: safety profile, duration of use and when should we stop? J Dermatolog Treat. 2010;21(5):272–5. Vanaman Wilson MJ, Jones IT, Bolton J, Larsen L, Wu DC, Goldman MP.  A randomized, investigator-­blinded comparison of two topical regimens in fitzpatrick skin types III-VI with moderate to severe facial hyperpigmentation. J Drugs Dermatol. 2017;16(11):1127–32.

6

Microdermabrasion

6.1

Microdermabrasion

Microdermabrasion, introduced in 1985, is a mechanical exfoliation treatment used to diminish the appearance of mild sun damage, uneven texture, discoloration, and acne. Microdermabrasion removes the stratum corneum, has a temporary effect on the lipid moisture layer of the skin, and has been shown to increase collagen stimulation (El-Domyati et al. 2016; Fak et al. 2018). Microdermabrasion is a non-invasive procedure that produces subtle cosmetic effects. The benefits of its use have been studied to determine the level of improvement in visible skin appearance as well as the invisible benefits that occur in the deeper layers of skin (El-Domyati et  al. 2016). In addition, microdermabrasion treatments can prepare the skin for different medical procedures such as intense pulsed light (IPL) or photodynamic therapy (PDT). Microdermabrasion performs just under fractional ablative laser treatment in the preparation of the skin for PDT and with significantly less pain, making microdermabrasion a reasonable pre-­ treatment modality (Bay et al. 2017). Histologically, a decrease in the concentration of melanin, more uniform distribution of melanosomes, and increased collagen density with regular arrangement of collagen bundles are observed as a result of microdermabrasion treatment (El-Domyati et  al. 2016). Clinically, microdermabrasion offers mild-to-moderate effects in the appearance of hyperpigmented lesions such as melasma, but in patients with photo-aging characteristics, the effect can be mild. Available evidence does not support adequate lightening of pigments from microdermabrasion but laser, peels, or medications are considered to be more beneficial (El-Domyati et al. 2016; Shim et al. 2001; Karimipour et al. 2010). Alternatively, worsening of acne lesions has been reported after microdermabrasion and so should be used with caution as treatment for acne; hence it might not be an appropriate indication for acne treatment (Karimipour et al. 2010). Preparation of the skin with microdermabrasion immediately prior to an intense pulsed light (IPL) procedure is an additional option. Microdermabrasion © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_6

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can provide a more effective IPL treatment because the IPL light is thought to penetrate the skin more effectively due to the removal of superficial debris prior to IPL treatment. The combination treatment of microdermabrasion and IPL represents a synergistic approach to noninvasive skin rejuvenation (Strasswimmer and Grande 2006). A series of microdermabrasion treatments is necessary to achieve optimal skin rejuvenation results although fine lines seem to be minimally amenable to its effects (Shim et al. 2001). Histologic improvements typically occur after just three microdermabrasion treatments but after six microdermabrasion treatments, the effects have demonstrated to be greater and included thickening of the dermis and new collagen and elastin formation (Freedman et  al. 2001). A common interval for microdermabrasion is one treatment every 1–2 weeks for best results, and thereafter periodic maintenance treatments (Karimipour et  al. 2010). Treatment effects and recommendations are important to convey to aesthetic patients. Apprising patients they are receiving benefits to their skin, although they might not be immediately visible, and they might require multiple treatments to achieve desired results, will assist in managing expectations.

6.2

Types of Microdermabrasion Devices

Depending on the model of the microdermabrasion device, there may be separate glass or plastic containers that simultaneously infuse water or serums onto the skin during treatment or others that use crystals. Currently, there are three common types of microdermabrasion machines, (a) those that blow fine crystals onto the skin during treatment, (b) those that do not use crystals, and (c) those that do not use crystals but infuse water or serums onto the skin during the treatment. The crystals used in some microdermabrasion devices are aluminum oxide, magnesium oxide, sodium bicarbonate, and sodium chloride (see Fig. 6.1) (Shim et al. 2001). One of the potential complications with using a device that includes crystals is the potential for corneal irritation or abrasion if crystals become loose or get into the eye(s) of the patient. The model of microdermabrasion device that does not use crystals, but uses a diamond treated tip of varying grit depending on the depth of skin ablation desired or the condition being treated, seems to be more effective in increasing collagen stimulation. Crystal-free microdermabrasion appears to cause an added benefit of increased extracellular matrix protein when compared to the effect of microdermabrasion that uses crystals (Kirkland and Hantash 2012a). The type of device that infuses water or serums is sometimes referred to as a wet microdermabrasion or hydro-microdermabrasion (see Fig. 6.2). This type of hydro-­ microdermabrasion has become popular over the last couple of years. The hydro-­ microdermabrasion procedure is quite unique in that the hand-piece simultaneously delivers antioxidant serum, water, or solution and vacuums away the skin particles during treatment.

6.3  Considerations of Microdermabrasion

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Fig. 6.1  Example of crystal-free microdermabrasion device. Photo courtesy: Beth Haney, DNP, FNP-C, FAANP

6.3

Considerations of Microdermabrasion

The level of skin ablation from the microdermabrasion procedure is determined by the strength of the flow of crystals (if crystals used), user speed of movement of the hand-piece, and the number of passes per site. Slow movement of the hand-piece and a higher number of passes increase the depth of microdermabrasion (Grimes 2005; Kirkland and Hantash 2012b). Careful technique is advised over bony prominences such as the brow, temple, malar, or nasal areas to avoid side effects such as

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Fig. 6.2  Example of hydro-microdermabrasion device. Photo courtesy: Beth Haney, DNP, FNP-­C, FAANP

increased redness, superficial lacerations, or abrasions (Shim et al. 2001). Lower vacuum settings are preferred over thin skinned areas such as eyelids to avoid purpura or ecchymosis (Karimipour et al. 2010). Skin testing in a small area with the recommended settings is necessary prior to beginning microdermabrasion treatment to assess skin reaction and patient tolerance. A list of aspects to consider for microdermabrasion treatment includes patient selection and the advantages, disadvantages, and complications of the procedure. • The appropriate patient has slight discoloration, fine lines, and texture irregularities—significant photodamage, deep lines, and moderate hyperpigmentation are not the indications for microdermabrasion. • Advantages of microdermabrasion include minimal down time, few side effects, can be used on most skin types, and lower cost per treatment. • Disadvantages include the necessity for multiple treatments and less dramatic visible effects than other procedures such as IPL or laser. • Complications can include corneal irritation with using crystals, possible bruising, worsening of telangiectasia, superficial abrasions, and/or mild discomfort (Kirkland and Hantash 2012b).

6.4  The Microdermabrasion Procedure

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Fig. 6.3  Microdermabrasion. Photo courtesy: Beth Haney, DNP, FNP-C, FAANP

Most people find that microdermabrasion treatment is not painful. The treatment does not penetrate underlying tissues or cause bleeding and there is no need for the application of topical anesthetic. The sensation during treatment has been described as similar to a cat lick or rough paper being scraped over the skin. Microdermabrasion can be done in several different body areas on appropriate patients, including face, neck, chest, and hands (see Fig. 6.3) (Bernard et al. 2000).

6.4

The Microdermabrasion Procedure

The procedure itself is straightforward but the nuances of the practitioner’s experience and technique will dictate the result. As with all devices used in cosmetic dermatology, thorough training and experience, as well as knowledge regarding the operating principles of the equipment are essential prior to treating patients. In addition, knowledge and adherence to governing practice laws, including experience and training, are important parts of the practitioner’s practice. Patient skin type should be evaluated along with any contraindications before using microdermabrasion to treat patients. Contraindications to microdermabrasion

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treatment include, but are not limited to, (1) autoimmune diseases, (2) bleeding disorders, (3) pregnancy, (4) lactation, (5) open wounds or lesions in the area to be treated, (6) HSV outbreak in the area to be treated, (7) inflammatory skin conditions such as psoriasis or eczema, (8) keloid scar formation, (9) sun burn, (10) microdermabrasion immediately after injections or laser/IPL in the area to be treated, (11) after waxing, (12) patients with diabetes, and (13) patients with unidentified or suspicious lesions (Grimes 2005; Nguyen 2014). A sample microdermabrasion safety and treatment protocol. (This is not a legal or institutional document. The following items are not intended to replace legal guidelines or institutional policies and procedures, but provide a simple baseline regarding safety and treatment protocol.) 1. Ensure the machine is in good working order 2. Make sure a clean hand-piece is used for every treatment 3. Reusable tips should be cleaned with appropriate antiseptic or germicide 4. Always review the patient’s medical history and determine if there are any concerns or contraindications. If so, consult with the physician or other appropriate practitioner 5. Remove any jewelry and contact lenses 6. Cover patient’s eyes securely with pads or other protective eyewear 7. Ensure the patient’s skin is cleansed and all debris, makeup, and oils are removed because these substances can impair the machine function 8. Evaluate the patient’s skin 9. Check the tip for sharpness: Do a pass to the patient’s ventral forearm or behind the ear to test for sharp edges or scratching and avoid treatment if necessary, until tip is replaced. Check the vacuum setting during this time and watch for swelling. 10. Because every patient has a different level of tolerance, begin the treatment at a low vacuum setting and increase as tolerated 11. Treatments that are too aggressive can result in bleeding. At any sign of bleeding, the treatment must be stopped immediately 12. Begin treatment on one side of the face using gentler pressure on fragile or sensitive areas such as the forehead. Refer to the particular device training manual for more complete treatment parameters and technique 13. Avoid treatment to eyelids 14. Crystals should never be reused 15. After completing the treatment, rinse the skin with water or cool sponges. Apply sunscreen and moisturizer as appropriate 16. Cleaning of the device is determined by the type and model used—refer to operator manual for recommendations NOTE: All passes move in an upward direction from the jawline up and laterally from the center of the face. A cross-hatch technique may be used on areas that are not sensitive.

References

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Sample of after-care instructions for patients can include the following: • Your skin may feel slightly irritated for 2–24 h after treatment and this is a normal response. Do not be alarmed if there is no irritation and be assured the treatment is effective without feeling irritation. • Avoid peels, scrubs, or exfoliants for 7–10 days. • Avoid strenuous exercise for 24 h. • Makeup use is permissible but not encouraged immediately after treatment. • Avoidance of direct sun exposure is always recommended but especially during the 24 h after treatment. If sun exposure is unavoidable, sunscreen of 30+ SPF is strongly encouraged and can be applied immediately. • Optimal results occur after a series of at least three treatments and six are recommended (1–2 per week) followed by regular, periodic maintenance treatments.

6.5

Conclusion

Microdermabrasion is a widely used skin care treatment offered in many medical aesthetic practices that provide non-medical treatments such as waxing, facials, and other skin care services. The global breakdown of the percentage of people based on gender who received microdermabrasion in 2017 is 86% female and 14% male (rounded) (ISAPS 2017). The total number of microdermabrasion performed in the 2017 specifically in the USA is over 740,000 (ASPS 2017). The efficacy of microdermabrasion has been shown to improve various skin conditions in patients for such conditions including hyperpigmentation and acne. However, because microdermabrasion results are technique dependent, it is important to keep in mind that to attain the best result, the regimen might require the addition of topical medications (Karimipour et al. 2010; Chilicka et al. 2017).

References American Society of Plastic Surgeons (ASPS). Top five cosmetic plastic surgery procedures. 2017. Available from: https://www.plasticsurgery.org/. Bay C, Lerche CM, Ferrick B, Philipsen PA, Togsverd-Bo K, Haedersdal M. Comparison of physical pretreatment regimens to enhance protoporphyrin IX uptake in photodynamic therapy: a randomized clinical trial. JAMA Dermatol. 2017;153(4):270–8. Bernard RW, Beran SJ, Rusin L.  Microdermabrasion in clinical practice. Clin Plast Surg. 2000;27(4):571–7. Chilicka K, Maj J, Panaszek B. General quality of life of patients with acne vulgaris before and after performing selected cosmetological treatments. Patient Prefer Adherence. 2017;11:1357–61. El-Domyati M, Hosam W, Abdel-Azim E, Abdel-Wahab H, Mohamed E. Microdermabrasion: a clinical, histometric, and histopathologic study. J Cosmet Dermatol. 2016;15(4):503–13. Fak M, Rotsztejn H, Erkiert-Polguj A. The early effect of microdermabrasion on hydration and sebum level. Skin Res Technol. 2018;24(4):650–5. Freedman BM, Rueda-Pedraza E, Waddell SP. The epidermal and dermal changes associated with microdermabrasion. Dermatol Surg. 2001;27(12):1031–3; discussion 3–4.

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Grimes PE. Microdermabrasion. Dermatol Surg. 2005;31(9 Pt 2):1160–5; discussion 5. International Society of Plastic Surgery (ISAPS). ISAPS international survey on aesthetic/cosmetic procedures performed in 2017. Hanover: International Society of Aesthetic Plastic Surgery; 2017. Available from: https://www.isaps.org/wp-content/uploads/2019/03/ISAPS_2017_ International_Study_Cosmetic_Procedures_NEW.pdf. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: an evidence-based review. Plast Reconstr Surg. 2010;125(1):372–7. Kirkland EB, Hantash BM. Microdermabrasion: molecular mechanisms unraveled, part 1. J Drugs Dermatol. 2012a;11(9):e2–9. Kirkland EB, Hantash BM. Microdermabrasion: molecular mechanisms unraveled, part 2. J Drugs Dermatol. 2012b;11(9):e10–7. Nguyen T.  Dermatology procedures: microdermabrasion and chemical peels. FP Essent. 2014;426:16–23. Shim EK, Barnette D, Hughes K, Greenway HT. Microdermabrasion: a clinical and histopathologic study. Dermatol Surg. 2001;27(6):524–30. Strasswimmer J, Grande DJ.  Do pulsed lasers produce an effective photodynamic therapy response? Lasers Surg Med. 2006;38(1):22–5.

7

Permanent and Semi-­permanent Micro-­Pigment Treatments

7.1

Micropigmentation

Tattooing for medical or aesthetic purposes is commonly referred to as micropigmentation but the terms are used interchangeably. Tattooing is the process of depositing metabolically inert pigment granules into the dermis for medical indications and is considered permanent or semi-permanent depending on the depth and type of pigment. Professional pigments are non-toxic, non-allergenic, minute particles that are stable within the tissue (Thami 2018; Garg and Thami 2005). There are several reasons patients desire tattoos for aesthetic purposes, e.g., tremors, convenience, poor vision, allergies to makeup, and camouflage of various conditions such as vitiligo, scars, and birthmarks (De Cuyper 2008). Improvement of self-confidence for some people is a welcome benefit of having cosmetic enhancement. Tattooing was first used as a medical procedure to help camouflage nevi, scarring, or lip asymmetry. Earlier, tattoos were used in a variety of ways e.g. to mark prisoners, identify gladiators and slaves, and as body art in different cultures (Thami 2018; Vassileva and Hristakieva 2007). While tattooing for medical reasons was first documented in the 1800s, it was initially used cosmetically as eyeliner in 1984 on disabled women who did not have the desire or the ability to apply makeup on a daily basis. That earlier tattooing procedure was found to be safe and effective (Angres 1984). Tattooing or micropigmentation in aesthetics is performed by using one or more tattoo needles mounted on a manual or electrically driven device or by using a hand-­ held instrument with a row of very fine needles. Different shades of pigmentation can be achieved by using combinations of white, yellow, black, red, camel yellow, and brown pigments (Thami 2018; Garg and Thami 2005; Vassileva and Hristakieva 2007). The permanent tattoo pigment, once deposited into the skin, is retained intracellularly as well as extracellularly within collagen bundles for many years and permanent dyes can last long after death (Garg and Thami 2005; Wolfley et al. 1988). The most common element in tattoos is iron oxide, therefore, the patient must be aware © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_7

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that before any MRI scanning, the technician needs to be informed (Thami 2018). Some patients with tattoos have complained of a burning sensation during an MRI study and this can be an uncomfortable experience. Interestingly, there have been no dermal burns in the tattooed areas and the burning sensation immediately stops when the MRI is discontinued. It has been shown that the pigment from common tattoos does not reach a high enough temperature to cause thermal damage to the skin (Alsing et al. 2018). Cosmetic results of permanent or semi-permanent micropigmentation depend on the depth of pigment deposition, uniformity of pigment, location and placement, and vascularity of the area (Vassileva and Hristakieva 2007). Therefore, it is imperative that the practitioner have in-depth knowledge of the skin and tissues, but just as importantly, have an artistic eye. Tattooing/micropigmentation is generally safe without significant adverse effects but careful consideration of patient expectations and safety issues by using universal precautions are paramount for good outcomes. Risks from any type of tattooing include potential infections such as syphilis, tuberculosis, viral infections such as common warts, hepatitis B and C, and human immunodeficiency virus (HIV) (Garg and Thami 2005). These blood borne infections can be transmitted through repeated use of the same tattooing needles from one patient to another. Policies and guidelines in the USA and other countries have been adopted to help prevent spread of infections (Islam et al. 2016). Tattoo practitioners must use aseptic technique, universal precautions, and disposable needles.

7.2

Semi-permanent Pigment Treatments

7.2.1 Microblading Eyebrows are a frequently requested area for treatment because as the aging process progresses, the eyebrows can become thin and sparse. Microblading is a relatively new, manual method that does not use a normal permanent makeup or tattoo device; rather, it is a precise technique using free-hand strokes with a hand-held instrument (see Fig. 7.1). This free-hand technique is typically referred to as microblading but can be identified as brow micropigmentation, manual technique, hand method eyebrow semipermanent makeup, feather brows, 3D-6D Brows, cosmetic tattooing, eyebrow embroidery, and others. The method has become popular globally, likely due to the semi-permanent nature of the pigment, the gradual fading of the pigment, and the natural hair-like appearance of the result. Microblading technique uses a unique hand-held instrument consisting of a small row of very fine needles that deposit pigment into the dermis with tiny, slicing, feathering strokes (see Fig. 7.2). The pigment is implanted in the basal membrane, which divides the epidermis from the dermis layer of the skin (Nicol 2016). This creates very crisp, fine hair-like strokes that maintain their linear appearance after healing. As with any invasive aesthetic treatment, there are certain contraindications to microblading. Pregnancy, infection at the site of treatment, and open wounds in the area are contraindications and treatment should not be performed on patients with

7.2  Semi-permanent Pigment Treatments

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Fig. 7.1  Example of hand-held instrument and bottle of pigment. Photo courtesy: Beth Haney, DNP, FNP-C, FAANP Fig. 7.2  Example of the hand-held microblade technique and position. Photo courtesy: Beth Haney, DNP, FNP-C, FAANP

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these conditions. Patients with the following conditions should be cleared by a qualified provider prior to the procedure: • • • • • • • • • • • • •

Bleeding disorder Cardiac condition Diabetic patients Skin diseases Use of isotretinoin, or other retinoids Very sensitive or pain intolerant patients Active sunburn or frostbite Seborrheic dermatitis Very dry or peeling skin Excessive sebum, oily skin Acne Nevus in area of treatment Keratosis

Other treatment considerations include effect of neurotoxin or filler treatment on the outcome of the microblading procedure. Some practitioners suggest patients receive microblading treatment about 2–4  weeks before neurotoxin treatment to allow for desired shaping of the brows to coincide with the effect of the neurotoxin. If the patient tints or waxes the eyebrows, it should be done several days prior to microblading to clear the area of extra hairs. In addition, avoidance of aspirin, nonsteroidal anti-inflammatory (NSAIDS), vitamin E, and alcohol 7 days prior to treatment can help prevent posttreatment side effects such as bruising and swelling. Lastly, chemical peels, microdermabrasion, or other potentially irritating procedures should be completed 2–3 weeks prior to microblading to prevent increased sensitivity, redness, swelling, or other symptoms. Below are some potential side effects and complications with microblading and semi-permanent micropigment treatment:

• Pain: Topical anesthetic response is variable. • Infection: Infection is very unusual. • Uneven Pigmentation: This can result from poor healing, infection, bleeding, skin sloughing, incorrect technique, or other causes (touch-up at a subsequent appointment can correct any uneven appearance). • Brow Asymmetry: Adjustments may be needed during the follow-up session to correct any unevenness. • Swelling or bruising. • Reaction to the topical anesthetics. • Reaction to the pigment.

7.3 Permanent Pigment Treatment

63

Immediately after the microblading procedure, the color typically appears more vibrant or darker compared to the end result. Usually within 5–7 days the color will fade somewhat, soften, and look natural. The pigment continues to fade over several weeks and a touch-up or second treatment is expected during the first couple of months. After the initial treatment and additional touch-up, the results of microblading last between 6 months and 3 years depending on the condition of the patient’s skin, practitioner technique, pigment properties, and other variables.

7.3

Permanent Pigment Treatment

Tattooing is a form of permanent pigment treatment that is used for body decoration, radiation treatment, and camouflage of medical conditions such as scars or vitiligo, as well as cosmetic applications. The focus of this section will be on cosmetic tattoo applications including eyebrows, eyelids (lash lines or eyeliner), lip liner, lip, and cheek coloring. Cosmetic tattooing, also called micropigmentation, is performed with a hand-­ held, pen-like device with a rotating needle at the end. Some devices are made for specific applications such as permanent makeup application and can be programmed to deliver pigments exclusively into a certain depth. Because the depth of cosmetic tattoos is more superficial than tattoos used for body decoration, the pigment tends to fade out within several years (De Cuyper 2008). The needles used for micropigmentation procedures are disposable and for one time use on a single patient. In the past, infections occurred when the same needle was used on different patients (Islam et al. 2016). As previously mentioned, tattoo pigments are deposited into the skin and the pigment particles are retained in the intracellular and extracellular matrix of the collagen bundles and, therefore, can remain visible for many years (Garg and Thami 2005; De Cuyper 2008). There are different types and colors of inks and practitioners should use clinical and aesthetic judgment when choosing products. Colors range from natural skin colors to various shades of brown to black. Working with the patient to decipher what color and shape are most pleasing to them is important to achieve the best outcome. Many times, the practitioner will use the patient’s own favorite makeup as a guide for choosing color(s) to create a customized effect. Documentation of the colors and mixing ratios, if applicable, is important in the event of corrections, additions, or touch-ups. Examples of devices used for cosmetic tattooing procedures are shown in Figs. 7.3 and 7.4. The optimal level of pigment deposition is in the papillary dermis at a depth of approximately 1.0–2.0 mm. If the pigment is deposited any deeper, it can be carried away by pigment migration within months, and if the pigment is placed superficially, it can exfoliate within weeks and disappear (Thami 2018).

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Fig. 7.3  (L) Needle size for larger swaths of color. (R) Fine needle size for more precise lines such as hair strands (beautybuilt.com) Fig. 7.4  Hand-held tattoo device (beautybuilt.com)

References

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As with any tattoo treatment, there can be complications with the procedure, although with micropigment treatments, they are uncommon. Complications can include swelling, crusting, patient dissatisfaction with the outcome, infection, loss of eyelashes, scarring, and allergic reaction (Thami 2018). There are several kinds of inks, and they all vary in the percentage and combination of dyes, pigments, and additives. Most of the reported allergic reactions have involved red ink and inks that contain metal oxide can oxidize and turn black. Oxidized inks can be more difficult to remove than regular inks and this can be problematic (Thami 2018). In chronic cases, tattoo removal using laser or dermabrasion may be warranted (De Cuyper 2008). In addition, over time inks fade and might take on a gray, ashen, pink, or gold hue even when expertly placed, so periodic touch-ups will be required to maintain a pleasing color.

7.4

Conclusion

Permanent and semi-permanent tattooing can be a welcome aesthetic treatment and provide pleasing long-term effects. Eyebrows, lips, and cheeks can be enhanced while the eyes can be more defined with micropigmentation applied as eyeliner. The appearance of scars and disfiguring conditions can be reduced with appropriate placement of micropigments. However, because of the potentially long-lasting nature of this treatment, it is prudent to manage patient expectations, review complications, and address any questions or concerns the patient may have prior to the procedure.

References Alsing KK, Johannesen HH, Hvass Hansen R, Dirks M, Olsen O, Serup J. MR scanning, tattoo inks, and risk of thermal burn: an experimental study of iron oxide and organic pigments: effect on temperature and magnetic behavior referenced to chemical analysis. Skin Res Technol. 2018;24(2):278–84. Angres GG.  Eye-liner implants: a new cosmetic procedure. Plast Reconstr Surg. 1984;73(5):833–6. De Cuyper C.  Permanent makeup: indications and complications. Clin Dermatol. 2008;26(1):30–4. Garg G, Thami GP. Micropigmentation: tattooing for medical purposes. Dermatol Surg. 2005;31(8 Pt 1):928–31; discussion 31. Islam PS, Chang C, Selmi C, Generali E, Huntley A, Teuber SS, et al. Medical complications of tattoos: a comprehensive review. Clin Rev Allergy Immunol. 2016;50(2):273–86. Nicol NH. Anatomy and physiology of the integuentary system. In: Nicol NH, editor. Dermatologic nursing essentials: a core curriculum. 3rd ed. Southern Pines: Dermatology Nurses Association; 2016.

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Thami GP. Micropigmentation. In: Gupta S, Olsson MJ, Parsad D, Lim HW, van Geel N, Pandya AG, editors. Vitiligo: medical and surgical management. 1st ed. Hoboken: Wiley; 2018. p. 451–7. Vassileva S, Hristakieva E. Medical applications of tattooing. Clin Dermatol. 2007;25(4):367–74. Wolfley DE, Flynn KJ, Cartwright J, Tschen JA. Eyelid pigment implantation: early and late histopathology. Plast Reconstr Surg. 1988;82(5):770–4.

8

Superficial Chemical Peels

8.1

Chemical Peels Used in Aesthetics

Alpha hydroxy acids (AHAs) are derived from natural fruit acids, are nontoxic, and classified as organic carboxylic acids. Carboxylic acid has one hydroxyl group attached to the alpha position (α) of the carbon atom (Coleman and Brody 1997). Beta hydroxy acids (BHAs) are lipid soluble and are also organic carboxylic acids with one hydroxyl group attached to the beta position (β) of the carboxyl group (Green et al. 2009). Alpha and beta hydroxyl acids are common sources of superficial chemical peeling agents in aesthetics. Superficial chemical peels are derived from acids of various sources including plants and vitamins (Ball Arefiev and Hantash 2012; Fabbrocini et al. 2009). Superficial peels penetrate to the epidermis and are used alone or in combination with other treatments, such as facials or microdermabrasion, to enhance outcomes (Rendon et al. 2010). Superficial peels are used to refresh the skin and remove the stratum corneum through chemical exfoliation. Consultation with the patient should include side effects, benefits, and limitations of the superficial peeling agents. Management of expectations is important and the patient should understand that the effects are subtle and temporary, unlike the deep chemical peels that offer more clinically evident results because of histologic changes in the reticular dermis (Stegman 1982; Kligman and Kligman 1998). A variety of superficial chemical peels are available in different strengths but some agents require neutralization to terminate their action, whereas others are self-­ neutralizing. Superficial peeling agents that are self-neutralizing include salicylic acid (SA), trichloroacetic acid (TCA), lactic acid (LA), retinoic acid (RA), and Jessner solution (Lee et al. 2018). Superficial peeling agents that require neutralization with water or sodium bicarbonate to avoid over penetration are glycolic acid (GA) and pyruvic acid (PA) (Lee et al. 2018). Certain factors affect tolerability of peels such as the type of peeling agent, skin type, and concomitant use of skin care products (Rendon et al. 2010). Complications can be avoided through careful patient assessment and determination of risk factors © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_8

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such as (1) post-inflammatory hyperpigmentation, (2) frequent and intense sun exposure, (3) history of keloid formation, (4) extremely sensitive skin, and (5) darker skin type (Coleman and Brody 1997; Rendon et al. 2010). Superficial chemical peels are popular and generally safe treatments used in aesthetic practice to address rough skin texture, fine lines, melasma, and photodamage (Alam et al. 2002; Abdel-Motaleb et al. 2017). Chemical peels are slightly more popular than microdermabrasion in the USA although both treatments yield similar results (Alam et al. 2002; ASPS 2017; Karimipour et al. 2010). Perhaps the characteristic peeling effect from a chemical peel provides visible assurance of perceived effectiveness to the patient.

8.1.1 Salicylic Acid (SA) Peels Salicylic acid is a superficial peeling agent that is used for a variety of skin conditions including acne, melasma, and photodamage and is the only member of the beta-hydroxy acid family (Rendon et  al. 2010; Abdel-Motaleb et  al. 2017). Characteristics of SA include desmolytic action due to its ability to disrupt cellular junctions, rather than breaking or lysing intercellular keratin filaments as once thought (Arif 2015). Salicylic acid is able to reduce clogging of skin pores from accumulation of skin cells and keratin in the pilosebaceous unit and so is helpful in limiting acne (Abdel-Motaleb et al. 2017; Arif 2015; Habif 2016). Histologic results of SA peels demonstrate more pronounced dermal collagen and elastic fibers, positive alterations in epidermal thickness, and replacement of some skin defects with organized tissue that produces increased smoothness (Abdel-Motaleb et al. 2017). Salicylic acid peels are safe for most skin types and are commonly used for acne because of its desmolytic properties (Arif 2015; Habif 2016). Salicylic acid peels self-neutralize and typically cause light peeling within about 2 days (Lee et al. 2018). Although the safety profile of SA peels is excellent, caution is recommended when using any peel due to the potential for irritation or inflammation (Lee et al. 2018).

8.1.2 Trichloroacetic Acid (TCA) Peels Trichloroacetic acid (TCA) is used as a superficial peeling agent in the range of 10–30% although higher percentages are used as medium depth peeling agents (Fabbrocini et al. 2009; Rendon et al. 2010; Lee et al. 2018). Higher percentages of TCA are associated with more complications and are appropriate for discrete or smaller areas (Lee et al. 2018). Trichloroacetic acid is self-neutralizing and does not require water or bicarbonate to terminate its action (Fabbrocini et al. 2009; Lee et al. 2018). The TCA peels can be used alone or in combination with other peeling agents such as glycolic acid or salicylic acid depending on the desired effect and condition of skin (Fabbrocini et al. 2009; Rendon et al. 2010). The mechanism of action of TCA is to expel epidermal proteins and cause coagulative cellular necrosis (Fabbrocini et al. 2009; Abdel Hay et al. 2019). This action leads to superficial layers of skin peeling.

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8.1.3 Lactic Acid (LA) Peels Lactic acid is a mild AHA peeling agent commonly used to help reduce uneven texture, acne breakouts, and hyperpigmentation (Sachdeva 2010). The effects of these peels are optimal when used in a series every 1–2 weeks depending on skin response. Lactic acid peels do not require neutralization. The LA peels work by causing detachment of corneocytes from each other and subsequent desquamation of the stratum corneum (Dayal et al. 2017). Lactic acid peels are safe to use in darker ethnic skin types and produce a good response when used for acne, superficial acne scarring, and/or post-inflammatory hyperpigmentation (Rendon et al. 2010; Sachdeva 2010). Lactic acid is also a component of the Jessner peel solution and it works well in combination with other AHAs.

