Non-Invasive Cosmetic Procedures 9781607952251, 9781607951506

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Non-Invasive Cosmetic Procedures Thomas Procedures in Facial Plastic Surgery

R. James Koch, MD Director Northern California Face and Laser Institute Palo Alto, California, USA

2012 PEOPLE’S MEDICAL PUBLISHING HOUSE—USA SHELTON, CONNECTICUT

People’s Medical Publishing House-USA 2 Enterprise Drive, Suite 509 Shelton, CT 06484 Tel: 203-402-0646 Fax: 203-402-0854 E-mail: [email protected] © 2012 PMPH-USA, Ltd. All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording, or otherwise), without the prior written permission of the publisher. 11 12 13 14/PMPH/9 8 7 6 5 4 3 2 1 ISBN-13: 978-1-60795-150-6 ISBN-10: 1-60795-150-9 Printed in China by People’s Medical Publishing House Copyeditor/Typesetter: Spearhead Global, Inc. Cover designer: Mary McKeon Library of Congress Cataloging-in-Publication Data Non-invasive cosmetic procedures : Thomas procedures in facial plastic surgery / R. James Koch. p. ; cm. Includes bibliographical references. ISBN-13: 978-1-60795-150-6 ISBN-10: 1-60795-150-9 I. Koch, R. James. [DNLM: 1. Face—surgery. 2. Cosmetic Techniques. 3. Reconstructive Surgical Procedures—methods. 4. Surgical Procedures, Minimally Invasive—methods. WE 705] LC classification not assigned 617.5⬘2059—dc23 2011033035

Notice: The authors and publisher have made every effort to ensure that the patient care recommended herein, including choice of drugs and drug dosages, is in accord with the accepted standard and practice at the time of publication. However, since research and regulation constantly change clinical standards, the reader is urged to check the product information sheet included in the package of each drug, which includes recommended doses, warnings, and contraindications. This is particularly important with new or infrequently used drugs. Any treatment regimen, particularly one involving medication, involves inherent risk that must be weighed on a case-by-case basis against the benefits anticipated. The reader is cautioned that the purpose of this book is to inform and enlighten; the information contained herein is not intended as, and should not be employed as, a substitute for individual diagnosis and treatment.

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Contributors Jeffrey D. Pollard, MD Medical Director Facial Plastic Surgery Réviance Plastic Surgery & Aesthetic Center San Jose, CA Mary Lynn Moran, MD 2973 Woodside Road Woodside, CA Vishal Banthia, MD Medical Director Réviance Plastic Surgery and Aesthetic Center San Mateo, CA Basil M. Hantash, MD, PhD Department of Dermatology Division of Plastic Surgery Stanford University School of Medicine Stanford, CA

Matthew M. Hanasono, MD Department of Plastic Surgery MD Anderson Cancer Center Houston, TX Thomas H. M. Moulthrop, MD Clinical Professor Department of Otolaryngology Tulane University School of Medicine New Orleans, LA Calvin M. Johnson, Jr., MD Facial Plastic and Reconstructive Surgery Hedgewood Surgical Center New Orleans, LA Brian P. Kim, MD Kaiser Permanente Orange CountyAnaheim Medical Center Anaheim, CA

Table of Contents Chapter 1 Soft Tissue Fillers...............................................................................1 Jeffrey D. Pollard, Thomas H. M. Moulthrop, and Calvin M. Johnson, Jr. Introduction ..................................................................................................................................................1 Facial Analysis ................................................................................................................................................2 Preoperative Considerations .........................................................................................................................3 Technique.......................................................................................................................................................3 Preferred Injection Techniques......................................................................................................................5 Natural Facial Rhytids and Depressions........................................................................................................5 Natural Facial Convexities ...........................................................................................................................11 Special Applications.....................................................................................................................................13 Postoperative Care .......................................................................................................................................14 Complications .............................................................................................................................................15 Suggested Readings......................................................................................................................................15

Chapter 2 Botulinum Toxin ............................................................................... 17 Jeffrey D. Pollard, Thomas H. M. Moulthrop, and Calvin M. Johnson, Jr. Introduction ................................................................................................................................................17 Facial Analysis ..............................................................................................................................................19 Preoperative Considerations .......................................................................................................................20 Technique.....................................................................................................................................................22 Upper One-Third of The Face.....................................................................................................................22 The Periocular Region .................................................................................................................................26 The Perioral Region .....................................................................................................................................27 The Cervical Region ....................................................................................................................................29 Special Applications.....................................................................................................................................30 Postoperative Care .......................................................................................................................................30 Complications .............................................................................................................................................31 Suggested Readings......................................................................................................................................31

Chapter 3 Laser Skin Resurfacing

33

Vishal Banthia, Basil M. Hantash, and R. James Koch Introduction ................................................................................................................................................33 Facial Analysis ..............................................................................................................................................33 Preoperative Assessment .............................................................................................................................34 Technique.....................................................................................................................................................37 Postoperative Care .......................................................................................................................................40 Complications .............................................................................................................................................41 Conclusion ...................................................................................................................................................43 Suggested Readings......................................................................................................................................44

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Chapter 4 Nonablative Lasers and Lights .....................................................45 Basil M. Hantash, Vishal Banthia, and R. James Koch Introduction ................................................................................................................................................45 Facial Analysis ..............................................................................................................................................46 Preoperative Considerations .......................................................................................................................47 Technique.....................................................................................................................................................47 Postoperative Care .......................................................................................................................................48 Complications .............................................................................................................................................48 Vascular Lasers (532-1064 nm) ...................................................................................................................48 Mid-Infrared Lasers (1320-1550 nm) .........................................................................................................49 Light sources (400-1200 nm) ......................................................................................................................51 Conclusion ...................................................................................................................................................54 Suggested Readings......................................................................................................................................54

Chapter 5 Laser Skin Tightening: Nonablative Skin Rejuvenation...........55 Basil M. Hantash, R. James Koch, and Brian P. Kim Introduction ................................................................................................................................................55 Facial Analysis ..............................................................................................................................................55 Preoperative Considerations .......................................................................................................................56 Technique.....................................................................................................................................................56 Postoperative Care .......................................................................................................................................57 Complications .............................................................................................................................................57 1320 nm Nd:YAG Laser System...................................................................................................................57 1064 nm Nd:YAG Laser System...................................................................................................................58 1100 nm to 1800 nm Spectrum ...................................................................................................................59 1550 nm Laser System .................................................................................................................................60 Radiofrequency and Laser ...........................................................................................................................61 Conclusion ...................................................................................................................................................61 Suggested Readings......................................................................................................................................62

Chapter 6 Radiofrequency Tissue Tightening ..............................................63 R. James Koch and Brian P. Kim Introduction ................................................................................................................................................63 Preoperative Considerations .......................................................................................................................64 Technique.....................................................................................................................................................64 Results ..........................................................................................................................................................65 Postoperative Care and Complications .......................................................................................................66 Conclusions .................................................................................................................................................67 Acknowledgments .......................................................................................................................................67 Suggested Readings......................................................................................................................................67

Chapter 7 Microdermabrasion ........................................................................ 69 Matthew M. Hanasono and R. James Koch Introduction ................................................................................................................................................69 Facial Analysis ..............................................................................................................................................71 Preoperative Considerations .......................................................................................................................71 Technique.....................................................................................................................................................72 Postoperative Care .......................................................................................................................................74

Table of Contents / ix

Complications .............................................................................................................................................74 Summary .....................................................................................................................................................75 Suggested Readings......................................................................................................................................75

Chapter 8 Chemical Peels ..................................................................................77 Vishal Banthia, Basil M. Hantash, and R. James Koch Introduction ................................................................................................................................................77 Facial Analysis and Preoperative Considerations........................................................................................77 Technique.....................................................................................................................................................78 Postoperative Care .......................................................................................................................................81 Complications .............................................................................................................................................81 Suggested Readings......................................................................................................................................82

Chapter 9 Cosmeceuticals .................................................................................85 Mary Lynn Moran Introduction ................................................................................................................................................85 What is a Cosmeceutical? ............................................................................................................................85 Indications ...................................................................................................................................................86 Physiology ....................................................................................................................................................86 Function.......................................................................................................................................................86 Moisturizers .................................................................................................................................................87 Rejuvenators ................................................................................................................................................89 Antioxidants ................................................................................................................................................90 Physiology ....................................................................................................................................................90 Topical Application ......................................................................................................................................90 Sunscreens and Sunblocks ...........................................................................................................................93 Conclusion ...................................................................................................................................................94 Suggested Readings......................................................................................................................................94

Index

95

1 Soft Tissue Fillers Jeffrey D. Pollard, MD, Thomas H.M. Moulthrop, MD, and Calvin M. Johnson, Jr., MD

Introduction Surgeons are experiencing tremendous growth in the field of facial cosmetic surgery. Part of this growth is based on an increasing demand for noninvasive procedures which will offer valuable interventions to new patient populations, and augment or streamline interventions in the traditional patient population. These techniques are also being enthusiastically embraced by consumers. Many contemporary Americans would prefer to take a “pill”, or find a “quick fix” to resolve health and beauty issues rather than undergo more elaborate or timeconsuming procedures. In addition to satisfying immediate gratification, these procedures can offer other valuable advantages. Because there are an increasing number of treatment applications, and relatively few medical contraindications, noninvasive procedures have created an expanded treatment population, capturing younger and older patients. Fewer health and logistic restrictions allow for a relative ease of access to this form of treatment compared to traditional surgical procedures. Office-based treatment allows the surgeon to have more influence over the ambience and style of delivery, which also translates into convenient scheduling for patients and surgeons. In most situations, they offer high yield results with limited recovery demands, coupled with a comfortable treatment experience. Soft tissue fillers (STFs) are a perfect example of this phenomenon. The only point of contention is that they are usually not a permanent solution. Although this seems inconvenient, conservative surgeons typically prefer non- or semi-permanent products in most applications, particularly when treating younger patients. Although not inherently

obvious to consumers or product designers, there is value and comfort in knowing that patients can elect to return to their original appearance if they desire. There are increasing numbers of products becoming available, and as the field of STFs grows they will continue to evolve. There is no way to accurately predict which STFs will become FDA approved or be considered the mainstream in 5 or 10 years. For that reason, a lengthy discussion about the current popular materials is not warranted. Likewise there is little significance in discussing the STFs that “used to be”. Suffice it to say that there have been, and will continue to be, many advances with respect to safety, tolerance (allergy), consistency, pliability, treatment site duration, ease of use and deployment, shelf life, and preparation. Many current products perform well in these categories, and depending on the site of interest and the comfort level of the surgeon, a variety of products may be used. STFs can be classified by the body’s ability to break down and excrete the material. All products fall into a spectrum of biodegradability. Along this continuum, there are tradeoffs with respect to treatment site duration and long-term complications such as granulomas and extrusion. Products also have distinct origins (autologous, cadaveric, bacterial, animal, synthetic, or otherwise bioengineered) which may have an impact at the time of delivery given a patient’s immunologic response, religious beliefs, and the physician’s overall comfort level with product design. The materials also have differing particle sizes and consistencies. Furthermore, some products are known for requiring a degree of “overcorrection”, while others do not. Lastly, some products have unique features like the radio-opacity of calcium hydroxylapatite.

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TABLE 1-1 Types of Soft Tissue Fillers

TABLE 1-2 Areas of The Face that tend to Exhibit Natural Facial Rhytids and Depressions Amenable to STF Therapy

Types of Soft Tissue Fillers Collagen Hyaluronic Acid Fat Acellular dermis Polymethylmethacrylate beads Calcium hydroxylapatite beads Poly-L-lactic acid

The best choice of STF for any given surgeon is the one that maximizes each of the above valuable characteristics and can provide consistent and effective results in their hands. Because surgeon individuality plays an important role in this procedure, there may never be a unanimously favorite material. As new products emerge, they should be evaluated and compared to each surgeon’s current standard (Table 1-1).

Facial Analysis Facial analysis has a more immediate level of significance with STFs because in many circumstances the treatment will be administered during the patient’s initial office visit. Therefore a rapid and accurate assessment must be made, and a focused and understandable treatment plan must be presented to the patient. Analysis is based on targeted

Natural Facial Rhytids & Depressions Glabellar region Nasojugal grooves Melolabial folds Marionette lines Perioral region Chin region

facial units that are amenable to STF enhancement (Figure 1-1). The nature of a STF is to camouflage, efface, or otherwise augment natural or secondary soft tissue depressions by providing a volume/mass effect controlled by the amount and consistency of the filler used. Specific to the lips, and in some cases the nose, a STF can be used to enhance fullness in a unit that has a natural tendency toward convexity. Thus, each treatment site should be evaluated with these specific goals in mind (Tables 1-2, 1-3, 1-4). During the evaluation, be aware of pre-existing facial asymmetry. In addition, one should not lose sight of the fact that facial lines and depressions, whether natural or secondary, are a normal component of the adult human face. They can help to convey liveliness, animation, and character. In most circumstances they cannot, and should not, be completely effaced.

Glabella Nasojugal Groove

Nose Perioral

Melolabial Folds Lip augmentation Marionette Lines

Chin augmentation

Figure 1-1. Targeted treatment sites.

Soft Tissue Fillers / 3

TABLE 1-3 Areas of The Face with Natural Convexity Amenable to STF Therapy Natural Facial Convexities Lips Nasal tip

include: (1) autoimmune, dermatologic, or other systemic disorders that predispose to poor wound healing or an exuberant inflammatory response to tissue manipulation (e.g., the Koebner Phenomenon), and (2) active infection at the treatment site. Blood thinners can be considered a relative contraindication.

TABLE 1-4 Special Facial Applications For STFS

Consent

Special Applications

Once a candidate is deemed to be appropriate for treatment, a formal consent process should ensue. Among other standard consent items, the patient should be counseled regarding the anticipated need for repeat injections (a general guideline is 6 to 9 months). At times, serial injections at 4 to 6 week intervals may be needed for optimum aesthetic outcome at a given site. Because of the evolving nature of STFs, surgeons should routinely review and become familiar with specific product labeling, manufacturer’s indications and recommended depth of treatment, and any ancillary test requirements (primarily allergy testing). Key product-specific and defining characteristics such as the origin and make-up of the material should be touched on. Certain products are being used for “off-label” (nonFDA approved) applications and, when applicable, this should be disclosed during the consent process. Additionally, photographs should be consented to and obtained before and after the procedure.

Depressed scar effacement (Traumatic, iatrogenic, acne) Post-rhinoplasty augmentation Cheek Augmentation Lateral Brow Enhancement Temporal Atrophy

Preoperative Considerations Approach Because STFs are often readily available for application, the surgeon must build a level of trust (rapport) with new patients in a more rapid sequence then is generally necessary with patients considering invasive procedures that require a longer consultation, deliberation, and scheduling period. Although the term “noninvasive” may convey a sense of security and immunity, due diligence is required on the part of the surgeon. In addition to obtaining a standard medical history, assessment of medications, and allergies, each patient should be asked targeted questions related to facial STF treatment (Table 1-5).

Contraindications Patients with a known allergic response to any component of a particular product, or with a general history of anaphylaxis should not be considered for STF augmentation. Other contraindications TABLE 1-5 Treatment Specific Questions Treatment Specific Questions Allergies Autoimmune or dermatologic conditions Past facial treatments Current facial treatments Prior experience with STFs Pain/needle tolerance Specific expectations

Setting Up The setup should be well thought out and practical. A simple tray would typically include a cleaning agent, anesthetic of choice, alcohol prep pads, gauze pads, needles, the STF, sterile gloves, an ice pack or cool compress, and a handheld mirror (Figure 1-2). As discussed in the introduction, the STF of choice will depend on a number of variables including site of treatment, depth, and area of coverage, product feel, and experience.

Technique The nature of soft tissue augmentation is typically repetitive. Therefore, particular attention must be paid to the delivery, results, and overall patient experience to solidify the patient’s confidence in the product and the surgeon. Attention to these details will increase the patient’s satisfaction and likelihood to follow up for additional treatment. The following is a recommended sequence of events that can be

4 / Soft Tissue Fillers

TABLE 1-6 Preferred Injection Techniques Preferred Injection Techniques Serial puncture Linier threading Fanning Cross-hatching Layering

Figure 1-2. Typical procedure setup.

applied to any treatment site. Site-specific considerations will be discussed in the next section. 1. Prepare the patient for the experience. 2. Clean the face to remove make-up. 3. Depending on the patients expectations, experience, and pain tolerance, address the need for topical or regional anesthesia. Approaches to anesthesia include one or any combination of: verbal reassurance, auditory diversion with soft music, distraction by stimulating a separate pressure point, ice, topical agents like betacaine, and injection of an anesthetic agent as a field or regional nerve block. General anesthesia can be administered when STFs are used as an adjunct to invasive procedures in the operating room. It is advisable not to pre-inject the treatment site, as the anesthetic volume will augment the appearance of the site. Some products contain lidocaine which acts at the treatment site immediately following the application. 4. Keep the patient in a comfortable semirecumbent or upright position. This will maintain the natural appearance of the treatment site and allow for better judgment during the procedure. 5. Prepare the treatment site with a sterilizing agent such as rubbing alcohol.

6. Prime the STF by activating the syringe until the material is expressed at the tip of the needle. In most cases, 30- or 27-gauge needles are indicated. Changing the needle gauge will affect the flow rate of the material and the degree of tissue trauma. 7. Insert the needle (typically with the bevel up) and inject the STF using one or more of the preferred injection techniques (Table 1-6). In typical applications, the STF should be delivered into the mid to deep dermis or at the junction of the deep dermis and subcutaneous fat. Injections into the superficial dermis have a limited application in the treatment of fine superficial lines, but may cause striking tissue distortion and higher rates of extrusion. Deeper injections will tend to have much less surface definition and typically result in wasted STF volume. In addition, some thicker products (e.g., cross-linked collagen) have been associated with vascular compromise following deep injections. 8. After the needle is inserted, deposit the material by using steady pressure on the plunger while withdrawing the needle at an even rate. Realtime visual assessment of the treatment site during application of the material will enhance the surgeon’s judgment about the volume needed to achieve a successful injection. 9. After each injection, re-evaluate the site visually and with gentle palpation. Make note of any irregularities. 10. Re-inject if needed. It is advisable to limit the number of repeat injections, as each additional injection is associated with diminishing returns related to judgment (due mostly to localized swelling), in addition to causing further pain, tissue trauma, and potential for bruising. Needles will become dull with use, so changing needles frequently will allow for a more accurate and smooth delivery. 11. Palpate the site and gently massage the STF to promote a smooth and even distribution

Soft Tissue Fillers / 5

of the material. The procedure is generally forgiving if too much material is injected or there is an uneven distribution of the material. Excess material can often be redistributed or even expressed out of the insertion site using digital massage. Holding gentle pressure at the insertion site can help to limit bleeding and bruising. 12. When satisfied with the look and feel of the treated site, consider showing the patient the immediate results. This serves a dual purpose. First, it gives the patient a reasonably valid reference point about the final result. In the hours and days to come, the patient may express anxiety about looking “overdone”. These feelings can be quelled by reassuring the patient with respect to swelling, and by asking them to recall the way the site appeared in the office. Second, it is often difficult for a patient to remember the original appearance of a treatment site (even minutes after the injection). Therefore, as an aid to emphasizing the before and after appearance, it is helpful to show a “side to side” comparison when possible – for example when treating bilateral Melolabial folds. In some, but not all cases, an interactive approach like this can help to embolden a patient’s trust, confidence, and overall satisfaction with the surgeon and the procedure.

of the needle, although some advanced users will extend the length of advancement in select cases by allowing the skin to bunch up at the hub. Finally, the needle is withdrawn at a steady rate while the plunger is depressed with a constant pressure (Figure 1-3B).

Fanning & Cross-Hatching The fanning technique utilizes linear threading in a serial fan-like distribution either through a single or multiple entry sites. This, along with the crosshatching technique, which is defined by a checkerboard pattern, is used primarily for deeper and more voluminous injections where bulk STF needs to be applied in a smooth and widespread distribution (Figure 1-3C, D).

Layering Layering is a technique that can be used when addressing very deep rhytids. Typically a thicker material is injected at the junction of the dermis and subcutaneous fat, followed by a smaller particle STF more superficially. This approach allows the surgeon to eliminate a majority of the problem with a deeper, bulkier product, while maintaining a controlled and polished finish by switching to a material that allows for more superficial finesse .

Preferred Injection Techniques Serial Puncture Using serial punctures, the needle is inserted at a 45 degree angle to the desired depth and the STF is injected while maintaining the position of the needle (or with minimal traveling of the needle). This technique is ideal for “spot” applications such as acne scars or when addressing the nasal region. It may also be the method of choice for beginners, as it allows the surgeon to break the treatment site down into smaller segments which can be addressed in “baby steps” (Figure 1-3A & C).

Linier Threading Linier threading is the most widely used technique for routine rhytids of the face. Here the needle is inserted more shallow to the desired depth and then quickly lowered to a near parallel orientation to the plane of the treatment site. The needle is advanced at an even depth along the length of the rhytid. Advancement is typically limited by the hub

Natural Facial Rhytids and Depressions The Glabellar Region (Figure 1-4) Because of the orientation and habitual contraction of the corrugator and procerus muscles, the glabella has the potential to develop deep and striking rhytids. Although botulinum toxin is the first line of treatment to reduce and prevent progression of the glabellar furrows, they will often need to be addressed with a STF as an adjunctive procedure. There is added value in combining botulinum toxin with a STF in that it may help impede the metabolism and migration of the material in highly animated areas of the face (Figure 1-5).

Nasojugal Grooves (Figure 1-6) The naturally occurring fold or hollowing known as the tear trough deformity is a product of regional volume loss, elastosis, and ptosis of the malar soft

6 / Soft Tissue Fillers

B A

C

E

D

Figure 1-3 A-E. Injection techniques.

Soft Tissue Fillers / 7 Glabellar lines

Figure 1-4. Glabellar region.

Figure 1-5. Before and after glabellar STF.

Nasojugal Groove

Figure 1-6. Nasojugal grooves.

8 / Soft Tissue Fillers

tissues contrasted with the pseudoherniation of the lower orbital fat pads seen with typical aging. Malar fat repositioning and lower blepharoplasty comprise the traditional approach to this situation. However, STFs can be used as adjunctive treatment or even as a stand alone procedure. When addressing the Nasojugal groove, consider using a broader distribution of material and start with a conservative goal in mind. Keep in mind that the nasojugal groove encompasses a transition zone from eyelid skin to cheek skin. The quality and characteristics of these two skin types differ somewhat. Because the lower eyelid skin is considerably thinner, injections that are placed too high are likely to create lumps. Serial injections of “microdrops” down on the periosteum provide for an evenly distributed and natural filler result. Note that the nasojugal groove is also very susceptible to edema related to allergy and inflammation. Patients with this tendency should be approached with caution, because fluctuations in tissue edema will affect the treatment result (Figure 1-7). Figure 1-7. Before and after nasojugal groove STF.

Melolabial Folds (Figure 1-8) Perhaps the most frequently treated facial rhytid, STFs offer distinct advantages for treatment of the melolabial folds. For one thing, the melolabial folds (also referred to as the nasolabial folds) aren’t completely addressed by any invasive procedures

without the risk of distorting surrounding facial features. In addition, the cost-benefit considerations when comparing to a rhytidectomy, heavily favor the STFs. A standard approach to the melolabial fold is the linier threading technique. Layering may

Melolabial Folds

Figure 1-8. Melolabial folds.

Soft Tissue Fillers / 9

also help to achieve reduction of moderate or deep folds while maintaining a controlled and polished finish. Cross-hatching or fanning out the STF at the melolabial triangle (formed at the superior aspect of the melolabial fold as it approaches the alar groove) will help to soften this transition area (Figure 1-9).

Perioral Region (Figure 1-10) Repetitive contraction of the orbicularis oris muscle combined with age-related volume loss are intrinsic causes to fine radial rhytids about the lips. Extrinsic factors such as sun-related elastosis and smoking can expedite and worsen the appearance of these lines. STFs can be used as stand alone treatment or as an adjunctive procedure following chemical, laser, or other re-epithelializing treatment of the perioral complex. Persistent radial lines and the occasional mid-philtral horizontal crease are best approached with a relatively thin and soft material. This will allow the surgeon to use a 30-gauge needle in this highly sensitive area, and provide for a more natural appearance and feel. The linier threading and serial puncture techniques can be applied here, as each line is treated with a separate needle stick.

Figure 1-9. Before and after melolabial fold STF.

Perioral Region

A

B Figure 1-10. A and B, Perioral region.

10 / Soft Tissue Fillers

Marionette Lines

Figure 1-11. Marionette lines.

Due to what is believed to be heightened mobility of the tissues, STFs may have a shorter treatment duration when applied to the perioral region. In light of this, patients need to be counseled regarding the likely need to treat on a more frequent basis. Characteristics specific to each patient and STF used will define the optimal time frame.

Marionette Lines (Figure 1-11) Age-related ptosis and volume loss of the midface combined with perioral muscle activity could translate into a distinct rhytid or fold that extends inferiorly from the oral commissures. These marionette lines are inferior and medial to the melolabial folds and tend to run in a parallel fashion to them. In many ways, the treatment is the same as for melolabial folds. Fine lines can be addressed with a smaller needle in a linear threading or serial puncture approach. With deeper folds, consideration should be given to layering. With any perioral application,

patients should be counseled about the possibility of more frequent treatment sessions (related to increased mobility of the area and injectable volume limitations) (Figure 1-12).

Chin Region (Figure 1-13) Activity of the mentalis muscle over time can cause a transverse furrow to evolve between the chin and the lower lip. In addition, dimpling and other fine lines can form in this region. Because of its strength and location, the mentalis muscle is a good candidate for conservative botulinum toxin therapy. As with the glabella, there is added value in combining botulinum toxin with a STF in that it may help impede the metabolism and migration of the material in this area. The linear threading technique can be used for transverse furrows, while dimples and smaller lines can be addressed with serial punctures. Deep furrows may benefit from layering (Figure 1-14). Consider performing a subcision of

Figure 1-12. Before and after marionette line STF.

Soft Tissue Fillers / 11

Figure 1-13. Chin region diagram.

the mental crease prior to treating with a STF for maximal correction. More substantial chin augmentation (sculpting) can be achieved with higher volumes of longer lasting and thicker STFs. Fanning, cross-hatching, and layering may all be employed, as a smooth, broad, and symmetric distribution will enhance outcomes in this region. Pre-treatment with botulinum toxin will facilitate intraoperative judgment and limit postoperative migration. In many cases deep serial injections down onto the periosteum will provide for suitable projection in lieu of a solid chin implant. This may be ideal for a patient who wants to “try it on” before committing to a permanent implant. Consider treating the Pre-Jowl Sulcus in a similar fashion to rejuvenate the jawline. It may be prudent to stage the treatment in 2 or 3 sessions at 4 to 6 week

intervals to achieve a natural result without overcorrection (Figure 1-14).

Natural Facial Convexities Lips (Figure 1-15) Perhaps the most frequently treated convex facial feature, STFs offer distinct advantages for treatment of the lips. Invasive and more disruptive procedures like surgical implantation of SMAS, Gore-Tex, or Silicone can be avoided for the price of repeat office visits. STFs offer patients a noninvasive solution to a common concern with typically high yield, accurate, and natural appearing results. Furthermore, with the softer materials available, success is not only gained in aesthetic appearance, but also in tactile

Figure 1-14. Before and after chin augmentation.

12 / Soft Tissue Fillers

8

7 4

3 6

1

5

2

Figure 1-15. Lips diagram.

sensation which is vital and unique to this facial treatment site. There are several items to consider when approaching the lips. Have an understanding of the patient’s true concerns and desires. Likewise, ensure that the patient understands the limits of STFs and has reasonable expectations. Patients who had limited volume of the vermillian lip in their youth are unlikely to leave the treatment room with voluptuous, pouty lips as a result of STFs. Despite that, patients can be reminded of the fact that relatively small changes are proportionally larger in smaller lips and can still provide big returns aesthetically. Physically, it is important to know the role of the lips in the overall aesthetic balance of the patients face. With that in mind, it is vital to maintain reasonable proportion and scale to the lips. Avoid obscuring cupids bow and the natural concavity of the philtral column. Don’t lose site of the threedimensional nature of the lips. Overcorrection can lead to over-projection which is unnatural-appearing and is a telltale sign of iatrogenic augmentation. During the assessment, take note of the white line (at the junction of the vermillion and cutaneous lip), the vermillion, and the commissures. Treatment is typically performed with multiple threading maneuvers using a 30- gauge needle, and progressing around the mouth in a symmetric fashion. The procedure should typically start by placing STF along the perimeter of the lips at the white line. This helps to showcase the lips by giving them better definition and can also help prevent lipstick from “bleeding” into radial perioral rhytids. Careful attention should be paid to maintaining and/or enhancing the central curvature of cupids bow. Additionally, subtle augmentation

along the border of the philtrum can enhance the contour of the cutaneous upper lip. Next, STF can be injected into the vermillion to restore volume lost because of age-related atrophy or enhance existing volume in youthful patients. The typical entry site for the needle is lateral and at the level of the junction of the “dry” and “wet” red lip. When tolerated, a 1 1/4-inch 27-gauge needle can allow the surgeon to evenly distribute a thread of material across 1/2 of the lip without the need for serial punctures. The needle should be inserted into the bulk of the lip at a depth that will prevent any irregular surface contouring, but allow for visible external volume change. While addressing the lower lip, the oral commissures can be addressed. When STF is placed into the lower lateral vermillion lip, there is a secondary benefit of supporting the upper lateral lip. The upward support will create the appearance of an up-turning and more youthful oral commissure. Following each injection, bimanual massage should be used to smooth out any irregularities (Figure 1-16).

Nasal Region (Figure 1-17) Although not considered a common treatment site for STFs, there are aspects of the nose that are amenable to STF augmentation as first-line therapy (“primary injection rhinoplasty”), or in combination with traditional rhinoplasty. The areas of natural convexity include the tip lobule, soft triangles, columella, and alar rims. Thick, longer lasting materials are ideal for this application. The nose can be quite sensitive to injections, so extending treatment duration by selecting longer acting products is reassuring to most patients. Thicker materials are

Soft Tissue Fillers / 13

Figure 1-17. Nasal region diagram.

Figure 1-16. Before and after lip augmentation.

favored because they can provide a better scaffold for heavier nasal skin. Bare in mind that pin-point accuracy is paramount because there is little migration and metabolism of fillers in this area and small volumes can create dramatic changes. As a result, an individual puncture at each treatment site is the technique of choice.

Special Applications Depressed Scar Effacement Traumatic, acne, or iatrogenic scars on the face can have irregular depressions. In addition to initial resurfacing efforts, STFs can play a valuable role. Traditional scar management should be employed for a reasonable length of time depending largely on the wound healing properties of the particular site (typically 6 to 12 months). Scars can be unpredict-

Figure 1-18. Before and after depressed scar STF.

able with respect to their depth and presence or lack of normal dermal and epithelial layers. In addition scars can have irregular adhesions that tether them to deeper soft tissues. Examining the scar visually and tactilely will help to assess its candidacy for STF augmentation. The optimal scars are depressed 1-2 mm, soft, and not fixed to deep tissues. The thickness of the surrounding skin and the location of the scar should help determine the thickness of the material to be used. To prevent dimpling and tethering, it may be useful to prepare the treatment site with subcision by sweeping a sturdy needle point under the scar, thereby lysing any adhesions. Deposition of the material is then best performed by serial puncture beginning at the perimeter and working centrally (for elliptical scars) or by linear threading along the length of the scar (for linear scars) (Figure 1-18). Treatment of keloids or patients with a history of keloids is not recommended.

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Post-Rhinoplasty Augmentation Even in the most experienced hands, irregular contouring of the nasal skin can present following traditional rhinoplasty. A variety of postoperative contour defects ranging from subtle to severe can be addressed with STFs, thereby obviating the need for time consuming, difficult, and low yield revision operations. In many cases pin-point accuracy can be reliably achieved with STFs that would be nearly impossible to achieve with traditional revision rhinoplasty techniques. Generally speaking, smaller defects are easier to correct with STFs, and harder to address surgically. Treatment scenarios to consider include: any small depression on the nasal dorsum or sidewall, deficiency of the radix, supratip, columella, soft triangles, or pre-maxilla, an acute nasolabial angle, bifid nasal tip, notching or deficiency of the alar rims. As with primary nasal injections, the postoperative nose can be quite sensitive, so extending treatment duration by selecting longer acting products is beneficial. Again, thicker materials are favored, and small volumes can create dramatic changes. An individual puncture per treatment site is usually sufficient (Figure 1-19).

Lipodystrophy Large scale augmentation (sculpting) needed to address significant soft tissue volume loss can be achieved by using higher volumes of longer lasting, and thicker STFs. Fanning, cross-hatching, and layering may all be employed, as a smooth,

broad, and symmetric distribution will enhance outcomes in this application. It may be prudent to stage the treatment in 2 or 3 sessions at 4 to 6 week intervals to achieve a natural result without overcorrection.

Postoperative Care Immediately following the procedure it is wise to revisit each of the treatment sites and verify that there isn’t any active oozing. Take this opportunity to clean any dry blood, expressed material, or residual topical anesthetic from the face. Invite the patient to have a quick look with a hand-held mirror, and then apply ice or a cool compress to the treatment sites. Fifteen to twenty minutes of “on” and “off ” cooling as tolerated is generally sufficient to impede immediate swelling. Patients should then remain relatively inactive and with somewhat upright posture for several hours following the procedure to limit excessive blood flow to the face and subsequent swelling. They should be able to return to typical, nonstressful daily activities. Follow-up intervals depend largely on the experience level of the patient, the treatment sites involved, and the type of material used. The latter two variables have been discussed throughout the chapter. Patient experience relates to the patient’s comfort level with the procedure and the surgeon’s gestalt of any compliance, anxiety, or intangible issues that may exist with newer patients. It is advisable to offer a 1-2 week check-up for new patients to ensure their satisfaction and assess for touch-ups. Experienced

Figure 1-19. Before and after post-rhinoplasty augmentation.

Soft Tissue Fillers / 15

patients will generally know when to call for followup, or can be booked at regular intervals.

Complications Overall, complications from STF injections are rare. Of the possible adverse outcomes, however, the most common are typically related to technique. These would include asymmetry, lumpiness, dimpling, and insufficient or excessive augmentation. These problems can be addressed with touch-ups, massage, the passage of time, and reassurance. Some materials will have a variable response to injectable treatments such as hyaluronidase and steroids. Product extrusion can be seen in the immediate post-treatment phase or in the long term. Immediate extrusion from the injection site is typically caused by overzealous manipulation of the treated tissues by the surgeon or patient. Longer term extrusion may result from superficial placement of the product and should be managed expectantly. More serious complications are quite rare, but deserve mention. Allergic reactions are uncommon, particularly when anticipated and tested for with higher risk products. Standard treatment algorithms for allergic reactions can be followed and adapted given the severity of the allergic response. Antibiotics are not routinely given with STF augmentation, but should be employed if there is any evidence of infection. Infected treatment sites should be monitored closely and treated vigilantly. Formation of a hematoma may require expedient drainage. Intra-

vascular injection can be problematic with some larger materials (i.e., cross-linked collagen), but can be avoided by selecting a product with a profile that complements the treatment site, combined with proper product placement and knowledge of the anatomy. If blood flow has been impaired, vasodilating agents and blood thinners can be employed along with daily follow-up to monitor for progression of the condition or secondary complications such as infection. In the event of granuloma formation, steroid injections may temporize their growth, but an excision can offer definitive treatment.

Suggested Readings Glogau RG. Systematic evaluation of the aging face. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. London: Mosby, 2003, pp. 2357–2360. Johnson CM, Jr., Alsarraf R. The Aging Face: A Systematic Approach. W.B. Saunders Company, 2002. Johnson CM Jr, To WC. A Case Approach To Open Structure Rhinoplasty. W B Saunders Co, 2004. Koch RJ. An Overview of Facial Wrinkles. The Western Journal of Medicine 1997; 167(6), 428. Larrabee WF, Makielski KH, Henderson J. Surgical Anatomy of the Face, Second Edition. Lippincott Williams & Wilkins, 2003. Lowe NJ, Carruthers A, Carruthers E, et al. Textbook of Facial Rejuvenation: The Minimally Invasive Combination Approach. London: Marin Dunitz Ltd., 2002. Papel ID. Facial Plastic & Reconstructive Surgery, Second Edition. Thieme Medical Publishers, 2002. Tardy ME, Thomas JR, Brown R. Facial Aesthetic Surgery. Mosby-Year Book, 1995.

2 Botulinum Toxin Jeffrey D. Pollard, MD, Thomas H.M. Moulthrop, MD, and Calvin M. Johnson, Jr., MD

Introduction As discussed in the introduction to Soft Tissue Fillers (Chapter 1), there has been considerable growth in the field of facial cosmetic surgery. Part of the growth and evolution of this field is attributed to patients and physicians utilizing more noninvasive procedures. Treatment applications are increasing while medical contraindications are decreasing, thereby creating expansion of the treatment population, capturing younger and older patients. Fewer health and logistical restrictions allow for a relative ease of access to this form of treatment compared to traditional surgical procedures. Office-based treatment allows the surgeon to have more influence over the ambience and style of delivery, which also translates into convenient scheduling for patients and surgeons. In most situations they offer high yield results with limited recovery demands, coupled with a comfortable treatment experience. Botulinum Toxin (Btx) is another perfect example of this phenomenon. As with most soft tissue fillers, Btx does not offer a permanent solution. Nonetheless, transient therapeutic interventions may be preferable in many circumstances, especially when treating younger patients or those with conditions that are expected to resolve over time like Bell’s Palsy. Despite the inconveniences, there is value and comfort in knowing that patients can elect to return to their original appearance if they desire. Botulinum toxin is found in nature as a large molecule produced by the bacteria Clostridium botulinum. Although several types of the toxin are produced, type A (BTX-A) seems to have the most potent effect in humans. The toxin itself is quite

sensitive to heat, but otherwise relatively resistant to other environmental insults such as mild pH changes, enzymatic breakdown, and alcohol. All types are neurotoxins with a high affinity for the neuromuscular junction. The toxin binds to the presynaptic membrane, is internalized, and then released into the cytoplasm. It then disrupts the nerve cell’s ability to release acetylcholine. This is the focal point of the mechanism of action, and it is achieved by cleavage of specific SNARE proteins that facilitate acetylcholine vesicle binding and release at the presynaptic membrane into the synaptic cleft. The toxin catalyzes this cleavage process in the cytoplasm and thereby blocks the ability of the acetylcholine vesicles to fuse with the nerve membrane. Without the release of this vital neurotransmitter, the postsynaptic muscle cell remains in flaccid paralysis (Figure 2-1). The resulting paralysis or weakness can be marked, but is only temporary. This is likely caused by the combined effects of peripheral nerve sprouting and eventual repopulation of the effected SNARE proteins in the original terminal nerve ending. Baseline muscle function typically returns in about 4 months, but can be variable by as many as 6 weeks in either direction. Btx found its application in the treatment of facial rhytids because of its ability to weaken or paralyze muscles. The rhytids that are amenable to Btx therapy are those that form as a result of facial animation. These wrinkles occur naturally, over time, because of the repetitive and sometimes habitual contraction of the underlying facial musculature. As these muscles contract, they draw up the overlying

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Preformed visicles Acetylcholine within vesicles

Synaptobrevin (VAMP) (site for B,D,F & G)

SNAP-25 (site for A,C &E) SNARE proteins

Synaptio fusion complex Nerve terminus

Syntaxin Acetylcholine neurotransmitter released Acetylcholine

Synaptic cleft

Muscle cell

Acetylcholine receptor

Pre-synaptic Nerve Cell Membrane

Internalized botulinum toxin Botulinum toxin

Figure 2-1. The neuromuscular junction.