8.1.4 Retinoic Acid Retinoic acid, or tretinoin (Retin-A®), is a vitamin A derivative and used as a topical preparation to treat acne and diminish the appearance of fine lines and hyperpigmentation (Manaloto and Alster 1999; Fulton et al. 1974). Tretinoin is not applied in the office setting as a peel but when used at home, it causes slight temporary peeling. Consistent use of tretinoin at home results in lightening of the skin, reduction of fine lines, thickening of the dermis, and the creation uniform cell configuration that leads to smoother skin (Manaloto and Alster 1999). The improvement of skin texture and reduction of fine lines are attributed to the increase in epidermal and dermal thickness and compaction of the stratum corneum (Manaloto and Alster 1999; Kligman et al. 1986; Draelos et al. 2016). Tretinoin is applied once per day at bedtime. The most common side effects include mild erythema, light peeling or flaking, dryness, and irritation (Manaloto and Alster 1999; Fulton et al. 1974; Kligman et al. 1986; Thielitz et al. 2008). The initial light peeling and irritation typically resolve in 4–8 weeks and use of daily moisturizer can help decrease dryness (Manaloto and Alster 1999; Kligman et al. 1986) Tretinoin is applied for 8–12  months and then can be decreased to a frequency of twice a week for maintenance of skin improvement if desired (Kligman et  al. 1986). If tretinoin use is discontinued, the effects diminish and eventually cease; therefore, continued maintenance use can be recommended (Kligman et al. 1986; Thielitz and Gollnick 2008).

8.1.5 Jessner and Modified Jessner Peels The Jessner peel (JP) was formulated by Dr. Max Jessner M.D., a German dermatologist. Jessner peel was made popular by Dr. Monheit, M.D. when he combined TCA with the Jessner peel to make a powerful chemical peel for skin rejuvenation (Coleman and Brody 1997; Monheit 1989). The combination of TCA and JP is a frequently used combination peel because of their synergystic effect. The JP

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solution is a combination of salicylic acid 14%, lactic acid 14%, and resorcinol 14% in 95% ethanol and is commonly used as a superficial chemical peel (Coleman and Brody 1997; Fabbrocini et al. 2009; Grimes et al. 2005). The resorcinol component in the JP adds a skin lightening effect, and so it provides an added benefit in patients who have pigment concerns (Fabbrocini et al. 2009). The advantages of the JP include an excellent safety profile, enhancement of the effect of the TCA peel, and minimal erythema and peeling in most patients (Fabbrocini et al. 2009). The disadvantages of the JP peel is increased desquamation in some patients and the solution must be stored in dark bottles to avoid oxidation (Fabbrocini et  al. 2009). Jessner peel is available in one strength, but the depth of penetration into the skin can be increased by applying several layers during the peel process (Puri 2015). The Modified Jessner peel (MJP) is the alternative version of the JP and is a solution of salicylic acid 17%, lactic acid 17%, and citric acid 8% in ethanol 95% (Fabbrocini et al. 2009; Grimes et al. 2005; Saleh et al. 2018). The MJP contains citric acid instead of resorcinol. Modified Jessner peel can be used on patients who have history of allergic reaction to resorcinol or increased risk of hyperpigmentation such as in darker skin types (Puri 2015; Saleh et al. 2018).

8.1.6 Glycolic Acid and Pyruvic Acid Peels Glycolic acid (GA) and pyruvic acid (PA) peels are superficial peels commonly used in aesthetics. These peeling agents require neutralization with water or bicarbonate to stop the chemical action (Coleman and Brody 1997; Lee et al. 2018). End points for neutralization of these peels are onset of erythema or at 5 min if no erythema is noted (Fabbrocini et al. 2009; Lee et al. 2018). The advantage of the GA peel is its effectiveness in treating photodamage. The GA peel has a quick application process, mild erythema and desquamation, and a short recovery period (Fabbrocini et al. 2009; Lee et al. 2018). The disadvantages of GA peels include a burning or stinging sensation during the peel application and the risk of ulceration if the peel remains too long on the skin (Fabbrocini et al. 2009). The pyruvic acid (PA) peel can be used safely on darker skin types and it has short healing time with mild erythema and peeling. Pyruvic acid peels process on the skin for a short period of time, typically 3–5 min before neutralization (Fabbrocini et al. 2009). The mild effects of PA peels are ideal for patients who do not want extended desquamation and recovery. However, during application of the PA peel, patients might notice strong vapors and intense stinging until the solution is neutralized (Fabbrocini et al. 2009).

8.1.7 Superficial Peels The table below is a summary of commonly used peeling agents, strengths, and timing. This table is not prescriptive and should be modified for the individual patient skin type and conditions (Fabbrocini et al. 2009; Lee et al. 2018).

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Very superficial peeling agents • Glycolic acid: 30–50%, applied briefly (1–2 min) • Jessner solution: applied in one to three coats • Low-concentration resorcinol, 20–30%: applied briefly (5–10 min) • TCA 10%: applied in one layer Superficial peeling agents • Glycolic acid, 50–70%: applied for a variable time depending on skin response (2–5 min) • Pyruvic acid, 40–50%: applied for a variable time depending on skin response (3–5 min) • Jessner solution, Modified Jessner: applied in 4–10 layers • Resorcinol: 40–50%, applied for 30–60 min • TCA: 10–30%

8.2

Conclusion

Chemical peels are commonly used to improve skin texture, decrease hyperpigmentation, and reduce fine lines. Superficial chemical peels are generally safe and predictable, however, caution should be exercised with all peels. Careful attention to skin response in self-neutralizing peels is important to avoid unexpected reactions in patients with sensitive skin. When using peels that require neutralization, vigilant observation of erythema endpoints and/or peel processing times are essential to prevent adverse effects. The peel application is quick and simple, and yield good results in patients with mild-to-moderate photodamage or aging concerns. Chemical peels are an effective option for skin rejuvenation and provide improvement of hyperpigmentation and fine lines with consistent use. Thorough consultation and management of patient expectations are important to ensure patient satisfaction when using chemical peels for skin rejuvenation.

References Abdel Hay R, Hegazy R, Abdel Hady M, Saleh N. Clinical and dermoscopic evaluation of combined (salicylic acid 20% and azelaic acid 20%) versus trichloroacetic acid 25% chemical peel in acne: an RCT. J Dermatolog Treat. 2019:1–6. https://doi.org/10.1080/09546634.2018.1484 876. Abdel-Motaleb AA, Abu-Dief EE, Hussein MR. Dermal morphological changes following salicylic acid peeling and microdermabrasion. J Cosmet Dermatol. 2017;16(4):e9–e14. Alam M, Omura NE, Dover JS, Arndt KA. Glycolic acid peels compared to microdermabrasion: a right-left controlled trial of efficacy and patient satisfaction. Dermatol Surg. 2002;28(6):475–9. American Society of Plastic Surgeons (ASPS). 2017 top five cosmetic plastic surgery procedures. 2017. Available from: https://www.plasticsurgery.org/. Arif T. Salicylic acid as a peeling agent: a comprehensive review. Clin Cosmet Investig Dermatol. 2015;8:455–61.

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Ball Arefiev KL, Hantash BM. Advances in the treatment of melasma: a review of the recent literature. Dermatol Surg. 2012;38(7 Pt 1):971–84. Coleman WP 3rd, Brody HJ. Advances in chemical peeling. Dermatol Clin. 1997;15(1):19–26. Dayal S, Amrani A, Sahu P, Jain VK. Jessner’s solution vs. 30% salicylic acid peels: a comparative study of the efficacy and safety in mild-to-moderate acne vulgaris. J Cosmet Dermatol. 2017;16(1):43–51. Draelos Z, Lewis J, McHugh L, Pellegrino A, Popescu L. Novel retinoid ester in combination with salicylic acid for the treatment of acne. J Cosmet Dermatol. 2016;15(1):36–42. Fabbrocini G, De Padova MP, Tosti A. Chemical peels: what’s new and what isn’t new but still works well. Facial Plast Surg. 2009;25(5):329–36. Fulton JE Jr, Farzad-Bakshandeh A, Bradley S.  Studies on the mechanism of action to topical benzoyl peroxide and vitamin A acid in acne vulgaris. J Cutan Pathol. 1974;1(5):191–200. Green BA, Yu RJ, Van Scott EJ. Clinical and cosmeceutical uses of hydroxyacids. Clin Dermatol. 2009;27(5):495–501. Grimes PE, Padova MPD, Tosti A. Color atlas of chemical peels. Berlin: Springer; 2005. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. St Louis: Elsevier; 2016. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: an evidence-based review. Plast Reconstr Surg. 2010;125(1):372–7. Kligman AM, Grove GL, Hirose R, Leyden JJ. Topical tretinoin for photoaged skin. J Am Acad Dermatol. 1986;15(4 Pt 2):836–59. Kligman D, Kligman AM. Salicylic acid peels for the treatment of photoaging. Dermatol Surg. 1998;24(3):325–8. Lee KC, Wambier CG, Soon SL, Sterling JB, Landau M, Rullan P, et al. Basic chemical peeling-­ superficial and medium-depth peels. J Am Acad Dermatol. 2018. https://doi.org/10.1016/j. jaad.2018.10.079. Manaloto RM, Alster TS. Periorbital rejuvenation: a review of dermatologic treatments. Dermatol Surg. 1999;25(1):1–9. Monheit GD. The Jessner’s + TCA peel: a medium-depth chemical peel. J Dermatol Surg Oncol. 1989;15(9):945–50. Puri N. Efficacy of modified Jessner’s peel and 20% TCA versus 20% TCA peel alone for the treatment of acne scars. J Cutan Aesthet Surg. 2015;8(1):42–5. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol. 2010;3(7):32–43. Sachdeva S. Lactic acid peeling in superficial acne scarring in Indian skin. J Cosmet Dermatol. 2010;9(3):246–8. Saleh F, Moftah NH, Abdel-Azim E, Gharieb MG. Q-switched Nd: YAG laser alone or with modified Jessner chemical peeling for treatment of mixed melasma in dark skin types: a comparative clinical, histopathological, and immunohistochemical study. J Cosmet Dermatol. 2018;17(3):319–27. Stegman SJ. A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthet Plast Surg. 1982;6(3):123–35. Thielitz A, Abdel-Naser MB, Fluhr JW, Zouboulis CC, Gollnick H. Topical retinoids in acne--an evidence-based overview. J Dtsch Dermatol Ges. 2008;6(12):1023–31. Thielitz A, Gollnick H. Topical retinoids in acne vulgaris: update on efficacy and safety. Am J Clin Dermatol. 2008;9(6):369–81.

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Acne

9.1

Acne Pathogenesis and Diagnosis

9.1.1 Epidemiology Acne is a source of embarrassment and it can impact self-esteem. Severe acne is a serious problem and can leave disfiguring scars, to the extent that there is a risk of suicide in susceptible individuals (Cotterill and Cunliffe 1997; Dalgard et al. 2008). Acne treatment and prevention are important components of aesthetics because a significant percentage of men and women will develop acne during their lifetime. Post-adolescent women suffer from acne more often than post-adolescent men, whereas boys tend to have more acne breakouts than girls during adolescence (Collier et al. 2008). Self-reported studies often demonstrate a higher prevalence of acne than those studies that use clinical data. The evidence shows the prevalence of acne in post-adolescent age groups is as follows (Collier et al. 2008): • • • •

Twenty to Twenty nine years: 43% men and 51% women, respectively Thirty to Thirty nine years: 20% men and 35% women, respectively Forty to Forty nine years: 12% men and 26% women, respectively Fifty years and older: 7% men and 15% women, respectively

9.1.2 Etiology and Pathogenesis Acne is a hereditary disease that involves the pilosebaceous unit. Acne is most active in areas where the sebaceous glands are the largest and most numerous such as on the face, back, chest, and upper outer arms (Habif 2016). Early acne lesions form from blockage of sebum and keratinized cells in the canal of the hair follicle. The bacteria, Propionibacterium acnes (p. acnes), proliferates in sebum and causes an alteration in the follicular epithelial lining of the hair follicle. This alteration leads to the formation of plugs and comedones when sebum production increases © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_9

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and is affected by the change in follicular keratinization in susceptible individuals (Habif 2016). The result of this process is an inflammatory response that contributes to the formation of acne comedones (Cong et al. 2019). In closed comedones, a pustule forms from sebum that has become sticky from the effects of the p. acnes bacteria mixed with the keratin in the follicular canal (Habif 2016; Cong et al. 2019; Yang et al. 2018). This creates a plug that leads to irritation and inflammation that eventually leads to a papule, pustule, or cyst (Habif 2016). If the follicular pore dilates and opens to the surface of the skin, the lesion is termed an open comedo or blackhead. If the follicular pore remains closed, the lesion is referred to as a closed comedo or whitehead (Habif 2016). Acne lesions are formed by hormonal influence on the sebaceous gland which affects the secretion of sebum. The hormone testosterone directly affects the sebaceous gland by increasing gland size and metabolic rate, whereas estrogen decreases sebaceous gland secretion and activity (Habif 2016). Regulation of hormones is a treatment option for acne, and this is the mechanism by which combination oral contraceptive (COC) pills improve acne. Often, women complain about recurrent, monthly acne breakouts or worsening of chronic acne during the luteal phase of the menstrual cycle (Beckmann et  al. 2014). The luteal phase occurs after ovulation and before menses and a surge of progesterone happens during this phase of menstruation. Progesterone stimulates sebaceous glands to produce and secrete sebum and this action can lead to the formation of acne lesions. The COC pills decrease acne breakouts caused from hormones by preventing the progesterone surge during the menstrual cycle in women (Habif 2016; Beckmann et al. 2014). Another potential cause of acne is diet, however, the data associating acne with nutrition and specifically, dairy intake, is conflicting. Whereas some evidence points to increased dairy intake as a contributor to acne, there are no clinical data generated through clinical trials that confirm the association between nutrition and acne (Habif 2016; Cong et al. 2019; Aghasi et al. 2019; Juhl et al. 2018; Claudel et al. 2018; Kucharska et al. 2016; LaRosa et al. 2016). However, the prudent practitioner would advise patients who suffer with acne to monitor their diet and determine if dairy products or other food affect their acne breakouts. A common misconception regarding the cause of acne is level of hygiene. Acne lesions begin in the pilosebaceous unit therefore, external hygiene habits do not cause acne lesions (Habif 2016). However, the use of certain cleansers and other topical products may contribute to irritation and eruption of additional lesions (Habif 2016). Acne prone skin is sensitive to harsh chemicals and abrasives and should be treated gently. Aggressive picking and squeezing of acne lesions can lead to hyperpigmentation and permanent scarring. In addition, delay in treatment of acne is a significant factor of the formation of acne scars (Habif 2016; Layton et al. 1994; Marson and Baldwin 2019). Acne lesions are generally classified as (1) mild inflammatory acne, (2) moderate to severe inflammatory acne, (3) severe inflammatory acne: (Habif 2016) • Mild inflammatory acne is defined as fewer than 20 pustules (Habif 2016). The erythema and inflammation of the acne lesion is caused by the growth of p. acnes inside the comedones (Habif 2016; Cong et al. 2019). The lesions of mild inflammatory acne include papules and pustules (Habif 2016).

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• Moderate to severe inflammatory acne is defined as more than 20 lesions, with few visible comedones, and can result suddenly from stress. The lesions of moderate to severe acne include papules and pustules (Habif 2016). • Severe inflammatory acne is defined as inflamed, localized cysts on the face, chest, upper arms, and/or back and can also include papules and pustules (Habif 2016). Acne scars form after collagen and other tissue damage and is secondary to inflammation. This inflammation can lead to permanent skin changes and fibrosis (Yang et al. 2018; Layton et al. 1994; Bhargava et al. 2018). Acne scars are commonly described as icepick, boxcar, rolling, and/or hypertrophic (Bhargava et  al. 2018; Dierickx et al. 2018). Icepick acne scars are generally sharply demarcated, deep and narrow, and extend into the deep dermis. Boxcar acne scars are sharply demarcated, shallow or deep, round or oval depressions that have a flat bottom. Rolling acne scars are described as wide, shallow, or deep depressions with sloping edges. Hypertrophic acne scars are raised and confined within the original border of the acne lesion, whereas keloid scars fold over the original border of the acne lesion (Layton et al. 1994; Bhargava et al. 2018).

9.1.3 Psychological Aspects of Acne Stress is known to exacerbate acne breakouts through biochemical mechanisms that are linked to cholinergic signaling that promote acne formation (Li et al. 2013). A component of the stress response in cutaneous cells is acetylcholine. Acetylcholine signaling has been implicated in the formation of acne lesions because acetylcholine stimulates the cholinergic response in stress induced skin disorders (Schlessinger et al. 2017; Curtis and Radek 2012). The connection between stress and acne has prompted recent research for novel treatments based on hormonal and neurotransmitter pathways and their involvement in the development of acne. Because botulinumtoxin type A (BoNT/A) blocks the action of acetylcholine, it is currently being investigated as a potential treatment for acne (Li et  al. 2013; Schlessinger et  al. 2017; Curtis and Radek 2012; Shuo et al. 2019). Acne is also associated with anxiety and depression. Anxiety and depression associated with acne are likely due to the patient’s altered physical appearance and subsequent embarrassment (Ramrakha et  al. 2016; Halvorsen et  al. 2011). It has been reported that people with severe acne have social implications such as avoiding school or having difficulty in the work place (Habif 2016; Halvorsen et  al. 2011). Depression attributed to acne can result in impaired social functioning and suicidal ideation so prompt evaluation and treatment is essential (Dalgard et  al. 2008; Halvorsen et al. 2011; Simic et al. 2017). Important psychosocial benefits have been demonstrated with isotretinoin (Accutane ®) therapy but a direct cause-and-effect relationship between isotretinoin and depression has not been established (Habif 2016; Bray et  al. 2019; Li et  al. 2019; Suarez et al. 2016). Patients with severe acne who are candidates for isotretinoin therapy but have a history of depression can have improved psychosocial health with isotretinoin therapy because of improvement in their acne (Habif 2016;

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Simic et al. 2017; Bray et al. 2019; Li et al. 2019). The decision to start isotretinoin therapy is made only by a qualified provider. Patients who are prescribed isotretinoin should be educated on the signs and symptoms of depression and assessed for mental health changes at every visit (Habif 2016).

9.1.4 Treatments Therapy for acne depends on the type and severity of the lesions. Mild acne might respond well to topical preparations such as retinoids, benzoyl peroxide, topical antibiotics, or a combination of these (Habif 2016). Mild–to-moderate acne might respond best to topical preparations with the addition of an oral antibiotic (Habif 2016). Moderate acne regimens typically begin with topical antibiotics and gradually incorporate oral antibiotics, benzoyl peroxide, retinoids, or in some cases, isotretinoin (Habif 2016; Cong et al. 2019). Severe acne requires aggressive treatment and should be referred to a dermatologist. If a patient with severe, cystic acne has minimal scarring, a trial of conventional topical and oral medications is acceptable prior to starting isotretinoin (Habif 2016). However, if a patient suffers from severe, cystic acne and has scarring or a chronic history of treatment failure, isotretinoin can be first line treatment (Habif 2016). Combination therapy such as light-based treatments can be added to isotretinoin therapy without having to wait an extended period of time as previously recommended (Spring et al. 2017). There is insufficient evidence to support the delay of microdermabrasion, superficial chemical peels, surgical procedures, and fractional laser procedures for patients receiving isotretinoin or having recently completed isotretinoin therapy (Spring et al. 2017). Isotretinoin can be used in women but contraception is required due to the teratogenic property of isotretinoin (Habif 2016). Women can also take oral combination contraceptive pills or spironolactone as additional acceptable acne treatment options as long as she has no contraindications to the medications (Beckmann et al. 2014). Strict adherence to the iPledge program is essential for isotretinoin therapy and requires blood studies of liver function, complete blood cell count, and triglycerides (Habif 2016). Patients who suffer with acne and acne scarring frequently look to aesthetic practitioners for guidance. However, even with rapid and appropriate treatment, scars may form so management of patient expectations is essential. Patients should understand their acne might never be cured, but it can be managed as effectively as possible with the goal of preventing scar formation (Habif 2016; Layton et al. 1994; Bhargava et al. 2018). Acne scars are embarrassing and, in some cases, disfiguring. Prevention of acne and acne scars is paramount because once acne scars have developed, they are difficult to treat effectively (Layton et al. 1994; Bhargava et al. 2018; Dierickx et al. 2018). Fractional lasers and radiofrequency treatments can provide improvement in most types of acne scars and can be used effectively with topical preparations and oral medications (Marson and Baldwin 2019; Shuo et  al. 2019). Generally, a

9.2 Conclusion

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combination of treatments provides superior outcomes than single treatments (Bhargava et al. 2018). Photodynamic therapy (PDT) is a combination treatment that utilizes a topical photosensitizing agent with a light source that activates the medication (Le Pillouer-­ Prost and Cartier 2016; Nootheti and Goldman 2007). An intense pulsed light (IPL) device or blue light is commonly used as the activating component in PDT and the photosensitizing agent is aminolevulinic acid (ALA). This combination treatment affects the formation of acne lesions through the direct effect on the sebaceous gland. PDT works by decreasing the size and metabolism of the sebaceous gland and subsequently leads to decreased plug formation (Nootheti and Goldman 2007). ALA is absorbed by the sebaceous gland, activated by certain spectrums of light, and frequently used in combination with a light-based treatment (Friedmann and Goldman 2016). Alternatively, laser resurfacing procedures are effective in reducing moderate acne scars, although in some cases, more than one treatment may be necessary (Marson and Baldwin 2019; Xu and Deng 2018). Patient expectations must be managed, and a thorough review of potential side effects should be included in the consultation. In addition, review of the expected healing time, pain control, cost, and the possibility for concomitant medication therapy, are key aspects of information patients should receive when considering laser treatment for acne scarring (Habif 2016; Marson and Baldwin 2019; Bhargava et al. 2018; Xu and Deng 2018). Another option for treatment of acne scars is dermal filler. Dermal filler can improve the appearance of certain types of acne scars by adding small amounts of volume to sunken areas. Rolling acne scars and shallow boxcar scars can improve with dermal filler treatment however, the results are temporary and multiple treatments may be required (Bhargava et al. 2018). Icepick and deep boxcar acne scars have demonstrated little improvement with dermal filler treatment but surgical interventions and ablative laser procedures have been shown to improve these types of acne scars (Bhargava et al. 2018).

9.2

Conclusion

Depending on the severity of the acne, chemical peels and other options such as microdermabrasion, IPL, PDT, and laser treatments can be effective in the treatment of acne (Draelos et al. 2016). Unfortunately, these treatments may be expensive or inconvenient for some patients. Topical preparations including antibiotics, salicylic acid, or benzoyl peroxide in conjunction with or without oral antibiotics might be a more reasonable option for some patients (Draelos et al. 2016). Thorough consultation with the patient is essential to establish a regimen that the patient would use consistently. If the patient finds the routine too difficult to follow or if results are not noticed immediately, they might discontinue the regimen. In some cases, referral to a dermatologist would be appropriate. Management of expectations is an important part of caring for people who suffer from acne. While some therapies such as laser may yield smoother skin and fewer

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breakouts within weeks, patients must understand that topical therapies can take months of consistent use before they notice improvement in their skin (Habif 2016; Draelos et al. 2016).

References Aghasi M, Golzarand M, Shab-Bidar S, Aminianfar A, Omidian M, Taheri F. Dairy intake and acne development: a meta-analysis of observational studies. Clin Nutr. 2019;38(3):1067–75. Beckmann CR, et al. Obstetrics and gynecology. 7th ed. Philadelphia: Wolters Kluwer; 2014. Bhargava S, Cunha PR, Lee J, Kroumpouzos G. Acne scarring management: systematic review and evaluation of the evidence. Am J Clin Dermatol. 2018;19(4):459–77. Bray AP, Kravvas G, Skevington SM, Lovell CR. Is there an association between isotretinoin therapy and adverse mood changes? A prospective study in a cohort of acne patients. J Dermatolog Treat. 2019:1–6. https://doi.org/10.1080/09546634.2019.1577545. Claudel JP, Auffret N, Leccia MT, Poli F, Dreno B. Acne and nutrition: hypotheses, myths and facts. J Eur Acad Dermatol Venereol. 2018;32(10):1631–7. Collier CN, Harper JC, Cafardi JA, Cantrell WC, Wang W, Foster KW, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol. 2008;58(1):56–9. Cong TX, Hao D, Wen X, Li XH, He G, Jiang X. From pathogenesis of acne vulgaris to anti-acne agents. Arch Dermatol Res. 2019;311(5):337–49. Cotterill JA, Cunliffe WJ. Suicide in dermatological patients. Br J Dermatol. 1997;137(2):246–50. Curtis BJ, Radek KA. Cholinergic regulation of keratinocyte innate immunity and permeability barrier integrity: new perspectives in epidermal immunity and disease. J Invest Dermatol. 2012;132(1):28–42. Dalgard F, Gieler U, Holm JO, Bjertness E, Hauser S.  Self-esteem and body satisfaction among late adolescents with acne: results from a population survey. J Am Acad Dermatol. 2008;59(5):746–51. Dierickx C, Larsson MK, Blomster S. Effectiveness and safety of acne scar treatment with nonanimal stabilized hyaluronic acid gel. Dermatol Surg. 2018;44(Suppl 1):S10–S8. Draelos Z, Lewis J, McHugh L, Pellegrino A, Popescu L. Novel retinoid ester in combination with salicylic acid for the treatment of acne. J Cosmet Dermatol. 2016;15(1):36–42. Friedmann DP, Goldman MP.  Photodynamic therapy for cutaneous photoaging: a combination approach. Dermatol Surg. 2016;42(Suppl 2):S157–60. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. St. Louis: Elsevier; 2016. Halvorsen JA, Stern RS, Dalgard F, Thoresen M, Bjertness E, Lien L. Suicidal ideation, mental health problems, and social impairment are increased in adolescents with acne: a population-­ based study. J Invest Dermatol. 2011;131(2):363–70. Juhl CR, Bergholdt HKM, Miller IM, Jemec GBE, Kanters JK, Ellervik C. Dairy intake and acne vulgaris: a systematic review and meta-analysis of 78,529 children, adolescents, and young adults. Nutrients. 2018;10(8):E1049. Kucharska A, Szmurlo A, Sinska B. Significance of diet in treated and untreated acne vulgaris. Postepy Dermatol Alergol. 2016;33(2):81–6. LaRosa CL, Quach KA, Koons K, Kunselman AR, Zhu J, Thiboutot DM, et al. Consumption of dairy in teenagers with and without acne. J Am Acad Dermatol. 2016;75(2):318–22. Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of acne scarring and its incidence. Clin Exp Dermatol. 1994;19(4):303–8. Le Pillouer-Prost A, Cartier H.  Photodynamic photorejuvenation: a review. Dermatol Surg. 2016;42(1):21–30. Li C, Chen J, Wang W, Ai M, Zhang Q, Kuang L. Use of isotretinoin and risk of depression in patients with acne: a systematic review and meta-analysis. BMJ Open. 2019;9(1):e021549.

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Li ZJ, Park SB, Sohn KC, Lee Y, Seo YJ, Kim CD, et al. Regulation of lipid production by acetylcholine signalling in human sebaceous glands. J Dermatol Sci. 2013;72(2):116–22. Marson JW, Baldwin HE.  New concepts, concerns, and creations in acne. Dermatol Clin. 2019;37(1):1–9. Nootheti PK, Goldman MP.  Aminolevulinic acid-photodynamic therapy for photorejuvenation. Dermatol Clin. 2007;25(1):35–45. Ramrakha S, Fergusson DM, Horwood LJ, Dalgard F, Ambler A, Kokaua J, et al. Cumulative mental health consequences of acne: 23-year follow-up in a general population birth cohort study. Br J Dermatol. 2016;175(5):1079–81. Schlessinger J, Gilbert E, Cohen JL, Kaufman J. New uses of abobotulinumtoxinA in aesthetics. Aesthet Surg J. 2017;37(suppl_1):S45–58. Shuo L, Ting Y, KeLun W, Rui Z, Rui Z, Hang W. Efficacy and possible mechanisms of botulinum toxin treatment of oily skin. J Cosmet Dermatol. 2019;18(2):451–7. Simic D, Penavic JZ, Babic D, Gunaric A. Psychological status and quality of life in acne patients treated with oral isotretinoin. Psychiatr Danub. 2017;29(Suppl 2):104–10. Spring LK, Krakowski AC, Alam M, Bhatia A, Brauer J, Cohen J, et  al. Isotretinoin and timing of procedural interventions: a systematic review with consensus recommendations. JAMA Dermatol. 2017;153(8):802–9. Suarez B, Serrano A, Cova Y, Baptista T. Isotretinoin was not associated with depression or anxiety: a twelve-week study. World J Psychiatry. 2016;6(1):136–42. Xu Y, Deng Y.  Ablative fractional CO2 laser for facial atrophic acne scars. Facial Plast Surg. 2018;34(2):205–19. Yang JH, Yoon JY, Moon J, Min S, Kwon HH, Suh DH. Expression of inflammatory and fibrogenetic markers in acne hypertrophic scar formation: focusing on role of TGF-beta and IGF-1R. Arch Dermatol Res. 2018;310(8):665–73.

Part III Minimally Invasive Procedures: Neurotoxins

Pharmacology of Neurotoxins: Onabotulinum Toxin (Botox®), Abobotulinum Toxin (Dysport®), Incobotulinum Toxin (Xeomin®), and Prabotulinumtoxin-xvfs (Jeuveau™)

10

10.1 Botulinum Toxin 10.1.1 The History Clostridium botulinum is an anaerobic, spore-forming bacterium that creates a toxin under the appropriate conditions (Carruthers and Carruthers 2005a). Clostridium botulinum was first identified in 1895 by Professor Emile Pierre Marie van Ermengem when an illness broke out at a picnic in Belgium after people ate salted, raw ham. Subsequently, in 1920, Dr. Herman Sommer began the isolation and development process of the toxin and in 1946 it was finally isolated by Edward Shantz for the US Army. The function of the molecule was discovered by A.S.V. Burgen in 1949 (Burgen et al. 1949). In 1952, Burgen urged Vernon Brooks to continue his studies on botulinum toxin while Brooks was working toward a PhD. Then, in 1953, medical application of the botulinum toxin ensued when Dr. Vernon Brooks inadvertently became the “godfather for the Botox® treatment of many dystonias and other involuntary muscle movements” after discovering the mechanism of action of the botulinum toxin (Brooks 2001). It wasn’t until 1977 when Alan B. Scott and colleagues injected the first patients with botulinum toxin type A by applying principles discovered by Dr. Vernon. These first patients were suffering with strabismus and had relief from Dr. Scott’s novel treatments using botulinum toxin. Dr. Scott then reported his findings in 1980 and he named the substance Oculinum (eye aligner). In 1989, Allergan obtained approval by the FDA to market Oculinum as Botox ® (US Dept. of Health 2009 docket # FDA-2008-P-0061). There are three major commercial brands of BoNT/A products available worldwide: onabotulinumtoxinA (ONA) marketed as Botox®/Vistabel® by Allergan Inc. (Irvine, CA), abobotulinumtoxinA (ABO) marketed as Dysport®/Azzalure® by Ipsen (Paris, France), and incobotulinumtoxinA (INCO) marketed as Xeomin®/ Bocouture® by Merz Pharmaceutical Gmbh (Frankfurt, Germany). The fourth US FDA approved BoNT/A, prabobotulinumtoxin-xvfs (PRABO) marketed as Jeuveau™ by Evolus (Korea), was released in the US market mid-2019. Three © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_10

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other manufacturers based in Korea and China produce three additional BoNT/A brands marketed mainly in Asia: Medy-Tox (Korea) owns Meditoxin/Neuronox/ Siax brands, Hugel Inc. (Korea) has Botulax (also Zentox or Regenox in other countries), and Lanzhou Institute for Biologic Products (Lanzhou, China) produces a BoNT/A called BTXA and is distributed by local/regional companies under different brand names. Botulinumtoxin type B (BoNT/B) (rimabotulinumtoxinB) was approved by the US FDA in 2000 with the trade name Myobloc/Neurobloc for the treatment of cervical dystonia. The product is presently marketed by US WorldMeds in the USA and by Eisai Europe Limited in Europe (Aoki and Guyer 2001). BoNT/B is not currently used in aesthetics due to the different mechanism of action and higher side effect profile and so is beyond the scope of this text.