Botulinum Toxin / 19

skin which can, over time, lead to the formation of rhytids in a direction perpendicular to the vector of muscle contraction. By temporarily weakening or paralyzing the offending muscle, the skin is allowed to resettle and conform to the face without the dominant influence of muscle contraction. In most cases this will significantly alleviate (yet not typically erase) the appearance of rhytids. In some circumstances Btx therapy can be combined with soft tissue fillers or traditional surgical procedures to achieve maximum rhytid effacement. Although BTX-A is the most common neurotoxin used clinically for facial aesthetic treatment, there are other types (primarily type B [BTX-B]) that have been under active investigation. Some have advocated that BTX-B offers a solution to patients that have a limited response to BTX-A. In the future, these other types may gain ground in clinical usage because of better handling properties, duration of effect, or longer shelf life, however at this point the potency, availability, and proven clinical effectiveness of BTX-A have kept it in the limelight. As a general word of caution, it is important to remember that each type has a distinct potency and that there is not a 1:1 relationship when comparing units between types. As with all new products, it is important to review and become familiar with specific product labeling, manufacturer’s indications, and current FDA guidelines.

Use the detailed images in this chapter to locate these areas on the facial image: Forehead Crow's Feet Lip Area Chi Platysma

Figure 2-2. Targeted treatment sites.

Although Btx therapy is largely touted as a temporary solution to an inevitably worsening problem because of aging, there is a growing belief that there may be longer lasting secondary effects. For one, muscles held in flaccid paralysis may atrophy over time. As a result, when the neuromuscular junction does return to normal activity, the muscle will be weaker. Additionally, there may be changes in the underlying makeup of the skin. A reduction or cessation of the repetitive manipulation of the skin may allow for collagen replenishment at the base of the rhytids. Furthermore, with habitual muscle contraction, eliminating the end-action may, over time, disrupt the existing feedback loop and allow for retraining at the level of the central nervous system. Any or all of these factors may contribute to the longevity of Btx therapy and can play a valuable role in patient counseling.

Facial Analysis Facial analysis has a more immediate level of significance with Btx treatment because in many circumstances the treatment will be administered during the patient’s initial office visit. Therefore a rapid and accurate assessment must be made, and a focused and understandable treatment plan must be presented to the patient. Analysis is based on targeted facial regions that are amenable to Btx therapy (Figure 2-2).

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There are some special aesthetic applications for Btx that are not specifically related to rhytid effacement, but have other secondary effects based on the principle of selected muscle weakness. One such application is restoring facial symmetry in cases where there has been an insult to the facial nerve such as Bell’s Palsy or Vestibular Schwannoma. Another application is brow elevation by selective weakening of the orbicularis oculi muscle. The most common treatment indications can be grouped into facial regions (Table 2-1). During the evaluation, be aware of pre-existing facial asymmetry. In addition, do not lose sight of the fact that facial animation and the resulting rhytids are normal features of the human face. Facial animation is vital to expressing human emotions and over activity and relative lack of motion both can have a negative impact on human interaction. A hyperdynamic brow can carry just as much negative connotation as a frozen one. Thus it is advantageous to find a harmonious balance by creating a youthful appearance while maintaining adequate animation.

Figure 2-3. Muscles of facial expression: 1-corrugator supracilii and procerus complex, 2-frontalis, 3-orbicularis oculi, 4-levator palpebrae superioris, 5-zygomaticus minor, 6-zygomaticus major, 7-risorius, 8-orbicularis oris, 9-depressor anguli, 10-depressor labii inferioris, 11-mentalis, 12-platysma.

The mechanism of action of Btx is at the neuromuscular junction of the underlying muscle, thus any given treatment site must have an associated target muscle for there to be a treatment effect. Having a working knowledge of the anatomy of the muscles of facial expression is critical to understanding, evaluating, and treating rhytids with Btx (Figure 2-3). During the evaluation, the examiner should be able to visualize the underlying muscle groups in their mind’s eye and relate them to the surface features. Paring rhytids with muscles in this way will help the examiner differentiate which ones are most likely to respond to treatment.

Preoperative Considerations Approach Because Btx is often readily available for application, the surgeon must build a level of trust (rapport) with new patients in a more rapid sequence than is generally necessary with patients considering invasive procedures that require a longer consultation, deliberation, and scheduling period. Although the term “noninvasive” may convey a sense of security and immunity, due diligence is required on the part of the physician. In addition to obtaining a standard medical history, assessment of medications, and allergies, each patient should be asked targeted questions related to aesthetic facial Btx treatment (Table 2-2).

Contraindications One of the advantages of noninvasive procedures is that they are generally appropriate for a larger pool

TABLE 2-1 Regions And Treatment Sites of The Face And Neck Upper 1/3 of the Face

Periocular Region

Perioral Region

Cervical Region

Forehead rhytids Glabellar rhytids Brow elevation

Crow’s feet Lower eyelid muscle hypertrophy

Radial lip rhytids The chin

Platysmal banding Horizontal rhytids

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TABLE 2-2 Treatment Specific Questions

procedures, patients with unrealistic expectations should not undergo therapy.

Treatment-Specific Questions Allergies Neuromuscular conditions (myasthenia gravis, or Lambert-Eaton Syndrome) Peripheral motor neuropathies (amyotrophic lateral sclerosis) Medications (aminoglycoside or other medication that interferes with neuromuscular transmission) Past Btx treatment & response history Time of last Btx treatment History of infection at treatment site Active pregnancy/breast Feeding Pre-existing cardiovascular disease Eyelid ptosis Other currrent aesthetic facial treatments Pain/needle tolerance Specific expectations

of patients. However, there are a few contraindications for Btx which require attention. Btx is strictly contraindicated in patients with a known allergic response to any component of the product, or with a general history of severe anaphylaxis. Likewise, Btx should not be administered to a treatment site that is actively infected. Additionally, patients with neuromuscular conditions or peripheral motor neuropathies such as myasthenia gravis, amyotrophic lateral sclerosis, or Lambert-Eaton Syndrome are not appropriate candidates for treatment as they have an existing predisposition to muscle weakness that, if exacerbated, may affect vital body functions. Toxin effects may also be potentiated by co-administration of Btx with aminoglycosides or other agents that change neuromuscular transmission like curare-like depolarizing blockers, lincosamides, polymyxins, quinidine, magnesium sulfate, anticholinesterases, and succinylcholine chloride. Pregnant women and breast feeding mothers should typically avoid Btx injections until they have completed lactation. Patients with pre-existing cardiovascular disease may not be candidates for Btx. Eyelid ptosis and lower lid laxity are relative contraindications and care should be given when treating the periocular muscles in these patients as Btx can exacerbate these conditions. Other contraindications include autoimmune, dermatologic, or other systemic disorders that predispose to poor wound healing or an exuberant inflammatory response to tissue manipulation (e.g., the Koebner Phenomenon). Blood thinners can be considered a relative contraindication. Finally, as with all aesthetic

Consent Once a candidate is deemed to be appropriate for treatment, a formal consent process should ensue. Among other standard consent items, the patient should be counseled regarding the anticipated need for repeat injections (a general guideline is roughly four months). Furthermore, the relatively slow onset of action should be reinforced (up to 48 hours for noticeable changes, and roughly 1 week for maximal effect). Btx is often used for “off-label” (non-FDA approved) applications and, when applicable, this should be disclosed during the consent process. Btx is currently FDA approved for the treatment of glabellar rhytids in adult patients 18 to 65 years of age. Btx is prepared with human albumin and thus carries the potential for virally transmitted diseases or Creutzfeldt-Jakob disease – although there have been no reports of this occurring. Lastly, photographs should be consented to and obtained before and after the procedure.

Special Consideration About Preperation and Dosing of Botulinum Toxin There is a lack of interchangeability between Botulinum Toxin products. Units of biological activity of any particular Btx product cannot be compared to or converted into Units of any other Btx products. For simplicity, the dilution and dosing suggestions mentioned in this chapter are intended for use with onabotulinumtoxinA (Botox Cosmetic). This dosing is not the same as, or comparable to other botulinum toxin products such as abobotulinumtoxinA (Dysport). It is wise to adhere to the presribing guidelines included with the specific Btx product being used.

Setting Up The setup should be well thought out and practical. A simple tray would typically include a cleaning agent, topical anesthetic of choice, alcohol prep pads, gauze pads, needles, Btx in pre-loaded syringes, sterile gloves, an ice pack or cool compress, and a handheld mirror (Figure 2-4). BTX-A typically comes in a 100unit vial that needs to be reconstituted with 0.9% preservative-free sterile saline. Prior to reconstitution, it should be kept in refrigerated storage. The amount of saline added will determine the resulting number

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4.

5.

6.

Figure 2-4. Typical procedure setup.

of units per 0.1cc. Because the average desired dose per injection in facial aesthetics is between 2 and 5 units, the typical volume used for reconstitution is 2 to 5cc. The best method for delivery is via a tuberculin 1cc syringe. When using higer concentrations of Btx, another option that will yield greater control is to use a 0.3cc “insulin” syringe with a hubless 31-gauge needle. As an example then, if 4cc of diluent is used, each 1cc syringe would contain 25 units of BTX-A, and 2.5 units would be delivered with every 0.1cc injection. Keep in mind the number of units delivered is the standard measure, not the volume delivered, although larger volumes may lead to an increased area of diffusion per a given unit dose.

Technique As with soft tissue fillers, the nature of Btx therapy is typically repetitive. Therefore, particular attention must be paid to the delivery, results, and overall patient experience to solidify the patient’s confidence in the product and the surgeon. Attention to these details will increase the patient’s satisfaction and likelihood to follow up for additional treatment. The following is a recommended sequence of events that can be applied to any treatment site. Site-specific considerations will be discussed in the following section. 1. Prepare the patient for the experience. 2. Clean the face to remove make-up. 3. Depending on the patients expectations, experience, and pain tolerance, address the need for

7.

8.

9.

10.

anesthesia (typically topical). Approaches to anesthesia include one or any combinat-ion of: verbal reassurance, auditory diversion with soft music, distraction by stimulating a separate pressure point, ice, or topical agents like betacaine. Keep the patient in a comfortable semi-recumbent or upright position. This will maintain the natural appearance of the treatment site and allow for better judgment during the procedure. Prepare the treatment site with a sterilizing agent like rubbing alcohol. Alcohol should be allowed to completely dry before the administration of Btx. Prime the syringe until the solution is expressed at tip of the needle. A 30- or 31-gauge needle will allow for a more controlled and comfortable injection. Insert the needle to a depth that is soundly into the bulk of the target muscle and slowly inject the desired number of units. Injections into the deep dermis or subcutaneous fat have a limited application and rely entirely on diffusion of the Btx through additional tissue plains. After the injection, withdraw the needle and apply pressure over the puncture site with a gauze pad. Know the treatment layout well and work through the treatment site in a smooth and methodical manner. Maintaining communication with the patient throughout the session often helps improve their comfort level and keeps them apprised of the progress being made. Changing needles frequently will allow for a less tissue trauma and a more comfortable experience.

Upper One-Third of The Face Forehead Rhytids (Figure 2-5) The forehead dominates the area of the upper onethird of the face. The forehead and the underlying frontalis muscle play a significant functional role in human expression (Figure 2-6). The forehead, however, tends to offer very little when it comes to improving ones overall aesthetic appearance. In fact, the forehead is often partially obscured from view by hair and hats. Generally, the forehead tends not to add anything significant to facial aesthetics, however it can significantly detract from it. The impact of Btx at the level of the forehead is two-fold. The functional gain is the minimization of

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Figure 2-5. Forehead region.

hyperdynamic forehead movement which can lessen the visual impact of “shocked” and “surprised” expressions. The aesthetic gain is in reduction of the horizontal rhytids that contribute to an aged appearance and distract the focus of an observer away from the middle one-third of the face. A typical treatment layout for BTX-A therapy to the forehead would involve two to seven injection

Figure 2-6. Forehead treatment sites.

sites depending on the degree of involvement of the forehead. The injection sites can be grouped based on symmetry and employed as series of injections as needed to address the underlying musculature. An average treatment may deliver 10 to 15 units. Patients will typically experience a return of baseline function at roughly 4 months (Figure 2-6 and Figure 2-7).

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Pitfalls Excessive, inferior, and unopposed weakening of the frontalis (in the absence to reciprocal treatment of the glabellar complex of muscles) may result in an overall downward and medially rotated displacement of the brow. This contributes to a stern, angry, or quizzical appearance. Exacerbation of upper crow’s feet rhytids as a result of accentuated brow ptosis can also be seen following overtreatment of the forehead. Injections should generally be avoided within a 1 cm margin from the edge of the supraorbital rim, most importantly at the midpupillary line where diffusion can affect the upper eyelid levator. Adjustments to the treatment layout need to be made when treating patients with smaller versus larger forehead heights.

Glabellar Rhytids (Figure 2-8)

Figure 2-7. Before and after forehead Btx treatment.

The glabella was the first and remains the only FDAapproved site for aesthetic usage of Btx. Because of the orientation and habitual contraction of the corrugator and procerus muscles, the glabella has the potential to develop deep and striking rhytids, often referred to as “frown lines.” Again, these features contribute to a stern, angry, or quizzical expression. And again, the impact of Btx is twofold. There is a functional gain by minimizing the

Figure 2-8. Glabellar region.

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Figure 2-9. Glabellar treatment sites.

negative connotation of hyperdynamic muscle activity at the glabella, and aesthetic relief by secondary effacement of glabellar complex rhytids. Although soft tissue fillers can help efface these furrows, Btx should be considered as the first line of therapy in this region. A typical treatment layout for BTX-A therapy to the glabellar region would involve five injection sites. An average treatment may deliver 10 to 15 units. Patients will typically experience a return of baseline function at roughly 4 months (Figures 2-9 and 2-10).

brow. The reality is that this is generally possible to achieve clinically, although there is somewhat wide variability in results between patients and treatment sessions. Furthermore the benefits, when present, are typically modest. Nonetheless, when achieved, it provides for a nice secondary gain that can complement the results of primary forehead and glabella

Pitfalls Ptosis of the upper eyelid is the major concern when treating the glabella and brow with Btx. Injections should generally be avoided within a 1 cm margin from the edge of the supraorbital rim, most importantly at the midpupillary line where diffusion can affect the upper eyelid levator. Should significant ptosis occur, eye drops containing adrenergic agonists can be used to stimulate Müller’s muscle.

Brow Elevation (Figure 2-11) Because Btx therapy has the ability to selectively weaken directional muscle pull, it has been debated whether brow elevation can be achieved by comparatively increasing upward vector strength in strategically advantageous places about the

Figure 2-10. Before and after glabellar Btx treatment.

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Figure 2-13. Before and after brow elevation Btx treatment.

Figure 2-11. Brow elevation. Orbicularis oculi

treatment, and demonstrates the advantages and challenges of striving for perfection by using clinical finesse (Figure 2-12 and Figure 2-13).

The Periocular Region Crow’s Feet and Lower Eyelid Muscle Hypertrophy (Figure 2-14) The fan-like rhytids of the temple that converge on the lateral canthus are commonly referred to as Figure 2-14. Periocular region.

x

x

x

Series 1

x

Series 2

Figure 2-12. Treatment layout of brow elevation.

“crow’s feet.” The crow’s feet form in a radial fashion because of the underlying orbicularis oculi muscle. Thin skin, smoking, and sun exposure contribute to the incidence and prominence of these wrinkles. Crow’s feet create a tired, aged, and weathered appearance. In addition to the crow’s feet, the orbicularis oculi muscle can contribute to a mounded appearance of the lower eyelid which is exacerbated when smiling. This is caused by hypertrophy of the pretarsal orbicularis oculi muscle. When treated conservatively in the appropriate candidate, Btx can result in a reduction of this dynamic muscle bunching. During the evaluation, true muscle hypertrophy should

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x

x

x

x

x

x

x

Series 1

x

Series 2

Figure 2-15. Periocular treatment sites.

be differentiated from simple redundancy of the lower eyelid skin (a problem not amenable to Btx). Palpation of the orbicularis oculi muscle during forced eyelid closure can give the examiner a better sense of the lateral extent of the target muscle. A typical treatment layout for BTX-A therapy to the crow’s feet would involve four to six injection sites depending on the size and degree of regional involvement of the orbicularis muscle. The injections can be employed as a series of injections as needed to address the underlying musculature. An average treatment may deliver 10 to 15 units on each side of the face. Patients will typically experience a return of baseline function at roughly four months (Figure 2-15 and Figure 2-16).

Pitfalls It is important to recognize that the orbicularis oculi muscle contributes only partly toward the formation of “smile lines” (which may include the inferior crow’s feet lines). Smile lines are due in part

to the zygomaticus muscles upward distribution of skin into the periorbital region. These lines should be noted and pointed out to the patient during the evaluation, not only because the animation contributes to a happy, youthful appearance, but because treating the zygomaticus muscles is not advised and may lead to facial droop. As with glabellar and brow treatment, injections should not be placed within a 1 cm margin of the bony orbital rim. Injections too close to the lateral canthus may result in weakness of the lateral rectus muscle and diplopia. Additionally, too much Btx treatment to the crow’s feet can result in a reduced ability to show empathy via facial animation and can be perceived as insincerity. Treatment of lower eyelid hypertrophy may result in net widening of the palpebral fissure as well as lower lid laxity. Upper eyelid ptosis (as mentioned with previous treatment sites) is also a concern. Therefore, In addition to the general contraindications mentioned previously in the chapter, patients with lagophthalmos, ectropion, or significantly dry eyes should be avoided or treated with extreme caution when using Btx in the periorbital region.

The Perioral Region Radial Lip Rhytids & the Chin (Figure 2-17) While Btx is probably not the best single agent approach to management of perioral wrinkles and rhytids of the lower one-third of the face, it can offer modest relief in specific areas. As with other treatment regions, the goal should be subtle weakening of the target muscles, not paralysis, as this can lead to an aesthetic and functional disaster. Even slight

Figure 2-16. Before and after periocular “Crows Feet” Btx treatment.

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6

5

7 8 9

10

11

12

Figure 2-17. Perioral region and chin.

muscle weakness may be unacceptable in patients who depend on accurate perioral muscle control like wind-instrument musicians. The orbicularis oris muscle, smoking, age-related volume loss, and sun exposure are the primary causes for radial rhytids about the lips. These lines that encroach on and violate the vermillion are often a source of “lipstick bleeding” and contribute to an aged, worried, and weathered appearance. A conservative approach is needed when addressing the orbicularis oris. It is often beneficial to counsel patients that small doses administered in an incremental fashion will help to prevent ex-

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X X

X

cessive weakening of the lips. A typical treatment layout for BTX-A therapy to the orbicularis oris would involve 2 to 3 sites on each effected lip. An average starting point may be as little as 1/2 unit per injection site. Upon re-evaluation at 1-2 weeks, an incremental increase can be made using an additional 1/2 unit per injection site as needed. Continue in this mannor until the optimal response is acheived. The cumulative dose may now be used as a baseline estimate applied to subsequent treatments. Furrows, wrinkles, and asymmetry of the chin can all be caused by hyperdynamic activity of the mentalis muscle. Fortunately, this is the best perioral target muscle to treat with Btx because it is relatively simple to inject, effective, consistent, and there aren’t any other forms of therapy that can achieve as much in this area with a single injection. A typical treatment layout for BTX-A therapy to the chin would involve two injection sites. An average treatment may deliver 5 to 7 units. Patients will typically experience a return of baseline function at roughly 4 months (Figure 2-18 and Figure 2-19).

Pitfalls As with perioral soft tissue fillers (which are wonderful stand-alone or adjunctive products in this area), Btx may have a decreased length of effect because of the relative hypermobility of the perioral complex. Patients should be counseled regarding this tendency.

X X

X Series 1 X Series 2

Treatment Layout perioral region

X

X

Figure 2-18. Chin treatment sites.

Botulinum Toxin / 29

Injections should remain superficial and should be placed symmetrically from the midline when treating lip lines, so as not to create asymmetry or affect the lip elevators and depressors. Small volumes and doses should be employed to prevent unwanted diffusion and incompetency of the lips. Patients with a cleft chin have a midline mentalis muscle diastasis and should therefore have two lateral treatment injections to allow for delivery of the Btx into the belly of each muscle band. When treating the mentalis muscle, care should be taken not to inject the more superiorly oriented orbicularis oris muscle or the more laterally oriented depressor labii inferioris muscles.

The Cervical Region Platysmal Banding & Horizontal Rhytids (Figure 2-20)

Figure 2-19. Before and after lip or chin Btx treatment.

The platysma muscle envelopes the deeper contents of the neck and is continuous with the superficial musculoaponeurotic system (SMAS) of the face. With age and use, this muscle can form vertical banding along the length of the anterior neck. They are classically formed at the anterior-free margin of the muscle, however they can also appear more laterally toward the middle or posterior edge of the muscle. These bands can cause a stressed or strained

Sternocleidomastoid muscle Esternal Jugular vein Platysma muscle

Figure 2-20. Cervical region.

30 / Botulinum Toxin

appearance and can be distracting to the observer’s eye. Horizontal cervical rhytids may also form over time. Much like the forehead, the neck tends not to add anything significant to facial aesthetics, and can significantly detract from it. Fortunately, Btx therapy to the platysma can be quite effective and has clear advantages when compared to the more invasive options of platysmaplasty or SMAS incorporating facelift procedures. A typical treatment layout for BTX-A therapy to the neck would involve two to three injection sites per muscle band. The injection sites can be grouped based on the number of bands and employed as series of injections as needed to address the underlying musculature. An average treatment may deliver 5 to 7 units per muscle band. Patients will typically experience a return of baseline function at roughly 4 months (Figure 2-21).

Pitfalls When treating the platysma, superficial (erring on pre-platysmal) injections are crucial so as not to risk weakening the deeper muscles that facilitate speech and swallowing.

Special Applications Hemifacial Paralysis Conditions like Bell’s palsy or vestibular schwannoma can leave patients with temporary or permanent hemifacial weakness or paralysis. The resulting asymmetry has aesthetic implications. In an effort to provide the face with more favorable balance or

symmetry, Btx therapy can be used to selectively weaken target muscles on the contralateral side of the face. Managing patients with these conditions requires a more clinical judgment because there is no inherent symmetry to the treatment layout. Because of this fact, accurate and methodical record keeping is essential to providing consistent therapy over time. To complicate matters, underlying conditions that are evolving (such as Bell’s palsy in the resolution phase) present the challenges of dynamic treatment conditions from session to session. Despite these challenges, even the most subtle changes can often times bring great satisfaction to these patients.

Postoperative Care Immediately following the procedure, it is wise to revisit each of the treatment sites and verify that there isn’t any active oozing or hematoma formation. Take this opportunity to clean any dry blood or residual topical anesthetic from the face, and then apply ice or a cool compress to the treatment sites. Fifteen to twenty minutes of “on” and “off ” cooling as tolerated is generally sufficient to impede immediate swelling. Because muscle activity can expedite the uptake of the neurotoxin, patients should make an effort to use the target muscles more than their baseline activity over the ensuing 1-2 hours. Because the Btx is injected in a liquid form, it is advisable to refrain from any deep manipulation of the tissue (such as massage) for roughly 48 hours due to the possibility of unintended diffusion to non-targeted muscle groups and subsequent com-

Figure 2-21. Cervical treatment sites.

Botulinum Toxin / 31

plications. Remaining relatively inactive and with somewhat upright posture for several hours following the procedure is always helpful in limiting excessive blood flow to the face and subsequent swelling following any injection procedure. Patients should, however, be able to return to typical, nonstressful daily activities. Follow-up intervals depend largely on the experience level of the patient, the historical trends collected for any given patient, and the treatment sites involved. The latter variable has been discussed throughout the chapter. Patient experience relates to the patient’s comfort level with the procedure and the surgeon’s gestalt of any compliance, anxiety, or intangible issues that may exist with newer patients. It is advisable to offer a 1-2 week check-up for new patients to ensure their satisfaction and assess for touch-ups. Experienced patients will generally know when to call for follow-up, or can be booked at regular intervals.

Complications Overall, complications from Btx injections are rare. Of the possible adverse outcomes, however, the most common are typically related to technique. These would include localized pain, inflammation, tenderness, swelling, erythema, bleeding, bruising, asymmetry, insufficient or excessive muscle weakness at the target site, and regional muscle weakness or paralysis as a result of diffusion. All of these problems can be addressed with conservative measures, the passage of time, and reassurance. Touch-ups can be used when the initial treatment is insufficient after a reasonable amount of time. Specific regional complications were discussed in each section dedicated to specific treatment sites. It should again be mentioned that there is a lack of interchangeability between Botulinum Toxin products. Dosing errors could result in unintended aesthetic consequences and medical complications. It is wise to adhere to the prescribing guidelines included with the specific Btx product being used. More serious complications are quite rare, but deserve mention. Allergic reactions and anaphylaxis are uncommon. Standard treatment algorithms for

allergic reactions can be followed and adapted given the severity of the allergic response. Antibiotics are not routinely given with Btx therapy, but should be employed if there is any evidence of infection. Infected treatment sites should be monitored closely and treated vigilantly. Formation of a hematoma may require expedient drainage. Arrhythmias, myocardial infarction, seizure, syncope, exacerbation of myasthenia gravis, and acute angle closure glaucoma are discussed in BTX-A product inserts albeit without specific evidence of causal relationships in most cases. Suffice it to say that people with significant underlying disease that would predispose for one of these conditions should be screened for during the analysis. Treatment may result in the formation of measurable amounts of antibodies in some patients. The incidence of this can probably be reduced by using fewer units per treatment and increasing the time interval between treatments. Neutralizing antibodies can cause a muted or absent therapeutic response, and can show cross-reactivity between Btx types. Generally speaking, the relatively small doses used in aesthetic facial treatment probably portend to a very small percentage of patients that actually develop antibodies. By avoiding excessive use of Btx, a patient’s long-term benefit can be maximized.

Suggested Readings Glogau RG. Systematic evaluation of the aging face. In: Bolognia JL, Jorizzo JL, Rapini RP, editors. Dermatology. London: Mosby, 2003, pp. 2357–2360. Johnson CM, Jr., Alsarraf R. The Aging Face: A Systematic Approach. W.B. Saunders Company, 2002. Koch RJ. An Overview of Facial Wrinkles. The Western Journal of Medicine 1997; 167(6), 428. Larrabee WF, Makielski KH, Henderson J. Surgical Anatomy of the Face, Second Edition. Lippincott Williams & Wilkins, 2003. Lowe NJ, Carruthers A, Carruthers E, et al. Textbook of Facial Rejuvenation: The Minimally Invasive Combination Approach. London: Marin Dunitz Ltd., 2002. Papel ID. Facial Plastic & Reconstructive Surgery, Second Edition. New York: Thieme Medical Publishers, 2002. Tardy ME, Thomas JR, Brown R. Facial Aesthetic Surgery. Mosby-Year Book, 1995.

3 Laser Skin Resurfacing Vishal Banthia, MD, Basil M. Hantash, MD., PhD and R. James Koch, MD

Introduction

Facial Analysis

Although surgical repositioning maintains a fundamental role in facial rejuvenation, it fails to completely address the overlying aged skin. This has led to the emergence of laser resurfacing devices, which, via a different approach, enhances the overall quality of photo-damaged skin, especially in younger patients and other nonsurgical candidates. The goal of laser resurfacing is to render aged skin more youthful and radiant by improving dyspigmentation, wrinkles, and scars, as well as potentially reducing the risk of skin cancer. Thus far, two different types of laser resurfacing have been developed-nonablative and ablative. Generally, nonablative resurfacing is utilized in cases where superficial retexturing is not required because its main mechanism of biological action involves inducing a thermal injury in the dermis and subsequent remodeling of collagen. Sparing of the epidermis is usually achieved through adjunctive surface cooling. On the other hand, ablative laser resurfacing is the current gold standard for skin tightening and textural enhancement, as it removes the entire epidermis and parts of the dermis in an attempt to regenerate fresh vibrant skin in place of photo-damaged skin. Other ablative resurfacing modalities include dermabrasion and chemical peels, both of which will be described in other dedicated chapters within this volume. This chapter discusses ablative laser resurfacing techniques, beginning with an elaboration of the key historic successes and ending with a brief introduction on the current cutting edge developments entering the market.

Analysis of facial skin begins with the fundamental understanding of aesthetic and basic anatomic principles. The use of aesthetic subunits to divide the face is a common practice and is based on underlying bony facial contours and similarities in skin texture and color (Figure 3-1). A strong command over these subunits allows the experienced physician to appropriately tailor the treatment of each subunit in order to avoid post-treatment irregularities, especially in transition zones. The skin is made up of three main layers known as the epidermis, dermis, and hypodermis

Figure 3-1. Facial aesthetic subunits: forehead, periorbital, nose, cheek, and perioral regions.

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Stratum Granulosum Stratum Corneum

Epidermis

Stratum Spinosum Stratum Basale

Papillary Dermis Reticular Dermis

superficial fascia

Figure 3-2. Cross-sectional anatomy of the skin demonstrating its layers.

or subcutaneous fat (Figure 3-2). The epidermis forms the most superficial layer with a specialized outer barrier made of nonliving keratinized cells, the stratum corneum. The epidermis also contains a metabolically active layer of stem cells known as the stratum basale, which is responsible for the constant skin regeneration. Four cell types have been identified in the epidermis thus far, and include keratinocytes, melanocytes, and Langerhans’ and Merkel cells. Keratinocytes are the predominant cell type within the epidermis and can be found in different stages of differentiation from least to most as one moves from deeper to more superficial layers. Pigment-producing melanocytes (i.e., melanin) are found within the basal layer of the epidermis and deserve special mention because their destruction or stimulation during resurfacing may clinically manifest in hypo- or hyperpigmentation. The underlying dermis represents the main source of nourishment for the overlying avascular epidermis. The dermis also houses peripheral nerve fibers, collagen, elastic fibers, fibroblasts, adnexal appendages, and extracellular matrix. The dermis consists of two main arbitrary divisions, the upper and thin papillary dermis and the deeper and thicker reticular dermis. Chronic sun exposure as well as intrinsic aging result in epidermal thinning, slowed epidermal renewal, decreased collagen content, the accumulation of solar elastosis (damaged elastin) in the dermis, and loss of subcutaneous fat. Cutaneous laser resurfacing allows the treating physician

to slow or reverse some of these changes by stimulating neocollagenesis and epidermal turnover and regeneration. In cases where the epidermis is fully removed, intradermal appendages (i.e., pilosebaceous units and apocrine and eccrine glands) provide a source of epidermal stem cells capable of epithelial regeneration. For this reason, the laser surgeon must exercise caution when resurfacing appendage-poor areas such as the neck to lessen the risk of poor wound healing and scarring.

Preoperative Assessment Aesthetic surgeons must always balance achieving optimal results while minimizing the risks of adverse events. A key to this end, is first determining the needs of each patient and performing an accurate and detailed preoperative evaluation. It is critical that all physicians ensure all patients maintain realistic expectations to avoid post-treatment disappointment. The risks of overly aggressive treatment should also be clarified while providing a full spectrum of methods to approach the patient’s specific aesthetic concern. The postoperative course and care should be fully explained, so the patient can respond appropriately to ensure a smooth recovery. The history should elicit factors that may impair wound healing and potentially increase the risk of scarring and other complications. Absolute contraindications for ablative resurfacing include unrealistic patient expectations, active acne, collagen

Laser Skin Resurfacing / 35

vascular or connective tissue disorders, keloid predisposition, and isotretinoin (Accutane, Roche Pharmaceuticals, Nutley, NJ) use within the past 12 months. In addition to decreasing epidermal turnover, isotretinoin targets and compromises sebaceous gland function which also impairs skin reepithelialization. Relative contraindications include a history of herpetic infections, psoriasis, diabetes mellitus or other immunodeficiency state, smoking, pregnancy, and skin hypersensitivity (to topical sunscreen, makeup, and ointments). A history of previous chemotherapy, radiation exposure, and chemical/laser peels may also be relevant in certain cases. It is always a good practice to perform a patch test before performing the full treatment, to gauge the skin reaction to ablative laser resurfacing, especially in patients with Fitzpatrick skin types IV to VI for reasons discussed below. Physical examination should highlight areas of photoaging, including dyschromias, scars, actinic changes, and epidermal growths. The type of resurfacing modality to employ depends upon key guiding principles: (1) subunits affected by pathology (i.e., one subunit vs. full face); (2) depth of pathology; (3) wrinkle severity; and (4) classification of sun-reactive Fitzpatrick skin type (Table 3-1). Several wrinkle severity schemes have been described including the Glogau classification which grades skin from I (mild) to IV (severe) based upon rhytids and photoaging. As a general rule, patients with higher Fitzpatrick skin types are at greater risk especially for developing pigmentary complications and should be treated with caution. After laser resurfacing, postinflammatory hyperpigmentation occurs in approximately 20-30% of patients with skin type II while 90-100% patients with skin types IV or higher are affected. The authors typically exclude patients with type VI skin as ablative resurfacing candidates although superficial peels (i.e., glycolic acid) and TABLE 3-1 Fitzpatrick Sun-Reactive Skin Types Skin Type

Skin Color

Tanning Response

I II

White White

III

White

IV V

Brown Dark Brown

VI

Black

Always burns; never tans Usually burns; tans with difficulty Sometimes mild burn; tan average Rarely burns; tans easily Very rarely burns; tans very easily No burn; tans very easily

fractional laser resurfacing as described below may be options to consider. Whether pretreatment with skin lightening agents reduces the incidence of hyperpigmentation remains controversial; however, the authors routinely pretreat patients with types IV or V skin (Asian and Hispanic descent, respectively) or those anticipated to have hyperpigmentation problems with a combination cream containing hydroquinone 4-8%, hydrocortisone 1%, Retin-A 0.05% to 0.1% at twice per day dosing for 4-6 weeks. Such a preoperative regimen may in fact increase epidermal turnover in all skin types and hasten the reepithelialization process. A thorough understanding of resurfacing techniques and the associated advantages and disadvantages will aid the facial surgeon in selecting the most appropriate treatment modality that meets the unique objectives of each patient. Table 3-2 offers a general comparison strategy for cutaneous resurfacing that matches ideal patient characteristics with a particular resurfacing method. At the conclusion of the preoperative visit, standard preoperative photographs are taken. For ablative procedures, prophylactic medications, and postoperative instructions are provided for patient review. Blood-thinning medications including aspirin, nonsteroidal anti-inflammatory drugs, vitamin E, and herbal therapies are generally not discontinued for laser resurfacing, although following this practice may decrease the severity of oozing postoperatively. Prophylactic medications include oral antibiotic and antiviral agents. Typical regimens include ciprofloxacin, 500 mg twice per day for 7-10 days, for Pseudomonas coverage; valacyclovir, 500 mg twice per day for 10 days for herpes prophylaxis. Some encourage double coverage with a cephalosporin in addition to ciprofloxacin. The antibiotics and antiviral agents are begun 1 and 2 days prior to the procedure, respectively. When local and topical anesthesia are employed, patients are also prescribed diazepam 10 mg, one to two tablets of 5 mg hydrocodone/500 mg acetaminophen, and compazine 10 mg to be taken 3045 minutes prior to the start of the procedure. Since laser plumes pose a risk of exposure to bloodborne pathogens, a mask should be worn during the procedure and, in certain cases, the surgeon may consider obtaining preoperative laboratory investigations including a hepatitis panel and HIV screen. A final point of discussion in the preoperative consultation involves anesthesia. Topical lidocaine

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TABLE 3-2 Resufacing Techniques: Advantages and Disadvantages Resurfacing Technique

Advantages

Disadvantages

Nonablative

• No to minimal downtime • Not technically demanding • No to minimal postoperative cleansing regimen • May be used on all skin types

Dermabrasion

• Equipment and setup costs minimal • Minimal thermal damage to deeper/surrounding tissues

• Expensive equipment costs • Minimal clinical improvement • Minimal long-term data • Inconsistent reproducibility of desired clinical results • Technically difficult and requires significant experience • Risk of exposure to airborne pathogens • Postoperative cleansing and care regimen

Chemical Peels

• Equipment and set-up costs minimal • Large area can be treated quickly • Not technically demanding • Superficial peels may be used safely and effectively on Type IV or higher skin types (glycolic, TCA 25%)

Laser Resurfacing (Pulsed CO2, Er:YAG)

• CO2 laser resurfacing is almost bloodless • Easier to discern endpoints of treatment • Precise depths of ablation • Risk of airborne pathogen transmission minimal • Collagen remodeling can occur • Post-operative results can be remarkable

is applied 1 hour prior to the procedure and 0.25% marcaine with 1:200,000 epinephrine is used for nerve blocks. Subdermal local anesthetic using 1%

• Blind procedure (depths and endpoints may be inaccurate and difficult to control) • Potential errors in preparation of desired concentration of peel • Phenol peel requires monitoring if used for multiple subunits • Highly concentrated TCA (50% or higher) has poor safety margin • Postoperative cleansing and care regimen • Cost of equipment • Longer set-up time and requires more specific safety measures • Suboptimal hemostasis associated with traditional Er:YAG • Longer downtime, especially after CO2 resurfacing • Risks increase significantly with skin types IV and higher • Postoperative cleansing and care regimen

Ideal Patient Characteristics • Younger patients (30-40s) • Mild and fine rhytidosis especially in crow’s feet area • Limited photodamage • Melasma • Localized regions with depressed surface irregularities (i.e., deep pitted acne scars) • Isolated scar/scar revision • Perioral rhytids • Younger patients (ages 35-50) • Superficial mild to moderate rhytids • Perioral rhytids (deeper peels)

• Older patients (ages 55 and above) • CO2: Moderate to severe rhytidosis • Er:YAG: mild to moderate rhytidosis

lidocaine with 1:100,000 epinephrine may be necessary in some areas, particularly in the immediate preauricular area. Although optional, at least some

Laser Skin Resurfacing / 37

intravenous sedation is recommended for deeper laser resurfacing.