10.1.2 Types of BoNT/A Used in Aesthetics In 2009, the United States Food and Drug Administration mandated non-trade names for all approved BoNT/A. The mandated names are in attempt to clarify differences of the formulations. The chemical formulations of the three BoNT/A differ slightly, cannot be substituted, and have different dosing curves (Sundaram et al. 2016). The variations of the formulations depend on the production and process of each manufacturer. The potency of each BoNT/A is different, and the medications are not interchangeable. For example, the dose of BoNT/A is measured in units. A unit is defined as the median dose, administered by intraperitoneal injection, needed to kill 50% of mice in a test sample after a specified test duration. Each manufacturer creates individual assays for their product (Fonfria et al. 2018). The concentration of onabotulinumtoxinA (Botox®), incobotulinumtoxinA (Xeomin®), and prabotulinumtoxin-xvfs (Jeuveau™) is 4  units per 0.1  mL and sold as 100  units in 2.5  mL solution per vial (Evolus 2019; Allergan 2017; Merz Pharmaceuticals LLC 2018). Whereas dosing of abobotolulinumtoxinA (Dysport®), is 10 units per 0.1 mL and sold as 300 units in 3.0 mL per vial (Ipsen Biopharmaceuticals Inc 2017). Of the four types of BoNT/A, onabotulinumtoxinA (Botox®) has 39 indications in 40 countries for treatment of a variety of conditions including bladder spasms, cervical dystonia, facial spasms, migraine headaches, blepharospasm, and depression. OnabotulinumtoxinA is also the most widely studied neurotoxin for therapeutic and cosmetic purposes, with over 2800 articles and over 400 peer-reviewed articles worldwide between 1986 and 2013 (Mohindru et al. 2013). Currently, BoNT/A is the most popular non-surgical cosmetic procedure in the world (ISAPS 2016; Frevert 2015; Botox 2018). The safety and efficacy profile of BoNT/A is excellent when used appropriately in patients. The data on abobotulinumtoxinA (Dysport®) and incobotulinumtoxinA (Xeomin®) are also growing as more practitioners use and recommend these products (Sundaram et al. 2016).

10.2  Mechanism of Action and Structure of BoNT/A Action

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10.2 Mechanism of Action and Structure of BoNT/A Action 10.2.1 Mechanism of Action To comprehend how BoNT/A works in the musculature of the face and neck, an understanding of the synaptic communication and neurotransmitter relationship is necessary. All four commercial brands of BoNT/A for cosmetic indications work in similar ways. Soluble N-ethylmaleimide sensitive factor adaptor proteins (SNAPs) and SNAP receptors (SNAREs) are the main targets of BoNT/A (Rizo and Sudhof 2012). Injection of the BoNT/A molecule into the muscle blocks neuromuscular transmission by binding to surface receptors on motor nerve terminals thereby entering the nerve terminals, and inhibiting the release of the neurotransmitter, acetylcholine (Frevert 2015). This inhibition occurs as the pH-induced translocation of the toxin light chain to the cell cytosol cleaves SNAP-25, a pre-synaptic protein that is crucial in the successful docking and release of acetylcholine from vesicles within nerve endings (Frevert 2015; Aoki and Guyer 2001). The result is a decrease in the target muscle activity (see Figs. 10.1 and 10.2). In addition, there is some evidence the affected muscle might atrophy, and subsequent re-innervation of the muscle can occur, thus slowly reversing BoNT/A action. Transmission starts to happen gradually as the neuromuscular junction recovers from SNAP-25 cleavage and as new nerve endings are formed (Allergan 2017; Merz Pharmaceuticals LLC 2018; Ipsen Biopharmaceuticals Inc 2017;

Fig. 10.1  Normal transmitter (acetylcholine) release in muscle. Used with permission from Professor Bal Ram Singh, PhD, Institute of Advanced Sciences

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Fig. 10.2  Mechanism of action of botulinumtoxinA. Note the cleaving of the SNAP-25 complex. Used with permission from Professor Bal Ram Singh, PhD, Institute of Advanced Sciences

Frevert 2015; Aoki and Guyer 2001). This phenomenon may be associated with the term “muscle memory” when referring to the longer lasting cosmetic effect of the BoNT/A on select patients (Carruthers and Carruthers 2005a).

10.2.2 Structure Botulinum toxin consists of 150 kilodalton (kDa) neurotoxin and a set of neurotoxin-­ associated complexing proteins (NAPs), which together form high-molecular-­ weight complexes (Frevert 2015). All botulinum neurotoxin serotypes are synthesized as single chain proteins of 150 kDa that are cleaved into di-chain proteins consisting of a 50 kDa light chain and a 100 kDa heavy chain, connected by a disulfide bond (Frevert 2015). Different strains have been identified and produce eight distinct serotypes, types A–H.  Serotypes A and B have both been used in humans however, the therapeutic dose of BoNT/B is significantly higher than BoNT/A and has increased risk of side effects (Carruthers and Carruthers 2005a; Burgen et al. 1949; Brooks 2001).

10.3 Antibody Formation Decreased treatment effectiveness with BoNT/A has been attributed to antibody formation (Frevert 2015; Naumann et al. 2013). Treatment with any protein can result in antibody formation and detection is related to the sensitivity and specificity of the

10.4  Onset, Effect, and Duration of Neurotoxins

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assay. In addition, the method of specimen collection and handling, timing, underlying disease, medications, and other factors can play a role in antibody detection (Naumann et al. 2013). For these reasons, the detection of antibodies to Botox® cosmetic (and possibly other BoNT/A preparations) compared to antibody detection in other studies may be misleading. In three trials treating lateral canthal lines, only 14 (1.5%) out of 916 subjects developed binding antibodies and none (0%) developed neutralizing antibodies (Frevert 2015). Although factors for the creation of neutralizing antibodies to BoNT/A are not well understood, some studies have demonstrated more frequent treatments or higher dosing may contribute to the formation of neutralizing antibodies (Allergan 2017; Frevert 2015; Naumann et al. 2013). A generally accepted practice is to inject the lowest effective BoNT/A dose at the longest feasible interval, usually every 3–4 months (Allergan 2017; Frevert 2015).

10.4 Onset, Effect, and Duration of Neurotoxins There are few studies about onset of BoNT/A, and many studies report 2 weeks as a baseline for effect, although a small percentage of patients noted onset of effect as early as 1 day after treatment (Kassir et al. 2013). The onset of BoNT/A is different in every patient, although the individual will usually have consistent onset timing with any of the four available neurotoxins. For instance, if the patient notes full effect of onabotulinumtoxinA in about 5 days, often that will be the usual time to onset of effect for that patient, regardless of brand used. There are exceptions and variation in patients, and the onset may occasionally vary, but for most patients it remains similar (Aoki and Guyer 2001). An example of variation between individuals includes the patient who experiences the BoNT/A effect onset in 9  days, while another patient experiences onset in 2  days. Because of this range, it is prudent to advise patients that the onset of BoNT/A can vary, thereby avoiding unnecessary call backs from confused or dissatisfied patients. A possible reason for the variation in time to onset and subsequent duration of BoNT/A effect in individual patients is that glycosylation patterns vary among adults, even when they are given the same dose (Pirazzini et al. 2017; Pellett et al. 2015). Different amounts of bound toxin likely correspond to different quantities of L-chains entering the nerve terminal and the associated effects on acetylcholine (Pirazzini et al. 2017; Pellett et al. 2015). The individual patient response can be dependent on the dose, so dosing may vary between patients. The effects of BoNT/A last approximately 3–4 months in skeletal muscle nerve terminals and about 1 year in the autonomic nerve terminals (Pellett et al. 2015). This explains the longer lasting effect of treatments with BoNT/A for axillary hyperhidrosis versus glabellar rhytids (Pirazzini et al. 2017). The pharmacokinetics of BoNT/A are extremely difficult to study because the doses used in treatment correspond to very low amounts of protein (Simpson 2013). Also, the BoNT/A molecules bind rapidly, affect the injected muscle, and have little effect on the surrounding muscles. The unbound toxin is thought to be swept away and diluted in the lymphatic system, unable to bind elsewhere due to low concentration (Simpson 2013;

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Carli et  al. 2009; Carruthers and Carruthers 2005b). The effects and properties of BoNT/A have been studied extensively and there are no indications of long-term neuronal damage with repeated use of therapeutic doses used in aesthetics (Pirazzini et al. 2017). An additional characteristic of BoNT/A is that it cannot be reversed once injected and its activity continues until it naturally ceases. Currently, there are no available drugs to counteract the effects of the neurotoxin (Kassir et al. 2013).

10.5 Conclusion Neurotoxin pharmacology is complex, and the properties are widely studied. The effects of BoNT/A are temporary and consistent, and these qualities provide a good foundation for study. BoNT/A is the most popular nonsurgical cosmetic dermatological procedure worldwide and its popularity increases every year (ASPS 2017). BoNT/A is the only strain of botulinum neurotoxin that is approved for aesthetic indications, but evidence for other uses continues to emerge (Magid et  al. 2015; Rzany et al. 2018). Knowledge of the characteristics of BoNT/A ensures optimal effectiveness and safety with the best patient outcomes.

References Allergan. Botox® cosmetic prescribing information [package insert]. Irvine: Allergan; 2017. American Society of Plastic Surgeons (ASPS). 2017 top five cosmetic plastic surgery procedures. 2017. https://www.plasticsurgery.org/documents/News/Statistics/2017/cosmetic-proceduretrends-2017.pdf. Available from: https://www.plasticsurgery.org/. Aoki KR, Guyer B. Botulinum toxin type A and other botulinum toxin serotypes: a comparative review of biochemical and pharmacological actions. Eur J Neurol. 2001;8(Suppl 5):21–9. OnabotulinumtoxinA (Botox): drug information Lexicomp [internet]. 2018. Available from: https://www.uptodate.com/contents/onabotulinumtoxina-botox-drug-information?search= botulinum%20toxin%20type%20a&source=search_result&selectedTitle=1~124&usa ge_type=default&display_rank=1#F6038541. Brooks V. The history of neuroscience in autobiography. Cambridge: Academic; 2001. 115 p. Burgen A, Dickens F, Zatman L. The action of botulinum toxin on the neuro-muscular junction. J Physiol. 1949;109(1–2):10–24. Carli L, Montecucco C, Rossetto O. Assay of diffusion of different botulinum neurotoxin type a formulations injected in the mouse leg. Muscle Nerve. 2009;40(3):374–80. Carruthers A, Carruthers J. In: Dover JS, editor. Procedures in cosmetic dermatology: botulinum toxin. Philadelphia: Elsevier Saunders; 2005a. 141 p. Carruthers A, Carruthers J.  Prospective, double-blind, randomized, parallel-group, dose-­ ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg. 2005b;31(10):1297–303. Evolus. Juveau (r) highlights of prescribing information [package insert]. Evolus 2019. Available from: https://info.evolus.com/hubfs/Jeuveau_USPI.pdf. Fonfria E, Maignel J, Lezmi S, Martin V, Splevins A, Shubber S, et al. The expanding therapeutic utility of botulinum neurotoxins. Toxins (Basel). 2018;10(5):208. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs R D. 2015;15(1):1–9. International Society of Aesthetic Plastic Surgeons (ISAPS). ISAPS international study on aesthetic/cosmetic procedures performed in 2016: world wide. New York: ISAPS; 2016. Available from: https://www.isaps.org/wpcontent/uploads/2017/10/GlobalStatistics2016-1.pdf.

References

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Ipsen Biopharmaceuticals Inc. Dysport® full prescribing information. Basking Ridge: IB Inc; 2017. Kassir R, Kolluru A, Kassir M. Triple-blind, prospective, internally controlled comparative study between abobotulinumtoxinA and onabotulinumtoxinA for the treatment of facial Rhytids. Dermatol Ther (Heidelb). 2013;3(2):179–89. Magid M, Keeling BH, Reichenberg JS. Neurotoxins: expanding uses of neuromodulators in medicine--major depressive disorder. Plast Reconstr Surg. 2015;136(5 Suppl):111S–9S. Merz Pharmaceuticals LLC. Xeomin® full prescribing information. Greensboro: MP LLC; 2018. Mohindru A, Bulloch S, Kronfeld N, et al. Analysis of clinical and non-clinical, peer reviewed, published studies investigating the use of commercially available botulinum toxins: an online literature review. Poster presented at: second international congress on treatment of dystonia (ICTD), Hannover, Germany; 2013. Naumann M, Boo LM, Ackerman AH, Gallagher CJ.  Immunogenicity of botulinum toxins. J Neural Transm (Vienna). 2013;120(2):275–90. Pellett S, Tepp WH, Whitemarsh R, Bradshaw M, Johnson EA, Johnson BA. In vivo onset and duration of action varies for Botulinum neurotoxin A subtypes 1–5. Toxicon. 2015;107:37–42. Pirazzini M, Rossetto O, Eleopra R, Montecucco C. Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol Rev. 2017;69(2):200–35. Rizo J, Sudhof TC.  The membrane fusion enigma: SNAREs, Sec1/Munc18 proteins, and their accomplices--guilty as charged? Annu Rev Cell Dev Biol. 2012;28:279–308. Rzany B, Bechara FG, Feise K, Heckmann M, Rapprich S, Worle B.  Update of the S1 guidelines on the definition and treatment of primary hyperhidrosis. J Dtsch Dermatol Ges. 2018;16(7):945–52. Simpson L. The life history of a botulinum toxin molecule. Toxicon. 2013;68:40–59. Sundaram H, et al. Global aesthetics consensus: botulinum toxin type A—evidence-based review, emerging concepts, and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 2016;137(3):518–29.

Reconstitution and Dosing of Neurotoxins

11

11.1 Storage The medications come as either lyophilized (abobotulinumA or incobotulinumA) or vacuum-dried (onabotulinumA or prabotulinumtoxinA-xvfs) powder and are reconstituted with a diluent. Storage of onabotulinumA, abobotulinumA, and prabotulinumtoxinA-xvfs must be refrigerated at 2–8 °C (36–46 °F) before reconstitution. However, incobotulinumtoxinA can be stored at room temperature (68–77  °F), refrigerated (36–46 °F), or frozen (−4 to +14 °F) before reconstitution (Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). IncobotulinumtoxinA may be a feasible option in offices where refrigeration is not possible. Prior to reconstitution, the vial contains the neurotoxin in the form of white powder or residue that is sometimes difficult to visualize (see Figs. 11.1 and 11.2). The apparent lack of contents in the vial can be surprising to novice aesthetic practitioners. The lot number and expiration date are listed on the vial and should be documented in the patient record. After the number of units, lot number, and expiration date are confirmed, the plastic vial lid is removed, and the rubber stopper is cleaned with an alcohol wipe. There are two methods to introduce the diluent into the vial. One way is to use a sterile 20g needle, without an attached syringe and insert it into the rubber top to express the increased pressure from the vial. Some practitioners might prefer to use a 20g needle without an attached syringe for two reasons: (1) to hear the hiss of the vacuum release that ensures proper packaging, and (2) to control the speed and velocity of the diluent as it is vacuumed into the vial. The second method of reconstitution uses a sterile 20g needle to draw up the appropriate amount of diluent into a 3 mL syringe and insert the attached needle into the rubber top. Since the vial is vacuum sealed, this action will cause the diluent to be automatically pulled into the vial and combined with the neurotoxin. Either method is acceptable and is based on practitioner preference.

© Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_11

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92 Fig. 11.1  Example of residue at the bottom of an unopened onabotulinumtoxinA vial prior to reconstitution. Note the subtle appearance of the product that presents as a film at the bottom border of the vial. Diluent must be added to create a solution that can be injected. Photo courtesy: Beth Haney, DNP, FNP-C, FAANP

Fig. 11.2  Example of contents in an unopened vial of abobotulinumtoxinA prior to reconstitution. Note the visibility of the product in the chunk, powder form. Photo courtesy: Beth Haney, DNP, FNP-C, FAANP

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Pressure builds up during the packaging process and is a sign the BoNT/A is fresh and properly packaged. During preparation of BoNT/A, if the hiss of pressure release after the 20g needle insertion into the vial is not heard, or if the diluent is not automatically pulled into the vial by needle and syringe method, it is recommended to contact the BoNT/A manufacturer for further information. After confirming patency of the product, reconstitution with the appropriate diluent makes it possible to draw the solution into the syringe for injection into the target treatment site (Carruthers and Carruthers 2005a).

11.2 Preparation Sterile, 0.9% sodium chloride or preservative-free 0.9% sodium chloride are the recommended reconstitution agents and there is no apparent difference in treatment onset, duration, or effect. All four commercially available brands must be stored at 2–8 °C after reconstitution. It is recommended that the reconstituted medication be used within 24 h to ensure potency (Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). Freezing any reconstituted neurotoxin solution is not recommended as it decreases or destroys the potency of the medication and renders it ineffective (Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). Variations in the ratio of diluent to toxin will determine the amount of solution that will be drawn into the syringe and the number of units ultimately injected into the muscle(s) of the patient. Since the practitioner can control the amount of diluent used to reconstitute the neurotoxin, there are several different strengths that can be produced for treatment. For example, 1 mL of sterile 0.9% sodium chloride solution added to a 100-unit vial of onabotulinumtoxinA would create a strength of 10 units per 0.1 mL of medication; this is a concentrated dose and a small amount of solution delivers a significant amount of neurotoxin (see Table 11.1). The number of units per injection correlates to the amount of diluent used. If the practitioner prefers to inject a higher concentration of BoNT/A, the solution can be customized i.e., less diluent creates a higher number of units per mL. Consideration of the spread of solution, potency of the medication, and precision of the effect are important when using smaller than the manufacturer recommended amounts of diluent. Conversely, the manufacturer recommended amount of 2.5 mL of diluent in a 100-unit onabotulinumtoxinA, prabotulinumtoxinA, or incobotulinumtoxinA vial would create full strength medication of 4 units per 0.01 mL (Merz Pharmaceuticals LLC 2018; Evolus 2019; Allergan 2017). Or, if the practitioner chooses to use a more dilute ratio of neurotoxin, a larger amount of 0.9% sodium chloride can be added to the vial. For example, adding 5.0 mL of 0.9% sodium chloride to a 100unit vial of onabotulinumtoxinA or incobotulinumtoxinA would create a dose of 2  units per 0.1  mL of medication (vs. the 4  units when 2.5  mL is used) (Merz Pharmaceuticals LLC 2018; Allergan 2017). This lower concentration would

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Table 11.1  Varying dosing concentrations OnabotulinumtoxinA/ PrabotulinumtoxinA 100-unit vial 1.0 mL 0.9% sodium chloridea = 10 units per 0.1 mL 2.0 mL 0.9% sodium chloride = 5 units per 0.1 mL 2.5 mL 0.9% sodium chloride = 4 units per 0.1 mL 4.0 mL 0.9% sodium chloride = 2.5 units per 0.1 mL 5.0 mL 0.9% sodium chloride = 2.0 units per 0.1 mL

IncobotulinumtoxinA 100-unit vial 1.0 mL 0.9% sodium chloridea = 10 units per 0.1 mL 2.0 mL 0.9% sodium chloride = 5 units per 0.1 mL 2.5 mL 0.9% sodium chloride = 4 units per 0.1 mL 4.0 mL 0.9% sodium chloride = 2.5 units per 0.1 mL 5.0 mL 0.9% sodium chloride = 2.0 units per 0.1 mL

AbobotulinumtoxinA 300-unit vialb 1.0 mL 0.9% sodium chloridea = 30 units per 0.1 mL 2.0 mL 0.9% sodium chloride = 15 units per 0.1 mL 3.0 mL 0.9% sodium chloride = 10 units per 0.1 mL 4.0 mL 0.9% sodium chloride = 7.5 units per 0.1 mL 5.0 mL 0.9% sodium chloride = 6.0 units per 0.1 mL

Bold indicates manufacturer recommended dilution rate With preservative or preservative-free b AbobotulinumtoxinA (Dysport) has different reconstitution parameters where the unit dose equals 2.5 times the unit dose for onabotulinumtoxinA (Botox®), prabobotulinumtoxinA (Jeuveau), and incobotulinumtoxinA (Xeomin®) to produce the same effect a

weaken the effect and shorten duration in patients when using 0.1 mL/2 units of medication per injection site (Carruthers et al. 2005). Alternatively, when using abobotulinumtoxinA, the full strength mixture would be 3.0 mL 0.9% sodium chloride in a 300-unit vial (Ipsen Biopharmaceuticals Inc 2017). This ratio would yield the manufacturer recommended 10 units per 0.10 mL. Or, if the practitioner prefers a more dilute blend, 5.0 mL 0.9% sodium chloride could be added to the 300-unit vial to create 0.1 mL/6 units per injection site. The ability to use different amounts of diluent for the reconstitution of neurotoxins gives practitioners a wide range of possible dosing. BoNT/A dosing should be thought of in terms of units vs. volume to minimize confusion and the potential for under or over dosing the patient. It is also prudent to note that the more dilute the solution, the more diffusion is produced and this can affect the treatment outcome (Carruthers and Carruthers 2005a). Another important note is that under-dosing can result in short, incomplete duration and effect of treatment, and the patient might not be satisfied with the outcome.

11.3 Dosing in Specific Sites The dose of neurotoxin injected for aesthetic treatment depends on the facial anatomy, musculature, and desired effect. For example, the strong muscles of the glabellar region, the procerus and corrugator supercili, usually require moderate doses for

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Table 11.2  Typical dosing of neurotoxin in facial muscles

Injection site Glabella (procerus/ corrugators) Forehead (frontalis) Crow’s feet (orbicularis oculi) Chin (mentalis) Corners of mouth (oral commissures) Upper and lower lip (orbicularis oris)

OnabotulinumtoxinA (Botox®) IncobotulinumtoxinA (Xeomin®) PrabotulinumtoxinA (Jeuveau®) 16–24 units, five injection sites (up to 50 units for men) 8–20 units, four to ten injection sites (up to 30–40 units for men) 8–16 units per eye (up to 20 for men) 8–12 units (up to 16 in men) 2–6 units each side (up to 6–8 units per side for men) 4–8 units upper lip, 4–8 units lower lip

AbobotulinumtoxinA (Dysport®) 40–60 units, five injection sites (up to 100 units for men) 20–50 units, four to ten injection sites (up to 60–80 units for men) 20–40 units per eye (up to 50 for men) 20–30 units (up to 40 in men) 5–15 units per side (up to 15–20 units per side for men) 10–20 units upper lip, 10–20 units lower lip

Note: These are average doses and individual treatment may vary according to the size of area, strength of muscles, desired effect, shape of eyebrows, and other factors

full muscle relaxation, whereas the orbicularis oris of the upper lip should have a very small dose injected to avoid upper lip dysfunction (Carruthers and Carruthers 2004). The table above of typical neurotoxin dosing used in aesthetic practice is for example only. The actual amount of neurotoxin and the injection sites may vary depending on the individual anatomy, muscular strength, and area of muscle contraction (see Table 11.2). Average doses of BoNT/A yield a consistent effect in most patients. However, a small portion of patients respond outside of the expected result. Patients of Asian descent often require lower doses of BoNT/A for reasons not entirely clear, but it has been demonstrated through cadaver dissection that the facial musculature of Asians is slightly different than Caucasians (Ahn et al. 2013). For example, the corrugators of Asians are “short, square type” whereas the corrugators of Caucasians are longer (Ahn et al. 2013). Other dosing factors to consider for individual patients is the depth of the wrinkle in the area, the amount of movement and muscle contraction, and the thickness of the muscle. Generally, women have thinner muscles than men and therefore might require less neurotoxin than a male patient in the same region (Carruthers and Carruthers 2005b). However, some women have thick muscles and might require an increased dose of neurotoxin whereas some men might have thinner muscles and require less neurotoxin (Lorenc et  al. 2013). Practitioners should customize treatment with BoNT/A, and carefully monitor the effect and duration of the treatment and response of each patient to ensure satisfaction and optimal outcome.

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Neurotoxin Administration (Example Only, Not for Use in Clinic)

1. Complete assessment and a medical history questionnaire with the patient. 2. Patients with a history of allergies to human albumin, significant neurological and autoimmune diseases, and pregnant or lactating patients should not be treated. 3. Upon passing medical screening, patient is to be fully informed of risks, benefits, and potential adverse reactions. 4. Informed consent is signed. 5. Neurotoxin is to be stored per manufacturer recommendations until ready for use. Once reconstituted, it must be refrigerated, not frozen. 6. Neurotoxin is to be reconstituted using aseptic technique and should be used within 4 h. 7. Vacuum to be released, using a sterile 18–22 gauge needle, with or without attached syringe of appropriate amount of diluent. If no vacuum is present, the neurotoxin manufacturer should be contacted, the vial will be sent back to the manufacturer, and a new vial used following the same procedure. 8. Neurotoxin should be reconstituted according to manufacturer directions. 9. The prescribed amount of neurotoxin is gently drawn up into a 1  mL syringe using a sterile 18–22 gauge needle. The needle is changed to a 30–32 gauge—½ inch needle for treatment. 10. Patients are asked to demonstrate the function of the muscle groups to be injected. 11. Prior to administration the practitioner will map out points of injection according to landmarks and location of appropriate muscles. Note: Increased dose may be necessary in male clients. 12. Caution should be used to administer neurotoxin at least 1 cm above the eyebrow and 1–1.5 cm from the lateral canthus to reduce the chance of eyebrow or eyelid ptosis. 13. After hand washing, the practitioner cleans the entire treatment area with alcohol or other appropriate antiseptic scrub and dons clean gloves. 14. The needle is inserted perpendicular to the skin. Procerus or Orbicularis Oculi (crow’s feet) injection is completed at a depth just beneath the ­epidermis. When injecting the Glabellar or Frontalis muscles, needle should advance into the belly of these muscles. Hyperhidrosis treatment in the axillae will typically consist of 10–25 subdermal injection sites of 2 units per site in each axilla. The appropriate amount of neurotoxin is injected into all sites, but never more than the maximum recommended doses. 15. After each injection, clean gauze can be applied for a few seconds to help stop occasional bleeding from the needle puncture. 16. When the procedure is complete, all patients should be given verbal posttreatment education and written post-treatment education. Patients are advised to report any problems or questions to the office immediately. 17. Follow-up in 2  weeks is recommended to ensure that the outcome is optimal.

References

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References Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg. 2013;39(12):1843–60. Allergan. Botox cosmetic prescribing information [package insert]. Irvine: Allergan; 2017. Carruthers A, Carruthers J. In: Dover JS, editor. Procedures in cosmetic dermatology: botulinum toxin. Philadelphia: Elsevier Saunders; 2005a. p. 141. Carruthers A, Carruthers J.  Prospective, double-blind, randomized, parallel-group, dose-­ ranging study of botulinum toxin type a in men with Glabellar Rhytids. Dermatol Surg. 2005b;31:1297–303. Carruthers A, Carruthers J, Said S. Dose-ranging study of botulinum toxin type A in the treatment of glabellar rhytids in females. Dermatol Surg. 2005;31(4):414–22; discussion 22. Carruthers J, Carruthers A. Botulinum toxin A in the mid and lower face and neck. Dermatol Clin. 2004;22(2):151–8. Evolus. Jeuveau highlights of prescribing information [package insert]. Santa Barbara: Evolus; 2019. Ipsen Biopharmaceuticals Inc. Dysport® full prescribing information. Basking Ridge: IB Inc; 2017. Lorenc ZP, Smith S, Nestor M, Nelson D, Moradi A. Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type A therapy. Aesthet Plast Surg. 2013;37(5):975–83. Merz Pharmaceuticals LLC. Xeomin full prescribing information. Greensboro: MP LLC; 2018.

Indications for Neurotoxin: Upper Face

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12.1 Patient Selection and Education Patient selection and education are important aspects in successful aesthetic BoNT/A treatment outcomes. Therefore, it is paramount that the patients understand that lines caused from muscle movement are the indications for BoNT/A treatment and it will not improve the appearance of photoaged skin or issues related to volume depletion. Photoaging and volume depletion treatment options are discussed elsewhere in this text (see Chaps. 3 and 19). Explanation of the treatment onset, duration, and effect is crucial for the patient to understand the limitations of treatment. Male patients typically require a higher dose of BoNT/A than female patients and patients of Asian descent may require lower doses (Ahn et al. 2013; Carruthers and Carruthers 2005a). Completing a thorough consultation and history will provide the opportunity for the practitioner to gather appropriate information, provide the patient with necessary material, and allow the patient to ask questions. It is crucial the patient has realistic expectations to alleviate potential disappointment. Honest and straightforward approaches work best and are appreciated by most patients; clear documentation of aspects that were discussed should be listed in the patient record. However, if during the consultation it is realized the patient has unrealistic expectations or s/he does not understand the effects of BoNT/A treatment, the patient will likely be dissatisfied. The consultation provides an opportunity for the practitioner to educate the patient further or to perhaps discourage treatment altogether. Because there are several factors involved in facial aging including effects of sun exposure, loss of volume, and bone resorption, many patients may require multiple modalities in addition to BoNT/A to attain an improved appearance and excellent outcome (Carruthers and Carruthers 2005b; Carruthers et al. 1996). The practitioner should not hesitate to perform a complete assessment and offer all this information to their patient. As of publication, there are no available studies on prabotulinumtoxinA, however the dosing is the same as onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin). © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_12

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12.2 Photographs Photographs provide an additional component of comprehensive documentation and should be taken of every patient before treatment and retained in the patient record (Carruthers and Carruthers 2003, 2005b; Kordestani et al. 2016). Photographic documentation will ensure effects from the BoNT/A treatment are accurately recorded and will also demonstrate pre-existing issues that are unrelated to the treatment itself or the outcome effects of BoNT/A. For example, if a patient complains of hooded, heavy lids after treatment, the pre-treatment photographs would document the lid position before the effects of the BoNT/A treatment and therefore, either support the patient’s complaint or indemnify the practitioner. Photographs provide documented evidence of appearance prior to treatment. In addition to photographs, consider that patients tend to heighten scrutiny of their skin and face after procedures, regardless of type of treatment provided. Patients often closely analyze their skin and face after initial aesthetic treatment, whether it is a neuromodulator, dermal filler, or laser procedure. On occasion, the treatment-­naïve patient might notice something on their face for the first time such as a pre-­existing skin lesion (e.g., nevus) or scar, a fold or wrinkle, or a myriad of other unrelated conditions. This is another example of benefit for utilizing pre-treatment photographs because they document the characteristics of the patient’s face prior to treatment. In addition, the patient may believe a new symptom or condition is related to the treatment and time passed may serve as an indicator of the patient’s perspective. The length of time passed since treatment can help determine the probable relationship between the BoNT/A and the onset of a new symptom. Distance in time of new complaint onset since treatment is an important variable for consideration of the complaint. For example, the author had a treatment-naïve patient who was anxious about receiving BoNT/A treatment and brought her adult daughter into the treatment room for support. The side effects, risks, and benefits of the treatment were reviewed extensively with the patient and daughter and they were given time to ask all of their questions. She consented to the treatment and it went very well. The patient was relieved that the actual injection process was expedient and she experienced no pain during treatment. However, when she was leaving the office, she felt that her forehead was numb. After a neuro assessment, the effects of BoNT/A were reviewed with the patient, including the fact that BoNT/A does not affect sensory nerves at the treatment site, and she felt better. At her 2 week follow-­up, she was very pleased with the outcome of her treatment and has been a consistent BoNT/A patient since. An additional example of a condition unrelated to BoNT/A treatment from the author’s practice is a situation in which a patient called and complained of sudden, recent onset of left sided facial paralysis although she had her BoNT/A treatment 4 months prior. It was recommended she visit her primary care provider (PCP) for evaluation for Bell’s palsy. She was examined by her PCP and was diagnosed with Bell’s palsy likely from the herpes virus, consistent with McCormick’s report (McCormick 1972). The prudent practitioner realizes BoNT/A injections are not

12.3 Select Types of Facial Lines

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recommended for placement in the zygomatic area because it would cause facial paralysis and an undesirable aesthetic outcome. Differentiating between and among BoNT/A effects and coincidental or unrelated situations is critical in aesthetic practice. Timely follow-up is recommended for all new patients to ensure satisfaction and answer any questions (Carruthers and Carruthers 2005b). Lastly, a patient who has an unexpected or unflattering result should be seen by the practitioner as soon as possible, especially since an easy correction can often be achieved. Patients who present at follow-up with asymmetrical or quizzical brows, or excessive movement in an area, can easily be treated and the problem resolved with a touch-up (Carruthers and Carruthers 2005b).