Technique General Considerations Relative to resurfacing techniques such as dermabrasion and chemical peels, ablative laser resurfacing permits more precise control over depth of injury with the adjunctive benefit of thermal coagulation of the dermis. The latter effect is responsible for collagen tightening as well as dermal remodeling. Over the past decade, there have been two major laser wavelengths employed for ablative laser resurfacing: pulsed carbon dioxide (CO2) at 10,600 nm and erbium:yttrium-aluminum-garnet (Er:YAG) at 2,940 nm. Both laser wavelengths utilize the principle of selective photothermolysis and rely on water as the chromophore. Er:YAG laser systems produce less tissue ablation (an average of 20 μm versus 62.5 μm for CO2) and less surrounding thermal damage. The pulsed CO2 laser has been shown to ablate less tissue with each pass while generating larger zones of thermal coagulation. Hence, Er:YAG laser resurfacing may be reserved for those patients with less severe and more superficial photodamage while pulsed CO2 is more appropriate for those with deep, severe rhytidosis and for those willing to accept the associated prolonged downtime. Typical Er:YAG resurfacing lasers, however are limited by poor intraoperative hemostasis and suboptimal clinical results, but combination Er:YAG and subablative CO2 systems have been developed to combat these pitfalls. Many laser surgeons believe that the dual mode laser systems yield aesthetic results comparable to the pulsed CO2. Regardless of which laser system is used, clear improvement with respect to mild to severe photodamage, acne scars, epidermal growths, and generalized elastosis is generally observed. In recent years, there has been a decline in the popularity of full face laser resurfacing because of the associated downtime, potential complications (in particular, delayed hypopigmentation), and significant postoperative care. To overcome these limitations, a novel technology involving fractional photothermolysis has been developed and will be discussed below. To date, significant longterm clinical efficacy has only been demonstrated with ablative resurfacing treatments such as the pulsed CO2.

TABLE 3-3 Instruments and Materials for Ablative Laser Resurfacing • Pulsed CO2 or Er:YAG laser system with computer pattern generator • Sterile gloves, masks to filter 0.1 μm laser plume particles • 4×4” gauze and cotton-tipped applicators soaked in saline, damp sterile cloth towels • Smoke evacuator • Metallic eye shields, tetracaine 0.5% eye drops • Wavelength appropriate eye protection for staff • Laser-safe endotracheal tube (if performing under general anesthesia) • Wet tongue blade • Emollient (e.g., Aquaphor) or biosynthetic dressing • Bactroban ointment (for application to nares)

Pulsed CO2 Laser Resurfacing In general, full face laser resurfacing involves 1 hour of procedural time. Table 3-3 lists the key instruments and materials necessary for ablative laser resurfacing. Initial precautionary measures involve testing the laser on a tongue blade prior to treating the patient, placing moist towels around the areas of treatment, and positioning protective eye gear. After inserting topical anesthetic eye drops (e.g., tetracaine 0.5%), lubricant-coated metallic eye shields are placed over the patient’s eyes. A smoke evacuator is used to suction airborne particles. • The patient’s skin is prepared using a nonflammable cleansing agent (i.e., saline). • As laser systems vary, recommended manufacturer settings are used. Energy settings below that which are recommended should never be used. Turning the power too low forces heat into the tissue instead of the laser vapor. At typical settings, pulsed CO2 ablates 50-150 μm per pass. • Using the computer pattern generator, single pulsed vaporizations are administered without leaving gaps in between treatment areas while avoiding overlap. Excessive overlap of the pulsed areas results in unwanted thermal damage. Leaving gaps between the pulse patterns, however, will result in a streaky appearance. • The forehead unit is treated first as this area is generally the easiest to perform. The hairline and eyebrows should be moistened to avoid singeing. Treatment is carried subtly into the hairline. Deeper rhytids are treated by direct lasering into furrows with a finer handpiece beam.

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• The first ablative pass removes epidermis; with the second pass, tissue tightening in the dermis is apparent. Fine lines and acne scars require 2-3 passes. Acne scars may require additional sculpting passes to blend edges with surrounding tissue. • After the first pass, grey-whitish tissue debris remains and can be wiped away with salinesoaked gauze prior to the next laser pass. If the patient has only mild photoaging, they may only require one pass. • In general, subsequent passes are performed at reduced fluences and density but not lower than that recommended by the laser manufacturer. The authors rarely perform more than two regional passes on the eyelids and more than three passes for other facial areas. The most common areas requiring multiple passes include glabellar/ forehead, perioral, and Crow’s feet areas. • For the perioral area, the treatment is extended just up to the vermilion border so that the lips appear fuller. Extension into the lips will blunt the vermilion border. The inferior border is feathered approximately two fingerbreadths below the jawline to avoid an abrupt demarcation line. • The laser surgeon must be wary of lasertissue interactions as well as the endpoint of resurfacing. In general, a pink appearance of tissue heralds the papillary dermis, and grey the upper reticular dermis. A yellowish or chamoisbrown appearance denotes the midreticular dermis (Figure 3-3). These tissue color changes are unique to the heating properties of the pulsed CO2 laser. The endpoint of treatment is signaled

Figure 3-3. The chamois appearance in the perioral region indicating endpoint depth in the midreticular dermis after CO2 laser resurfacing. Other visualized depths are the upper papillary dermis (pink) and the upper reticular dermis (gray).

by complete removal or effacement of the lesion, wrinkle, or scar although the absolute endpoint is reaching the level of the midreticular dermis. A fan can also be used to help ease any burning sensation experienced by the patient. This usually remits within 20 minutes. Immediately after resurfacing, the areas treated are covered with an occlusive dressing. Bactroban ointment is topically placed into the nares with a cottontipped applicator. • Laser resurfacing can be performed regionally especially for the periorbital and perioral subunits. Once two or more aesthetic subunits are resurfaced, it is generally appropriate to treat the entire face to avoid unsightly demarcation. If a regional procedure is performed, the aesthetic unit is blended in its boundaries for optimal camouflage. This can also be achieved using chemical peels. If combining a laser resurfacing procedure with a chemical peel, the peel must be performed first to avoid uncontrolled penetration of the peel into the skin. When laser resurfacing is used as an adjunct to surgery (i.e., rhytidectomy), treatments can be applied safely to areas where a skin flap has not been raised. Typically, periorbital and perioral regions are resurfaced in conjunction with surgery. Given the risk of vascular compromise to the skin, full-face laser resurfacing is generally reserved until 6-8 weeks after a facelift.

Pulsed Er:YAG Laser Resurfacing • Patient preparation and resurfacing techniques are essentially similar to those of pulsed CO2 although pulses are overlapped by 10%. At typical manufacturer-recommended settings, a single pass with the Er:YAG laser ablates approximately 20-30 μm per pass. • Unlike with CO2 resurfacing, minimal tissue debris is produced after each pass; therefore, wiping is not performed after each pass and residual debris may actually be removed by the Er:YAG laser treatment itself. Because there is minimal radial thermal coagulation, characteristic skin depth-color changes seen with pulsed CO2 laser are not observed. Instead, pinpoint bleeding is used as an indication of papillary dermal depth. Typically, 3-5 passes are used for full facial resurfacing. Oozing will be more noticeable with Er:YAG resurfacing; pressure can be applied to relevant areas with epinephrine-soaked sponges to reduce bleeding.

Laser Skin Resurfacing / 39

• Neck skin is thinner than facial skin and contains far fewer adnexal structures. Er:YAG laser resurfacing may be performed in the neck as it imposes less thermal damage. A single pass throughout the neck followed by a second pass at identical settings in the upper half are typical. Patients must have realistic expectations, as complete effacement of photoaging in the neck region is unlikely.

In the late 1990s, Er:YAG became very popular for skin resurfacing because of less discomfort, less recovery time, and less risk of complications. The main disadvantages were the diminished skin tightening effect and difficulty assessing the skin depth reached after each pass. This led to the development of the Contour™ (Sciton Inc., Palo Alto, CA) 2940 nm Er:YAG laser, with both ablative and coagulative functions. The user interface allows the physician to dial in the desired depth of ablation overcoming the depth issue as well as the amount of coagulation to manage the issue of bleeding and oozing. This additional heat perhaps also causes a more favorable skin tightening, similar to that of pulsed CO2 (Figures 3-4A–C). An application, which is gaining in popularity, is the MicroLaserPeel™, which is an Er:YAG treatment capable of minimal to full epidermal peeling (20-50 microns). This device is a good choice for patients seeking better results than those observed with microdermabrasion or light chemical peels, but who still desire minimal downtime. All things

Pulsed CO2 vs. Er:YAG Resurfacing: Current Preferences Earlier devices (1960s) used continuous wave CO2, which was associated with a high risk of scarring. To minimize this risk and other complications, pulsed CO2 systems were developed in the early 1990s capable of delivering high energy pulses with pulse durations that were shorter than the target’s thermal relaxation time. While these systems yielded reliable ablation and significant skin tightening, the aforementioned healing problems rapidly decreased their popularity.

A

Figure 3-4. Laser resurfacing using a 2940 nm erbium laser (Sciton Contour®).

B

C

40 / Laser Skin Resurfacing

considered, the dual-mode Er:YAG laser may offer the optimal balance of efficacy and safety.

Fractional Resurfacing Using a 1550 nm Erbium Glass Fiber Laser To minimize downtime and morbidity, a novel approach for treating cutaneous photoaging with fractional photothermolysis has been developed in recent years and deserves mention. With fractional photothermolysis, skin is resurfaced fractionally as opposed to undergoing full surface area treatment. Using this technology, the FraxelTM SR Laser System (Reliant Technologies, Palo Alto, CA) laser has been FDA-cleared for acne and surgical scars, melasma, dyschromias, periorbital wrinkles, and pigmented lesions. Although this nonablative resurfacing device has achieved excellent efficacy for most of the above indications, very modest results have been demonstrated in treatment of periorbital rhytides. More recently, however, the same company has developed a fractional CO2 laser resurfacing device in an attempt to overcome this limitation and more optimally address the desired balance between safety and efficacy for skin tightening. Using a similar pattern generator, the ablative fractional resurfacing device is configured to deliver a spot size of 120 µm as a microarray pattern using a 30 W CO2 laser. Preliminary studies performed with an investigational device demonstrated successful creation of a microscopic pattern of ablative and thermal injury in human forearm skin. Histologic examination revealed deep columns of thermal coagulation up to 2 mm in depth. These zones surrounded a cavity left from the vaporization of epidermal and dermal tissue. A very thin layer of eschar surrounded the vaporized cavity. Varying the pulse energy from 5 to 30 mJ led to a greater than threefold increase in lesion depth and twofold increase in lesion width. Immunohistochemical studies showed expression of heat shock protein 72 as early as 2 days post-treatment with significant reduction by 3 months. These studies also examined the expression of heat shock protein 47 and found detectable levels by 7 days that persisted at 3 months post-treatment. These findings are consistent with the role of heat shock protein 47 as a collagen chaperone, and suggest this treatment modality induced a long-term collagen remodeling process in the dermis. Remarkably, no evidence of scar formation was observed histologically or clinically. These exciting findings may provide for an ablative resurfacing modality capable of achieving significant skin tightening with an acceptable

patient downtime profile. Although this device has not yet been released for sale in the United States at the time of this writing, it is anticipated to become available in the fall of 2007. Ongoing studies will help further clarify the role this novel resurfacing approach will play in addressing the photoaged face. Another new, exciting new technology expands upon the first generation fractional devices (i.e., FraxelTM). Similarly based upon the concept of fractionated photothermolysis, Sciton’s ProFractionalTM is a 2940 nm Er:YAG laser able to penetrate deeply into the dermis by ablating narrow, clean channels to a selected depth. By eliminating collateral tissue heating and cleanly ablating tissue, this device more closely approximates the results of ablative technologies while still minimizing downtime. The ProFractional device can be used for full face rejuvenation or aggressive treatment of specific cosmetic subunits such as the periorbital or perioral regions. Penetration depth ranges from 25 μm to 1.5 mm with a scanned treatment pattern size of 6×6 mm or 20×20 mm. Although multiple, quick sessions are required for optimal treatment, preliminary studies suggest that results are excellent with respect to overall skin texture and tone and can be safely used in all Fitzpatrick skin types.

Postoperative Care Open and closed wound treatment approaches are generally used after ablative resurfacing procedures. The open wound care approach involves the application of Aquaphor® (Beiersdorf-Futuro, Inc., Cincinnati, Ohio) to treated areas. Until reepithelialization, dilute acetic acid soaks (one tablespoon white vinegar in one pint of tap water) should be applied for at least 15 minutes through the layer of petrolatum at least 4-5 times per day. Following the soaks, the skin should be pat dry with a soft towel and the emollient should be reapplied. Patients should not pick at scabs but rather let them wash off with the soaks. Once epithelialization is complete, a gentle moisturizing lotion such as Cetaphil (Galderma, Alliance, TX) lotion may be used in place of the thicker Aquaphor ointment and the acetic acid soaks may be discontinued. Instead, Cetaphil cleanser can be used. Additionally after reepithelialization, patients can wear powder-based makeup and sun protection using UV-A/UV-B sunblock with titanium dioxide or zinc oxide and an SPF over 30. Sun avoidance should be strictly enforced for 6-12 months.

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A

Figure 3-5. Immediate post-operative laser resurfacing care with occlusive dressing and overlying moist gauze. B

The authors recommend a closed wound care technique with the application of an occlusive biosynthetic dressing with Vigilon® (C.R. Bard, Inc., Murray Hill, New Jersey) or N-terface® (Winfield Laboratories, Inc., Richardson, Texas) over a lavish coating of Aquaphor. On top of this, cool moist gauze can be placed (Figure 3-5). This approach buffers the patient’s exposed dermis from the environment which can be a major source of discomfort. The occlusive dressing is applied for 1 day followed by an open wound care regimen as described above. More than with chemical peels and dermabrasion, post-laser resurfaced patients will have significant weeping, oozing, erythema, and edema and should be counseled accordingly. Patients are followed closely postoperatively and are usually seen at least 1, 7, 14, and 28 days after the procedure to monitor for potential complications. Figures 3-6A,B and 3-7A,B display typical postoperative results after resurfacing using the 2940 nm ContourTM erbium laser and the FraxelTM.

Complications Prolonged Erythema As with most complications, the severity of erythema depends upon the degree of tissue insult; the greater the depth of injury and remnant thermal

Figure 3-6. Preoperative (A) and postoperative (B) results after Sciton Contour 2940 nm erbium laser resurfacing.

damage, the greater the risk of prolonged erythema. After CO2 laser resurfacing, erythema usually subsides within 4 weeks, but may persist 6 months or longer. In the authors’ experience, average duration of postprocedure erythema associated with CO2 and Er:YAG is 3-6 weeks and 1-2 weeks, respectively. Hydrocortisone 2.5% can be used twice a day for 3-4 weeks for persistent erythema, but its application should not begin until 4-6 weeks after reepithelialization so that the normal wound healing process is not retarded. In addition, patients should adhere to strict sun precautions and avoidance of all potentially irritating topical compounds except those prescribed. A green-based makeup can be used and seems to offer the best camouflage. An acute change in erythema in the immediate postresurfacing period is worrisome. An increase in intensity of erythema may herald contact dermatitis or infection. Hypersensitivity to topical substances is one of the most common causes of severe erythema in the postoperative period. Fragrances or allergens within topical antibiotic ointments, soaps, moisturizers, or cosmetics are the usual culprits and, as a result, it is essential that all topical agents (make-up, sunscreens, moisturizers) are hypoaller-

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A

B

Figure 3-7. Preoperative (A) and postoperative (B) results after five treatment sessions using the Fraxel.

genic and without fragrance, aloe, vitamins, or other potentially sensitizing agents. One must first differentiate contact dermatitis from infection as the etiology of the hyperintense erythema. Contact dermatitis is often associated with pruritus and erythema. Once infection has been ruled out by culture, the offending agent must be discontinued. Topical corticosteroids such as DesOwen® cream (desonide, Galderma Laboratories, Inc., Forth Worth, TX) or Temovate® (clobetasol propionate cream, 0.05%, GlaxoSmithKline, Pittsburgh, PA), cool compresses, and oral antihistamines can hasten recovery and alleviate pruritis. Protracted, focal areas of erythema with induration and tenderness may herald incipient scar formation and should be promptly and aggressively treated with topical corticosteroid preparations or pulsed dye laser irradiation as described below.

Acne and Milia Acne and milia are common early but minor side effects. Abnormal follicular epithelialization and the use of occlusive healing ointments and dressings are thought to account for such skin blemishes, which usually occur within 2 weeks after resurfacing. While lesions resolve spontaneously and especially after occlusive ointments and dressings are discontinued, short courses of oral (i.e., minocycline) and topical antibiotics may be used for persistent acne flares.

Persistent milia may be treated with topical retinoic acid or manual unroofing using an 18-gauge needle or cotton tip applicators.

Infection Although occurring rarely in light of prophylactic regimens, infection should be rapidly identified and treated to avoid potential scarring. Significant pain more than 2 days after treatment may indicate a bacterial, fungal, or viral infection which usually occurs in the first 10 days after resurfacing. Focal areas of erythema, crusting, and yellow-green discharge after the second postoperative day are signs of infection. Crusting and discharge can be sent for Gram stain, KOH smear, and cultures as appropriate. Fungal infections may reveal satellite lesions with an erythematous base and slow reepithelialization. For Candida treatment, fluconazole is used. If infection occurs in the presence of prophylactic antibiotic administration, Pseudomonas or resistant staphylococcal or streptococcal infections must be considered. Antibiotic therapy should be guided accordingly and based upon cultures and sensitivities if resistance is suspected. Reactivation of the herpes simplex virus (HSV) is not an uncommon postresurfacing phenomenon. Despite adequate prophylaxis, however, up to 7% of patients may develop herpetic outbreaks. Diagnosis of HSV infection is essentially clinical and

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examination findings can include vesicopustules, punctate erosions, and crusting associated with pain and possible paresthesias. Vesicle formation, however, may not occur as the epithelium will have been stripped away. Cultures and smears may be helpful in definitive diagnosis if uncertainty exists. As with all types of infection, herpetic lesions should be treated promptly. If the patient is already taking an antiviral agent, the dosage of antiviral medications may be increased but a consultation with infection disease colleagues must be considered.

the entire face may best prevent resulting lines of demarcation around sites of relative hypopigmentation. Treatment involves blending the pigment gradient. Light peels with glycolic acid or TCA may help blunt the contrasting areas and awkward lines of demarcation. Other management schemes involve exposure to sunlight and topical psoralen application with controlled ultraviolet light therapy to stimulate melanocyte production. Given the recalcitrant nature of hypopigmentation, however, patients may need to embrace a lifetime application of camouflaging make-up.

Skin Dyschromia

Scarring

Hyperpigmentation occurs 3-4 weeks after resurfacing and can persist for several months if treatment is not begun. Exposure to direct sunlight can stimulate melanocyte activity and precipitate postinflammatory hyperpigmentation. Sun avoidance and potent sunscreens are, therefore, key in the postresurfacing period. Persistent hyperpigmentation is treated with a cream mixture of hydrocortisone 1%, hydroquinone 5%, and Retin-A 0.05% twice a day for 1 month on and 1 month off, until resolved. The problem usually resolves in 6-8 weeks, so the authors are slow to begin such a regimen. The hydroquinone can be increased to 8% in severe cases, and Retin-A can be increased to 0.1% for thick, sebaceous skin. Both should not be increased at the same time because this can cause significant skin irritation which can generate a cyclical course of persistent erythema and pigment changes. In addition, one must be cautious in the use of higher strength hydroquinone as patients may develop paradoxical onchrynosis. Other lightening agents (kojic acid) as well as azelaic acid, glycolic acid, and ascorbic compounds can also be used. Patients should be counseled that temporary mild hypopigmentation may also be an expected consequence of the resurfacing intervention especially in lower Fitzpatrick skin types but permanent hypopigmentation is fortunately uncommon. Onset of permanent hypopigmentation can occur late after 4-12 months, in particular after CO2 resurfacing. Patients with a prior history of resurfacing procedures may have an increased risk of developing hypopigmentation. True hypopigmentation is rare as most involved areas are pale relative to adjacent nontreated photodamaged skin. Thus, resurfacing multiple adjacent cosmetic facial units or perhaps

Hypertrophic scarring represents another rare but feared complication, which may stem from both intraoperative and postoperative events. Excessive tissue injury in the form of overlapped laser pulses or an overly aggressive treatment may herald future scarring. Erythema and associated induration are often precursors to hypertrophic scarring and should be treated early. One should have suspicion when noting such findings after infection or contact dermatitis. Potent class I topical corticosteroids (i.e., Temovate, 0.05%) can be applied twice a day for 2 weeks. Intralesional corticosteroid plus silicone gel or sheeting can also improve scarring. The use of 585-nm pulsed dye laser has been described to treat erythematous and persistent scars but requires multiple sessions.