12.3 Select Types of Facial Lines There are four main types of superficial facial lines or wrinkles; (1) dynamic lines, (2) static lines, (3) crush lines, and (4) photodamage lines. The lines relevant to this chapter are dynamic lines, static lines, and crush lines. Lines caused by photodamage and other forms of ultraviolet radiation are most appropriately treated with laser treatments, chemical peels, and/or topical preparations. Dynamic lines are formed from the dynamic motion of facial muscle contraction or expression (Carruthers and Carruthers 2005b). This muscle contraction causes lines to form in the superficial and occasionally deeper dermis layers of skin that run perpendicular to the muscle fibers. For example, the fibers of the frontalis run vertically, and the lines formed from contraction run horizontally. These types of lines respond best to neurotoxin treatment since the relaxation of the underlying muscle prevents repetitive dynamic muscle movement that lead to lines (Carruthers et al. 1996; Said et al. 2003). Static lines are lines that are visible on the skin when there is no muscle contraction or expression—they appear to be drawn on the face (Baumann et al. 2016). This type of line can make the person look older than their true age and patients should be counseled that consistent BoNT/A treatments will smooth the lines, make the skin look more youthful, and improve appearance (Baumann et al. 2016). Crush lines, on the other hand, are caused by repetitive pressure to the skin and underlying tissues. This type of line is created during months or years of habitual pressure to the area and not by muscle contraction; they are not dynamic lines caused from muscular expression. Crush lines are commonly a result of years of pressure from a sleeping position where the face is pressed into the pillow or sleeping surface for solid periods of time, usually hours. Another common way crush lines may form is from habitually resting the face on the hand while writing or reading. Neurotoxins are not the most appropriate treatment for crush lines since a relaxed muscle will not substantially diminish the appearance of the lines. These lines are quickly and easily demonstrated to the patient with application of physical pressure to the area that recreates the line. Using the finger pad, the practitioner presses on the area of note in the same direction as the line and the patient will see it re-created before their eyes. Crush lines are easily appreciated because they do not

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Fig. 12.1  Example of crush line and static line. Crush line is from external pressure to an area. Static lines are caused from muscle contraction or sun damage and are visible when the face is at rest. Photo: B. Haney, DNP, FNP-C, FAANP

follow the normal pattern of running perpendicular to the underlying muscle—they run at an unnatural angle, i.e., vertically down the lateral orbicularis oculi area or through the eyebrow (see Fig. 12.1). Demonstration of how physical pressure affects the line is beneficial for the patient to see because often the patient will unknowingly ask for crush lines to be improved with neurotoxin. Depending on the severity and cause, crush lines may be diminished with consistent tretinoin use, laser resurfacing, dermal fillers or smoothers, sleeping in a different position, changing habits, or a combination of these (Carruthers and Carruthers 2013, 2006, 2004). Additionally, a common misperception by patients is that the effects of the neurotoxin will remain for up to 6 months as described by the package insert or advertisement and especially if, during their consultation with the practitioner, 6 months is mentioned (Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). It is uncommon that a patient will have enduring effect for 6 months, although it is not unheard of (Baumann et al. 2016). Most patients report good effects for about 3–4 months and it is important to educate the patient appropriately to avoid disappointment.

12.5 Glabella (Procerus, Corrugator Supercilii, Nasalis)

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It is also important to remember that patients will have consistent effects for many years with appropriate treatment. However, since the natural aging process will continue to affect underlying tissues and structures, periodic review of expectations and possible addition of supportive treatments may be warranted to maintain the best appearance of the patient (Hellman 1927). In summary, information regarding the varying line types and potential treatments of must be shared with the patient, to assure patient management of their own expectations regarding possibilities and outcomes with aesthetic treatment. Patient expectations are a significant part of the entire aesthetic experience and managing expectations is crucial for both the patient’s level of satisfaction and the success of the practice.

12.4 Muscle Memory There is an occasional additional benefit of regular neurotoxin treatment that is commonly referred to as muscle memory. Muscle memory is the memory built by repeated practice and use of any muscle. In relationship to aesthetics, muscle memory can also be engaged. Muscle memory specific to neurotoxin injection occurs when a muscle or muscle group is repeatedly treated during appropriate intervals. The treated muscles eventually lose full contractility due to possible atrophy of the muscle with results of treatment remaining longer than a period of 3–4  months (Carruthers and Carruthers 2006; Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018). A common area of this phenomenon is the procerus and corrugator group. Affected patients experience decreased muscle contraction and smooth skin although the BoNT/A is no longer in effect. Consequently, the patient may ask for partial treatment or ask to stagger treatment areas that have full muscle contractility after 3 or 4 months. For example, if the patient has diminished BoNT/A effect in the orbicularis oculi areas but still enjoys good BoNT/A effect in the glabella, they may request treatment only in the orbicularis area at their appointment. A potential issue with alternating treatment sites is the lines formed from the strong and frequent contraction of the procerus and corrugator group will return, and the patient will notice less efficacy over time (Baumann et al. 2016). A more favorable approach might be treating the muscle group that is exhibiting muscle memory with a slightly lower dose during the appointment to ensure the smooth skin and lifted brows remain a constant outcome.

12.5 Glabella (Procerus, Corrugator Supercilii, Nasalis) The glabella region is comprised of a group of muscles, the procerus, corrugator supercilii, nasalis, and the depressor supercilii, that when contracted, pull the brows medially and downward causing a scowl (Carruthers and Carruthers 2005b, 2006; Hellman 1927; Zimbler et al. 2001). (see Fig. 12.2). Patients frequently complain about having “frown lines” or “11’s” between their brows and they report these lines make them appear angry or stressed, including

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Right corrugator shown here (bilateral) procerus

nasalis

Fig. 12.2  Glabella muscle complex. Adapted from P. Lynch, medical illustrator (Patrick 2006)

when the muscles are at rest. This area is often successfully treated with BoNT/A and when this group of muscles involved are treated, mainly the procerus and corrugator supercilii, the area becomes relaxed and the overlying skin becomes smoother (Carruthers and Carruthers 2006). Consequently, the muscles cannot contract, and this prevents the patient from creating a scowl that further deepens lines that may already exist. Typical dosing for the glabella is intramuscular injection of 20 units onobotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin) or 50 units of abobotulinumtoxinA (Dysport) using a 30 g ½ inch needle, evenly divided by five total injection sites. One injection of 4 units onobotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin), or 10 units abobotulinumtoxinA (Dysport) is placed in the belly of the procerus, one injection of 4 units onobotulinumtoxinA (Botox), prabotulinumtoxinA (Junveau) or incobotulinumtoxinA (Xeomin) or 10  units abobotulinumtoxinA (Dysport) deep into the medial corrugator, and one injection of 4  units onobotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin) or 10 units abobotulinumtoxinA (Dysport) about 1/3rd of the needle length into the lateral corrugator, for a total dose of 20 units or 50 units, respectively (see Fig. 12.1) (Allergan 2017; Ipsen Biopharmaceuticals Inc 2017; Merz Pharmaceuticals LLC 2018; de Maio et  al. 2017). The anatomy of the corrugator dictates the depth of injection. The medial corrugator originates deep near the periosteum and nasal bridge and as it traverses over the brow, it becomes more shallow (de Maio et al. 2017) (see Fig. 12.3).

12.6 Crow’s Feet (Orbicularis Oculi)

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Fig. 12.3  Injections sites for glabella treatment. Photo: B. Haney, DNP, FNP-C, FAANP

Sometimes, the muscles of the glabella have been overactive for many years and, depending on the patient’s unique anatomy and musculature, the lines in the area have become static and deep. These deeper lines are extremely challenging to treat successfully with neurotoxin alone and may require laser resurfacing and/or small amount of dermal filler for best results (Carruthers and Carruthers 2005b, 2006, 2013). Based on the effect of BoNT/A, it may also be used to prevent lines from occurring and is often sought out by younger people who want to maintain a virtually line-free appearance from an early age. BoNT/A treatment has been shown to not only smooth lines caused from years of muscle contraction, but it may also to avoid lines from forming in the first place (Raspaldo et al. 2011).

12.6 Crow’s Feet (Orbicularis Oculi) The crow’s feet treatment is one that should be thoroughly explained because the effect of BoNT/A in this area can be confusing to patients who believe they may not be able to smile. The round muscle around the eye, called the orbicularis oculi, is responsible for creating the lines at the lateral corners of the eye; when this muscle contracts, the eyes squint and thus produces lines that run perpendicular to the muscle fibers (Carruthers et al. 2016). Typical dosing for the orbicularis oculi muscle depends on the distribution of the lines perpendicular to the muscle. In some patients, the lines follow the entire

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Fig. 12.4  Fan-type line distribution. Photo: B. Haney, DNP, FNP-C, FAANP

Fig. 12.5  Linear line distribution. Photo: B. Haney, DNP, FNP-C, FAANP

orbicularis oculi muscle around the lateral canthal region of the eye to form a fantype arrangement (Fig. 12.4). In other patients, the distribution of lines in the lateral canthal region can be primarily below the lateral canthus in a linear fashion and necessitate injection sites in the lateral and lower areas exclusively (see Fig. 12.5). Injection technique for crow’s feet is precise. The needle bevel should be up and oriented away from the eye and the depth of the needle is inserted just to the superficial dermis level and approximately 1.5–2.0 CM temporal to the lateral canthus

12.6 Crow’s Feet (Orbicularis Oculi)

107

Fig. 12.6  Injection sites for the fan-type lines. Photo: B. Haney, DNP, FNP-C, FAANP

Fig. 12.7  Injection sites for lower and lateral canthus linear arrangement. Photo: B. Haney, DNP, FNP-C, FAANP

(Carruthers and Carruthers 2006; Allergan 2017). Dose ranges are from 8 to 16 units onobotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin) per side using 2–4 units per injection site or 20–40 units abobotulinumtoxinA (Dysport) per side using 5–10  units per injection site, depending on the distribution of the lines (Figs. 12.6 and 12.7) (Carruthers and Carruthers 2005b, 2006). Squinting through contraction of the orbicularis oculi results in crow’s feet and is different than the lines caused from contraction when other facial muscles are used for smiling (Carruthers and Carruthers 2005b, 2006). Squinting uses the orbicularis

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oculi muscle exclusively, whereas smiling uses the levator labii superioris alaeque nasi, levator labii superioris, zygomaticus major and zygomaticus minor muscles (Carruthers and Carruthers 2005b). These levator muscles pull the cheeks upward and cause the tissue to gather near the inferior and lateral part of the eye, often being mistaken for orbicularis oculi contraction. This muscle group differentiation can be acknowledged by the patient in having the patient look in the mirror and squint without smiling or moving the cheeks. This way, the patient will understand that treatment is effective if the squint is softened but smiling will continue to look natural. It is helpful to reiterate the fact that the orbicularis oculi are the muscles causing the crow’s feet when you ask the patient to demonstrate this expression. Static lines that are visible on the face at rest create an aged appearance, whereas few or absent lines on the resting face are youthful. The desired outcome of BoNT/A treatment is muscle relaxation that will prevent muscle contraction and therefore prevent lines from deepening or remaining static after expressive contraction (Raspaldo et al. 2011). This concept may be difficult for patients to understand initially because people equate muscle paralysis and no movement with a youthful look and believe if their face is moving or an area has motion, they do not appear youthful. The desired outcome of BoNT/A treatment in the orbital area is to create smooth skin at rest and not necessarily completely paralyze or “freeze” the muscles of the face (Carruthers and Carruthers 2006). A thorough explanation of this desired response to patients will alleviate confusion and set expectations appropriately.

12.7 Forehead The forehead is an area of concern for many patients. Static horizontal lines across the forehead are aging but can easily be treated with BoNT/A; however, care must be taken to avoid unexpected effects such as dropped eyebrows or a bossy forehead (Carruthers and Carruthers 2006). The frontalis muscles are flat and wide and encompass a large portion of the face above the brows. They are natural elevator muscles and when contracting, they lift the eyebrows and cause the horizontal lines across the forehead (de Maio et al. 2017; Carruthers and Carruthers 2007). A typical dose used in the treatment of horizontal forehead lines is between 6 and 12  units of onabotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin) or 15–30 units of abobotulinumtoxinA (Dysport) in the average female forehead, whereas more units may be necessary for male patients (Figs. 12.8 and 12.9). Male patients with larger foreheads and thicker frontalis muscles typically require 10–30  units onabotulinumtoxinA, prabotulinumtoxinA, or incobotulinumtoxinA or 25–70  units of abobotulinumtoxinA (Klein et  al. 2008; Frevert 2015; Lorenc et al. 2013a, b). Each injection site is generally 2 units of onabotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin) or 5 units of abobotulinumtoxinA (Dysport). When the frontalis muscles are relaxed with a neurotoxin, they create a smooth, line-free effect and consequently give a more youthful appearance. Caution should be used when treating the forehead because the BoNT/A may cause the brows to

12.7 Forehead

109

Fig. 12.8  An example of injection sites in the glabella and forehead of a male patient. Photo: B. Haney, DNP, FNP-C, FAANP

Fig. 12.9  An example of forehead sites in a female patient. Amount of neurotoxin and number of sites will depend on individual anatomy. Recommended additional sites when treating the forehead are in white. Photo: B. Haney, DNP, FNP-C, FAANP

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flatten or drop if placed too low or not dosed appropriately and these are not desired effects (Carruthers and Carruthers 2005b). The practitioner can prevent this is by treating the glabella area at the same time as the forehead and avoiding treatment of the forehead alone. The relaxation of the depressors of the glabella in conjunction with the relaxation of the frontalis will counteract the action of a relaxed frontalis and create a refreshed look (Carruthers and Carruthers 2005b; Kordestani et  al. 2016; de Maio et al. 2017). Although rare, there may be few instances in which the patient is best served by treatment of the frontalis alone. This calls for the individual assessment of the musculature and motion of the patient with the specific focus on the effect of exclusive treatment and possible effects of BoNT/A to this area. A common way to avoid eyebrow drop when treating the frontalis exclusively is to place the injection sites high in the forehead; however, it is strongly recommended to put at least a small dose in the glabella group in most cases (Carruthers and Carruthers 2005b, 2007). Regardless, it is not recommended to treat the forehead alone. Another consideration when treating the forehead is eyebrow shape and location. Shape and eyebrow elevation are determined by the opposing activity of the frontalis muscle, which elevates the brow (Carruthers and Carruthers 2007). Lower than recommended doses to the glabella does not produce eyebrow elevation and may even cause a drop of eyebrow height. In addition, even when recommended doses are used, it may take longer than 2 weeks to notice a lifting effect (Carruthers and Carruthers 2007). It is a generally accepted practice to inject 1 CM above the orbital bone and to avoid injecting below the lowest horizontal line of the forehead. In addition, keep the injection sites medial to the mid-pupillary line to avoid eyebrow drop and upper eyelid ptosis (Carruthers and Carruthers 2005b, 2006, 2007). This is effective for most patients however on occasion, not treating the lateral forehead near the temporal-­frontal junction can lead to overly pointed or “Spock” brows where the medial and mid-brow are unable to move but the lateral brow can pull up. This is because the frontalis muscles fibers in that area have not been treated (de Maio et al. 2017; Jaspers et al. 2011). This is an easy correction by adding a small amount of neurotoxin to the area of concern, first asking the patient to raise the brows to determine the active portion of the muscle. A 2 week in-person follow-up appointment provides the opportunity to provide this correction if necessary. Patients who have heavy, hooded upper eyelids might be best served by receiving a surgical consultation and having the excess skin removed prior to BoNT/A treatment (de Maio et al. 2017). Caution should be exercised in these patients because if the neurotoxin is not precisely placed in the correct location per the patient’s unique anatomy, the lids will become more hooded and feel heavier and the patient can endure these undesirable effects for weeks to months.

12.8 Bunny Lines (Nasalis) In some patients, the nasalis muscle contracts alone or in conjunction with the procerus and corrugator group when frowning, causing horizontal lines across the nose that are unappealing to some patients (Kordestani et al. 2016). If this is the case, the

12.9 Lower Eyelids (Inferior Orbicularis Oculi)

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Fig. 12.10  Typical injection sites for nasalis treatment. Photo: B. Haney, DNP, FNP-C, FAANP

patient might complain of oblique lines across the nose, typically referred to as “bunny lines” (Carruthers and Carruthers 2005a). These lines should be treated conservatively and with low doses of BoNT/A to both sides of the nasal area. Typical doses for treatment of the nasalis are 2–4 units per injection site of onobotulinumtoxinA (Botox), prabotulinumtoxinA-xvfs, or incobotulinumtoxinA (Xeomin) or 5–10  units of abobotulinumtoxinA into the belly of the upper nasalis as it transverses the nasal bone (Carruthers and Carruthers 2003). The injections should be given high on the lateral nasal wall, well above the nasofacial groove to avoid relaxing the levator labii superioris and causing upper lip ptosis (Fig. 12.10) (Carruthers and Carruthers 2003, 2005b). Depending on the severity and location of the lines, several sites may be injected for optimal effect (Carruthers and Carruthers 2005b). Care must be taken to avoid underlying structures such a tear ducts and vessels (de Maio et al. 2017). Treatment of this area will create a smoother nasal area by softening any existing lines and preventing those lines from deepening. Nasalis injection is an off-label area.

12.9 Lower Eyelids (Inferior Orbicularis Oculi) In some cases, neurotoxin treatment may be indicated for treatment of the inferior eyelid for the treatment of fine lines beneath the lower lash line. This area is problematic for some patients who complain about crêpey skin but cannot tolerate topical remedies such as tretinoin (Retin-A). A simple test to determine if patients are

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Fig. 12.11  Typical injection sites for under eye treatment. Photo: B. Haney, DNP, FNP-C, FAANP

candidates for BoNT/A treatment in this area is called a snap test (Raspaldo et al. 2011). This test is performed by gently pulling the skin of the lower eyelid downward and holding for several seconds, releasing the skin, and observing how quickly the skin snaps back into position (Oh et al. 2016). If the snap is immediate, the lid is healthy and does not demonstrate a long lag time, this person is likely a candidate for this treatment and will have a smoothing effect (Flynn et al. 2001, 2003). The dosing of this area is low, 1–2 units of onobotulinumtoxinA (Botox), prabotulinumtoxinA (Juveau), or incobotulinumtoxinA (Xeomin) or 2.5–5 units abobotulinumtoxinA placed centrally and very superficially under each eye, to prevent lower lid lag or difficulty closing of the eye (Fig. 12.11) (Raspaldo et al. 2011). The lower eyelid is an off-label area.

12.10 Conclusion Indications for BoNT/A in the upper face are varied and have proven to be effective in aesthetics in the treatment of the upper and midface. Careful injection technique and proper dosing results in fewer side effects and decreases the incidence of unexpected results. Understanding the resting and dynamic muscular anatomy of the facial muscles as well as the location of underlying structures will ensure the best outcome for the patient.

References Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recommendations on the aesthetic usage of botulinum toxin type A in Asians. Dermatol Surg. 2013;39(12):1843–60. Allergan. Botox cosmetic prescribing information [package insert]. Irvin: Allergan; 2017. Baumann L, Dayan S, Connolly S, Silverberg N, Lei X, Drinkwater A, et al. Duration of clinical efficacy of onabotulinumtoxinA in crow’s feet lines: results from two multicenter, randomized, controlled trials. Dermatol Surg. 2016;42(5):598–607.

References

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Carruthers J, Carruthers A.  Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg. 2003;29(5):468–76. Carruthers J, Carruthers A. Botulinum toxin A in the mid and lower face and neck. Dermatol Clin. 2004;22(2):151–8. Carruthers A, Carruthers J.  Prospective, double-blind, randomized, parallel-group, Dose-­ Ranging study of botulinum toxin type a in men with Glabellar Rhytids. Dermatol Surg. 2005a;31:1297–303. Carruthers A, Carruthers J. In: Dover JS, editor. Procedures in cosmetic dermatology: botulinum toxin. Philadelphia: Elsevier Saunders; 2005b. 141 p. Carruthers J, Carruthers A. The use of botulinum toxin type A in the upper face. Facial Plast Surg Clin North Am. 2006;14(3):253–60. Carruthers A, Carruthers J. Eyebrow height after botulinum toxin type A to the glabella. Dermatol Surg. 2007;33(1 Spec):S26–31. Carruthers J, Carruthers A.  In: Dover J, editor. Soft tissue augmentation. 3rd ed. Philadelphia: Elsevier; 2013. Carruthers A, Kiene K, Carruthers J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol. 1996;34(5 Pt 1):788–97. Carruthers A, Bruce S, Cox SE, Kane MA, Lee E, Gallagher CJ. OnabotulinumtoxinA for treatment of moderate to severe Crow’s feet lines: a review. Aesthet Surg J. 2016;36(5):591–7. de Maio M, Swift A, Signorini M, Fagien S, Aesthetic Leaders in Facial Aesthetics Consensus Committee. Facial assessment and injection guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the upper face. Plast Reconstr Surg. 2017;140(2):265e–76e. Flynn TC, Carruthers JA, Carruthers JA. Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye. Dermatol Surg. 2001;27(8):703–8. Flynn TC, Carruthers JA, Carruthers JA, Clark RE 2nd. Botulinum A toxin (BOTOX) in the lower eyelid: dose-finding study. Dermatol Surg. 2003;29(9):943–50; discussion 50–1. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs R D. 2015;15(1):1–9. Hellman M. Changes in the human face brought about by development. Int J Orthod Oral Surg Radiogr. 1927;13(6):475–516. Ipsen Biopharmaceuticals Inc. Dysport full prescribing information. Basking Ridge: IB Inc; 2017. Jaspers GW, Pijpe J, Jansma J. The use of botulinum toxin type A in cosmetic facial procedures. Int J Oral Maxillofac Surg. 2011;40(2):127–33. Klein AW, Carruthers A, Fagien S, Lowe NJ. Comparisons among botulinum toxins: an evidence-­ based review. Plast Reconstr Surg. 2008;121(6):413e–22e. Kordestani R, Small KH, Rohrich RJ. Advancements and refinement in facial neuromodulators. Plast Reconstr Surg. 2016;138(4):803–6. Lorenc ZP, Kenkel JM, Fagien S, Hirmand H, Nestor MS, Sclafani AP, et al. IncobotulinumtoxinA in clinical literature. Aesthet Surg J. 2013a;33(1 Suppl):23S–34S. Lorenc ZP, Smith S, Nestor M, Nelson D, Moradi A. Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type A therapy. Aesthet Plast Surg. 2013b;37(5):975–83. McCormick DP. Herpes-simplex virus as a cause of Bell’s palsy. Lancet. 1972;1(7757):937–9. Merz Pharmaceuticals LLC. Xeomin full prescribing information. Greensboro: MP LLC; 2018. Oh SH, Lyu B, Yim HB, Lee NY. Lower lid laxity is negatively correlated with improvement of the ocular surface disease index in dry eye treatment. Curr Eye Res. 2016;41(2):165–70. Patrick J. Lynch, medical illustrator, CC BY 2.5 [Internet]. 2006. Available from: https://commons. wikimedia.org/w/index.php?curid=1498032. Raspaldo H, Baspeyras M, Bellity P, Dallara JM, Gassia V, Niforos FR, et al. Upper- and mid-face anti-aging treatment and prevention using onabotulinumtoxin A: the 2010 multidisciplinary French consensus--part 1. J Cosmet Dermatol. 2011;10(1):36–50. Said S, Meshkinpour A, Carruthers A, Carruthers J. Botulinum toxin A: its expanding role in dermatology and esthetics. Am J Clin Dermatol. 2003;4(9):609–16. Zimbler MS, Kokoska MS, Thomas JR. Anatomy and pathophysiology of facial aging. Facial Plast Surg Clin North Am. 2001;9(2):179–87, vii.

Indications for Neurotoxins: Lower Face and Neck

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13.1 Patient Selection and Expectations It is important to understand that some patients with lower face concerns are candidates for additional treatment that can include dermal filler, laser resurfacing, or surgical intervention (Carruthers and Carruthers 2005; Carruthers et  al. 1996). Volume loss resulting in deep nasolabial folds, flattened cheeks, sunken oral commissures, and thin lips requires additional treatment with dermal filler to create the overall desired outcome of a smooth, younger looking appearance, whereas photo-­ aged, sagging skin may require laser or surgery (Carruthers and Carruthers 2013). Static fine lines of the upper lip and dimpling of the chin are areas frequently treated with neurotoxin, but drooping at the corners of the mouth, “gummy smile,” “bunny lines,” and neck bands are also appropriate areas for treatment and frequently sought out by patients for improvement (Carruthers and Carruthers 2005, 2003). As with any cosmetic dermatology treatment, the expectations of the patient are crucial to the outcome and the patient’s satisfaction with treatment. Direct communication that outlines the side effects, risks, and benefits of treatment must be relayed to the patient, and assurance of patient understanding is critical. The effects of using BoNT/A on the lower face are mostly tied to the softening of structures through muscle relaxation rather than “freezing” certain areas (Carruthers and Carruthers 2005). Also, the potential for the addition of dermal filler in combination to BoNT/A to more effectively rejuvenate the lower face is an essential component of the consultation and should be clear to the patient prior to treatment. When using BoNT/A on the lower face, there is potential for unexpected outcomes from the effects of the neurotoxin related to the weakening of the function of the lip such as the patient’s inability to enunciate words, play musical instruments, or smile normally (Carruthers and Carruthers 2004). The muscles of the lower face appear to be more responsive to the effects of BoNT/A and for this reason, lower doses are used in these muscles vs. the muscles of the upper face (Carruthers and Carruthers 2005, 2003). Exaggerated muscle weakness and/or dysfunction in the lower face can be avoided by having a keen knowledge of lower facial anatomy and muscle function, using small © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_13

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doses, and taking a conservative approach (Carruthers and Carruthers 2004). As of publication, there are no available studies on prabotulinumtoxinA (Jeuveau), however, the dosing is the same as onabotulinumtoxinA (Botox) and incobotulinumtoxinA (Xeomin). All lower face areas are off-label indications for BoNT/A treatment.

13.2 Gummy Smile Gummy smile is described as a smile where a large portion of the upper gum line is visible. It is caused by the contraction of the levator labii superioris alaeque nasi (LLSAN) muscle. BoNT/A treatment of this muscle results in the lengthening of the upper lip and decreased contraction and travel of the upper lip when smiling (Carruthers and Carruthers 2005; Mazzuco and Hexsel 2010). On occasion, a patient may complain about a naturally occurring asymmetric smile and want only one side treated; treatment on one side is quite acceptable (Carruthers and Carruthers 2005). The treatment for gummy smile is one injection site on each side into the LLSAN muscle using a low dose of BoNT/A, typically 1–4 units of onabotulinumtoxinA (Botox®), prabotulinumtoxinA (Jeuveau), or incobotulinumtoxinA (Xeomin®) or, alternatively, 2.5–10  units of abobotulinumtoxinA (Dysport®) (Carruthers and Carruthers 2004) (see Fig. 13.1). It is recommended to start with a low dose, and the patient be evaluated after 2 weeks to ensure the desired effect was reached and to avoid initial overtreatment and dysfunction (Mazzuco and Hexsel 2010).

Fig. 13.1  Injection sites to treat gummy smile. Graphic by Patrick J. Lynch, medical illustrator (2006)

13.3 Chin

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13.3 Chin Dimpling in the chin is a result of an active mentalis muscle and is most apparent during speaking or expression (Trevidic et al. 2015). This bunching up and dimpling of the chin can be an unwelcome feature in the overall facial appearance. Patients may not complain about the dimpling specifically, but might report they do not like how the chin looks. It is part of the practitioner’s responsibility to educate the patient on the treatment effect of BoNT/A on the chin and the potential improvement in appearance. Chin treatment is relatively easy and is usually one injection site, although two sites may be required for certain patients (Carruthers and Carruthers 2005; Trevidic et al. 2015). BoNT/A can also improve the appearance of an under-projected chin by changing the position of the mentalis muscle. If the mentalis muscle is contracted and bunched upwards, it changes the profile and decreases the projection of the chin. By injecting a small amount of BoNT/A into the mentalis, between 12 and 15 units of onabotulinumtoxinA or equivalent, the muscle will descend creating a more aesthetically pleasing contour and profile (Trevidic et al. 2015; Hsu and Frankel 2017) (see Fig. 13.2). In some cases, the unique composition and strength of the patient’s facial musculature, along with advancing age, create a deep groove or cleft in the chin that

Fig. 13.2  Injection sites to treat the mentalis. Graphic by Patrick J.  Lynch, medical illustrator (2006)

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intensifies the appearance of age (Carruthers and Carruthers 2005). In addition the chin softening of the BoNT/A treatment, these deep grooves may require a small amount of dermal filler to be placed into the cleft to soften the appearance of the chin (Moradi et al. 2019).

13.4 Oral Commissures (Down-Turned Corners) Down-turned angles of the mouth, sometimes called marionette lines, are a common complaint and patients report looking sad or angry. The depressor anguli oris (DAO) muscles are partly responsible for this issue; they are triangular shaped and originate from the mandible and terminate at the angle of the mouth (Carruthers and Carruthers 2005). The DAO are responsible for frowning and should be treated conservatively because if they are over-treated or if toxin diffuses into the nearby depressor labii inferioris, the lower lip may unnaturally protrude or result in an asymmetric smile (Trevidic et al. 2015). Injection of the DOA is best done near the mandible to avoid accidentally affecting surrounding muscles (Carruthers and Carruthers 2005; Trevidic et al. 2015) (see Fig. 13.3). When the DOA muscles are relaxed with an appropriate dose of BoNT/A, typical range is from 2–4u ona/inco/pra/botulinumtoxinA or 5–10u abobotulinumtoxinA,

Fig. 13.3  Injection sites for depressor anguli oris. Graphic by Patrick J. Lynch, medical illustrator (2006)

13.5 Perioral Rhytids (Lip Lines)

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the natural effect is for the DOA motion to travel upward thereby elevating the corners of the mouth. However, if the marionette lines are deep, it is important to understand that a more complete aesthetic result may require the addition of dermal filler (Braz et al. 2013).