Lower Eyelid Ectropion Lower lid ectropion is a rare complication after laser resurfacing as a careful history and physical examination will help prevent its occurrence. Patients with previous blepharoplasty or other lid surgeries and those with findings of lid laxity via the snap test are at risk. In such cases, fewer laser passes with lower energy densities around the lower lid or a concomitant lower lid tightening procedure are advised. Although ectropion usually improves with conservative management by way of taping and massage over time, surgical correction in the form of lid suspension procedures, placement of mucosal grafts, or midface/SOOF lifts may be warranted.

Conclusion Ablative resurfacing, especially in the form of laser, can produce truly safe and impressive aesthetic

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results but at the expense of risk and prolonged downtime. With increasing public demand for no downtime, no pain, and noninvasive rejuvenative procedures, there is a surge in interest in the marketing of nonablative devices. Results from these nonablative devices, however, are modest and, at times, inconsistent in comparison to their ablative counterparts although the recent introduction of fractional photothermolysis systems appear to be promising. Nonablative therapy requires careful patient selection, as some patients will fail to notice any clinical efficacy. Fundamentally, no ideal resurfacing procedure exists at the current time. It is therefore imperative to master and offer a variety of invasive (i.e., surgical), minimally invasive, and noninvasive treatment options to the patient in their search of facial rejuvenation.

Suggested Readings Alster TS.Cutaneous resurfacing with CO2 and erbium:YAG lasers: preoperative, intraoperative, and postoperative considerations. Plast Reconst Surg 1999;103:619–32. Alster TS, Lupton JR. An overview of cutaneous laser resurfacing. Clin Plast Surg 2001;28:37–52. Alster TS, Lupton JR. Prevention and treatment of side effects and complications of cutaneous laser resurfacing. Plast Reconst Surg 2002;109(1):308–16. Bass, LS. Rejuvenation of the aging face using Fraxel laser treatment. Aesth Surg 2005;25:307–09.

Chiu RJ, Kridell RW. Fractionated Photothermolysis: The Fraxel 1550-nm Glass Fiber Laser Treatment. Facial Plast Surg Clin North Am 2007;15(2):229–37. Greene D, Egbert BM, Utley DS, Koch RJ. In vivo model of histologic changes after treatment with the superpulsed CO2 laser, Erbium:YAG laser, and blended lasers: a 4 to 6-month prospective histologic and clinical study. Lasers Surg Med 2000;27: 362–72. Hantash BM, Bedi VP, Kapadia B, et al. In vivo histological evaluation of a novel ablative fractional resurfacing device. Lasers Surg Med 2007;39(2):96–107. Hantash BM, Mahmood MB. Fractional photothermolysis: a novel aesthetic laser surgery modality. Dermatol Surg 2007;33(5):525–34. Hardaway CA, Ross EV. Nonablative laser skin remodeling. Dermatol Clin 2002;20:97–111. Koch RJ. Laser skin resurfacing. Facial Plast Surg Clin North Am 2001;9(3):329–336. Narurkar VA. Skin rejuvenation with microthermal fractional photothermolysis. Dermatol Ther 2007;20 Suppl 1:S10–3. Rokhsar CK, Fitzpatrick RE. The treatment of melasma with fractional photothermolysis: a pilot study. Dermatol Surg 2005;31:1645–50. Roy D. Ablative facial resurfacing. Dermatol Clin 2005;23:549–59. Utley DS, Koch RJ, Egbert BM. Histologic analysis of the thermal effect on epidermal and dermal structures following treatment with the superpulsed CO2 laser and the erbium:YAG laser: an in vivo model. Lasers Surg Med 1999;24:93–102.

4 Nonablative Lasers and Lights Basil M. Hantash, MD, PhD, Vishal Banthia, MD, and R. James Koch, MD

Introduction Over the past decade, there has been a technological explosion in the field of laser medicine, providing for an increasing number of sophisticated treatment options for patients suffering from a diverse array of clinical problems. Most of these advances have hinged on the principle of selective photothermolysis (SP), which allows for selective absorption of laser energy by chromophores in the target tissue (Figure 4-1). Examples of commonly utilized chromophores include water, melanin, and hemoglobin, targeted by lasers and light sources that

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operate in the visible and infrared portions of the electromagnetic spectrum. The number of technologies exploiting this theory continues to rapidly expand and includes light-emitting diodes (LEDs; 420 nm or 630 nm), KTP (532 nm), pulsed dye (585 nm, 595 nm), ruby (694 nm), alexandrite (755 nm), diode (810 nm or 1450 nm), Nd:YAG (1064 nm or 1320 nm), erbium:glass (1540 nm), and intense pulsed light (IPL; 500-1200 nm) (Figure 4-2). These energy sources have been used to treat facial photoaging, vascular anomalies, melasma, rhytides, scars, and excessive hair growth. Each wavelength choice offers certain advantages at the expense of some

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Figure 4-1. Artist rendition of light absorption in tissue using selective photothermolysis concept.

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disadvantages, and therefore, patient treatments should be selected based on a balance of physician experience and patient goals. More recently, a novel concept termed fractional photothermolysis (FP) was developed that employs an erbium-doped (1550 nm) fiber laser source targeting water as a chromophore. Unlike SP, FP is intended to treat only a portion of the total chromophore found in the target tissue, thereby sparing a significant amount of target tissue. It is hypothesized that the sparing of healthy tissue allows the laser surgeon to avoid side effects related to bulk heating, leading to more rapid healing. FP has garnered much attention since its introduction, and a number of nonablative device manufacturers are currently pursuing its use for medical indications. Some of the more commonly used nonablative devices that have resulted from these two theories will be discussed in greater detail below and have been divided into three sections: vascular lasers, midinfrared lasers, and light-based devices.

Facial Analysis Experienced laser surgeons take into account a number of factors when selecting the most appropriate laser or light device for their patients. These decisions are based on a detailed analysis of the face using a classification scheme such as that presented below or in Chapter 3. Clinical photodamage is classified into three types: Type 1 – Lentigenes, telengiectasias, increased coarseness, symptoms of rosacea Type II – Rhytides, laxity, dermatochalasis, comedones Type III – Actinic Keratosis, nonmelanoma skin cancers, melanoma

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Figure 4-2. Artist rendition of electromagnetic spectrum. Various types of lasers are shown at respective wavelengths along spectrum.

Nonablative skin rejuvenation is capable of addressing types I and II photodamage. Type III photodamage restricted to actinic keratosis may be treated with specific nonablative light and laser devices. Each laser surgeon’s experience with or availability of a particular device may also influence the final treatment selected. In all cases, patients should be assessed in the appropriate lighting and in certain cases, in both the supine and upright positions. Patients undergoing nonablative laser treatments may have the false assumption that treatment with these devices will lead to a similar outcome as that achieved with more aggressive ablative laser devices or surgery. Therefore whenever possible, it is very useful to document the before and after appearance of each patient undergoing nonablative laser treatment in order to aid in setting realistic patient expectations and easy baseline reference during the course of therapy. Some laser surgeons employ digital analysis systems (e.g., Visioscan VC 98, Courage + Khazaka GmbH, Koeln, Germany) to remove the subjective nature of the facial analysis by providing a quantitative value for future comparison posttreatment. The ideal nonablative facial rejuvenation treatment modality effectively reduces signs of photodamage and photoaging without inducing significant patient downtime and recovery. After a successful facial analysis is performed, it is important to determine the patient’s goals during the initial consultation. Patients are best stratified based on the type of indication for which they seek treatment. For example, telangiectasia and erythema are best managed with an intense pulsed light device, KTP laser, or pulsed dye laser. Patients seeking textural skin improvements may be treated effectively with the 1320 nm Nd:YAG, a 1450 nm diode, or 1540 nm erbium:glass laser. For textural and

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pigmentary improvement, the 1540 nm erbium:glass may be the treatment of choice; whereas erythema and epidermal pigmentation may be managed with the intense pulsed light system. Fine wrinkles and mild rhytides can be treated with a mid-infrared device. In all cases, a series of treatments may be required to be spread out over the course of 3-6 months. Therefore, immediate results for some indications may not be seen, and this must be clearly communicated during the initial consultation. This is especially true in cases where dermal remodeling and neocollagenesis is expected.

Preoperative Considerations Past medical history should be elicited with special emphasis on the presence of risk factors that reduce optimal healing or increase the risk of an adverse event, as shown below: • Oral retinoids in the past 6 months • Active local or systemic infections • Medium or deep-level chemical peel in past 6 months • Ablative resurfacing in the past 6 months • Systemic corticosteroid use Laser surgeons should also take into consideration the following: • Known allergy to lidocaine • Predisposition to excessive scarring or keloid formation • History of herpes cold sores or zoster infection (if positive, Valtrex treatment should be instituted 1 day prior to or the morning of laser treatment) • Use of topical retinoids (most laser surgeons recommend discontinuation 2 weeks prior to laser treatment) Bleaching agents (such as hydroquinone) are sometimes employed in patients with darker skin types (Fitzpatrick type IV to VI) to reduce the risk of post-inflammatory hyperpigmentation. Although many device manufacturers make claims of safety in darker skin types, extreme caution should be exercised by performing test patches prior to treatment. In many cases, it will be necessary to lower settings to minimize adverse effects (blisters, scars, focal atrophy, textural change, and hyperor hypopigmentation) in higher Fitzpatrick skin type patients. Mid-infrared lasers operating in the 1320 nm or 1540 nm wavelengths have been used with increased safety in darker skin types. However, higher

energy settings at these wavelengths have resulted in post-inflammatory pigmentation secondary to melanin absorption or dermal-epidermal junction disruption with subsequent pigment drop-out. Caution should also be practiced in selecting the most appropriate cooling method as an adjunct, when possible. It is now understood that cryogen cooling devices operated at high settings, may lead to transient hyperpigmentation in darker skin types. Since some bleaching agents (containing, for example, retinoids and/or hydroquinone) have been shown to reduce the threshold for blistering from a nonablative laser treatment, caution should be practiced in properly selecting an anti-pigmentation agent. In addition to the retinoids and hydroquinone, agents such as Tri-Luma (Galderma Laboratories, CA) also contain steroids (fluocinolone acetonide 0.01%) and pretreatment exposure may lead to suboptimal wound healing because of localized immunosuppressive effects. Based on the degree of photodamage and chronologic aging, the ideal patient usually falls in the range of 35-55 years of age, with the exception of children who commonly present with vascular anomalies. Younger patients otherwise presenting for photodamage may demonstrate improved skin texture after treatment but the marginal benefit is often subtle, and therefore, preoperative counseling is of utmost importance in this subgroup. Aged patients with deep rhytides or severe skin laxity should be treated with ablative lasers or other invasive surgical techniques, as nonablative devices have not been beneficial to date.

Technique In general, the skin should be prepped with a gentle cleanser (e.g., acetone) in order to ensure even anesthesia penetration and to remove any makeup. Some physicians also apply a broad-spectrum, nontoxic microbicide for a minimum of 30 seconds which reduces the risk of bacterial infection by 99.99%. In addition to being flammable, agents such as chlorhexidine gluconate and isopropyl alcohol have been reported to cause ocular toxicity and are best avoided unless they are thoroughly washed off with water preoperatively. After applying a topical anesthetic solution (e.g., tetracaine) to the eyes, protective shields should be inserted when working in the periorbital region. The ideal shields are externally etched and coated with sterile ophthalmic petrolatum (Cox laser eye

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shields, Delasco, Council Bluffs, Iowa). Care should be exercised to select the correct fit in order to avoid ocular discomfort and trauma. Upon removal postprocedure, any residual petrolatum should be removed using a sterile saline wash, helping to minimize the incidence of blurry vision postoperatively. Saline moistened gauze pads may be substituted for eye shields if the periorbital region will not be treated. The laser surgeon should select an appropriate topical anesthetic (e.g. eutectic mixture of lidocaine-prilocaine) depending on the expected wait time prior to the procedure and history of anesthetic allergy of each patient. Some experienced laser surgeons caution against the use of topical anesthesia because of concerns about tissue maceration from the occlusive , as well as increasing the water content of the dermis, thereby altering the expected laser-tissue interaction. This has led to some physicians switching to liposomal lidocaine preparations, tumescent anesthesia, or regional nerve blocks supplemented with a sedative and analgesic combination delivered orally, intramuscularly, or intravenously. Some lasers such as the pulsed dye laser may be used without any anesthetic administration prior to treatment; however, this is rarely the case and patient comfort should supercede all other goals. The specific techniques used for each laser are described below in their respective sections. Finally, patients are optimally placed in the supine position during treatment. This helps to ensure patient safety in those rare cases of vasovagal reaction.

Postoperative Care The key to postoperative care following nonablative laser and light treatments, is ensuring patient comfort and appropriate skin management at home. Immediately following the procedure, an ice pack or cool compress may be applied to relieve any sunburn sensation. To decrease the associated pain, acetaminophen may be administered. Physical blocker sunscreens such as titanium dioxide or zinc oxide with a minimum sun protection factor of 30 should be recommended for daily use a minimum of 6 months post-treatment. Avoidance of direct sunlight and use of sun-protective clothing and wide-brimmed hats are beneficial measures. Frequent application of moisturizers such as petroleum jelly or other bland creams that do not irritate the treated skin can help reduce skin dryness and/ or flaking when applied frequently each day. Laser

surgeons should instruct their support staff to avoid recommending lotion moisturizers as they do not afford the appropriate lipid content during the catabolic post-treatment phase. In most cases, erythema lasts no more than 1 week and is treated with a brief course (24-48 hours postprocedure) of topical highpotency corticosteroids. In rare instances, patients experience itching may take over-the-counter oral anti-histamines (i.e., diphenhydramine). Significant edema will likely subside in 1 week; however, cool compresses, topical steroids, and/or NSAIDs may be administered at the discretion of the laser surgeon.

Complications In certain cases, the level of anesthesia is inadequate even with adjunctive cooling methods, resulting in some degree of pain intraoperatively. When breakthrough pain is experienced during nonablative laser treatment, the laser operator should stop treatment and immediately attend to the patient’s discomfort by applying additional topical anesthetic. Rarely, pain is intolerable and, if so, the treatment session is best discontinued. The postoperative risks should be discussed with all patients prior to treatment and include: infection, bruising, punctate bleeding, redness, swelling, blistering, and reactivation of herpes, pigmentary alteration, and scarring. In some cases such as following treatment with a 1540 nm erbium:glass laser, exfoliation may result. Pregnant women may experience focal hyperpigmentation following nonablative laser therapy; however, expecting mothers should be reassured that, at this time, there is no evidence of any risk to the fetus.

Vascular Lasers (532-1064 nm) Devices used for the treatment of vascular lesions include the KTP, pulsed dye laser (PDL), and Nd:YAG. The first system to become available was the flashlamp-pumped PDL (FLPDL). Since then, a number of other systems have been developed on the principle of SP. The FLPDL was optimized for the treatment of port wine stains with a 577 nm wavelength, right at the hemoglobin absorption peak. At this wavelength, the pulse duration (450 µs) is shorter than the thermal relaxation time of superficial cutaneous vasculature, allowing for efficient treatment. A high power flashlamp was used to excite electrons in rhodamine creating an emission of yellow light at 577 nm. Newer PDL

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devices are available at slightly longer wavelengths of 585 nm and 595 nm and employ pulse widths of 350 µs to 40 ms at fluences of 3-10 J/cm2. At these longer wavelengths and variable settings, the different oxygenation states of hemoglobin can be targeted allowing a variety of vessel sizes to be treated successfully. In order to reduce the incidence of adverse events, either bursts of cryogen-spray cooling or continuous delivery of chilled air is utilized. To reduce the chance of purpura, Candela (Wayland, MA) developed the V Beam system, a PDL device with variable pulsing. This system functions at 595 nm with a 7 or 10 mm spot size and 0.45-40 ms pulse duration. Similar devices named the V Star (Cynosure, Chelmsford, MA) and N Lite (USA Photonics, Nyack, NY) were also developed each with unique settings. A number of laser surgeons experienced in FLPDL have reported mild improvements in skin elasticity, dyschromia, and texture postoperatively. Others treating off-the-face have also observed some improvement in striae and hypertrophic/ keloid scars. The nature of this improvement may be via a reduction of dermal vasculature or through collagen remodeling, as evidenced histopathologically. One study showed histologic evidence of increased dermal collagen and a well organized elastin meshwork after one pass using a 585 nm FLPDL and a 450 ms pulse. The elastotic tissue was also replaced by increased cellularity and mucin deposition. These results were consistent with the blinded observer ratings showing that 9/10 with mild to moderate and 4/10 with moderate to severe wrinkles demonstrated clinical improvement at 6-14 months following treatment. Increasing the number of passes at subpurpuric fluences did not further enhance dermal neocollagenesis. Similar results were observed in another study using a 585 nm system and a 350 µs pulse duration at 6 months post-treatment. This was confirmed by electron microscopy showing ultrastructural changes consistent with new collagen deposition. A plethora of other wavelengths such as the 532 nm KTP, 755 nm alexandrite, 810 nm diode, and 1064 Nd:YAG have also been utilized for the treatment of vascular lesions. One study found treatment with a combination of KTP and Nd:YAG lasers demonstrated the most significant improvement in types I and II photodamage, although the KTP laser outperformed the Nd:YAG when compared head to head. In either case, a total of 3-6 treatments were required for maximal improve-

ment. Thus, it appears that vascular lasers may also find use for nonablative photorejuvenation. Optimal settings can help minimize or avoid side effects such as purpura, dyschromia, blistering, and scarring. Nd:YAG represents a better choice in darker skin types. A reduction in the repetition rate to increase the interval between pulses may be employed to reduce the risk of hypopigmentation in these patients. Nonoverlapping pulses at a fixed preset distance above the skin are the method of choice. Immediately upon administration of the pulse, the patient will feel a rubber band-like snap, but anesthesia is rarely required. Cool gel packs may be used, however, to alleviate any discomfort. In all cases, evanescent purpura and temporary blanching are the treatment endpoints for vessels. Persistent purpura or epidermal whitening correlate with posttreatment blistering and observation of either intraoperatively requires a reduction of laser parameters.