13.5 Perioral Rhytids (Lip Lines) Many patients find upper lip lines bothersome and aging and commonly refer to them as smoker’s lines. Patients with superficial lip lines at rest (static lines) benefit from BoNT/A treatment but it is important to understand the causes of upper lip lines can be due to a combination of factors including volume loss, muscle contraction, and sun exposure leading to skin breakdown (Carruthers and Carruthers 2005, 2004; Trevidic et al. 2015). As the orbicularis oris muscles start to thin, lines may begin to appear. Replacing volume with dermal fillers that are appropriate for superficial placement help to alleviate these lines are an option that can be used along with BoNT/A (Carruthers and Carruthers 2005). To replace lost lip body volume that contributes to upper and lower lip line formation, thicker dermal fillers in the lip body may be an option and help smooth the adjoining lines (Carruthers and Carruthers 2013; Bray et al. 2010). Some patients have hyperactive orbicularis oris muscles and when speaking or making expressions, the contraction of these muscles leads to static lines. If the patient has sufficient volume in the lip and simply has overactive muscles, the patient is a good candidate for monotherapy with BoNT/A because the effect will slightly relax the orbicularis oris and prevent tight contraction that ultimately leads to line formation (Carruthers and Carruthers 2005, 2004). The typical dose for lip line treatment is 1–2 units of onabotulinumtoxinA (Botox®), prabotulinumtoxinA (Jeuveau), or incobotulinumtoxinA (Xeomin®) or, alternatively, 2.5–5  units of abobotulinumtoxinA (Dysport®) in each injection site (Carruthers and Carruthers 2005). There are reports of slight upper lip eversion and increased lip size with BoNT/A treatment as the orbicularis oris muscle is relaxed (Carruthers and Carruthers 2005, 2003). Also, patients with lip lines that are visible only with muscle contraction but disappear at rest benefit from treatment because BoNT/A prevents those lines from becoming grooved into the superficial layer of skin (Carruthers and Carruthers 2003) (see Fig. 13.4). Sun exposure contributes to upper lip lines in the same way it does to other areas of the face and body; by causing DNA changes and breakdown of elastin and collagen fibers in the skin (Bitter 2000; Sondenheimer and Krutmann 2018; Petersen et al. 1992; Lowe et al. 1995). The effects of sun exposure coupled with hyperactive orbicularis oris muscles can be visible even in patients younger than 50 years. Carbon dioxide (CO2) fractional laser resurfacing treatment in addition to BoNT/A often lead to the best result in this subset of patients (Le Pillouer-Prost and Cartier 2016). Some patients may notice fine lip lines only with assistance of a regularly used magnifying mirror at home that enlarges their defect. However, these lines might be difficult to see by the practitioner. Before attempting to provide a solution for a concern that is virtually invisible, the patient must be thoroughly evaluated for body

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Fig. 13.4  Injection sites for lip lines. Graphic by Patrick J. Lynch, medical illustrator (2006)

dysmorphic disorder (BDD) (Phillips et al. 2019a, b). The practitioner must be able to see the lines without magnification and evaluate whether BoNT/A or a different treatment is most appropriate for these patients.

13.6 Platysmal Bands (Neck Bands) Neck changes that occur with aging are a frequent complaint of patients and some opt for a surgical procedure to mitigate these changes. However, treatment with BoNT/A can postpone surgery in appropriate patients. BoNT/A is used to treat the anterior neck by injection of the platysma muscles to create a smoother appearance (Jabbour et  al. 2017). The anatomy of the lower face and neck are interconnected, and the muscles in the region affect appearance (Carruthers and Carruthers 2005). The platysma originates in the upper chest as two, flat, wide muscles and ultimately blend into the lower facial muscles-the masseter, depressor anguli oris, mentalis, and orbicularis oris (Carruthers and Carruthers 2005; de Almeida et al. 2017). This explains why when the teeth are clenched and the lateral corners of the mouth are depressed, bands in the neck are visualized. The anatomy of the platysma differ slightly in patients; some having muscle fibers that run completely independent of

13.6 Platysmal Bands (Neck Bands)

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each other and some that remain attached until the submental area (Carruthers and Carruthers 2005; de Almeida et al. 2017). Changes in the platysma muscle structure lead to banding, where the separation of the platysma and subsequent fall of the submental fat and skin lead to laxity and, ultimately, an older looking neck (Carruthers and Carruthers 2005). In addition, loss of collagen and elastin within the skin in combination with breakdown from sun exposure lead to increased skin laxity (Lowe et al. 1995). A thorough consultation with objective input is important when assessing neck rejuvenation procedures because BoNT/A may need to be used in conjunction with another treatment such as laser or surgery (Carruthers and Carruthers 2005). Neck rejuvenation with BoNT/A is best performed in patients who do not have an excess of submental fat or sagging skin (Jabbour et al. 2017; Brandt and Boker 2004; Kane 2003). In the appropriate patient, treatment begins during assessment with the patient clenching their teeth and depressing the lateral mouth to exaggerate the platysmal bands. This will help determine where to place injection sites, normally between 2 and 6 sites per band (Jabbour et al. 2017). The practitioner grasps the band between the thumb and index finger and injects 2–10u of ona/inco/pra/botulinumtoxinA or 5–25u of abobotulinumtoxinA into each site approximately 1–2 cm apart, careful to avoid injecting too deeply and affecting swallowing (Carruthers and Carruthers 2005; Levy 2015) (see Fig.  13.5). Thinner bands require less toxin than thicker

Fig. 13.5  Possible injection sites for platysma1 bands. (Actual sites will vary depending on patient anatomy). Graphic by Patrick J. Lynch, medical illustrator (2006)

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ones—thicker bands may require up to 30u ona/inco/prabotulinumtoxinA or 75u abobotulinumtoxinA. Other reports have shown less amounts of BoNT/A is necessary to achieve good results so it is recommended to monitor each patient individually and determine the most appropriate dose based on effect (Kane 2003). As with other areas of the face, onset is several days and possibly up to 14 days so re-treatment is not recommended prior to this time (Carruthers and Carruthers 2005). An additional neck treatment is horizontal neck lines or necklace lines that can be softened with BoNT/A (Kane 2003). Low doses consisting of intradermal injections of 1–2u ona/inco/prabotulinumtoxinA or 2.5–5u abobotulinumtoxinA per site placed approximately 1  cm apart along the lines, reduce or eliminate these lines (Carruthers and Carruthers 2005; Kane 2003). Caution should be exercised to avoid impacting swallowing (Carruthers and Carruthers 2005).

13.7 Conclusion BoNT/A is an effective cosmetic procedure in the lower face and neck. Understanding anatomy and muscular activity of the face as well as the location of important nerves and structures will facilitate the best aesthetic the outcomes. Importantly, the dosage of BoNT/A in the mid and lower face and neck is more conservative than in the upper facial regions e.g., the brow and orbital areas, because of the apparent increased response of the muscles in the lower face. In some patients, the lower face would benefit from the addition of dermal fillers to give the best result.

References Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg. 2000;26(9):835–42; discussion 43 Brandt FS, Boker A. Botulinum toxin for the treatment of neck lines and neck bands. Dermatol Clin. 2004;22(2):159–66. Bray D, Hopkins C, Roberts DN. A review of dermal fillers in facial plastic surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18(4):295–302. Braz AV, Louvain D, Mukamal LV. Combined treatment with botulinum toxin and hyaluronic acid to correct unsightly lateral-chin depression. An Bras Dermatol. 2013;88(1):138–40. Carruthers J, Carruthers A.  Aesthetic botulinum a toxin in the mid and lower face and neck. Dermatol Surg. 2003;29(5):468–76. Carruthers J, Carruthers A. Botulinum toxin a in the mid and lower face and neck. Dermatol Clin. 2004;22(2):151–8. Carruthers A, Carruthers J. In: Dover JS, editor. Procedures in cosmetic dermatology: botulinum toxin. Edinburgh: Elsevier; 2005. 141p. Carruthers J, Carruthers A.  In: Dover JS, editor. Soft tissue augmentation. 3rd ed. Edinburgh: Elsevier; 2013. Carruthers A, Kiene K, Carruthers J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol. 1996;34(5 Pt 1):788–97. de Almeida ART, Romiti A, Carruthers JDA. The facial Platysma and its underappreciated role in lower face dynamics and contour. Dermatol Surg. 2017;43(8):1042–9.

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Hsu AK, Frankel AS.  Modification of chin projection and aesthetics with onabotulinumtoxinA injection. JAMA Facial Plast Surg. 2017;19(6):522–7. Jabbour SF, Kechichian EG, Awaida CJ, Tomb RR, Nasr MW. Botulinum toxin for neck rejuvenation: assessing efficacy and redefining patient selection. Plast Reconstr Surg. 2017;140(1):9e–17e. Kane MA. Nonsurgical treatment of platysma bands with injection of botulinum toxin a revisited. Plast Reconstr Surg. 2003;112(5 Suppl):125S–6S. Le Pillouer-Prost A, Cartier H.  Photodynamic photorejuvenation: a review. Dermatol Surg. 2016;42(1):21–30. Levy PM. Neurotoxins: current concepts in cosmetic use on the face and neck--jawline contouring/ platysma bands/necklace lines. Plast Reconstr Surg. 2015;136(5 Suppl):80S–3S. Lowe NJ, Meyers DP, Wieder JM, Luftman D, Borget T, Lehman MD, et  al. Low doses of repetitive ultraviolet a induce morphologic changes in human skin. J Invest Dermatol. 1995;105(6):739–43. Lynch PJ. Medical illustrator, CC BY 2.5 [Internet]. 2006. Available from: https://commons.wikimedia.org/w/index.php?curid=1498032. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010;63(6):1042–51. Moradi A, Shirazi A, David R. Nonsurgical chin and jawline augmentation using calcium hydroxylapatite and hyaluronic acid fillers. Facial Plast Surg. 2019;35(2):140–8. Petersen MJ, Hansen C, Craig S.  Ultraviolet a irradiation stimulates collagenase production in cultured human fibroblasts. J Invest Dermatol. 1992;99(4):440–4. Phillips KA, Dimsdale J, Solomon D. Body dysmorphic disorder: choosing treatment and prognosis [Internet]. Up to Date, Inc. 2019a. [cited 02-13-2019]. Available from: https://www.uptodate.com/contents/body-dysmorphic-disorder-choosing-treatment-and-prognosis. Phillips KA, Dimsdale J, Solomon D. Body dysmorphic disorder: general principles of treatment [Internet]. Up to Date, Inc. 2019b. [cited 02-10-2019]. Available from: https://www.uptodate. com/contents/body-dysmorphic-disorder-general-principles-of-treatment. Sondenheimer K, Krutmann J.  Novel means for photoprotection. Front Med (Lausanne). 2018;5:162. Trevidic P, Sykes J, Criollo-Lamilla G. Anatomy of the lower face and botulinum toxin injections. Plast Reconstr Surg. 2015;136(5 Suppl):84S–91S.

Neurotoxins: Other Uses and Future Possibilities

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14.1 Hyperhidrosis Excessive underarm sweating (axillary hyperhidrosis) is an approved indication for onabotulinumtoxinA (Botox) and has been a welcome addition to the group of conditions treated with BoNT/A. Axillary hyperhidrosis (AH) is an embarrassing condition for affected patients and consists of an over production of sweat beyond what is necessary to keep the body cool. Approximately 3–5% of people in the USA experience this bothersome condition (Rosen and Stewart 2018). Axillary hyperhidrosis usually becomes apparent before age 25, but typically those who suffer with palmar hyperhidrosis usually notice excessive palmar sweating prior to puberty (Rzany et al. 2018). In addition to BoNT/A, there are several approaches used to help control AH including topical application of aluminum chloride products, radiofrequency or ultrasound treatments, and, in intractable cases, surgical intervention (Rzany et al. 2018). BoNT/A treatment is reserved for patients who fail the more conservative treatments such as antiperspirants. The typical BoNT/A treatment for axillary hyperhidrosis consists of 15–20 subdermal or subcutaneous injection sites per axilla of 2 units onabotulinumtoxinA or 5u abobotulinumtoxinA (Rosen and Stewart 2018; Rzany et al. 2018; Pirazzini et al. 2017). Pain control at injection sites includes ice or topical anesthetic cream applied 30 min prior to treatment. The duration of the effect of BoNT/A in the axillae tends to be longer than intramuscular injection of the facial muscles, lasting about 6–9 months (Rzany et al. 2018). The longer duration is likely due to the unrealized stimulation by the sympathetic division of the autonomic nervous system on the sweat glands, since acetylcholine acts as neurotransmitter between nerve endings and sweat glands (Rzany et al. 2018; Pirazzini et al. 2017). Palmar hyperhidrosis can also be treated with BoNT/A successfully when topical hyperhidrosis remedies fail, however, studies are limited and this is an off-label indication (Rzany et al. 2018). Treatment of palmar hyperhidrosis can be a painful

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procedure and topical anesthetic is usually warranted. Injection of BoNT/A is well tolerated and may improve quality of life in people who suffer with hyperhidrosis of the axillae and palms (Wade et al. 2018).

14.2 Emerging Features of Botulinum Toxins Faster onset of BoNT/A is an often desired effect when patients are being treated aesthetically. Researchers are working with different strains and subtypes of BoNT/A but ongoing research is necessary to achieve a shorter standardized onset than the current 2–7  days (Allergan 2017; Ipsen Biopharm Ltd 2017; Merz 2018). Novel experimental studies have demonstrated immediate onset of BoNT/A effects when it is reconstituted with lidocaine and epinephrine; however, this technique has not become integrated into aesthetic practice to date (Gassner and Sherris 2000). Transdermal application of BoNT/A is a novel delivery system that is being studied for a variety of applications (Fonfria et al. 2018). Topically applied BoNT/A could be useful in aesthetics, pain control, and hyperhidrosis, especially in needle-­ phobic patients. While there was initial enthusiasm for a topical application for BoNT/A to treat hyperhidrosis and lateral canthal lines, as with the pharmacologic gel preparation RT001 (Revance Therapeutics Inc.), the trials were discontinued due to the lack of efficacy in study subjects (Fonfria et al. 2018; Schlessinger et al. 2017). Regardless, topical options are an exciting possibility and further research may ultimately yield an effective transdermal BoNT/A for cosmetic treatment. Topical BoNT/A preparation would be a welcome option for patients with conditions that require multiple injections in sensitive areas, for example the treatment for axillary or palmar hyperhidrosis. As research progresses, a technical barrier to producing an effective transdermal preparation has emerged. Because of the physical properties of the skin, an enhancer is necessary to carry the BoNT/A across the dermal barrier to become effective (Fonfria et al. 2018). Development of a transdermal type of BoNT/A is currently underway, but there are no results reported to date (Fonfria et al. 2018). Another version of BoNT, serotype E (BoNT/E), is currently being investigated and is demonstrating a shorter duration of action (Fonfria et al. 2018). Current clinical trials demonstrating safe and effective use of BoNT/E have yielded positive responses in musculoskeletal pain and in elective breast augmentation procedures (Fonfria et  al. 2018). Because BoNT/E a shorter acting strain, lasting about 3–6 weeks, it might be useful as an adjunct in pain control and for other therapeutic uses, including seizures (Fonfria et al. 2018).

14.3 Acne Acne is a common and often embarrassing disease. Treatments include topical and oral medications, acne washes, light-based treatments, and peels (Habif 2016). A

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novel use for intradermal BoNT/A as an additional acne treatment has emerged and is currently being investigated (Li et al. 2013; Shuo et al. 2019). Acne lesions form in the pilosebaceous unit and are influenced by hormones that lead to increased sebum production (Habif 2016). Increased sebum production leads to acne lesions and flares in susceptible individuals. Additionally, pore size has also been associated with sebum production (Habif 2016; Shuo et  al. 2019). Sebum production in human skin is increased through acetylcholine signaling, therefore because BoNT/A blocks acetylcholine, sebum production is decreased (Li et al. 2013). Literature supports that individuals with oily skin are more responsive to acetylcholine than those with normal skin because the concentration of acetylcholine receptors is higher in their sebaceous glands (Li et  al. 2013). This is why botulinum toxin intradermal injections significantly decrease sebum production in oily skin but not in those with normal skin (Li et al. 2013; Shuo et al. 2019). Oily skin, large pores, and acne lesions are problematic for many people. Pore size was also found to be decreased by the effects of BoNT/A injections and this can have a positive impact on the appearance of the skin (Li et al. 2013; Shuo et al. 2019). Options to alleviate skin and acne concerns are increasing with the advancement of new uses. The advent of intradermal BoNT/A injections offers an exciting new possibility for the treatment of acne (Schlessinger et al. 2017; Shuo et al. 2019). For more information on acne, see Chap. 9.

14.4 Facial Scars Scarring is a concern for many people who undergo surgical procedures or closure of traumatic wounds on the face (Sherris and Gassner 2002; Goodman 2010). Facial wounds and incisions can leave unsightly scars, especially in areas where muscle movement is frequent. BoNT/A relaxes muscles; therefore, it is postulated that the use of BoNT/A before, during, or after facial surgical procedures would decrease the tension on the closed edges of the incision and result in an improved cosmetic appearance (Sherris and Gassner 2002; Ziade et al. 2013; Gassner et al. 2000). Decreased tension on healing wounds or surgical sites results in less scarring. There is evidence that injecting surgical sites with the typical pre-procedure anesthetic and vasoconstrictor (lidocaine with epinephrine) mixed with BoNT/A saves the number of injections while also resulting in immediate local muscle paralysis (Gassner and Sherris 2000; Sherris and Gassner 2002). This local paralysis leads to improved cosmesis of facial scars (Ziade et al. 2013). Lastly, the reconstitution of BoNT/A with lidocaine and epinephrine did not affect the longevity or effect of the BoNT/A and muscle function returned after 3 months (Gassner and Sherris 2000). Although reconstitution of BoNT/A with an anesthetic and/or vasoconstrictor is not recommended by drug manufacturers, it might be an acceptable option for scar prevention in the future (Table 14.1).

128 Table 14.1  Therapeutic uses for botulinum neurotoxin

14  Neurotoxins: Other Uses and Future Possibilities Ophthalmology  1. Strabismusa, b, c  2. Nystagmus Neurology  1. Blepharospasma, b, c  2. Cervical dystoniaa, b, c  3. Writer’s crampb  4. Laryngeal dysphoniac  5. Hemifacial spasma, b, c  6. Tremor (essential, parkinsonism)  7. Tics  8. Bruxism  9. Focal spasticitya, b, c: Upper and lower limb spasticity  10. Cerebral palsya, b   Hyperhidrosisa, b, c  1. Focal: Axillary, palmar, plantar   Hypersalivation  1. Sialorrheab (motor neuron diseases/amyotrophic lateral sclerosis)  2. Droolingb (Parkinsonian syndromes)   Aesthetic (muscle)  1. Glabellar rhytidsa, b, c  2. Lateral canthus (orbital)a Pain   Muscular  1. Temporomandibular disorders  2. Low back pain   Non-muscular  3. Migrainea  4. Neuropathic pain  5. Trigeminal pain  6. Pelvic pain  7. Osteoarthritis Urology  1. Overactive bladdera, b, c (idiopathic or neurogenic detrusor overactivity)  2. Urinary retention  3. Bladder pain syndrome  4. Pelvic floor spasms  5. Benign prostate hyperplasia Gastroenterology  1. Chronic anal fissures Psychiatry  1. Depressiond Adapted from Pirazzini et al. (2017) a USA approved indication b EU approved indication c Evidence-based therapeutic indication d To be evaluated

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14.5 Conclusion BoNT/A indications are increasing as research on its effects grows. There are many exciting future possibilities for the increasing use of BoNT/A. Palmar and axillary hyperhidrosis are embarrassing conditions for patients and can be easily treated with BoNT/A. Due to the unique characteristic of BoNT/A, it has a longer lasting effect that when used for aesthetic concerns. Acne and pain control are additional conditions where BoNT/A use has shown promise and current research is ongoing.

References Allergan. Botox cosmetic prescribing information. 2017. Available from: https://www.accessdata. fda.gov/drugsatfda_docs/label/2011/103000s5236lbl.pdf. Fonfria E, Maignel J, Lezmi S, Martin V, Splevins A, Shubber S, et al. The expanding therapeutic utility of botulinum neurotoxins. Toxins (Basel). 2018;10(5):208. Gassner HG, Sherris DA.  Addition of an anesthetic agent to enhance the predictability of the effects of botulinum toxin type a injections: a randomized controlled study. Mayo Clin Proc. 2000;75(7):701–4. Gassner HG, Sherris DA, Otley CC. Treatment of facial wounds with botulinum toxin a improves cosmetic outcome in primates. Plast Reconstr Surg. 2000;105(6):1948–53; discussion 54–5. Goodman GJ. The use of botulinum toxin as primary or adjunctive treatment for post acne and traumatic scarring. J Cutan Aesthet Surg. 2010;3(2):90–2. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. St. Louis: Elsevier; 2016. Ipsen Biopharm Ltd. Dysport full prescribing information. 2017. Available from: https://www. accessdata.fda.gov/drugsatfda_docs/label/2016/125274s107lbl.pdf. Li ZJ, Park SB, Sohn KC, Lee Y, Seo YJ, Kim CD, et al. Regulation of lipid production by acetylcholine signalling in human sebaceous glands. J Dermatol Sci. 2013;72(2):116–22. Merz. Xeomin full prescribing information. 2018. Available from: http://www.xeomin.com/wpcontent/uploads/xeomin-full-prescribing-information.pdf. Pirazzini M, Rossetto O, Eleopra R, Montecucco C. Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol Rev. 2017;69(2):200–35. Rosen R, Stewart T. Results of a 10-year follow-up study of botulinum toxin a therapy for primary axillary hyperhidrosis in Australia. Intern Med J. 2018;48(3):343–7. Rzany B, Bechara FG, Feise K, Heckmann M, Rapprich S, Worle B.  Update of the S1 guidelines on the definition and treatment of primary hyperhidrosis. J Dtsch Dermatol Ges. 2018;16(7):945–52. Schlessinger J, Gilbert E, Cohen JL, Kaufman J. New uses of abobotulinumtoxinA in aesthetics. Aesthet Surg J. 2017;37(suppl_1):S45–58. Sherris DA, Gassner HG.  Botulinum toxin to minimize facial scarring. Facial Plast Surg. 2002;18(1):35–9. Shuo L, Ting Y, KeLun W, Rui Z, Rui Z, Hang W. Efficacy and possible mechanisms of botulinum toxin treatment of oily skin. J Cosmet Dermatol. 2019;18(2):451–7. Wade R, Llewellyn A, Jones-Diette J, Wright K, Rice S, Layton AM, et  al. Interventional management of hyperhidrosis in secondary care: a systematic review. Br J Dermatol. 2018;179(3):599–608. Ziade M, Domergue S, Batifol D, Jreige R, Sebbane M, Goudot P, et al. Use of botulinum toxin type A to improve treatment of facial wounds: a prospective randomised study. J Plast Reconstr Aesthet Surg. 2013;66(2):209–14.

Neurotoxin Adverse Reactions

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15.1 C  ontraindications and Adverse Effects Related to BoNT/A Botulinumtoxin type A is one of the most widely studied drugs in the world and although the safety and efficacy studies are positive, there are a few potential adverse effects but no reported deaths when used cosmetically (Dayan 2013). Absolute contraindications to BoNT/A treatment are few but include allergy to any of the components of the medication or pre-existing infection at the injection site. Further, BoNT/A prescribing instructions include avoidance of injection into patients with a history of neurological conditions or diseases. There is also an extremely remote potential of spread of viral illness or Creutzfeldt–Jakob disease although there has not ever been a reported case of either (Carruthers and Carruthers 2005; Allergan 2017). BoNT/A treatment is contraindicated in pregnant or lactating women, or women who are planning to become pregnant because there is scant literature on the safety of administration during these times. In animal studies, there are increased risks of toxicity (Allergan 2017; Ipsen 2017; Merz 2018; Pirazzini et al. 2017). However, it has been found that administration of BoNT/A during or before the first trimester of pregnancy, the outcomes are identical to the general population outcome (Brin et al. 2016). The following are the most commonly reported adverse reactions from BoNT/A cosmetic treatment: AbobotulinumtoxinA (Dysport®) • Glabellar Lines: (≥2%) nasopharyngitis, headache, injection site pain or reaction, upper respiratory tract infection, eyelid edema, eyelid ptosis, sinusitis, nausea, and blood present in urine (Ipsen 2017). OnabotulinumtoxinA (Botox®) • Glabellar Lines: eyelid ptosis (3%) • Lateral Canthal Lines: eyelid edema (1%) • Forehead Lines: headache (9%) and brow ptosis (2%) (Allergan 2017) © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_15

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IncobotulinumtoxinA (Xeomin®) • Glabellar Lines: (>1% of patients) headache (Merz 2018)

15.2 A  dverse Effect Related to the Penetration of Skin by the Needle As with any injection, there may be pain at the injection site due to penetration of the needle through the skin and subsequent stimulation of nerve endings. This pain may be decreased by the application of ice or topical anesthetic to the area at least 30 min prior to treatment, although many patients tolerate the procedure without anesthetic. Other potential ways to decrease the pain associated with BoNT/A treatment are use of smaller gauge needle, vibration injection technique, and/or use 0.9% sodium chloride solution with preservative as the diluent (Sharma et al. 2011). There is no evidence that preservative-free diluent or 32G needles are associated with better outcomes (Carruthers and Carruthers 2005; Price et al. 2010). Another adverse effect related to the penetration of skin by the needle is the potential for infection. Although it has been demonstrated through large studies that 70% isopropyl alcohol antisepsis does not decrease rates of infection, it may offer some protection against the extremely remote local infection rate (Pham and Perry 2009). However, BoNT/A treatment is contraindicated in the presence of infection at the treatment site to avoid introduction of pathogens into deeper tissue via needle puncture (Allergan 2017; Ipsen 2017; Merz 2018). In addition, best practice recommends the practitioner’s hands be clean, gloved, and free from pathogens. An additional adverse effect is bruising related to needle puncture. At any time a needle is inserted into the skin, there is a possibility it will graze or puncture a vessel. When the vessel opens, blood spills out into the surrounding tissue, with bruising commensurate with amount of blood leakage. Even a small drop of blood can leave a noticeable bruise. Some suggestions for patients to decrease the potential or amount of bruising are to avoid drinking alcohol, taking non-essential anticoagulants such as aspirin (unless medically indicated), non-steroidal anti-inflammatory drugs (NSAIDs), and herbal remedies such as garlic, ginger, vitamin E, fish oil, St. John’s wort, among others, for 7–10  days prior to treatment (Carruthers and Carruthers 2005; Emer and Waldorf 2011). Another option to help reduce the incidence of bruising a patient during treatment is the use of a near infra-red (NIR) vessel locator, i.e., Accuvein®. The NIR device displays a map of the superficial vessels of the skin so the practitioner can avoid puncture of a vein by a needle during aesthetic injection procedures. A device to assist practitioners in vein visualization can improve patient satisfaction and safety by helping to prevent bruising (see Fig. 15.1). Local swelling at the injection site is usually temporary, lasting 20–30 min. The solution of the neurotoxin is injected as a depot into spaces in the face where the tissue is thin and difficult to camouflage so the solution is visible in the local area

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Fig. 15.1  The near infra-red (NIR) light illuminates vessels under the skin and can help prevent bruising. Photo: B. Haney, DNP, FNP-C, FAANP

until it dissipates. This can be alarming for treatment-naive patients because the sites resemble insect bites immediately after injection. On occasion, an injection site may remain edematous for days or weeks if a deep vessel was injured and the blood remains contained under the superficial tissues causing a subcutaneous hematoma.

15.3 Adverse Effect Related to Technique Patient expectations will determine the level of satisfaction so expectations should be very clear before BoNT/A treatment. Management of patient expectations is an important aspect of any cosmetic procedure and should be thoroughly discussed and documented in the patient record. Undesired muscle impairment, ptosis of the eyelid(s), ptosis of the brow, asymmetry of brows or smile, plateau smile (orbital area), and decreased efficacy are all adverse effects related to technique and/or local diffusion of the BoNT/A into surrounding muscle fibers (Carruthers and Carruthers 2005; Allergan 2017; Ipsen 2017; Merz 2018).

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15.3.1 Undesired Muscle Impairment A common complaint from women is the formation of superficial upper lip lines or smoker’s lines. These superficial lip lines are caused by smoking, sun exposure, or volume loss. Many of these women deny ever smoking and are distraught at the appearance of these lines. But smoking is not the only cause for these lines and explanation of the role of sun exposure, volume loss, and/or muscle contraction should be reviewed with the patient. A low dose of BoNT/A into the fibers of the orbicularis oris has been found to be helpful in temporarily alleviating the appearance of upper and lower lip lines. However, if too large a dose is used, lip dysfunction is imminent and results from diffusion of too much neurotoxin into the orbicularis oris muscle fibers. The patient may notice asymmetrical smiling, difficulty pronouncing certain words, inability to whistle or play musical instruments, or impaired drinking and eating (Carruthers and Carruthers 2003, 2005). The patient who cannot tolerate these potential side effects, especially speakers, singers, and musicians, should be counseled about different options to treat lip lines such as laser resurfacing or dermal fillers/smoothers. Typical dosing for the treatment of fine lines around the mouth ranges from 4 units of onabotulinumtoxinA, prabotulinumtoxinA-xvfs, and incobotulinumtoxinA or 10 units of abobotulinumtoxinA up to 12 units of the former or 30 units, respectively, divided between 4 and 8 injection sites (Carruthers and Carruthers 2003, 2004). Since a lower BoNT/A dose is used around the mouth compared to the upper face, the effect does not last as long, typically about 6–8 weeks and this is another consideration to review with patients.

15.3.2 Eyelid Ptosis Eyelid ptosis is a potential side effect of BoNT/A treatment (Allergan 2017; Ipsen 2017; Merz 2018). Eyelid ptosis gives the patient a heavy lid sensation and a sleepy appearance that can last for days or weeks. This unfavorable side effect is caused from diffusion of the BoNT/A into the levator palpebrae superioris, and can be avoided by using precise technique (Carruthers and Carruthers 2006; Lorenc et al. 2013). This side effect is easily avoided by accurate placement of the BoNT/A no closer than 1 cm above the bony orbital rim and avoiding injecting beyond the midpupillary line when injecting the glabella area (Carruthers and Carruthers 2005; Lorenc et al. 2013). The application of pressure under the orbital bone during injection of the corrugators may help prevent ptosis. If eyelid ptosis occurs, it can be treated with apraclonidine drops if desired (Wijemanne et al. 2017). Apraclonidine is a prescription eye drop that helps to elevate the upper eyelid through stimulation of an adrenergic muscle located near the levator muscle called Muller’s muscle (Carruthers and Carruthers 2005; Wijemanne et al. 2017). These drops can be used as directed until the ptosis resolves, usually within several weeks or earlier.