Mid-Infrared Lasers (1320-1550 nm) There are three main mid-infrared wavelengths currently in clinical use – 1320 nm Nd:YAG (Cooltouch; Cooltouch Corp., Auburn, CA), 1450 nm diode (Smoothbeam; Candela Corp., Wayland, MA), and 1540 nm erbium:glass (Aramis; Quantel Medical, Clermond-Ferrand, France). More recently, a 1550 nm erbium-doped fiber laser that also utilizes water as a chromophore known as the Fraxel® was developed by Reliant Technologies, Inc. (Moutain View, CA). Although this section will briefly touch on the 1320 nm Nd:YAG, a more detailed discussion of the 1550 nm erbium-doped fiber laser can be found in Chapter 3. The clinical and histologic findings for midinfrared laser facial treatments have been studied extensively. The Cooltouch was the first nonablative laser marketed to physicians for medical use. It employs a 10 mm spot size and 200 ms pulse duration. The Cooltouch is characterized by a high scattering coefficient at 1320 nm, allowing for bulk dermal heating using water as a chromophore. Thus, dermal vasculature is targeted in addition to dermal collagen, which is denatured at temperatures of 60-70°C. The Cooltouch handpiece possesses a thermal sensor that detects surface Tmax and allows the user to obtain a temperature read immediately after a test patch. Fluence can be adjusted up or down based on this feedback system until reaching the optimal range of surface Tmax between 42-48°C. A number of studies have shown treatment with the

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1320 nm laser induces vascular damage, apoptosis, and edema histologically. These effects in combination, result in the release of inflammatory mediators that lead to neocollagenesis. Effects similar to the 1320 nm Nd:YAG have been reported with the 1450 nm diode laser. This wavelength also relies on water as the chromophore to affect dermal heating. The Smoothbeam utilizes a 250 ms pulse duration, slightly longer than the Cooltouch. However, it does not have a thermal sensor feedback system although it similarly delivers cryogen cooling pre-, during, and post-treatment. Thus far, the Smoothbeam has been used clinically for the treatment of rhytides and atrophic acne scars. Comparisons of the Cooltouch and Smoothbeam suggest nearly identical efficacy for rhytides, although one study showed superior efficacy with the 1450 nm diode laser for recontouring atrophic acne scars when using fluences of 9-14 J/cm2. Interestingly, the 1450 nm diode laser appears to damage sebaceous glands with one study demonstrating efficacy for the treatment of active acne. The effects of the 1450 nm diode have been clearly attributed to the laser itself, as cryogen cooling alone did not induce significant papillary dermal neocollagenesis. Although not as popular in the United States, the 1540 nm erbium:glass laser has been well studied in Europe. The mechanism of action is similar to the above mid-infrared lasers, with water as a chromophore; however, this depth of penetration at this wavelength is 2 mm allowing for full replacement of solar elastosis. The Aramis laser utilizes continuous contact cooling by placing a sapphire lens cooled to 5°C in the handpiece. The Aramis laser employes a 4 mm spot size, 3.5 ms pulse duration, and a fluence of 10 J/cm2. Profilometry studies revealed a 40% reduction in rhytides with a concurrent 17% increase in epidermal thickness, 6 weeks following a series of 4 treatments. These findings were confirmed by digital photography and ultrasound imaging. A separate study showed histologic evidence that treatment with the 1540 nm laser induced dermal collagen remodeling; these effects correlated with patient satisfaction and very few adverse events. Thus, these three mid-infrared laser devices all appear to promote neocollagenesis evidenced by histologic studies. However, our clinical experience has shown that the degree of histologic collagen remodeling does not always translate into predictable clinical changes, partly explaining the broad range of improvement reported in the literature (10-85%). The main challenge for future development will be

to optimize laser parameters in a manner that allows for more predictable clinical outcomes without an increase in the side effect profile. This may be limited in part because of current nonablative devices dependence on significant epidermal cooling. Because of the absence of epidermal thermal injury, the healing process may not fully recruit the epidermal stem cell population and its contribution to dermal remodeling. Indeed, it appears the field has quickly responded to this demand with the advent of FP, and the subsequent release of the first laser utilizing this novel principle, namely the Fraxel® (Reliant Technologies, Inc.; Mountain View, CA). The Fraxel® laser is purported to bridge this gap, by providing increased reliability and predictable clinical efficacy while maintaining a favorable side effect profile. A more extensive discussion of this technology and its efficacy for rhytides can be found in Chapter 3. Unlike other nonablative devices, Fraxel® does not have as a goal the complete sparing of the epidermis; therefore, contact cooling is not integrated directly into the handpiece. The Fraxel® laser utilizes a nonstationary handpiece capable of scanning across skin up to 8 cm/s. The 1550 nm erbium-doped fiber laser also utilizes water as a chromophore, but delivers a microarray pattern instead of a contiguous area treatment. Using an objective lens with high resolving power, the adjustable laser beam targets specific depths in the skin by varying the pulse energy. The resultant skin lesions termed microscopic treatment zones (MTZs) are 50-150 μm in diameter and can be deposited at densities up to 6400 MTZ/cm2 (Figure 4-3). This is accomplished by delivering up to

Figure 4-3. Fractionated photothermolysis demonstrating individual areas of microscopic zones of thermal necrosis.

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3000 precision pulses per second with each pulse inducing a single MTZ. The standard spot size is 140 μm and pulse energy of 6-20 mJ. A specialized beam deflector and high-speed pattern generator allow for deposition of MTZs in random patterns through a continuous beam, helping create a more blended appearance post-treatment. Because each beam maintains the same energy profile, interbeam fidelity is ensured, a feat not yet proven possible through the use of microarray filters. Unlike nonfractional laser devices that use a macroscopic spot size, the 1550 nm erbium-doped fiber laser was rationally designed to create MTZs as microscopic columns of thermal damage ( 4 J/cm2, in order to avoid bulk heating. A recent study looked at the efficacy of Fraxel® for treatment of periorbital rhytides in 30 patients who underwent four treatments (2500 MTZ/cm2 at 6-12 mJ) over a 2-3 week period. One month post-treatment, independent investigator evaluations found a moderate (score of 4 on a scale of 1 to 6) improvement in wrinkle appearance in 54% of subjects. Three months later, 34% of subjects were rated as moderately improved. Overall, 96% of patients experienced mild to moderate improvement in wrinkles and skin texture. A second study involving a series of three consecutive treatments (2,000 MTZ/cm2 at 8 mJ for facial areas; 1,500-2,000 MTZ/ cm2 at 8 mJ for nonfacial areas) spaced 3-4 weeks apart confirmed and extended the above findings. Investigators found an overall improvement of 51-75% in 73% (face) and 55% (off-the-face) of patients 9 months post-treatment. In both studies, the adverse effects (erythema and edema) were limited and short-lived, lasting on average several days

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Figure 5-5. Polaris WRTM combines radiofrequency and diode laser energies.

post-treatment. In addition to periorbital rhytides, the Fraxel® laser is also FDA-approved for sun damage, age (brown) spots, rough texture, acne scars, and melasma (only laser with this indication).

Radiofrequency and Laser The Polaris WRTM (Syneron Medical Ltd, Yokneam, Israel) combines bipolar radiofrequency and diode laser energies to treat both facial wrinkles and skin laxity (Figure 5-5). The combination of these two delivery methods produces selective dermal and epidermal heating and is termed electro-optical synergy (ELOSTM). It delivers radiofrequency energy in the range of 10 J/ cm2 to 100 J/cm2 and light energy (900 nm) from 10 J/cm2 to 50 J/cm2 in a sequential manner. Simultaneous thermoelectric cooling of the skin surface to 5°C provides epidermal protection throughout the pulse sequence. Electro-optical synergy works on the theory that two energy sources are better than one: the radiofrequency energy selectively penetrates into the dermis and heats the deeper tissue to cause collagen contraction, while the light diode energy augments this dermal effect but also targets more superficial epidermal pigmented and vascular lesions. The diode energy increases dermal temperature, which decreases tissue impedance and thereby enhances

the effect of radiofrequency energy conduction at the dermal level. Direct contact cooling prior to the delivery of any energy protects the epidermis from overheating and prevents any excessive radiofrequency effect at this level. The end result is tissue heating throughout the epidermis and dermis to a maximal depth of 2 mm. A limitation of this device lies in its electrode design. The bipolar, conductive coupling electrode results in the concentration of energy at the edges. This creates a very intense, shallow electric field that is useful for ablating tissue. However, it does not heat to a significant depth, and thermography has shown minimal radiofrequency effect except for superficial heating close to the bipolar electrode edges. The edge effect is best understood for cardiac intramural radiofrequency ablation. A recent study reported modest improvement in facial wrinkles in the majority of patients who underwent treatment with the PolarisTM system, with specific areas of treatment including the forehead, periocular region, midface and neck. These results were based on investigator, patient and independent evaluations. There was a generalized trend of decreasing benefit with time. However, by 6 months 81% of patients reported continued satisfaction with the procedure. Side effects were mild and limited to transient erythema and edema. No scarring or pigment alterations were reported. The PolarisTM system is designed to treat mild to moderate rhytides, skin laxity, vascular lesions, and pigmentary dyschromias. At the time of this writing, the FDA has granted 510K marketing clearance to the device for noninvasive wrinkle treatment. Up to three treatment sessions performed over several weeks are usually required for adequate effect.

Conclusion Many patients now seek lower cost minimal downtime procedures in place of more invasive surgery or traditional ablative laser therapy which are typically associated with higher risk of adverse events. Nonablative skin rejuvenation devices fill this patient trend and provide a welcome alternative. Minimally and noninvasive procedures have evolved with the state of current technology, along with increasingly informed and knowledgeable patients. Surgeons have always attempted to minimize the telltale signs of surgery, and this desire is increasingly reinforced by the current patient-driven trend to avoid the “operated” look.

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Suggested Readings Doshi SN, Alster TS. Combination radiofrequency and diode laser for treatment of facial rhytides and skin laxity. J Cosmet Laser Ther 2005;7(1):11–15. Goldberg DJ. Full-face nonablative dermal remodeling with a 1320 nm Nd:YAG laser. Dermatol Surg 2000; 26(10):915–918. Goldberg D, Metzler C. Skin resurfacing utilizing a lowfluence Nd:YAG laser. J Cutan Laser Ther 1999;1(1): 23–27. Goldberg DJ, Samady JA. Intense pulsed light and Nd:YAG laser non-ablative treatment of facial rhytids. Lasers Surg Med 2001;28(2):141–4. Hantash BM, Mahmood MB. 2007. Fractional Photothermolysis: A novel aesthetic laser surgery modality. Dermatol Surg; 33(5):1–10. Hardaway CA, Ross EV. Nonablative laser skin remodeling. Dermatol Clin 2002;20(1):97–111. Key DJ. Single-treatment skin tightening by radiofrequency and long-pulsed, 1064-nm Nd: YAG laser compared. Lasers Surg Med. 2007;39(2):169–75. Koch RJ. Laser skin resurfacing. Facial Plast Surg Clin North Am 2001;9(3):329–336. Kovoor P, Daly M, Pouliopoulos J, Dewsnap MB, Eipper V, Ross DL. Effect of inter-electrode distance on

bipolar intramural radiofrequency ablation. Pacing Clin Electrophysiol. 2005;28(6):514–20. Kulick M. Evaluation of a combined laser-radio frequency device (Polaris WR) for the nonablative treatment of facial. J Cosmet Laser Ther 2005;7(2):87–92. Romero P, Alster TS. Skin rejuvenation with cool touch 1320 nm Nd:Yag laser: the nurse’s role. Dermatol Nurs 2001;13(2):122,125–127. Ruiz-Esparza J. Near painless, nonablative, immediate skin contraction induced by low-fluence irradiation with new infrared device: a report of 25 patients. Dermatol Surg 2006;32(5):601–610. Taub AF, Battle EF Jr, Nikolaidis G. Multicenter clinical perspectives on a broadband infrared light device for skin tightening. J Drugs Dermatol. 2006;5(8): 771–8. Utley DS, Koch RJ, Egbert BM. Histologic analysis of the thermal effect on epidermal and dermal structures following treatment with the superpulsed CO2 laser and the erbium:YAG laser: an in vivo model. Lasers Surg Med 1999;24:93–102. Zelickson B, Ross V, Kist D, Counters J, Davenport S, Spooner G. Ultrastructural effects of an infrared handpiece on forehead and abdominal skin. Dermatol Surg. 2006;32(7):897–901.

6 Radiofrequency Tissue Tightening R. James Koch, MD and Brain P. Kim, MD

Introduction It is generally agreed that we have excellent modalities to resurface or peel the superficial layers of skin. This may be accomplished by the use of ablative lasers (such as pulsed carbon dioxide and erbium:YAG) or by other ablative modalities (such as chemical peels and dermabrasion). Nonablative skin or soft tissue tightening would certainly be desirable when there is no indication for superficial skin peeling. For example, if there was no actinic damage, pigment irregularities, or texture problems. In addition, leaving the epidermis and upper dermis intact would reduce the healing process. Furthermore, while we already have reliable surgical procedures, tissue repositioning without surgery would fit into the noninvasive realm. The ThermaCoolTM System (Thermage Inc., Hayward, CA) has been cleared by the Food and Drug Administration for the noninvasive treatment of wrinkles and rhytids. Currently, all other uses are investigational. In brief, it works by using radiofrequency (RF) energy to heat the skin. Concurrent cooling protects the epidermis during the treatment, and because of this one can safely deliver up to 144 joules/cm2 of energy to a treatment site. Because of its capacitive coupling treatment tip, it heats a uniformly large volume of tissue. The clinical effects of this are tightening of the treated tissue yielding a noninvasive browlift, facelift, or necklift. The mechanism for these effects are two-fold: (1) immediate contraction of existing collagen fibrils, and (2) a delayed wound healing response

which most likely entails neocollagen production by stimulated fibroblasts. Radiofrequency is a form of alternating electric current (AC current). Most medical RF devices like electrosurgery units operate at 500 kilohertz or more. Electric fields are created between two electrodes which cause molecules to rotate or move. At the surface of the skin, the charge is changing polarity from positive to negative, alternately attracting and repelling electrons and charged ions. Polar molecules are induced to rotate back and forth, vibrating at 6 million times per second. It is the resistance to this movement that creates heat in the tissue. The ThermaCool System consists of three principle components: the RF Generator, Cooling Module, and Handpiece Assembly (consisting of a handpiece and treatment tip) (Figure 6-1). The generator supplies RF power while continuously monitoring and displaying output current, output energy, treatment duration, and measured impedance. The return path for the electric current is through a return pad. The generator also controls the cooling module, which circulates coolant through the handpiece assembly. Canisters of coolant are utilized in the cooling module. The handpiece assembly delivers RF energy while cooling tissue by conduction (Figure 6-2). It is comprised of the reusable handpiece and the sterile, single-use treatment tip. Inside the handpiece, there is a force sensor that ensures that the tip is in contact with the patient, and that not too much or too little contact force is applied. In addition to the treatment tips, there are kits, which contain

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Figure 6-1. ThermaCool System consists of three principle components: the RF Generator, Cooling Module, and Handpiece Assembly (consisting of a handpiece and treatment tip).

coupling fluid, return pads, cryogen canisters, and skin marking paper.

stores information on its size, model, and its heating and cooling parameters. There are four thermistors, one in each corner, to detect the temperature of the tip and ensure proper cooling is delivered to protect the epidermis. Different heating profiles will be introduced through the use of different tips. So as new treatment tips are introduced to change depth of treatment and associated control parameters, one merely puts on a new tip and all of these settings are uploaded to the RF generator from the tip’s memory chip. Similar to a monopolar electrocautery or “Bovie” unit, an electric circuit is created by the device and the patient becomes part of this circuit. The current flows out of the RF generator, through the handpiece cable, through the treatment tip, and into the skin. Then the current flows through the patient’s body and is collected by a return pad on the patient’s back. It then flows through the return cable and back to the generator. There are three phases to the treatment cycle: precooling, simultaneous delivery of RF and cooling, and postcooling. After the tip comes into contact with the skin, coolant is sprayed on the back surface of the electrode. This draws heat out of the surface of the skin, and generates a thermal gradient. Then the RF energy and cooling are applied in parallel. At the end of RF delivery, the system initiates a postcool phase, which safely removes the heat. All of these phases are computer-controlled.

Preoperative Considerations Unlike most lasers, one is able to treat all skin types with this device. The depth of the heating achieved is tip-dependent, and not wavelength-dependent. Each tip contains an EPROM memory chip, which

Technique With regard to the actual procedure, our practice is to have the patient come in to the clinic 1 hour before the procedure. After jewelry is removed, topical

Figure 6-2. ThermaCool system handpiece assembly.

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5% lidocaine cream (ELA-Max® 5, Ferndale Laboratories, Ferndale, Michigan) is applied to the area to be treated for 1 hour and occluded. There is some discomfort experienced at the site being treated, but this is brief and there is no discomfort following the procedure. This sensation has been described as a building heat intensity that then dissipates. Clinicians have dealt with this by supplementing topical analgesics with regional nerve blocks and/or oral or IV sedation. Our current practice is to offer oral sedatives and analgesics but then the patient loses the ability to drive home. Most of our patients do not want this, and like the idea of it being a true “lunchtime” procedure. Some clinicians will use the level of discomfort as a guideline for treatment energy levels, maintaining the patient at a “2 1/2” on a four point discomfort scale to balance efficacy, patient comfort, and safety. After placement of the return pad, the skin marking paper is used to temporarily mark the treatment area. The coupling fluid is used liberally to facilitate contact between the skin site and treatment tip. Recommended treatment levels vary depending upon the area being treated (Figure 6-3). There is usually no change in the surface appearance of the treated skin, and any occurrences of local erythema and edema are usually resolved in 2 days. Repeat treatment sessions are usually performed after 2-3 months, and the author usually plans a series of 2-3 of these. Some clinicians report promis-

Figure 6-3. ThermaCool System Console Panel where desired treatment levels are entered.

ing results using multiple low energy passes in the same session. There may also be a place for maintenance treatments with prior treated patients getting annual treatments, for example.

Results The senior author (RJK) has performed seven Thermage-sponsored clinical trials to assist in the development of the device. These include the following studies: (1) the nonsurgical browlift, (2) facial treatment with moderate settings and multiple passes, (3) facial contouring with the medium depth tip, (4) the long-term wound healing effects of radiofrequency energy, (5) facial contouring with the deep tip, (6) the noninvasive tightening of arms, and (7) the noninvasive treatment of cellulite. We will focus on the first one. In an initial study treating the periorbital and forehead areas of 86 patients, the ThermaCool showed significant efficacy after a single treatment session: 83% showed improvement in the crow’s feet area using a standardized wrinkle score, and 50% rated their aesthetic change as good or very good (unpublished data from Thermage, Inc). A novel measurement system was developed for the quantification of brow position changes. Subsequently, we took part in a multi-institutional study to evaluate the effects of multiple treatment sessions on objective measures of efficacy. One hundred twenty five patients were randomized in a 1:2 ratio into either a single treatment or a multiple treatment group. The multiple treatment group was treated monthly for up to four treatments. At the Stanford site, there were a total of 40 subjects, the protocol was approved by the Institutional Review Board, and it was performed under a clinical trial agreement with Thermage, Inc. Similar to the single treatment study, patients were treated in the periorbital and forehead areas, and followed for 6 months after last treatment (which would be 9-month follow-up for the multiple treatment group). In addition, standardized wrinkle scoring was applied to blinded photographs by three independent reviewers at 2, 4, and 6 months. The preliminary results from our site suggest that approximately 60% of patients have significant brow elevation after 1 treatment, and approximately 80% of patients have significant brow elevation after 4 treatments. Common patient comments include “my eyes appear more open” and “my forehead is

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A

B

Figure 6-4. Patient treated with the 1.5 cm2 tip using multiple neck passes immediately following submental liposuction. (A) Baseline, (B) 9 months after treatment. Note improvement in neck contour.

smoother”. Many patients have pre-existing brow position asymmetries, and interestingly the ThermaCool treatment tends to equalize many of these discrepancies. In practice, there have been encouraging early results in its use for active acne and as a skin tightening adjunct to body liposuction. The author has seen very good results for shallow acne scars and in conjunction with neck liposuction (Figure 6-4).

A

Postoperative Care and Complications Because it is a nonablative procedure, there is no need for antibiotics, wound dressings, or ointments. We have treated all Fitzpatrick Sun-Reactive Skin types without hyper- or hypopigmentation, and have not experienced any complications to date.

B

Figure 6-5. Patient treated with the 1.5 cm2 tip using multiple facial passes during one treatment session. (A) Baseline, (B) 4 months after treatment. Note improvement in jawline.