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15.3.3 Brow Ptosis Brow ptosis results from too high a dose in the frontalis or injection sites placed too low and may last for the duration of treatment, 3–4 months. The patient may complain of heavy, flattened, dropped brows and a completely immobile forehead. On occasion, they can also experience puffiness to the eyelids. The practitioner can avoid brow ptosis by injecting the procerus and corrugator muscles along with the frontalis to ensure the counter balance of depressor and elevator muscles (see Chap. 2) (Carruthers and Carruthers 2006, 2007; Lorenc et al. 2013). In addition, injecting a small amount 1 cm above the orbital rim at the mid-pupillary line will help prevent brow and lid ptosis (Carruthers and Carruthers 2005; Kordestani et  al. 2016). Further, a technique can be used where a low dose of BoNT/A is injected at the lateral tail of the brow and procerus along with the frontalis; this can also help prevent brow ptosis. It is not recommended to treat the frontalis exclusively (Carruthers and Carruthers 2005, 2007, 2006; Lorenc et al. 2013).

15.3.4 Plateau Smile A patient may complain of a shelf or dent when they smile several days or weeks after BoNT/A treatment for crow’s feet. This happens because the injection sites were positioned too close to the lateral canthus and there is subsequent relaxation of the orbital muscles, while the remaining facial muscles continue to have full movement (Carruthers and Carruthers 2005). This results in an unbalanced look where the face moves normally when smiling but the eyes are motionless causing the cheek to create a crease commonly called plateau smile. One way to avoid this is to inject at least 1cm away from the lateral canthus and in some cases, avoid the lowest injection site altogether (Carruthers and Carruthers 2005, 2006).

15.3.5 Medication Tolerance A potential additional adverse effect is decreased length of effect from the BoNT/A medication on the treated muscles. Dose related concerns include shorter duration of effect but some patients have short duration of effect even when recommended doses have been administered. One theory is the muscle fibers that are undertreated with low doses do not have enough saturation of the toxin and therefore the result of treatment duration is shorter and/or weaker (Klein 2003; Carruthers et al. 2005). There is a potential increased risk of shorter treatment duration when patients are chronically under-dosed, that is, patients who repeatedly return before the recommended 3-month interval or who consistently receive lower than recommended doses (Frevert 2015; Carruthers et al. 2005). To ensure the best outcome, appropriate dosing is essential and frequent touchups should be avoided (Naumann et al. 2013).

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Fig. 15.2  Quizzical eyebrows and bruising from incomplete treatment and deep orbital injections. Photo: Beth Haney, DNP, FNP-C, FAANP

15.3.6 Patient Dissatisfaction Lastly, patient dissatisfaction can also be considered an adverse effect. Patients may not receive the outcome they expected and can be disappointed. Bruising, swelling, heavy lids, and unnatural shaped brows can result from treatment and should be discussed in the consultation (see Fig. 15.2) (Alam et al. 2002). Reassurance that with time or a slight adjustment using additional BoNT/A can help alleviate these effects. Occasionally, patients may want an outcome that would end up looking unnatural to the practitioner, for example, quizzical eyebrows. It is through open communication and discussion of appropriate treatment that would ultimately lead to the best outcome for the patient. Consequently, if the patient is insistent on obtaining an unnatural or odd look, the practitioner should review expectations and discuss potential unintended consequences of a displeasing appearance.

15.4 Conclusion BoNT/A treatments are generally safe and effective however, on occasion, adverse reactions can happen. Careful dosing and placement of BoNT/A in appropriate areas prevent most unsatisfactory outcomes. In addition, detection of exceedingly high patient expectations is paramount in achieving reasonable results and gentle but honest and direct communication with those patients is crucial. Common terms used by patients who have unrealistically high expectations are frozen, tight, and flat. An additional example of an unrealistic expectation is an eyebrow lift of over 3 mm from BoNT/A treatment (Carruthers and Carruthers 2007). Communication and education are important aspects of caring for patients and nurses are expert in delivering accurate information in an understandable format that patients can appreciate. When patients understand the limitations as well as the characteristics of BoNT/A, they will be better prepared and more satisfied. Patient expectations should be frankly discussed and consultations should include the identification of any asymmetries, redundant skin, and atypical facial features. Pretreatment photographs or a short video of every patient with a resting face and

References

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subsequent active face taken at the practice helps to identify issues and pre-existing flaws (Carruthers and Carruthers 2006).

References Alam M, Dover JS, Klein AW, Arndt KA. Botulinum a exotoxin for hyperfunctional facial lines: where not to inject. Arch Dermatol. 2002;138(9):1180–5. Allergan. Botox cosmetic prescribing information. Package insert. 2017. Available from: https:// www.accessdata.fda.gov/drugsatfda_docs/label/2011/103000s5236lbl.pdf. Brin MF, Kirby RS, Slavotinek A, Miller-Messana MA, Parker L, Yushmanova I, et al. Pregnancy outcomes following exposure to onabotulinumtoxinA.  Pharmacoepidemiol Drug Saf. 2016;25(2):179–87. Carruthers J, Carruthers A.  Aesthetic botulinum a toxin in the mid and lower face and neck. Dermatol Surg. 2003;29(5):468–76. Carruthers J, Carruthers A. Botulinum toxin a in the mid and lower face and neck. Dermatol Clin. 2004;22(2):151–8. Carruthers A, Carruthers J. In: Dover JS, editor. Procedures in cosmetic dermatology: botulinum toxin. Edinburgh: Elsevier Saunders; 2005. p. 141. Carruthers J, Carruthers A. The use of botulinum toxin type a in the upper face. Facial Plast Surg Clin North Am. 2006;14(3):253–60. Carruthers A, Carruthers J. Eyebrow height after botulinum toxin type a to the glabella. Dermatol Surg. 2007;33(1):S26–31. Carruthers A, Carruthers J, Said S. Dose-ranging study of botulinum toxin type a in the treatment of glabellar rhytids in females. Dermatol Surg. 2005;31(4):414–22. discussion 22. Dayan SH. Complications from toxins and fillers in the dermatology clinic: recognition, prevention, and treatment. Facial Plast Surg Clin North Am. 2013;21(4):663–73. Emer J, Waldorf H.  Injectable neurotoxins and fillers: there is no free lunch. Clin Dermatol. 2011;29(6):678–90. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs R D. 2015;15(1):1–9. Ipsen. Full prescribing onformation. 2017. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/125274s107lbl.pdf. Klein AW.  Complications, adverse reactions, and insights with the use of botulinum toxin. Dermatol Surg. 2003;29(5):549–56; discussion 56. Kordestani R, Small KH, Rohrich RJ. Advancements and refinement in facial neuromodulators. Plast Reconstr Surg. 2016;138(4):803–6. Lorenc ZP, Smith S, Nestor M, Nelson D, Moradi A. Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type a therapy. Aesthet Plast Surg. 2013;37(5):975–83. Merz. Xeomin; Highlights of prescribing information. 2018. Available from: http://www.xeomin. com/wp-content/uploads/xeomin-full-prescribing-information.pdf. Naumann M, Boo LM, Ackerman AH, Gallagher CJ.  Immunogenicity of botulinum toxins. J Neural Transm (Vienna). 2013;120(2):275–90. Pham T, Perry JD.  Botulinum toxin type a injection without isopropyl alcohol antisepsis. Ophthalmic Plast Reconstr Surg. 2009;25(3):178–9. Pirazzini M, Rossetto O, Eleopra R, Montecucco C. Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol Rev. 2017;69(2):200–35. Price KM, Williams ZY, Woodward JA. Needle preference in patients receiving cosmetic botulinum toxin type a. Dermatol Surg. 2010;36(1):109–12. Sharma P, Czyz CN, Wulc AE. Investigating the efficacy of vibration anesthesia to reduce pain from cosmetic botulinum toxin injections. Aesthet Surg J. 2011;31(8):966–71. Wijemanne S, Vijayakumar D, Jankovic J. Apraclonidine in the treatment of ptosis. J Neurol Sci. 2017;376:129–32.

Part IV Minimally Invasive Procedures: Temporary Dermal Fillers

Pharmacology of Temporary Dermal Fillers

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16.1 Temporary Dermal Fillers Temporary dermal fillers are the second most popular nonsurgical aesthetic treatment worldwide (ISAPS 2017). Temporary fillers offer a safe and effective solution to volume loss associated with aging. There are three types of temporary fillers included in this text: hyaluronic acid (HA), calcium hydroxyapatite (CaHA), and ploy-L-lactic acid (PLLA).

16.2 Hyaluronic Acid (HA) Fillers Hyaluronan, or HA, is a naturally occurring linear polysaccharide that is found in the skin, epithelial, connective, and other tissues. Because it is innate in our skin and lacks a protein component, HA does not require skin allergy testing prior to injection, making it convenient to use (Carruthers and Carruthers 2013). The nature of this glycosaminoglycan is hydrophilic and is able to bind 1000 times its molecular weight in water and this characteristic makes it a good substance for adding volume to skin and facial tissue (Carruthers and Carruthers 2013; Allemann and Baumann 2008). As we age, the amount of naturally occurring HA in human skin decreases and subsequently, we begin to produce less HA. This phenomenon plays an important role in the appearance of aging, wrinkle formation, decreased tissue elasticity, and hydration (Carruthers and Carruthers 2013; Bray et al. 2010). When in its natural state, HA has an approximate half-life of 24–48 hours before it is broken down and metabolized in the liver into water and carbon dioxide (Carruthers and Carruthers 2013; Bray et al. 2010; Duranti et al. 1998; Reed et al. 1990; Laurent et al. 1991). In human skin, HA is broken down by hyaluronidase and free radicals (Allemann and Baumann 2008; Bray et al. 2010). Natural HA injected into the skin would break down quickly through enzymatic action so would not be appropriate to use for cosmetic purposes because it would not provide a lasting effect in aesthetic patients. © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_16

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Processes have been developed through the use of available technology, where HA products currently last months to years. The HA molecules are stabilized using crosslinking technology with hydroxyl groups and provide the long-lasting qualities of modern HA fillers. The crosslinking agent in the Restylane® and Juvederm® HA families of products is 1,4-butanediol diglycidyl ether (BDDE) (Allemann and Baumann 2008; Bray et al. 2010; Allergan 2013; Galderma 2018). These processes have made injectable HA stable and more resistant to break down. The HA filler families are developed using slightly different technologies. The Juvederm® family of products are sterile, biodegradable, non-pyrogenic, viscoelastic, clear, colorless, homogenized gel implant produced by Streptococcus equi bacteria, developed through a fermentation process and crosslinked with BDDE (Allemann and Baumann 2008; Allergan 2013). The Restylane® family of products are made of hyaluronic acid generated by a Streptococcus species of bacteria, also chemically crosslinked with BDDE, stabilized and suspended in phosphate buffered saline (Galderma 2018). Belotero Balance® is a HA product that is sterile, non-­ pyrogenic, viscoelastic, homogenous, clear gel implant bacterially fermented, manufactured from Streptococcus bacteria, and is crosslinked with BDDE (Flynn et al. 2013). Physical and chemical properties influence the characteristics of HA fillers. The different attributes of HA fillers include aesthetic indication, injection properties, desired amount of volume, expected outcome, longevity, and side effects. The HA fillers also differ in particle size, crosslinking of the HA molecules, the amount of crosslinking in the product, as well as the G-prime or viscosity of the product. These features of HA products guide the practitioner in choosing the appropriate filler for specific effects (Carruthers and Carruthers 2013; Allemann and Baumann 2008; Flynn et al. 2013).

16.2.1 G-Prime and Particle Size G-prime is a measurement of the stiffness of the hyaluronic gel product and this characteristic helps determine the appropriate area and depth for placement in the skin. G-prime also contributes to the increased longevity of the effect of the HA products, i.e., the higher the G-prime, the longer the filler might last (Carruthers and Carruthers 2013; Allemann and Baumann 2008; Duranti et  al. 1998; Tezel and Fredrickson 2008). Generally, thicker products are not suitable to be placed in the superficial layers of skin due to the possibility of long-lasting swelling, uneven result, and the residual visibility of the product as a bluish tint called the Tyndall effect (Carruthers and Carruthers 2013). The modern, crosslinked HA dermal fillers of the Belotero®, Juvederm®, and Restylane® families of products are frequently used to replace volume or soften fine lines in the face. These fillers include both crosslinked or high weight, and non-­ crosslinked or low weight, HA molecules within their gel vehicle. The higher the

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concentration of crosslinked HA molecules, the longer the effect will last in the skin (Carruthers and Carruthers 2013; Allemann and Baumann 2008; Tezel and Fredrickson 2008). After injection into the skin, the non-crosslinked hyaluronic acid is quickly broken down and only the crosslinked, larger molecular weight polymers are left behind. The reason for the low weight, non-crosslinked molecules in the product is thought to allow ease of injection through the needle or cannula (Allemann and Baumann 2008; Bray et al. 2010). If the gel consisted of purely large weight, crosslinked molecules, the product would not be conducive to injection through a small caliber needle. Another relevant aspect of the HA fillers is particle size. A process where the particles are formed into specific sizes is employed by some manufacturers, but other manufacturers use a different method called Hylacross (Juvederm®) to create their products (Allergan 2016). In the sizing method, particle size is created through a process where crosslinked HA is pushed through a customized screen to create different, specific sizes of the particles. Smaller sizes are made into lower G-prime, or less viscous products, whereas the larger particle sizes are made into the higher G-prime or more viscous products (Allemann and Baumann 2008). To date, there is no scientific data on which process yields the preferred longevity profile or outcome. The concentration of the different HA products is listed in Table 16.1 (Duranti et al. 1998; Allergan 2013, 2016; Galderma 2016a, 2016b, 2018; Flynn et al. 2013; Alam and Tung 2018; Greene and Sidle 2015). HA fillers break down slowly over time but on occasion, a small number of patients may believe the effect has diminished within an unreasonably short time period. Comparison of clear, pre-treatment photographs with current photographs generally demonstrate the continued effect of the filler. Visual documentation is very important and subjective patient perception is one of the myriad of reasons to take pre-treatment photographs. Table 16.1  Various concentrations and particle sizes of HA fillers Product Restylane Restylane Lyft Restylane Refyne Restylane Defyne Juvederm Juvederm ultra plus Juvederm Voluma Belotero

Concentration of HA (mg/mL) 20 20 20 20 24 24 20 22.5

Particle size 250 μm 650 μm – – Varies Varies – N/A

While some have the same concentration, larger particle size creates longer lasting effects

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16.3 Calcium Hydroxyapatite: (Radiesse®) Calcium hydroxyapatite (CaHA) is the generic name for the temporary filler, Radiesse® and is made of the same compound as human bone (Ridenour and Kontis 2009; Lee and Lorenc 2016). Initially, CaHA was used as a treatment for urinary stress incontinence, as a radiographic marker, and for vocal cord restoration (Carruthers et  al. 2008; Belafsky and Postma 2004; Rees et  al. 2008; Mevorach et al. 2006). CaHA was first approved in the USA in 2006 for aesthetic treatment of naso-labial folds (NLF) and lipoatrophy of HIV. CaHA is an opaque, sterile, non-pyrogenic, semi-solid, cohesive implant, whose principal component is synthetic calcium hydroxylapatite suspended in a gel carrier of glycerin, sodium carboxymethylcellulose, 0.3% lidocaine hydrochloride, and sterile water (Merz 2016). CaHA is made up of 70% carrier gel and the remaining 30% is CaHA microspheres that are suspended in the gel. The characteristics of CaHA make it radiopaque and visible on CT scans and X-ray studies (Carruthers et al. 2008). CaHA injectable implant (1.5 cc and 0.8 cc) has a calcium hydroxylapatite particle size range of 25–45 μg and should be injected with a 25 gauge outer diameter to 27 gauge inner diameter needle (Carruthers and Carruthers 2013; Merz 2016). The needles necessary for injection are included in the packaging. If needles other than the manufacturer provided needles are used for injection, they should be used following manufacturer instruction (Merz 2016). During injection of CaHA into the skin, the gel evenly distributes the CaHA microspheres for a uniform placement and dispersal. The product requires no skin testing prior to administration and this makes it a convenient choice for facial augmentation (Lee and Lorenc 2016). The carrier gel dissipates within several weeks and the CaHA microspheres remain in the tissue at the injection site until they slowly break down into calcium and phosphate ions (Ridenour and Kontis 2009). After injection of the product, the carrier gel is broken down and phagocytized. The remaining CaHA particles act as a support substance or scaffolding that allows for new collagen formation (Carruthers and Carruthers 2013). Post-market studies indicate CaHA lasts up to 2 years and also induces collagenesis when it is placed in the skin. The ensuing collagenesis in susceptible patients may contribute to the lasting effect of this filler (Carruthers and Carruthers 2013; Ridenour and Kontis 2009; Merz 2016). However in older patients with less skin elasticity, collagenesis from CaHA placement may be decreased and these patients may require larger amounts of product.

16.4 Poly-l-Lactic Acid: (Sculptra) Poly-l-lactic acid (PLLA) is the generic name for the temporary filler, Sculptra ®. This PLLA product was first FDA approved in 2004 for facial lipoatrophy associated with human immunodeficiency virus (HIV) (Engelhard et al. 2005; Humble and Mest 2004). PLLA is the active and durable ingredient and is a synthetic

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biodegradable polymer that is used for soft tissue augmentation. It is a freeze-dried powder of PLLA and must be rehydrated with 5 mL sterile water per vial prior to injection. The particle size of PLLA is 40–60 μm (Carruthers and Carruthers 2013; Galderma 2016c). The effect of PLLA is through stimulation of an inflammatory tissue response that leads to collagen deposition. This PLLA product for injection is composed of PLLA microparticles, sodium carboxymethylcellulose, and non-pyrogenic mannitol (Galderma 2016c; Schierle and Casas 2011). The PLLA package insert recommends letting the product rehydrate for 2 hours; however, 48 hours has proven more successful clinically by reducing the incidence of undesired nodule formation. The volume correction outcome with PLLA has been shown to last up to 2 years (Schierle and Casas 2011; Narins 2008). After the product is injected, the PLLA component is hydrolyzed into lactic acid monomers that induce a localized foreign body response in the tissue through the recruitment of monocytes, macrophages, and fibroblasts. Then, a capsule is formed around each microsphere as the lactic acid is metabolized, and this results in collagen deposition by the host fibroblasts. The new tissue volume is the result of dermal fibroplasia and subsequent increased dermal thickness (Humble and Mest 2004; Schierle and Casas 2011). PLLA is biodegradable and biocompatible and has been used in medical devices such as absorbable sutures and mesh (Schierle and Casas 2011). Due to its unique mechanism of action, it acts differently than autologous fat, CaHA, and HA fillers when used for facial rejuvenation. Stimulation of collagen formation takes time; therefore, the effect of PLLA treatment will not be immediate, and usually requires more than one treatment session (Galderma 2016c; Schierle and Casas 2011). The initial fullness from injection is due to the sterile water component of the PLLA product and this resorbs within 24–48 hours. So, the patient will notice an immediate re-volumizing effect after treatment, but will soon see it disappear (Narins 2008). The novice injector is wise to avoid the temptation to fill the area to full corrected state when using PLLA because it generally requires more than one treatment session to allow for adequate collagen formation (Humble and Mest 2004; Schierle and Casas 2011). Therefore, a series of treatments is recommended to avoid overcorrection and the final outcome is dependent on the number of treatment sessions. In addition, the patient should be informed the length of time for PLLA effects to be noticeable can be up to 2 months. Patient expectations, possible side effects, and treatment outcomes of PLLA should be reviewed with the patient at every visit. Practitioner knowledge of product handling and injection technique is important to avoid a poor outcome. Factors that can contribute to poor outcome and nodule/papule formation while using PLLA include (Carruthers and Carruthers 2013; Narins 2008): 1 . Placement of product that is too superficial 2. Product injected into active muscles 3. Inadequate product hydration time 4. Poor suspension of particles

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It is important to note that many aesthetic patients want to see improvement quickly and they might become anxious if the results are not clearly visible within a week or two. This concern has led some practitioners to use a HA filler at the same time of PLLA treatment so the patient will notice an immediate improvement (Attenello and Maas 2015).

16.5 Conclusion Knowledge of temporary dermal filler pharmacology will assist the practitioner in making the most appropriate dermal filler choice. The importance of understanding the intrinsic properties of different temporary dermal fillers cannot be overemphasized. It is vital that the practitioner is well versed in the type(s) of temporary dermal filler available to achieve the most aesthetically pleasing outcome. When used appropriately, temporary dermal fillers offer a safe and effective solution to facial volume loss. The properties of different temporary dermal fillers include variations in viscosity, particle size, and duration. Because the variation of temporary dermal filler characteristics dictates the outcome, it is important for the practitioner to review the onset, effect, and duration with the patient prior to treatment.

References Alam M, Tung R.  Injection technique in neurotoxins and fillers: planning and basic technique. J Am Acad Dermatol. 2018;79(3):407–19. Allemann IBB, Baumann L. Hyaluronic acid gel (Juvéderm™) preparations in the treatment of facial wrinkles and folds. Clin Interv Aging. 2008;3(4):629–34. Allergan. Juvederm Voluma XC package insert. Dublin: Allergan; 2013. Allergan. Juvederm XC product insert. Dublin: Allergan; 2016. Attenello NH, Maas CS. Injectable fillers: review of material and properties. Facial Plast Surg. 2015;31(1):29–34. Belafsky PC, Postma GN.  Vocal fold augmentation with calcium hydroxylapatite. Otolaryngol Head Neck Surg. 2004;131(4):351–4. Bray D, Hopkins C, Roberts DN. A review of dermal fillers in facial plastic surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18(4):295–302. Carruthers JC, Carruthers A. Soft tissue augmentation. 3rd ed. Edinburgh: Elsevier; 2013. Carruthers A, Liebeskind M, Carruthers J, Forster BB. Radiographic and computed tomographic studies of calcium hydroxylapatite for treatment of HIV-associated facial lipoatrophy and correction of nasolabial folds. Dermatol Surg. 2008;34(Suppl 1):S78–84. Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid gel for soft tissue augmentation. A clinical and histological study Dermatol Surg. 1998;24(12):1317–25. Engelhard P, Humble G, Mest D. Safety of Sculptra: a review of clinical trial data. J Cosmet Laser Ther. 2005;7(3–4):201–5. Flynn TC, Thompson DH, Hyun SH. Molecular weight analyses and enzymatic degradation profiles of the soft-tissue fillers Belotero balance, Restylane, and Juvederm ultra. Plast Reconstr Surg. 2013;132(4 Suppl 2):22S–32S. Galderma. Instructions for use Restylane Refyne. 2016a. https://www.galderma.com/us/sites/g/ files/jcdfhc341/files/2019-01/Restylane_Defyne_IFU.pdf.

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Galderma. Instructions for use Sculptra aesthetic. 2016b. https://www.galderma.com/us/sites/g/ files/jcdfhc341/files/2019-01/Sculptra_Aesthetic_IFU.pdf?_ga=2.24111801.2048014387. 1563584048-732257343.15635840. Galderma. Instructions for use Sculptra aesthetic. 2016c. https://www.galderma.com/us/sites/g/files/ jcdfhc341/files/2019-01/Sculptra_Aesthetic_IFU.pdf?_ga=2.24111801.2048014387. 1563584048-732257343.15635840. Galderma. Restylane Lyft with lidocaine package insert. Galderma. Instructions for use Restylane Lyft. 2018. https://www.galderma.com/us/sites/g/files/jcdfhc341/files/2019-01/Restylane_ Lyft_with_Lidocaine_IFU.pdf. Greene JJ, Sidle DM. The hyaluronic acid fillers: current understanding of the tissue device interface. Facial Plast Surg Clin North Am. 2015;23(4):423–32. Humble G, Mest D. Soft tissue augmentation using sculptra. Facial Plast Surg. 2004;20(2):157–63. ISAPS. International survey on aesthetic/cosmetic procedures performed in 2017. 2017. https:// www.isaps.org/wp-content/uploads/2019/03/ISAPS_2017_International_Study_Cosmetic_ Procedures_NEW.pdf. Laurent UB, Dahl LB, Reed RK. Catabolism of hyaluronan in rabbit skin takes place locally, in lymph nodes and liver. Exp Physiol. 1991;76(5):695–703. Lee JC, Lorenc ZP. Synthetic fillers for facial rejuvenation. Clin Plast Surg. 2016;43(3):497–503. Merz. Radiesse lidocaine injectable implant. Raleigh: Merz North America Inc.; 2016. Mevorach RA, Hulbert WC, Rabinowitz R, Kennedy WA, Kogan BA, Kryger JV, et al. Results of a 2-year multicenter trial of endoscopic treatment of vesicoureteral reflux with synthetic calcium hydroxyapatite. J Urol. 2006;175(1):288–91. Narins RS.  Minimizing adverse events associated with poly-L-lactic acid injection. Dermatol Surg. 2008;34(Suppl 1):S100–4. Reed RK, Laurent UB, Fraser JR, Laurent TC. Removal rate of [3H]hyaluronan injected subcutaneously in rabbits. Am J Phys. 1990;259(2 Pt 2):H532–5. Rees CJ, Mouadeb DA, Belafsky PC. Thyrohyoid vocal fold augmentation with calcium hydroxyapatite. Otolaryngol Head Neck Surg. 2008;138(6):743–6. Ridenour B, Kontis TC. Injectable calcium hydroxylapatite microspheres (Radiesse). Facial Plast Surg. 2009;25(2):100–5. Schierle CF, Casas LA. Nonsurgical rejuvenation of the aging face with injectable poly-L-lactic acid for restoration of soft tissue volume. Aesthet Surg J. 2011;31(1):95–109. Tezel A, Fredrickson GH.  The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther. 2008;10(1):35–42.

Indications and Placement of Temporary Dermal Fillers

17

17.1 Techniques for Injection of Dermal Filler The increasing popularity of dermal fillers has led it to become the second most frequently performed nonsurgical cosmetic dermatology procedure in the world to address the aging face (ISAPS 2017). Over time, the face develops different degrees of age-related conditions and it can be challenging to improve the appearance using only one type of filler. Several dermal fillers with varying levels of viscosity are now approved for use to address different facial concerns. There are varying levels of volume loss and different causes of lines and using several dermal filler options to correct facial volume loss will often achieve the best outcome. The face is composed of deep, mid-range, and superficial tissues that age in different rapidity and effect. Because of the differences in anatomy, some tissues require deeply placed, more viscous, and larger amounts of filler whereas other tissues may need tiny, shallow aliquots placed directly and superficially into the wrinkle (Duranti et al. 1998; Carruthers and Carruthers 2013; Moradi et al. 2013) (see Figs. 17.1 and 17.2). In general, superficial defects require thinner fillers that can be placed closer to the surface of the skin and blended easily. It is important to realize, when these fillers are placed superficially, they can have a temporary blanching effect that should not be confused with the blanching or color change evident during a vascular event (Bray et al. 2010). The blanching of a superficially placed filler occurs immediately and resolves within seconds, whereas the blanching from vascular compromise may be delayed and remains for minutes to hours or longer (DeLorenzi 2014). Deeper defects tend to require more viscous filler and are generally placed deeper within the skin (Bray et al. 2010; Alam and Tung 2018). For safety purposes and more control of the outcome, a small volume of 0.10  mL per injection site is recommended (Moradi and Watson 2015).

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Placement of injectable soft tissue fillers

Epidermis

Dermis

Subcutaneous tissue

Muscle Periosteum Bone Soft tissue filler placement in the superficial dermis (A), mid-dermis (B), and subdermal (subcutaneous) layer (C). Soft tissue fillers may also be placed just above the periosteum (D).

Fig. 17.1  Soft tissue filler placement in the superficial dermis (A), mid-dermis (B), and subdermal (subcutaneous) layer (C). Soft tissue fillers may also be placed just above the periosteum (D). Reproduced with permission from: Carruthers A, Carruthers J, Humphrey S. Injectable soft tissue fillers: Overview of clinical use. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Copyright © 2018 UpToDate, Inc. For more information visit www.uptodate.com

The following are the FDA approved products and recommended depths (USDA 2018): Belotero Balance (HA with lidocaine) Juvéderm Ultra and Ultra Plus (HA with lidocaine) Juvederm Volbella (HA with lidocaine) Juvederm Vollure (HA with lidocaine) Juvéderm Voluma (HA with Lidocaine) Restylane Silk (HA with lidocaine) Restylane Lyft (HA with lidocaine) Restylane (HA with lidocaine)

Superficial dermis Mid to deep dermis Lips Mid to deep dermis Deep dermis, subcutaneous to supraperiosteal Superficial dermis and lips Deep dermis, subcutaneous to supraperiosteal Mid to deep dermis; dermal-epidermal junction

17.1 Techniques for Injection of Dermal Filler

a

Linear threading

151

b

Depot/serial puncture

d

Cross-hatching

Retrograde

Antegrade

c

Fanning

Fig. 17.2  Soft tissue dermal filler injection techniques. (a) Linear threading. (b) Depot\serial puncture. (c) Fanning. (d) Cross-hatching. Reproduced with permission from: Carruthers A, Carruthers J, Humphrey S. Injectable soft tissue fillers: Overview of clinical use. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Copyright © 2018 UpToDate, Inc. For more information visit www.uptodate.com Restylane Defyne and Refyne (sodium hyaluronate with lidocaine) Radiesse (Calcium hydroxyapatite) Versa + and Versa (HA with and without lidocaine) Sculptra (PLLA)

Mid to deep dermis Subdermis Mid to deep dermis Deep dermis

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17.1.1 Linear Threading Technique Linear thread technique is useful for trough-like lines and folds that require lines of filler deposited along the length of the fold, for example naso-labial folds (NLF), vermillion border, oral commissures, or areas where a straight line of filler can soften the appearance of the area. Linear threading may be done by inserting the needle into the skin at a depth that would camouflage the filler and using the “push ahead” method whereby the needle is advanced as the filler is being injected. The retrograde method, where the needle is inserted completely and filler is deposited as the needle is withdrawn, may also be used. Both techniques are acceptable and are a matter of practitioner preference (Bray et al. 2010; Alam and Tung 2018). Some believe the push ahead method results in less trauma to the vessels and therefore less bruising, however, placement may not be as precise (Carruthers and Carruthers 2013; Bray et al. 2010; Alam and Tung 2018). Some of the benefits of linear threading are fewer needle punctures and less discomfort for the patient.

17.1.2 Cross-Hatch and Fanning Technique The cross-hatch technique is quite literally several linear threads laid in one direction and the addition of a second group of linear threads going in the perpendicular direction to create a lattice work of filler. This technique can be appropriate for areas requiring a substantial amount of filler to re-volumize a broader area such as the cheek (Alam and Tung 2018). Again, more than one technique may be suitable for a specific area and placement of suitable filler in appropriate depths can produce the best outcome. The fanning technique places a small to moderate amount of filler in a triangular or fan shape. Using one needle insertion site, advancing the needle into the area for correction, depositing filler as the needle is pulled half way to 2/3 out of the skin, avoiding complete withdrawl of the needle. Then, the needle is re-directed in an arc-like fashion until a fan shaped area of filling is achieved (Alam and Tung 2018).

17.1.3 Serial Puncture Technique The serial puncture technique places small to large amounts of filler into varying depths of the face depending on the characteristic of the deficit (Alam and Tung 2018). Superficial lines, for example, can be treated effectively with a very small amount of lower viscosity filler placed in the shallow dermis or even just beneath the epidermis multiple, tiny depots and in close proximity to the previous site. The resulting tiny papules smooth out nicely over 24–48 h and provide a good correction of tiny, superficial lines. Deeper deficits benefit from larger depots of filler placed in the deep dermis or periosteum levels (Alam and Tung 2018). While there are more needle puncture sites with the serial puncture technique, there is less risk of penetrating vessels.

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Additionally, serial puncture can be used as a superficial technique in a higher layer of skin over the deeper placement of filler into the dermis in patients who need volume restoration via boluses in the deeper planes (Carruthers and Carruthers 2013; Alam and Tung 2018). This approach works well in patients with deep NLFs who also have superficially etched lines from photodamage in the same area.

17.2 Indications for Dermal Filler While there are many indications for dermal filler and multiple products available, only approved uses are recommended. Currently, there are various products that cause different results. Some products are considered permanent, such as fat, silicone, or surgical implants, whereas others, such as hyaluronans, poly-L-lactic acid (PLLA), and calcium hydroxylapatite (CaHA), are temporary. The temporary products will be discussed in this text. Most facial aspects can be treated safely and effectively with dermal filler, however appropriate training is crucial to avoid complications and achieve the best outcome. Multiple treatment areas will be discussed in this text including cheek augmentation, lip enhancement, peri-oral and naso-labial areas, glabellar region, temples, jawline, earlobes, hands, and sub-orbital areas, however, not all of these areas are approved at time of publication. Scar revision will also be briefly mentioned because certain scars are easily corrected with the proper use of dermal filler. While this is not an exhaustive list of areas treated, these areas are very commonly done (see Fig. 17.3).

Fig. 17.3  Common sites of dermal filler injection; glabella, infra-orbital, NLF, melomental, cheeks, and jawline. Photo courtesy Beth Haney, DNP, FNP-C, FAANP

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17.3 Cheek Augmentation The cheeks are an important facial structure that convey the appearance of youth. Full cheeks are often noted in young children and give a cheerful look to the face. When the cheeks begin to flatten with aging, the face loses the youthful appearance and it looks as if the entire face begins to drop. A widely accepted image of youth is an inverted triangular shaped face where the cheeks are the widest area and the chin/ jawline is the smaller area (Coleman and Grover 2006). In aging, the cheek bones and the fat pads atrophy, the cheeks begin to transform and flatten, the jowls are accentuated, and the triangle becomes reversed (Whitaker and Bartlett 1991; Shaw et al. 2010; Pessa et al. 2008; Binder and Azizzadeh 2008). Practitioners are now able to replace the lost cheek volume and create a more youthful appearance using a variety of dermal filler products. Temporary products include hyaluronic acid (HA), PLLA, and CaHA (Merz 2016a; Allergan 2013; Galderma 2016a, 2018). Surgical lifting is also an option for patients however, surgery alone will not replace lost volume that occurs with aging. Rather, surgery removes excess skin and improves tissue ptosis through elevation (Biskupiak and Sclafani 2010; Austin and Weston 1992). Many times, when patients opt for the surgical lift, the additional procedure of re-­volumizing with dermal filler creates the best outcome. The malar eminence is the area of the cheek that is maximally projected and reflects the most light (Carruthers and Carruthers 2013). It is comprised in the zygomatic arch and the superior border of the cheek (Carruthers and Carruthers 2013). The Hinderer method allows the practitioner to locate the malar eminence easily by drawing two imaginary lines and optimizing filler placement in the superior-lateral area where the two lines intersect. The first line is drawn from the lateral canthus of the eye to the angle of the mouth, the second line is drawn from the nasal crease to the tragus (see Fig. 17.4) (Carruthers and Carruthers 2013). An example of before and after cheek augmentation with temporary dermal filler is shown in Fig. 17.5. Fig. 17.4  Hinderer lines drawn to identify the malar eminence (blue dot). Lines are drawn from the lateral canthus of the eye to the angle of the mouth, the second line is drawn from the nasal crease to the tragus. Photo: B. Haney, DNP, FNP-C, FAANP

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Fig. 17.5  Before and after cheek augmentation with HA dermal filler. Photo: B. Haney, DNP, FNP-C, FAANP

Prior to starting cheek augmentation, pointing out facial asymmetries and documenting them with photographs will help manage expectations and assist the patient in understanding possible corrections (Carruthers and Carruthers 2005). Assessment of the face from the front, sides, and diagonally at close range and from two to three feet away will give the practitioner a comprehensive view of the patient’s face and provide good information on the deficits and necessary correction (Carruthers and Carruthers 2013). Following specific techniques and guidelines is suggested however, since every face is unique and has specific deficits, the aesthetic practitioner will need to use subjective judgment in addition to standard protocols. Knowledge of facial anatomy and the various properties of the different dermal fillers used is crucial in obtaining an excellent outcome (Binder and Azizzadeh 2008).

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17.3.1 Types of Dermal Fillers for Cheek Augmentation: Temporary 17.3.1.1 Hyaluronic Acid Fillers When using HA, the higher density fillers are preferred in the cheek because of the volumizing effect they provide (Ave and Issa 2018). Cheek augmentation with the higher density HAs requires deep placement of the dermal filler to avoid lumps. The results are immediate and typically last 6–24 months depending on the amount of filler used, location, and desired effect (Moradi and Watson 2015; Allergan 2013, 2016a; Galderma 2018; Narurkar et al. 2016). Topical anesthetic can provide comfort from the initial pierce of the needle and should be applied 30  min prior to the procedure, if necessary (Allergan 2013; Galderma 2018). However, topical anesthetic is not always needed since most HA fillers now have lidocaine in the HA gel. Needles are included in the packaging of the HA fillers and are recommended to use unless the practitioner prefers cannulas which are available tools but incur an additional cost. Boluses of product ranging from 0.1 to 0.2 mL are recommended to avoid an excessive amount of product in one place and prevent incompatible pressure on surrounding structures, however in some cases, larger boluses may be appropriate (Allergan 2013). Typically, the needle is inserted at an angle perpendicular to the bone. With any filler injection it is important to control the needle direction since the filler will be deposited where the bevel of the needle tip is located. Novice injectors often focus on the skin where the puncture occurs rather than where the needle tip is actually located after insertion. After inserting the needle, it is important to aspirate before injecting product to ensure the needle is not in a vessel. Be aware however, there may not be an immediate flash of blood because of the pressure gradient in the tissues, so it is recommended to hold the plunger back for 7–10 seconds each time (Cohen et al. 2015; Scheuer et al. 2017). Unfortunately, aspiration might not always confirm intravascular insertion of the needle and currently, there is not a completely reliable method to determine this so close observation of the skin during injection is essential. In addition, knowledge of danger zones and facial structures is crucial to avoid serious side effects (Scheuer et al. 2017). Insertion of the needle to the supraperiosteum under the muscle allows the product to be deposited deeply and it is easily concealed by the overlying tissues (Alam and Tung 2018). After the needle is removed, the area can be massaged to the desired shape and contour if necessary. Additional sites along the malar eminence and the infra-malar triangle provide correction and re-volumization to the mid-face (Binder and Azizzadeh 2008; Narurkar et al. 2016). Occasionally, cheek augmentation will improve the appearance of hollow infra-orbital (tear trough) spaces. If not, additional treatment under the eye with a lower G-prime HA may be warranted.

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157

17.3.2 Collagen Stimulators 17.3.2.1 Poly-L-Lactic Acid (PLLA) PLLA works by causing fibroneogenesis. PLLA microspheres are injected within a dilute aqueous suspension and require more than one treatment spaced weeks to months apart because the neogenesis takes time to occur (Engelhard et  al. 2005; Humble and Mest 2004). The product is injected into various depths of the skin, depending on the area of the face, using a very dilute solution to avoid side effects including nodule formation. Training by experienced practitioners on the use of this product is crucial since there are specific techniques that should be mastered with PLLA (Humble and Mest 2004). PLLA can be placed in the subcutaneous layer of the cheeks, NLF, and lower face using a cross-hatch or fanning technique and small (0.1 –0.2 mL) amounts of product. The zygoma, mandible, and maxillary areas can be injected deeply onto the periosteum using slightly larger (0.2 –0.3 mL) amounts of product (Carruthers and Carruthers 2013). Practitioners should use caution because nodule formation can occur with PLLA if injected too superficially. Additionally, some facial structures such as the parotid gland, masseter, blood vessels, and areas near the eyes and lips should be avoided when using PLLA to prevent nodule formation from product clumping. Massaging the area after injection is also recommended to help prevent nodule formation. Aspiration with every injection is important to avoid intravascular injection (Narins 2008; Schierle and Casas 2011). The patient should be instructed to continue massaging the area over the next few days. A popular regimen is using the rule of 5’s; 5 min, 5 times a day for 5 days (Carruthers and Carruthers 2013). The aesthetic result of PLLA treatment occurs over time and is not immediately noticeable. The tiny particles of PLLA become encapsulated by fibrous tissue and provide generalized volumization and can last more than 18 months (Schierle and Casas 2011). The result from PLLA treatment can take more than one session for the patient to appreciate any difference in appearance. Because of the delayed onset of fibroneogenesis, some practitioners inject PLLA and an HA filler during the treatment session for immediate improvement (Attenello and Maas 2015). 17.3.2.2 Calcium Hydroxyapatite (CaHA) CaHA is an additional option for cheek volumization and is composed of calcium hydroxyapatite spherical particles in a gel base (Merz 2016a). A conservative approach is recommended since this product naturally provides a correction ratio of 1:1 and no need to add extra amounts, unlike the HAs which can require a small amount of over correction. CaHA provides an immediate effect that is appreciated by patients, but it also stimulates fibroneogenesis over time that likely accounts for its longevity of 1–2 years or longer (Galderma 2016a; Narins 2008; Schierle and Casas 2011). As with any dermal filler, avoidance of vascular injection and danger zones is key.

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17.4 Lip Enhancement The aging process includes thinning of the lips and the formation of upper and lower lip lines (Austin and Weston 1992). Chronic orbicularis oris muscle contraction and sun exposure also contribute to the aging of peri-oral area and these are discussed in other chapters. Changes to the lip area are bothersome to many patients and lip enhancement is a popular request in aesthetic practices. Many patients point out they do not want to look like a “duck” or have a “shelf.” Rather, they would like a fuller and natural look, so the practitioner must have a thorough understanding of lip tissue, function, and the patient’s unique anatomy. Some patients have naturally full lips, others have very thin lips and there is a range in between. Realistic patient expectations are crucial for a good outcome. Practitioners must take into consideration the entire face and especially the lower region when assessing the potential for lip augmentation because other areas, such as the melomental folds or chin, may need to be addressed as well. Assessment of all patients should include the entire facial structure, mouth shape, and if the patient desires a change in the shape of the lips (see Fig. 17.6). Pain control is an important consideration when treating the lips. Patients report they have previously had their lips augmented and the treatment was so painful, they didn’t think they would do it again. Lidocaine is now in the gel of the majority of fillers and provides a more comfortable experience for patients (Allergan 2016a, b; Galderma 2016b, 2017). Additionally, if the patient has no allergy to any ingredient of a topical anesthetic, application of an anesthetic cream is can prevent pain from the initial needle penetration. Allowing the topical anesthetic to absorb for about 20–30 min typically results in reasonable anesthesia and a more relaxed and comfortable patient.

0

1

2

3

4

Very thin

Thin

Moderately thick

Thick

Full

Fig. 17.6  Example of lip size per the Merz Scale (Stella and Di Petrillo 2014)

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When treating the lips, there are several common scenarios. Although not exhaustive, they all require different approaches. • • • • •

a patient with thin lips would like them fuller, a patient with full lips would like them enhanced, a patient would like lip enhancement but very subtle or “unnoticeable,” a patient would like already large, augmented lips even larger, a patient would like correction of a scar that makes lips look uneven. Approaches to lip treatments:

1. A patient with thin lips may require more than one treatment over several months and up to a year to gradually achieve full lips in a natural progression. A common mistake is to attempt to create full lips on a patient who does not have the space for a large amount of filler. The result can be an unnatural or oddly shaped lip. Very small amounts (up to 0.1 mL total) placed in the vermillion border of the upper and lower lips combined with linear threading and possibly adding small boluses to the body of the lip gives a natural, slightly fuller look. Gradual progression over several treatment sessions can give the patient a chance to make interim decisions on the final outcome. Usually, a total of 0.5 mL is sufficient for the first session but because the treatment is influenced by subjective interpretation, evidence on amount is limited (Cohen et al. 2013). 2. The patient who wants enhanced lips is usually younger who would like their natural lips fuller. Occasionally, the patient will have a naturally wide smile and prefer a pouty look with more fullness in the center of the lips and an accentuated cupid’s bow. In this patient, it would be important to avoid adding filler to the lateral edges of the lip. Other patients might like the lower lip larger than the upper or vice versa. Linear threading technique in the body of the lips using small amounts in each of the four sections (up to 0.2 mL each) provides natural plumping. In addition, serial punctures of tiny aliquots (/= 2 mg cm(−2) during a sunny holiday prevents erythema, a biomarker of ultraviolet radiation-induced DNA damage and suppression of acquired immunity. Br J Dermatol. 2019;180(3):604–14. Pickett A, Mewies M.  Serious issues relating to the clinical use of unlicensed botulinum toxin products. J Am Acad Dermatol. 2009;61(1):149–50. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman AA, Campbell CF, Rohrich RJ. Facial danger zones: techniques to maximize safety during soft-tissue filler injections. Plast Reconstr Surg. 2017;139(5):1103–8. Urdiales-Galvez F, Delgado NE, Figueiredo V, Lajo-Plaza JV, Mira M, Ortiz-Marti F, et  al. Preventing the complications associated with the use of dermal fillers in facial aesthetic procedures: an expert group consensus report. Aesthet Plast Surg. 2017;41(3):667–77. Wadstrom T. Molecular aspects of bacterial adhesion, colonization, and development of infections associated with biomaterials. J Investig Surg. 1989;2(4):353–60. Weinkle S, Saco M. Approach to the mature cosmetic patient: aging gracefully. J Drugs Dermatol. 2017;16(6):s84–s6.

Part V Laser and Light-Based Treatments and Skin Tightening

Laser and Light-Based Treatments

19

19.1 Normal Skin Aging and Skin Type Normal skin begins to show signs of aging at around 30–35 years old, even in people who have little previous sun exposure. Aging skin becomes more fragile and hair follicles, sweat glands, and sebaceous glands begin to shrink. These changes result in a reduced sebum production and drier skin (Habif 2016). During normal aging, subcutaneous fat is decreased, the epidermis thins, and fine wrinkles begin to appear. However, this process is accelerated with sun exposure and this exposure promotes photodamage. Photodamage leads to pigmentary and texture changes and loss of resilience in the skin (Habif 2016). Genes are an important factor in pigment expression and melanin production, and genes also influence the development of photoaging and pigment disorders (Fitzpatrick et al. 1967; Fitzpatrick 1971). The classification of pigment expressed in the skin has been simplified through the Fitzpatrick sun reactive skin type (FSRST) system. This system is based on the amount of melanin in the skin and patient responses to sunlight exposure (see Tables 19.1 and 19.2) (Habif 2016; Addison 2016; Fitzpatrick 1975, 1988). The FSRST classification system determines levels of sunburn or suntan based on patient answers to questions regarding their skin response to sun exposure and is termed minimal erythema doses (MEDs). One MED is equivalent to 15 to 30 min of noon exposure in northern 20°–45° latitudes or 30 mJ/cm2 (Fitzpatrick 1988). The increase in pigmentation after exposure of human skin to sunlight or ultraviolet light (UV) from artificial sources is known as tanning (Quevedo et al. 1975). Sun avoidance is the most efficient way to decrease the amount of sun exposure and skin damage from harmful UV radiation. Sunscreen applied to exposed areas several times a day while outside is vital to prevent skin changes and skin cancers. Physical sun blocks such as ultraviolet protection factor (UPF) clothing, hats, and sunglasses can provide greater protection than sunscreen lotions (Kullavanijaya and Lim 2005). Clothing might be more convenient and better utilized because there is no re-application required. In addition, long sleeved UVP tops and © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_19

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194 Table 19.1  Fitzpatrick sun reactive skin typesa

19  Laser and Light-Based Treatments Skin color—unexposed skin White: Type I     Type II     Type III     Type IV Brown: Type V Black: Type VI

Sunburn Yes Yes Yes No No No

Tan No Minimal Yes Yes Yes Yes

Adapted from Fitzpatrick (1988) a Based on verbal response regarding first, unprotected sun exposure of 45–60 min or three minimal erythema doses (MEDs) Table 19.2  Erythema and tanning reactions type to first exposure in summera

Type I Type II Type III Type IV

Always burn, never tan Usually burn, tan less than average (with difficulty) Sometimes mild burn, tan about average Rarely burn, tan more than average (easily)

Adapted from Fitzpatrick (1988) a Based on patient responses to initial sun exposure of three minimal erythema doses (MEDs)

swimming suits are believed to be less harmful than chemical sunscreens to the environment, delicate ocean coral reefs, and marine life (Kullavanijaya and Lim 2005; Raffa et al. 2019).

19.2 Photodamage Ultraviolet light is responsible for most visible skin changes and skin cancer formation. The unit measure of light wavelength is the nanometer (nm). The wavelengths of sunlight that reach the Earth are from 290 nm to 400 nm. The UV light is divided into UVA, UVB, and UVC (Habif 2016). The UVA wavelength is considered long wave and is between 320 and 400 nm. The UVB wavelength is considered medium wave and is between 290 and 320 nm. The UVC wavelength is considered short wave and is between 100 and 290 nm; however, this wavelength is almost completely absorbed by the ozone layer (Habif 2016; Kullavanijaya and Lim 2005). UVA radiation is constant throughout the day and year and its levels remain stable. The longer wavelengths of UVA penetrate deeply and can reach the dermis and subcutaneous fat levels of the skin (Habif 2016). About 50% of the radiation from UVA penetrates the skin in the absence of direct sunlight, i.e., in the shade (Schaefer et al. 1998). This explains why patients occasionally report darkening of their skin but insist they have been in the shade. Also, UVA rays penetrate glass windows and car windshields so these clear barriers do not offer any protection from UVA. Furthermore, UVA are the specific UV rays that cause dermal photoreactions to medications and products (Habif 2016). UVA and UVB rays work synergistically to produce changes in the skin that can lead to skin cancer (Habif 2016; Addison 2016). The shorter wavelengths of UVB

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radiation produce more harmful effects than UVA and UVB is worse in the summer months (Habif 2016). In addition, UVB rays are more intense during the hours of 10:00 AM and 2:00 PM (Habif 2016). The skin responds to UVB radiation with erythema, sunburn, suntan, inflammation, and pigmentary changes (Habif 2016; Quevedo et al. 1975). It is important to realize that snow, water, and sand reflect UVB radiation and many outdoor activities expose the skin to these harmful rays (Habif 2016). In addition, sunbeds that supply UVA and UVB through artificial sunlight cause three times as many deoxyribonucleic acid (DNA) photoproducts that lead to DNA mutation than natural light, and this increases the risk of skin cancer (Barnard et al. 2018). Chronic ultraviolet (UV) light exposure results in photodamage and thinning of epidermal and dermal layers (Habif 2016). Additional characteristic skin changes from UV exposure include the formation of pigmented lesions and telangiectasia, changes in skin texture, and epidermal malignancies (Habif 2016; Bitter 2000). The visible signs of photodamage include chronic redness, freckles, lentigines, wrinkles, and formation of yellow papules called solar elastosis (Habif 2016).

19.3 Intense Pulsed Light (IPL) Intense pulsed light (IPL) flash lamp technology has been used for the treatment of photoaged skin and skin rejuvenation since the mid-nineties (Goldman 1997). The IPL is a non-coherent, broadband-based light source, with an absorption spectrum between 500 nm and 1200 nm, and a light spectrum in the near-infrared region (see Fig. 19.1) (Bitter 2000). Subsequently, IPL treatments are able to improve multiple components of photodamaged skin and can yield a dramatic visible improvement (Bitter 2000). The IPL uses a process called selective photothermolysis where energy is absorbed by molecules, known as chromophores, in the skin and tissue (Kullavanijaya and Lim 2005; Friedmann and Goldman 2016; Hare 2013). Chromophores absorb the energy from the ILP and those cells are destroyed or altered (Kullavanijaya and Lim 2005). Common chromophores in human skin are hemoglobin, water, and melanin (Hare 2013). As an example, energy from the IPL is absorbed by the melanin in a lentigo, but because there are fewer or absent chromophores in the surrounding skin, the lentigo is affected and the surrounding skin is spared (Lin et al. 1998; Parrish et al. 1983). Common uses for IPL are to decrease erythema from rosacea and to lighten pigmented lesions from sun exposure. Because of selective photothermolysis technology, melanocytes and blood vessels in the skin are affected but the surrounding tissue is not, and the outcome is a more even skin tone (Parrish et al. 1983; Anderson and Parrish 1983). The IPL devices use flash lamps, computerized power supplies, and optical filters to produce light pulses of specific duration, intensity, and spectrum and the settings can be customized according to skin type and condition (see Fig.  19.2) (Ciocon et al. 2009). Available cutoff filters include 515, 550, 560, 570, 590, 615, 645, 690, and 755 nm. These filters provide cutoff depths and function by blocking the emission of shorter wavelengths of light. For example, the longer 560 nm wavelength filter allows light absorption of 560  nm but not the shorter wavelength of

196

19  Laser and Light-Based Treatments 0.01 nm

400 nm

10 nm

400 nm

700 nm

Visible

100 µm

1m

700 nm

Fig. 19.1  Electromagnetic spectrum illustration showing visible spectrum location. Note the shorter wavelengths toward the ultraviolet (UV) spectrum and the longer wavelengths toward the infra-red (IR) spectrum. Shorter wavelengths of UV cause damage to human skin. Source: Spectre InfraRed.svg

515 nm (Ciocon et al. 2009; Augustyniak and Rotsztejn 2017). Longer wavelengths have less intense effects on the skin than shorter wavelengths. Longer wavelength filters can decrease light absorption by epidermal melanin. Unfortunately, these filters are not always able to prevent shorter wavelengths from leaking through and being absorbed by the skin. This leakage can cause excessive temperatures in the skin that can lead to burns (Ciocon et al. 2009; Augustyniak and Rotsztejn 2017; Li et al. 2016). For this reason, careful patient selection, skin type assessment, and a spot test in the treatment area prior to embarking on the entire procedure is essential (Li et al. 2016; Thaysen-Petersen et al. 2017). The IPL treatment is effective in treating vascular and pigment concerns associated with photoaging and, with repeated sessions, can improve skin texture through collagen stimulation (Bitter 2000; Ciocon et  al. 2009; Li et  al. 2016; Ping et  al. 2016). Careful skin evaluation and typing is essential to provide safe and effective IPL treatments. There is an increased risk of adverse outcomes such as hyperpigmentation, crusts, blisters, and scars in darker skinned patients because of increased light (heat) absorption by melanin (Ciocon et al. 2009; Thaysen-Petersen et al. 2017). Higher cutoff filters, i.e., 690 nm, allow the emission of longer wavelengths, which reduce light absorption by melanin and provide safer treatment for darker skin types. Alternatively, patients with light skin can tolerate higher energy levels and shorter wavelengths, i.e., 560 nm (Ciocon et al. 2009; Augustyniak and Rotsztejn 2017; Ping et al. 2016). It is not recommended to provide IPL treatments to patients with a suntan because the amount of melanin is increased in sun exposed skin, and therefore, treatment

19.3  Intense Pulsed Light (IPL)

197

Fig. 19.2  Example of an intense pulsed light device (IPL). Photo: Beth Haney, DNP, FNP-C, FAANP

could result in burns (Addison 2016). Moreover, patients who continue to expose their skin to the UV radiation of the sun further the photoaging process. Patients who are interested in IPL treatment for photodamage should make the commitment to protect their skin from UV radiation. IPL treatment uses short pulses of light to deliver heat energy into the skin. During treatment, the IPL raises the temperature of the skin and stimulates renewal of the epidermis and production of collagen (Bitter 2000; Ciocon et  al. 2009; Augustyniak and Rotsztejn 2017; Ping et al. 2016). Eye protection for the patient and the practitioner is required due to the intense brightness of the flash during treatment. A clear gel is applied to clean skin prior to treatment to help keep the skin cool and protected. Colored gel is not recommended because the light energy could be absorbed by the color and lead to epidermal injury. The IPL procedure is not an entirely pleasant one. Throughout the IPL treatment, the patient will experience sudden and warm snaps, and unexpected, simultaneous bright flashes during each pulse. Because of the startling nature of IPL treatment,

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the patient should be informed of this sensation beforehand. In addition, pain from the IPL procedure should be addressed. Pain tolerance of each individual can vary and the level of discomfort during IPL treatment can range from slight discomfort to moderate pain. Topical anesthetic may be used before treatment to enhance patient comfort although it is not always necessary. When treatment is complete, the gel is removed, and sunscreen is applied if there is a chance of sun exposure. The patient should be given post-treatment instructions that include (1) sun avoidance tips, (2) skin cleansing and moisturizing instructions, (3), sunscreen instructions, (4) possible skin responses, (5) topical product instructions/recommendations, (6) follow-up instructions, and other pertinent information.

Example of pre-treated skin

After several intense pulsed light (IPL) treatments

19.4  Lasers in Aesthetics

199

19.4 Lasers in Aesthetics Laser is an acronym for light amplification by stimulated emission of radiation (LASER). Light is composed of waves and the distance between the two crests of these waves is called the wavelength that is measured in meters (Hare 2013). Color of the light in the visible spectrum is determined by the length of the wave or wavelength (see Fig. 19.1) (Hare 2013). The laser is a device which produces coherent light, an intense collimated beam of monochromatic light in which all the light waves are of the same length and travel in the same direction (Carruth 1984). All lasers have the same four primary components, the laser medium, optical cavity, power supply or pump, and the delivery system. The medium is the substance the light waves travel through and can be a solid, liquid, or gas (Hare 2013; Bloom 1966). The lasing mediums are (1) solid laser mediums—ruby, alexandrite, erbium (Er), diode, or neodymium: yttrium-aluminum-garnet (Nd:Yag), (2) liquid medium—a fluid containing rhodamine dye, and (3) gas medium—carbon dioxide (CO2), argon, copper vapor, helium neon, or krypton (Hare 2013; Bloom 1966). The lasing medium contained in the laser tube is usually the name of the laser, for example, carbon dioxide (CO2) laser, alexandrite laser, or pulsed dye laser (see Table 19.3) (Carruth 1984). These lasers are used in aesthetics to treat various skin conditions and the choice of laser device is determined by wavelength and energy output (see Table 19.3) (Hare 2013). The optical cavity is the portion of the laser device that surrounds the medium and contains the amplification process. Amplification of light occurs when an external source of energy is added to the laser medium through electrical Table 19.3  Examples of laser types, mediums, and wavelengths Laser type Pulsed dye Ruby Alexandrite Diode Nd:Yaga Er:Glassb Er:Yagc Carbon dioxide (CO2)

Medium Liquid Solid state Solid state Solid state Solid state Solid state Solid state Gas

Wavelength 577–695 nm 694 nm

Clinical use Vascular, pigment Pigment, hair reduction

755 nm

Hair reduction, pigment, tattoo removal

800 nm

Hair reduction

1064 nm, 1320 nm 1540–1550 nm

Hair reduction, non-ablative skin resurfacing Non-ablative skin resurfacing

2940 nm

Skin resurfacing

10,600 nm

Skin resurfacing, tissue cutting, coagulation, vaporization

Nd:YagE—neodymium: yttrium-aluminum-garnet Er:glass—erbium glass c Er:Yag—erbium: yttrium-aluminum-garnet a

b

200

Highly reflective mirror

19  Laser and Light-Based Treatments

Flashlamp (pump source)

Partially reflective mirror

Laser output ND:YAG crystal (laser medium)

Optical resonator

Fig. 19.3  Example of Nd:Yag solid state laser components (Lakkasuo 2010)

stimulation, flash lamp, radiofrequency, or chemical reaction where chemical bonds are created or destroyed to make energy (Hare 2013). This process forces the resting atoms of the laser medium to drive their electrons to an unstable, higher energy orbit (Hare 2013). The excitation of the electrons emits energy and creates the laser beam which is allowed to escape through a small hole in the reflective mirror in the chamber and transported through the arm or delivery system of the device (see Fig. 19.3) (Hare 2013). Laser energy can be modified to perform various actions and can cut, coagulate, or vaporize tissue (Parrish et al. 1983).

19.4.1 Skin Resurfacing The use of the carbon dioxide (CO2) and erbium: yttrium-aluminum-garnet (Er:YAG) lasers is an effective therapy for rejuvenation of photodamaged skin of the face, neck, chest, and hands and for improvement of facial acne scars (Carruth 1984; Prignano et al. 2011; Walgrave et al. 2012; Fitzpatrick 2002; Ortonne et al. 2006; Manuskiatti et al. 2013; de Vries and Prens 2015; Pozner and Goldberg 2006; Waibel et al. 2018). A number of laser devices have been developed to help reduce the recovery period because many patients cannot tolerate a long period of down time to recover from a laser treatment. Rather than utilizing fully ablative lasers for skin rejuvenation procedures, qualified practitioners now use non-ablative or fractional lasers resulting in less down time and quicker healing time (Hare 2013; Fitzpatrick 2002; Pozner and Goldberg 2006). Accordingly, management of patient expectations is important because less intense treatments may not provide dramatic results that could be expected. Fractional resurfacing lasers treat fractions of skin and the laser parameters are set according to the skin type, condition, and clinical indication. The fractional lasers create microscopic columns of thermal damage in the skin rather than completely vaporize the epidermis (Hare 2013; Fitzpatrick 2002; Alexiades-Armenakas et  al. 2012). These columns of thermal damage are called microscopic thermal zones and

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because these zones are specifically targeted, healing time is reduced and there is less damage to surrounding viable tissue (Hare 2013; de Vries and Prens 2015; Pozner and Goldberg 2006). The CO2 and erbium lasers target the chromophore of water (Pozner and Goldberg 2006; Waibel et al. 2018). Since the epidermis has little water content, it is generally protected during fractional laser treatments (Hare 2013; Pozner and Goldberg 2006). Fractional laser treatments effectively provide skin rejuvenation and are a good option for many patients. Appropriate patient selection, review of the procedure, necessary medication administration, and review of the recovery process are important. Most patients require topical anesthesia and/or oral medication for pain control during laser treatment. In addition, patients with a history of herpes simplex virus (HSV) should be treated prophylactically with anti-viral medication and some practitioners recommend every patient receive HSV prophylaxis regardless if the patient has a history of HSV (Prignano et al. 2011; AlexiadesArmenakas et al. 2012). The fractional laser procedures are generally short in duration and often less than 30 min for a complete treatment to the face. Many patients tolerate the procedure well. After the laser treatment is completed, patients typically report a “sunburned” sensation and no persistent pain. Recovery from a fractional laser treatment can vary from 3 to 14 days and generally, there is some degree of peeling/sloughing in 3–5 days (Walgrave et al. 2012; Fitzpatrick 2002). Erythema from laser resurfacing usually resolves in 2 weeks but can persist for 3 months (Fitzpatrick 2002; Alexiades-Armenakas et al. 2012). A topical barrier of a petroleum based product such as Aquafor® is recommended after treatment for 1–2 days to keep a layer of protection on the healing skin and after that, regular moisturizers usually suffice (Fitzpatrick 2002). Possible complications from laser treatments include burns, scarring, infection, prolonged erythema, hyperpigmentation, and hypopigmentation. The periphery of the face, particularly along the jawline, is more prone to these complications (Fitzpatrick 2002). The risk of adverse events is related to removal of the protective barrier of the epidermis and the depth of laser penetration (Walgrave et al. 2012; Fitzpatrick 2002; Nicol 2016). Careful monitoring of the patient who has undergone laser resurfacing is essential to ensure a good outcome. Patients should be advised to follow-up in the office as directed and especially if any signs of infection develop such as pus, increasing redness or pain, or oozing (Alexiades-Armenakas et al. 2012). Acneiform eruptions may occur after treatment and could be due to the occlusive nature of petroleum based products therefore, prolonged use of these products is not recommended (Alexiades-Armenakas et al. 2012).

19.4.2 Hair Removal Humans are born with about five million hair follicles and produce no more during the lifespan, although some follicles become active during different phases of life, i.e., puberty (Habif 2016). Hair growth cycles are important to understand when considering laser hair reduction treatment because lasers used for hair reduction are

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only effective during certain growth phases (Lin et al. 1998). Although there are three phases of hair growth, each follicle behaves independently (James et al. 2006). The three stages of hair growth are anagen, catagen, and telogen (Kolarsick et al. 2011). The hair in the anagen growth phase contains the highest number of melanocytes which absorb high levels of heat (Lin et al. 1998). The heat from the laser is absorbed by the melanocytes in the hair and is transferred to the hair bulb where it damages the hair follicle (Lin et al. 1998). The absorbed heat results in impaired production of matrix cells, if matrix cells are produced at all (Sadick and Prieto 2003). Damage to the hair follicle from laser decreases the formation of hairs in the treated area. Because not all hairs are in one growth phase at the same time, effective laser hair reduction consists of a series of treatments (for more detail on hair growth cycles, see Chap. 2). During the anagen phase of hair growth, the hair responds best to laser treatment (Lin et al. 1998). The anagen phase lasts approximately 30–45 days therefore, the time between laser hair reduction treatments is about every 4–8 weeks (Habif 2016). Intermittent timing helps ensure the highest number of hair follicles are damaged during the anagen growth phase. Subsequently, hairs in the anagen phase contain the highest number of melanocytes and absorb more heat than hairs in a different phase (Lin et al. 1998). Lasers used for hair reduction are effective in destroying darker hair and sparing lighter skin through selective photothermolysis. Selective photothermolysis is a process where laser light is absorbed by the melanin in hair, but because there are fewer chromophores in the skin, the hair is affected but the skin is spared (Lin et al. 1998; Parrish et al. 1983). Darker skin types can be treated with laser for hair reduction as long as the hair is darker than the skin however, the results are not optimal (Agarwal et al. 2016). Therefore, darker hair on lighter skin in a series of treatments spaced approximately 4–8 weeks apart yields the best result from laser hair reduction.

19.5 Conclusion Light-based treatments are effective for skin rejuvenation and hair reduction. The IPL is a light-based skin rejuvenation option with a short recovery time and it is ideal reducing the appearance of photodamage. The IPL treatment results in smoother skin, decreased hyperpigmentation and redness, and long lasting results when UV exposure is limited. Laser skin resurfacing results in collagen stimulation and can also provide dramatic improvement in skin texture and fine lines (Prignano et al. 2011). The laser resurfacing procedure is more intense than IPL and has a longer recovery period however, this procedure yields a long lasting result. Hair reduction is an additional indication for laser and is effective in most skin types but it is most effective in lighter skinned people with dark hair (Agarwal et al. 2016). Careful assessment of the skin prior to treatment and management of patient expectations is vital when considering light-based options for skin rejuvenation or hair reduction. Training and utilization of appropriate parameters according to skin type and condition are crucial for patient safety and excellent outcomes.

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References Addison KF. Photodamage, photodermatoses, and aging skin. In: Nicol NH, editor. Dermatologic nursing essentials: a core curriculum. 3rd ed. Philadelphia: Wolters Kluwer; 2016. Agarwal M, Velaskar S, Gold MH. Efficacy of a low fluence, high repetition rate 810 nm diode laser for permanent hair reduction in Indian patients with skin types IV-VI.  J Clin Aesthet Dermatol. 2016;9(11):29–33. Alexiades-Armenakas MR, Dover JS, Arndt KA.  Fractional laser skin resurfacing. J Drugs Dermatol. 2012;11(11):1274–87. Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science. 1983;220(4596):524–7. Augustyniak A, Rotsztejn H. Intense pulsed light (IPL) treatment for the skin in the eye area - clinical and cutometric analysis. J Cosmet Laser Ther. 2017;19(1):18–24. Barnard IRM, Tierney P, Campbell CL, McMillan L, Moseley H, Eadie E, et al. Quantifying direct DNA damage in the basal layer of skin exposed to UV radiation from sunbeds. Photochem Photobiol. 2018;94(5):1017–25. Bitter PH. Noninvasive rejuvenation of photodamaged skin using serial, full-face intense pulsed light treatments. Dermatol Surg. 2000;26(9):835–42; discussion 43 Bloom AL. Gas lasers. Appl Opt. 1966;5(10):1500–14. Carruth JA. Lasers in medicine and surgery. J Med Eng Technol. 1984;8(4):161–7. Ciocon DH, Boker A, Goldberg DJ. Intense pulsed light: what works, what’s new, what’s next. Facial Plast Surg. 2009;25(5):290–300. de Vries K, Prens EP.  Laser treatment and its implications for photodamaged skin and actinic keratosis. Curr Probl Dermatol. 2015;46:129–35. Fitzpatrick TB. The biology of pigmentation. Birth Defects Orig Artic Ser. 1971;7(8):5–12. Fitzpatrick TB. Soleil et Peau. J Med Esthet. 1975;2:33–4. Fitzpatrick TB.  The validity and practicality of sun-reactive skin types I through VI.  Arch Dermatol. 1988;124(6):869–71. Fitzpatrick RE. Maximizing benefits and minimizing risk with CO2 laser resurfacing. Dermatol Clin. 2002;20(1):77–86. Fitzpatrick TB, Miyamoto M, Ishikawa K. The evolution of concepts of melanin biology. Arch Dermatol. 1967;96(3):305–23. Friedmann DP, Goldman MP.  Photodynamic therapy for cutaneous photoaging: a combination approach. Dermatol Surg. 2016;42(Suppl 2):S157–60. Goldman MP. Treatment of benign vascular lesions with the photoderm VL high-intensity pulsed light source. Adv Dermatol. 1997;13:503–21. Habif TP. Clinical dermatology: a color guide to diagnosis and therapy. 6th ed. St. Louis: Elsevier; 2016. Hare HHW. Basic laser RG. In: Goldberg D, editor. Physics and safety. 2nd ed. New  York: Springer; 2013. James WD, Berger TG, Elston DM. Andrews’ diseases of the skin: clinical dermatology. 10th ed. London: Elsevier; 2006. Kolarsick P, Kolarsick MA, Goodwin C. Anatomy and physiology of the skin. J Dermatol Nurses Assoc. 2011;3(4):203–13. Kullavanijaya P, Lim HW. Photoprotection. J Am Acad Dermatol. 2005;52(6):937–58; quiz 59-62 Li D, Lin SB, Cheng B. Intense pulsed light: from the past to the future. Photomed Laser Surg. 2016;34(10):435–47. Lin TY, Manuskiatti W, Dierickx CC, Farinelli WA, Fisher ME, Flotte T, et al. Hair growth cycle affects hair follicle destruction by ruby laser pulses. J Invest Dermatol. 1998;111(1):107–13. Lakkasuo. Own work, CC BY-SA 3.0, File:Lasercons.svg - Wikimedia Commons. Schematic diagram of a Nd:YAG laser, for laser construction 2010. Manuskiatti W, Iamphonrat T, Wanitphakdeedecha R, Eimpunth S.  Comparison of fractional erbium-doped yttrium aluminum garnet and carbon dioxide lasers in resurfacing of atrophic acne scars in Asians. Dermatol Surg. 2013;39(1 Pt 1):111–20.

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Nicol NH.  Anatomy and physiology of the integumentary system. In: Nicol NH, editor. Dermatologic nursing essentials: a core curriculum. 3rd ed. Pitman: Dermatology Nurses Association; 2016. Ortonne JP, Pandya AG, Lui H, Hexsel D. Treatment of solar lentigines. J Am Acad Dermatol. 2006;54(5 Suppl 2):S262–71. Parrish JA, Anderson RR, Harrist T, Paul B, Murphy GF. Selective thermal effects with pulsed irradiation from lasers: from organ to organelle. J Invest Dermatol. 1983;80(1 Suppl):75s–80s. Ping C, Xueliang D, Yongxuan L, Lin D, Bilai L, Shaoming L, et al. A retrospective study on the clinical efficacy of the intense pulsed light source for photodamage and skin rejuvenation. J Cosmet Laser Ther. 2016;18(4):217–24. Pozner JN, Goldberg DJ.  Superficial erbium:YAG laser resurfacing of photodamaged skin. J Cosmet Laser Ther. 2006;8(2):89–91. Prignano F, Bonciani D, Campolmi P, Cannarozzo G, Bonan P, Lotti T. A study of fractional CO(2) laser resurfacing: the best fluences through a clinical, histological, and ultrastructural evaluation. J Cosmet Dermatol. 2011;10(3):210–6. Quevedo WC, Fitzpatrick TB, Pathak MA, Jimbow K. Role of light in human skin color variation. Am J Phys Anthropol. 1975;43(3):393–408. Raffa RB, Pergolizzi JV Jr, Taylor R Jr, Kitzen JM, Group NR. Sunscreen bans: coral reefs and skin cancer. J Clin Pharm Ther. 2019;44(1):134–9. Sadick NS, Prieto VG. The use of a new diode laser for hair removal. Dermatol Surg. 2003;29(1):30– 3; discussion 3-4 Schaefer H, Moyal D, Fourtanier A. Recent advances in sun protection. Semin Cutan Med Surg. 1998;17(4):266–75. Thaysen-Petersen D, Erlendsson AM, Nash JF, Beerwerth F, Philipsen PA, Wulf HC, et al. Side effects from intense pulsed light: importance of skin pigmentation, fluence level and ultraviolet radiation-a randomized controlled trial. Lasers Surg Med. 2017;49(1):88–96. Waibel S, Pozner J, Robb C, Tanzi E. Hybrid fractional laser: a multi-center trial on the safety and efficacy for photorejuvenation. J Drugs Dermatol. 2018;17(11):1164–8. Walgrave SE, Kist DA, Noyaner-Turley A, Zelickson BD. Minimally ablative resurfacing with the confluent 2,790 nm erbium:YSGG laser: a pilot study on safety and efficacy. Lasers Surg Med. 2012;44(2):103–11.

Non-surgical Facial Skin Tightening

20

20.1 Skin Tightening Technology Surgical procedures remain the gold standard but many aesthetic patients would like to have a non-surgical option to tighten their skin. Smooth, taut skin is a sign of youth and since collagen turn over decreases by 6% each decade, the skin slowly and insidiously becomes less supported by the collagen structure, accelerating the appearance of aging (Fabi and Goldman 2014). While there are only a few technologies currently used to tighten the skin, there are numerous skin tightening devices available to practitioners. These devices are available from manufacturers all over the world and vary in overall efficacy, patient comfort, and delivery options. Non-surgical skin tightening modalities heat the underlying dermis and subcutaneous fat at controlled depths without harming the superficial layers of skin. Heating the tissue to sufficient temperatures stimulates neo-collagenesis, but if the temperature becomes excessive, irreversible denaturation changes the specific structure of collagen into a random gelatinous form (Greene and Green 2014). This complication from treatments using earlier protocols led to divots and pockets in the skin that needed correction with filler; additionally, there were also a few reported cases of hyperpigmentation (Greene and Green 2014; Friedmann et  al. 2018; Wu 2007). With the advancement of newer technologies and protocols, these complications are remote but did gain early media attention and has been referred to as skin “melting” from fat necrosis due to excessive temperature during treatment (Wu 2007). Non-surgical technologies include radiofrequency (RF), infra-red (IR), and micro-focused ultrasound (MFU), and some devices offer a combination of these. The energy of these devices is transformed into heat mainly by water contained in the tissue and as a result, the energy is dispersed at controlled depths (Dierickx 2006). The depth and width of the heated area can be adjusted by varying parameters of the energy source and, if applicable, corresponding cooling system. Effective treatment temperatures of the skin depend on the device and range from 40 to 70 degrees Celsius (C) or 104–158 degrees Fahrenheit (F). In addition, patient © Springer Nature Switzerland AG 2020 B. Haney, Aesthetic Procedures: Nurse Practitioner’s Guide to Cosmetic Dermatology, https://doi.org/10.1007/978-3-030-19948-7_20

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perception of pain is an important indicator of effective energy selection (Dierickx 2006; Dover et al. 2007; Carruthers et al. 2014). Collagen becomes denatured at around 60–65 °C or 140–149 °F and then remodels with additional hyaluronic acid, reticular volume, and elastin content at about 10 weeks (Dierickx 2006; Gutowski 2016; Hantash et al. 2009).

20.1.1 Radiofrequency Radiofrequency (RF) uses electrical energy to stimulate the cells of the skin to create heat rather than directly transferring heat into the tissues. There are two types of RF electrode configurations available, monopolar and bipolar. The monopolar devices use one active electrode on the skin, whereas the bipolar devices use two electrodes, one placed a short distance from the other over the treatment area, typically encased in a hand-piece. Monopolar RF devices produce heat through a high frequency electric current, which flows through the transducer, through the skin and body structures, and back to a grounding pad on the patient’s body (Carruthers et al. 2014). Typically, RF travels through structures with the highest water content with greatest resistance by fat and generally, monopolar devices penetrate deeper than bipolar devices (Beasley and Weiss 2014). The pain during the treatment is related to the duration of the pulse; therefore, some devices are more painful than others, depending on how the pulses are delivered. The effect of collagen stimulation appears to be dependent on the temperature and the length of time the heating takes place within the skin; those patients who have higher temperature and treatment times tend to have improved results (Carruthers et  al. 2014). Monopolar RF devices have been associated with side effects such as burns and limited improvement in skin laxity, whereas the newer technology of bipolar devices have led to increased efficacy and fewer side effects because of the creation of a closed electrical circuit using both positive and negative electrodes (Nelson et al. 2015). There are currently two pulse delivery systems in monopolar devices, stamped and dynamic or continuous. The dynamic method is usually less painful because the practitioner is continuously moving the hand-piece, as in the Exilis® device, and the pulses of heat are spread over a larger specific area vs. a smaller more intense pulse of heat (Beasley and Weiss 2014). Also, since melanin is not a target for RF energy, these treatments are safe for all skin types (Greene and Green 2014). The first facial skin tightening device, ThermacoolTC™ (Thermage Inc., Hayward, CA), FDA approved in 2002, uses monopolar RF technology to heat deeper dermal layers while preserving the integrity of the epidermis (Beasley and Weiss 2014). This system heats tissue by pairing RF to the skin by a thin membrane that distributes the RF energy over the area of tissue beneath the surface membrane and a cryogen system simultaneously cools the epidermis for protection (Dierickx 2006). Currently, there are different treatment tips available to the practitioner, so the desired area can be treated according to skin concern. Initial collagen remodeling within the heated tissues is thought to be the mechanism for the immediate but

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Fig. 20.1  The Thermage® Device. Photo: www.thermage.com

temporary tissue contraction; subsequent neo-collagenesis further tightens the dermal tissue over time (Dierickx 2006; Alexiades-Armenakas et al. 2010; Taub et al. 2012) (Fig. 20.1). The bipolar devices produce significantly similar results as the monopolar but the bipolar are often used with light-based technologies to make them more effective (Greene and Green 2014; Beasley and Weiss 2014). Bipolar RF devices have the two poles built into the hand-piece itself and the RF travels from the positive to the negative pole. The depth of RF penetration and heating of the tissue is determined by the spacing of the electrodes on the hand-piece and is typically 1–4 mm of the skin surface (Greene and Green 2014; Beasley and Weiss 2014). Theoretically, the depth of penetration is widely thought to be half the distance between the

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Fig. 20.2  The Exilis device. Photo: www.exilis.com

electrodes, but there is little evidence to support this claim. Bipolar RF is not as penetrating as monopolar RF and provides more uniform heat distribution so it is not as painful (Greene and Green 2014; Beasley and Weiss 2014) (Fig. 20.2).

20.1.2 Infrared Like the previously mentioned technology, the IR wavelengths, such as 1064-nm Nd:YAG, 1320-nm Nd:YAG, 1450-nm diode, 1540-nm erbium:glass, also heat the dermal layer for purposes of skin tightening. Water is the target and transforms the energy into heat from IR that allows for uniform heating of a targeted area and the corresponding volume (Dierickx 2006). The near-IR and IR lasers/light sources used with a cooling device target water in the dermis and cause a rise in dermal temperature that results in skin tightening and increased collagen production

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(Chilukuri et al. 2017). The IR wavelength spectrum from 1100 to 1800 nm is ideal for targeting the reticular dermis and providing tightening, although the epidermis must be cooled to avoid epidermal destruction and injury (Dierickx 2006). Some currently available devices provide the cooling necessary to protect the epidermis during treatments, whereas others require an auxiliary cooling mechanism. Some combination skin tightening devices use laser with RF technology (Greene and Green 2014). The carbon dioxide (CO2) fractional laser is a popular treatment to tighten the thin skin around the eye, including the eyelids, but extreme caution and appropriate eye protection for both the patient and practitioner are warranted.

20.1.3 Micro-Focused Ultrasound The MFU devices are an additional option for dermal skin tightening and utilize mechanical sound waves characterized by frequency and intensity (Gutowski 2016; Chilukuri et al. 2017). The sound waves travel through the tissue causing molecules to oscillate. This mechanical effect transforms into heat in a similar way to RF (Chilukuri et al. 2017). The MFU devices are capable of delivering heat to deeper levels in the skin and can be programmed to target deep dermis in addition to the superficial musculoaponeurotic system (SMAS). The SMAS lies beneath the subcutaneous fat, encases the facial muscles of expression, and extends superficially to connect with the dermis (Har-Shai et  al. 1996, 1997). The SMAS is made up of collagen fibers and elastic fibers interspersed with fat cells, similar to the dermal layer of the skin but it has more durable holding property and less delayed relaxation after lifting procedures than the skin alone (Gutowski 2016; Har-Shai et  al. 1996, 1997). These qualities make the SMAS a desirable target for noninvasive skin tightening treatments. The Ulthera® (Ulthera Inc., Mesa, AZ.) device delivers transcutaneous MFU energy from the hand-piece to the specific tissue depth set by the practitioner (Fig. 20.3). A monitor allows ultrasound visualization of subcutaneous fat and levels of skin where the energy will be delivered and allows the practitioner to avoid certain structures such as bone (Gutowski 2016). The focal energy delivery is distributed in predetermined lines consisting of a row of thermal coagulation points and results in evenly spaced zones 2–3 mm apart (Baumann and Zelickson 2016). The target depths available on the MFU device are as follows (Baumann and Zelickson 2016): • 1.5 mm—targets the dermis for more superficial collagen stimulation • 3.0 mm—targets deep dermis • 4.5 mm—targets the SMAS Skin tightening procedures using RF or MFU are attractive options to patients who want to avoid surgical intervention, increased potential for side effects, and longer healing times. Non-surgical skin tightening yields satisfactory results for appropriate patients and offers good results with no down time.

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Fig. 20.3 The Ulthera® Device. Photo: https://ultherapy.com/physicians/science-behindultrasound-skin-lift/

Improvement in the delivery of these technologies has led to safer treatments, a larger patient base, and higher patient satisfaction, but patient selection must be carefully considered to avoid patient disappointment in the results. Although most patients note some improvement, younger patients with mild skin laxity are the best candidates for non-surgical skin tightening whereas older patients with excessive skin laxity or tissue ptosis would not see significant improvement and would likely benefit from a surgical procedure (Dierickx 2006; Alexiades-Armenakas et al. 2010; Alster and Tanzi 2004; MacGregor and Tanzi 2013). Radiofrequency and ultrasound devices have demonstrated improvement in skin laxity through repeated treatments over time. These results are derived from an increase in dermal collagen formation however, it is thought that the initial results of these treatments are from short-term effects from edema (Alster and Tanzi 2004; Boisnic et  al. 2017). Subsequently, patients may note a drop off in improvement after 10–14 days and note improvement again after 4–6 months (Carruthers et al. 2014). Treatment results vary depending on the device used and some yield best results after more than one treatment (Greene and Green 2014). Cost is a factor to consider when assessing patients for these treatments and should be included in the initial consultation along with what to expect during treatment and the anticipated outcome. Both radiofrequency and ultrasound devices have been shown to have similar efficacy (Alhaddad et al. 2019). However, one possible drawback of any of the skin tightening modalities is pain during treatment and the potential need for local anesthesia. Device manufacturers have developed devices and protocols in efforts to mitigate pain such as using lower energies and repeating treatments over a predetermined time frame rather than one treatment (Greene and Green 2014). After treatment, most patients are able to resume normal activities. Some patients may experience a mild, deep heating sensation after treatment that normally

References

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disappears after 1–2  h. Some erythema and edema are present immediately after treatment but usually resolve within the first 24 h. A cooling gel or other soothing product may be used after treatment to reduce erythema and edema and provide some additional comfort. In the rare event of a superficial burn, from a treatment that is more aggressive than the patient skin can tolerate, standard wound care and careful follow-up are recommended (Dierickx 2006).

20.2 Conclusion Although there is promise from nonsurgical skin tightening treatments to the face and neck, there are no long-term outcome studies that have captured improvement for over 1 year (Fabi and Goldman 2014; Nelson et al. 2015; Taub et al. 2012; Britt and Marcus 2017; Northington 2014). Patient expectations are crucial to manage. Positive patient experience depends upon careful patient selection of those who have mild skin laxity and realistic, modest expectations that hover around 20–30% improvement. Based on these considerations, non-surgical skin tightening treatments in appropriate patients have yielded satisfaction rates over 50% (Dierickx 2006; Alexiades-Armenakas et al. 2010; Baumann and Zelickson 2016; MacGregor and Tanzi 2013; Northington 2014).

References Alexiades-Armenakas M, Rosenberg D, Renton B, Dover J, Arndt K. Blinded, randomized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-­ lift to treat skin laxity. Arch Dermatol. 2010;146(4):396–405. Alhaddad M, Wu DC, Bolton J, Wilson MJ, Jones IT, Boen M, et al. A randomized, split-face, evaluator-blind clinical trial comparing monopolar radiofrequency versus microfocused ultrasound with visualization for lifting and tightening of the face and upper neck. Dermatol Surg. 2019;45(1):131–9. Alster TS, Tanzi E.  Improvement of neck and cheek laxity with a nonablative radiofrequency device: a lifting experience. Dermatol Surg. 2004;30(4 Pt 1):503–7; discussion 7. Baumann L, Zelickson B. Evaluation of micro-focused ultrasound for lifting and tightening neck laxity. J Drugs Dermatol. 2016;15(5):607–14. Beasley KL, Weiss RA. Radiofrequency in cosmetic dermatology. Dermatol Clin. 2014;32(1):79–90. Boisnic S, Divaris M, Branchet MC, Nelson AA. Split-face histological and biochemical evaluation of tightening efficacy using temperature- and impedance-controlled continuous non-­ invasive radiofrequency energy. J Cosmet Laser Ther. 2017;19(3):128–32. Britt CJ, Marcus B. Energy-based facial rejuvenation: advances in diagnosis and treatment. JAMA Facial Plast Surg. 2017;19(1):64–71. Carruthers J, Fabi S, Weiss R. Monopolar radiofrequency for skin tightening: our experience and a review of the literature. Dermatol Surg. 2014;40(Suppl 12):S168–73. Chilukuri S, Denjean D, Fouque L. Treating multiple body parts for skin laxity and fat deposits using a novel focused radiofrequency device with an ultrasound component: safety and efficacy study. J Cosmet Dermatol. 2017;16(4):476–9. Dierickx CC.  The role of deep heating for noninvasive skin rejuvenation. Lasers Surg Med. 2006;38(9):799–807.

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Dover JS, Zelickson B, Physician Multispecialty Consensus Panel. Results of a survey of 5,700 patient monopolar radiofrequency facial skin tightening treatments: assessment of a low-­ energy multiple-pass technique leading to a clinical end point algorithm. Dermatol Surg. 2007;33(8):900–7. Fabi SG, Goldman MP. Retrospective evaluation of micro-focused ultrasound for lifting and tightening the face and neck. Dermatol Surg. 2014;40(5):569–75. Friedmann DP, Bourgeois GP, Chan HHL, Zedlitz AC, Butterwick KJ. Complications from microfocused transcutaneous ultrasound: case series and review of the literature. Lasers Surg Med. 2018;50(1):13–9. Greene RM, Green JB. Skin tightening technologies. Facial Plast Surg. 2014;30(1):62–7. Gutowski KA. Microfocused ultrasound for skin tightening. Clin Plast Surg. 2016;43(3):577–82. Hantash BM, Ubeid AA, Chang H, Kafi R, Renton B. Bipolar fractional radiofrequency treatment induces neoelastogenesis and neocollagenesis. Lasers Surg Med. 2009;41(1):1–9. Har-Shai Y, Bodner SR, Egozy-Golan D, Lindenbaum ES, Ben-Izhak O, Mitz V, et al. Mechanical properties and microstructure of the superficial musculoaponeurotic system. Plast Reconstr Surg. 1996;98(1):59–70; discussion 1–3. Har-Shai Y, Bodner SR, Egozy-Golan D, Lindenbaum ES, Ben-Izhak O, Mitz V, et al. Viscoelastic properties of the superficial musculoaponeurotic system (SMAS): a microscopic and mechanical study. Aesthet Plast Surg. 1997;21(4):219–24. MacGregor JL, Tanzi EL. Microfocused ultrasound for skin tightening. Semin Cutan Med Surg. 2013;32(1):18–25. Nelson AA, Beynet D, Lask GP. A novel non-invasive radiofrequency dermal heating device for skin tightening of the face and neck. J Cosmet Laser Ther. 2015;17(6):307–12. Northington M.  Patient selection for skin-tightening procedures. J Cosmet Dermatol. 2014;13(3):208–11. Taub AF, Tucker RD, Palange A. Facial tightening with an advanced 4-MHz monopolar radiofrequency device. J Drugs Dermatol. 2012;11(11):1288–94. Wu WT.  Achieving optimal results with thermage using mesoanesthesia and revised treatment parameters. Aesthet Surg J. 2007;27(1):93–9.

Index

A Acne hormone regulation, 74 luteal phase, 74 mild inflammatory acne, 74 moderate inflammatory acne, 74, 75 photodynamic therapy (PDT), 51, 77 scars, 74–77, 200 severe inflammatory acne, 75 treatment, 43, 51, 73, 76, 127 Actinic keratosis (AK), 21, 23, 42, 43 B Biofilm, 177, 181, 187–188 C Calcium hydroxyapatite (CaHA), 31, 141, 144, 145, 153, 154, 157, 169, 170, 173, 178, 181 Radiesse®, 144, 151 Chemical peels glycolic acid, 70 Jessner peel, 69 lactic acid, 69 pyruvic acid, 70 salicylic acid, 68 tretinoin, 24, 42–45, 69, 102, 111 trichloroacetic acid, 68 Cleansers, 45–47, 49 D Dermal fillers cheeks, 27, 154 complications, 177–188 indications, 37, 153, 174 Jawline (mandible), 168

hands, 153 lips, 158 nodule formation, 180–181 orbital area, 153 perioral filler (oral commissures), 119 pharmacology, 146 placement, 173 scars, 160 Tyndall effect, 142 vascular compromise, 149 Dermis, 8, 23, 47, 52, 59, 60, 67, 75, 106, 152, 165, 181, 194, 209 E Ephelides, 21 Epidermis, 8, 22, 23, 41, 47, 60, 67, 197, 201, 206, 209 F Facial bones, 17, 25 Facial muscles, 12, 24, 37, 95, 101, 107, 112, 120, 125, 135, 209 Fascia, 7, 12, 30, 172 G G-prime, 142–143, 156, 161, 167, 168, 178, 181–184 Granuloma, 177, 183 H Hair anagen, 11 catagen, 11 growth phases, 202 telogen, 12

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214 Hyaluronic acid complications, 177 correction, 177, 178 indications, 125, 167 pharmacology, 146 placement, 152, 156 I Intense pulsed light (IPL), 24, 51, 52, 77, 160, 195–197, 202 L Laser, 5, 11, 24, 51, 65, 76, 77, 101, 102, 105, 115, 121, 160, 199, 200, 202 complications, 183, 201 Laser hair removal, 201–202 Lentigo (lentigines), 21, 45, 195 M Microdermabrasion, 51, 52, 62, 67, 68, 77 hydro-dermabrasion, 52 Micropigments, 62, 65 tattooing, 59 Moisturizers emollient, 47 humectants, 47, 49 N Neurotoxins abobotulinumtoxinA (Dysport®), 84, 104 antibody formation, 87 brow ptosis, 135 complications, 62 contraindications, 55 dosing, 95 eyelid ptosis, 134 hyperhidrosis, 59, 125 incobotulinumtoxinA (Xeomin®), 84 indications, 84 lip asymmetry, 59 mechanism of action, 85 onabotulinumtoxinA (Botox®), 94 pain control, 77 pharmacology, 88 placement, 154, 165

prabobotulinumtoxin-xvfs (Jeuveau™), 83 rimabotulinumtoxinA (Myobloc®), 84 soluble N-ethylmaleimide sensitive factor adaptor protein (SNAP), 85 soluble N-ethylmaleimide sensitive factor adaptor protein receptor (SNARE), 85 P Peels alpha-hydroxy acid, 67 beta-hydroxy acid, 67, 68 glycolic acid, 67, 68, 70, 71 Jessner peel, 69–70 lactic acid, 67, 69, 70 pyruvic acid, 67, 70, 71 resorcinol, 69–71 retinoic acid, 67, 69 salicylic acid, 67–70 superficial peels, 67, 68, 70–71 trichloroacetic acid (TCA), 67, 68 Poly-L-Lactic acid (PLLA), 31, 141, 144–145, 151, 153, 154, 157, 169, 178, 181 Sculptra®, 144–146, 151 Psychological aspects body dysmorphic disorder (BDD), 35 depression (Botox and), 75 S Seborrheic keratosis (SK), 21 Skin anatomy, 17 Skin tightening bi-polar, 206 infra-red (IR), 208, 209 micro-focused ultrasound (MFU), 205, 209 monopolar, 206 radiofrequency (RF), 206 Subcutaneous fat, 7, 9, 10, 30, 193, 205, 209 T Tissue necrosis, 173, 177, 183 Tyndall effect, 142, 173, 177, 180–182 W Wavelengths, 194–196, 199, 208