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Conclusions Our experience is that our very good ThermaCool results have been comparable to that of the minimally invasive procedures; that is, endoscopic browlift for brow ptosis, and mini-facelift for moderate facial elastosis (Figure 6-5). For the neck, there is not yet a time-tested minimally invasive procedure, thus our current options for significant laxity is a traditional facelift (via neck component) versus ThermaCool. Many patients do not want the cost, risk, and down time associated with surgical procedures, and this gives them an alternative. We have always attempted to reduce the telltale signs of surgery, but the patient-driven trend is avoidance of an “operated” look.

Acknowledgments The author wishes to acknowledge Bader Bellahsene for his assistance with the technical description of the device, and Pam Buckman, RN for her assistance with the clinical studies.

Suggested Readings Frankel AS, Kamer FM. Chemical browlift. Arch Otolaryngol Head Neck Surg 1998;124(3):321–23.

Frankel AS, Kamer FM. The effect of blepharoplasty on eyebrow position. Arch Otolaryngol Head Neck Surg 1997;123(4):393–36. Gorti GK, Ronson S & Koch RJ. Wound Healing. Facial Plast Surg Clin North Am 2002;10:119–127. Koch RJ. Clinical Challenges in Otolaryngology-Head & Neck Surgery: Endoscopic Browlift is the Preferred Approach for Rejuvenation of the Upper Third of the Face. Arch Otolaryngol Head Neck Surg 2001;127(1): 87–90. Koch RJ. Laser Skin Resurfacing. Facial Plast Surg Clin North Am 2001;9(3):329–36. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast. Surg 1991;15(2): 141–47. Nowak KC, McCormack MC & Koch RJ. The Effect of Superpulsed Carbon Dioxide Laser Energy on Keloid and Normal Dermal Fibroblast Secretion of Growth Factors: A Serum-Free Study. Plast Reconstr Surg 2000;105(6):2039–48. Troilius C. A comparison between subgaleal and subperiosteal brow lifts. Plast Reconstr Surg 1999;104(4): 1079–90; discussion 91–92. Utley DS, Koch RJ & Egbert BM. Histologic Analysis of the Thermal Effect on Epidermal and Dermal Structures Following Treatment with the Superpulsed CO2 Laser and the Erbium:YAG Laser: An In Vivo Model. Lasers Surg Med 1999;24:93–102. van den Bosch WA, Leenders I, Mulder P. Topographic anatomy of the eyelids, and the effects of sex and age. Br J Ophthalmol 1999;83(3):347–52.

7 Microdermabrasion Matthew M. Hanasono, MD and R. James Koch, MD

Introduction Microdermabrasion is a skin resurfacing technique developed in Italy in 1985. It is widely used throughout Europe and Australia. It was approved for use in the United States by the Food and Drug Administration in 1996 as a Class I (non-life-sustaining) device and made commercially available in 1997. It is a noninvasive modality that is used to improve skin appearance and texture. Advantages include fast results, no anesthetic requirement, safety, and rapid recovery time. In high demand by patients for perceived benefits in skin texture and appearance, microdermabrasion has earned an important place in the skin resurfacing armamentarium. Other factors contributing to microdermabrasion’s appeal include its affordability, ease of use, and quick results. It has been estimated by The American Academy of Cosmetic Surgery to be the second most widely used cosmetic procedure after botulinum toxin injection. Like conventional dermabrasion, microdermabrasion mechanically removes layers of skin using abrasives. The effects of microdermabrasion, however, are generally limited to the epidermis rather than the dermis. Indications include treatment of acne scars, fine lines, unwanted pigmentation, and other superficial skin damage associated with aging and sun exposure. Clinically and histologically, microdermabrasion appears to be more comparable to lighter chemical peels, such as the alpha hydroxy acid peels, than conventional dermabrasion. Like the lighter chemical peels, the technique is considered safe in the hands of an appropriately trained medical technician, nurse, or physician. Multiple studies have been performed to examine the efficacy of microdermabrasion. Tsai et al., were the first to report the technique in the peer-

reviewed medical literature. They summarized their results with 41 patients treated for facial scarring. Lesions treated included acne scars, traumatic scars, surgical scars, one burn scar, and one angiofibroma. Acne scars were treated a mean of 15 times to achieve satisfactory clinical improvement while traumatic and surgical scars were treated a mean of four times each. All patients achieved significant improvement as judged by the patient and the physician. Shim et al., performed six to seven treatments in 14 patients over twelve weeks. Patients reported statistically significant improvements in skin roughness, pigmentation, and overall appearance, although the patients were also allowed to resume retinoid or alphahydroxy acid treatment within several days after the procedure, which may have confounded the results. No improvements were noted in rhytids. Lloyd reported his experience in treating patients with grade II to III acne, also on systemic and topical antibiotics as well as retinoid therapy. Twenty-four patients completed the study with 38% achieving excellent, 34% good, 17% fair, and 12% poor results. Coimbra et al., noted significant improvement in hyperchromic discoloration and a high degree of satisfaction in all treated patients. Tan et al., found more modest results in ten subjects undergoing five to six treatments at 30 mm Hg for photodamage. Only mild improvement was noted by physician assessment. Skin temperature increased and sebum content decreased. There was also a decrease in skin stiffness, an increase in skin compliance, and a temporary increase in skin roughness. The investigators ascribed most of the noted changes to increased blood flow and persistent edema after treatment. Alam et al.,compared microdermabrasion to glycolic acid peels by performing a randomized, unblinded controlled study. One side

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of each patient’s face was treated with 20% glycolic acid and the other with microdermabrasion. In a series of ten patients, seven patients reported greater improvement on the side treated with glycolic acid, one patient reported greater improvement on the side treated with microdermabrasion, and two patients reported no preference. Physician investigators reported no differences between the two sides of each patient’s face and could not differentiate between pre- and post-treatment photographs. The mechanism of action of microdermabrasion has also been examined in several histologic studies. Rubin and Greenbaum performed punch biopsies in three patients before and after six treatments with microdermabrasion. The level of penetration was found by histologic examination to be to the stratum corneum. The post-treatment biopsies also showed normalization of the stratum corneum, epidermal thickening, and increased collagen deposition in the papillary dermis. They felt that the repeated intraepidermal injury improved photodamaged epidermis gradually and stimulated changes in the dermis leading to increased collagen deposition. This observation that epidermal wounding can affect dermal changes has previously been reported. Hernandez-Perez and Ibiett performed skin biopsies before and after a series of five treatments in seven patients. Epidermal thickening was noted, as were improved epidermal cell polarity, and a decrease in basal cell liquefaction. Tan et al., performed facial skin biopsies in two patients and forearm biopsies in two patients. Facial post-treatment biopsies showed a significant increase in orthokeratosis and slightly decreased rete ridge patterns. There was slight dermal edema, a mononuclear cell infiltrate in the upper reticular dermis and vascular ectasia, which they ascribed to the negative pressure. Freedman et al., also reported histologic increases in epidermal and papillary dermal thickness, flattening of rete pegs, vascular ectasia, perivascular inflammation, and hyalinization of the papillary dermis with newly deposited collagen and elastin. Unlike traditional dermabrasion, which is a “deep” resurfacing technique, microdermabrasion is a superficial technique. Superficial techniques produce less dramatic results but are associated with less discomfort, risk, and recovery time. Dermabrasion is a technique utilizing burrs or fraises to create a wound down to the level of the dermis. This stimulates a controlled fibrosis that can improve deep rhytids or scars. Deep rhytids and scars cannot be treated with removal of the epidermis alone. Results

of dermabrasion are comparable to those of CO2 laser under the appropriate conditions. However, dermabrasion has several drawbacks. One problem with dermabrasion is that it is dependent on technique. The coarseness of the fraise, number of brush strokes, pressure of the hand piece, and time of tissue contact all affect the depth and extent of injury. As a deep wounding modality, there is a risk of hypertrophic scarring, hypopigmentation, and postinflammatory hyperpigmentation. Exposure to blood-borne pathogens is a risk to the operator. Chemical peels cause a controlled partial thickness injury to the skin surface. Some agents peel to a deep level, causing injury to the papillary and occasionally the reticular dermis, others to a more superficial level restricted to the epidermis and sometimes the superficial dermis. Alpha hydroxy acids, salicylic acid, resorcinol, trichloroacetic acid, beta-naphthol, and others are used to treat the superficial layers of skin. A deeper peel can be achieved by some of these agents depending on the concentration, duration, and frequency of application. Tricholoroacetic acid, for example, can achieve a deep peel at high concentrations or with immediate reapplication. Phenol is used as a deep peeling agent and is felt by some to achieve a more consistent and reliable result for deeper skin wounding than trichloroacetic acid. Phenol is associated with well-known cardiotoxic effects and must be applied with simultaneous cardiac monitoring, and may, more rarely, be associated with hepatotoxic, neurotoxic, and nephrotoxic effects. Deep peeling agents are indicated for photoaging and deeper rhytids such as perioral wrinkles and crow’s feet adjacent to the eyes, which are not treated by facelifting and blepharoplasty procedures, respectively. Microdermabrasion is more appropriately compared to the lighter chemical peels, such as the alpha hydroxy acids. This group of chemoexfoliants includes glycolic, citric, and lactic acids. These acids are derived from natural food products. Alpha hydroxy acids also reduce the thickness of the stratum corneum by decreasing epidermal cohesions. Alpha hydroxy acids can significantly improve the condition of hyperkeratinization, giving “aged” skin a smoother and healthier appearance. Glycolic acid, which is the most commonly used alpha hydroxy acid, is available in creams and lotions for daily use in concentrations between 8% and 15 %. In solutions, concentrations of 30 to 50% are available. Concentrations under 50 % allow discohesion of corneocytes, while higher strengths result in

Microdermabrasion / 71

epidermolysis. A concentration of 70% results in a medium depth peel, equivalent to 35% trichloroacetic acid. Alpha hydroxy acid peels (e.g., 30% glycolic acid) like microdermabrasion, can be used on all skin types to improve the appearance and texture of the skin. Patients with abnormal keratinization such as blocked pores, blackheads, ichthyosis, dry flaky skin, psoriasis, and fine etchings from sun damage and aging benefit form alpha hydroxy acid peels. Laser facial resurfacing utilizes light energy to create wounding to a precise depth of penetration and is an alternative treatment for photoaging and deeper wrinkles. Results comparable to traditional dermabrasion are achieved in the treatment of rhytids and acne scarring with the additional advantages of more accuracy, less risk of blood-borne pathogen infection, and less risk of hypopigmentation. Commonly used lasers in skin resurfacing included the pulsed CO2 laser and the Erbium: YAG laser. In summary, microdermabrasion is an attractive alternative for patients interested in facial rejuvenation but unwilling to undergo the discomfort, cost, risks, and longer recovery time of other techniques. However, as a superficial resurfacing technique, results are limited. Several studies, including those mentioned above, have generally reported trends in histologic improvement, primarily consisting of thinning of the stratum corneum, normalized epidermal architecture, epidermal thickening, and dermal thickening. Many providers also find that microdermabrasion stimulates patient interest in other offered procedures, including deeper peels or laser resurfacing.

Facial Analysis During the aging process, the stratum corneum becomes thickened with increased keratinization. This occurs because of a decrease in epidermal desquamation with increased corneum cohesion and a decrease of water content. There is reduced collagen and decreased elastin in the dermal layer as well. These histologic changes result in dry, flaky, inelastic skin. In general, microdermabrasion enhances skin texture by removal of the superficial layers of the epidermis, primarily the stratum corneum. It softens and modifies fine lines caused by the mimetic musculature around the mouth and in the forehead as well as the lines on the cheeks caused by aging and actinic damage. It is useful for reducing

skin pigmentation and helps to contract enlarged pores. In patients with acne, microdermabrasion exfoliates and suctions out clogged pores. With repeated treatment (typically ten treatments), microdermabrasion smoothes the margins of acne and traumatic scars. As with other resurfacing modalities, the Fitzpatrick type of skin should be noted. Microdermabrasion has proven safe in the treatment of all skin types, including types IV-VI, in which the role of chemical peels, laser resurfacing, and dermabrasion is limited. Darker skin types, such as Fitzpatrick types V and VI, should, however, receive less aggressive treatment to minimize the chance of minimize the chance of postinflammatory hyperpigmentation. The skin should also be carefully examined for lesions consistent with active infection (a contraindication to the procedure) or neoplasm, which may warrant biopsy or further investigation. As mentioned, microdermabrasion has been used in the treatment of multiple conditions, including acne, acne scars, hyperpigmentation, rough skin, actinic damage, and striae. These conditions should be assessed and pointed out to the patient.

Preoperative Considerations Stated indications include acne comedones and pustules as well as acne scars, superficial rhytids, superficial hyperpigmentation, melasma, scars, keratoses pilaris, milia, enlarged or oily pores, blackheads, and for improvement of skin texture and vitality. It may be used as an adjunctive therapy to accelerate or maintain other skin resurfacing treatments such as tretinoin or laser treatment. Some physicians also use microdermabrasion to blend laser-resurfaced skin with adjacent nontreated areas. Others use microdermabrasion as a preparation for deeper chemical peels. One of the difficulties of trying to create a uniform peel is the uneven penetration of chemical agents through the stratum corneum. Microdermabrasion is used first to remove the stratum corneum. An acid is then applied during the same session to achieve more uniform penetration and a better peel. Microdermabrasion can be used on the neck, back, hands, and chest areas as well as the face. In fact, microdermabrasion can be used on virtually all parts of the body. Back and chest acne eruptions, as well as superficial age spots of the hands and chest are reported to be responsive to treatment. Microdermabrasion is also stated to have some

72 / Microdermabrasion

A

B

Figure 7-1. Pre- (A) and post-treatment (B) photographs of a patient who received six treatments using an aluminum oxide microdermabrasion device.

effect on improving the appearance of stretch marks by blending them with adjacent normal skin, particularly when applied to new lesions of less than 6 months. Treatment of stretch marks is felt to require higher power levels and more frequent treatments. Microdermabrasion is considered a “lunchtime” procedure. Post-treatment redness and edema are very mild. Treatment with microdermabrasion is minimally disruptive to the patient’s social life. The mild erythema and desquamation can be easily camouflaged by cosmetics throughout the treatment period. Visible results are usually noticed after the first treatment. More significant and lasting results occur with repeated treatments, typically six or more. Manufacturers’ contraindications include conditions not treatable by microdermabrasion. Patients with undiagnosed lesions, cutaneous malignanacies, recent herpes outbreaks, warts, active, weeping acne, active rosacea, unstable diabetes, and autoimmune disorders are also not candidates. Patients using retinoids or strong alpha hydroxy acids are advised to discontinue use for approximately 3 days prior to treatment. A uniform guideline has not been established for herpes prevention and some manufacturers recommend antiviral treatments for patients with a tendency toward outbreaks. Rosacea and telengiectasias are relative contraindications as they may be exacerbated. Patients taking isotretinoin may develop hypertrophic scarring when treated with deeper skin resurfacing modalities such as laser and dermabrasion. It has therefore been recommended that patients should wait 1 year following the discontinuation of isotretinoin to begin microdermabrasion treatments. As mentioned

above, microdermabrasion is considered safe in all Fitzpatrick skin types. A full-face microdermabrasion treatment takes about 15 to 30 minutes. Treatments can be repeated every 1 to 2 weeks. Our patients typically require six to eight treatments for facial rejuvenation and nine to ten treatments for scars (Figure 7-1). Fees are generally more affordable than laser and traditional dermabrasion as well as most chemical treatments.

Technique Microdermabrasion equipment consists of a small tabletop unit connected to a handpiece by flexible tubing through which air is circulated to produce a stream of fine particles that are recollected by a suction opening contained in the same handpiece (Figure 7-2). Dirt, oil, surface debris, and dead skin loosened by the impact of particles are also

Figure 7-2. Microdermabrasion device including handpiece, tubing, and vacuum unit.

Microdermabrasion / 73

collected by the handpiece suction. The instrument is controlled via a foot pedal. The units are generally intended to be portable. Training is available on-site for all models from all manufacturers. Most manufacturers offer units that utilize sterilized aluminum oxide crystal particles, also known as corundum crystals, white fused Alumina, and Bauxite, as abrasives. These particles are approximately 100 microns in diameter, are insoluble in water and organic solvents, and have a melting point of 2000 °C. They are reported to be nontoxic for ingestion and are not known to be carcinogenic. The crystals are not reusable both from an infection-control standpoint as well as from an efficacy standpoint as usage dulls the sharp edges of the crystals. Other manufacturers offer systems that utilize sodium chloride, magnesium oxide, or sodium bicarbonate. Most microdermabrasion units function by creating a closed-loop negative pressure system that causes abrasive particles to be passed over the skin, although sodium chloride and sodium bicarbonate units utilize positive pressure to propel the particles instead. Compared to laser equipment, start-up costs are minimal. Medical and nonmedical models are available from multiple manufacturers. Medical models are intended for use in physicians’ offices and are capable of reaching deeper layers of skin while nonmedical models are intended for the salon and spa environment. Medical models can only be sold if they will be used under the direction of a physician. Nonmedical models use lower pressures and require more effort and time to use. As of 2005, there were more than 36 models of microdermabrasion units available in the United States.

Figure 7-3. The skin should be held taut so that skin is not drawn up into the handpiece.

Prior to treatment, the patient should cleanse and rinse the skin and allow it to dry completely. Eye protection for the patient and operator as well as surgical masks for operator is recommended. The patient should be appropriately draped and the hair covered to prevent getting crystals in the hair. All jewelry and contact lenses should be removed. Testing on a dry portion of the medial arm can be performed to determine the level of vacuum and crystal pressure used. The depth of abrasion is determined by the flow rate, vacuum pressure, speed of movement of the hand piece, and the number of passes made. The particle flow rate and vacuum pressure determine the volume of particles impacting the skin. Slow movement of the hand piece and a higher number of passes increase the depth of abrasion. The treatment is adjusted to produce a mild pink glow and to avoid excessive erythema. The vacuum should be reduced when treating sensitive periorbital and neck skin. The skin should also be held taut so that excess skin is not drawn up into the hand piece (Figure 7-3). The eye region should be treated from medial to lateral to prevent inadvertent injury to the eyes by residual crystals left on the handpiece. Likewise, the operator should work outwards from the mouth. Short, rapid strokes are made. Five to seven Pounds per Square Inch (PSI) are generally used for the face and three to four PSI for the neck and eyelids. A second pass is made except around the eyelids and neck. The second pass should be made at right angles to the first pass to avoid streaking (Figure 7-4). Further passes, if needed, are made in alternate directions for optimal results. More aggressive technique, consisting of higher vacuum pressure, slower strokes, and more passes, is generally used to treat

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Figure 7-4. The second pass is made at right angles to the first to avoid streaking.

acne scars. We have found that the vacuum level correlates with the discomfort level. The handpiece is moved across the skin with a gliding motion. If the hand piece is held in place it can cause deeper injury with pinpoint bleeding.

Postoperative Care At the end of the procedure, the skin appears pink without bleeding or prominent erythema. Immediately after treatment, patients note a silky smooth texture to their skin. Healing generally takes about three days. The overall improvement is less dramatic than can be achieved with laser resurfacing or deep chemical peels. The depth of abrasion is dependent on several factors including: the velocity of air flowing through the handpiece, the number of particles per second impacting the skin, the number of passes of the handpieces made across the skin, the thickness and texture of the skin, and the size of the particle. After the procedure, the used crystals, which are collected in a container, are disposed. A fine residue of crystals remains on the skin and can be removed with a soft brush followed by wiping the skin with moist, disposable sponges. Special care should be taken to immediately remove crystals from the eye area. If crystals get into the eye, it should be immediately flushed with saline solution. A moisturizer and sunscreen are recommended afterward. Cos-

metics can be applied over the moisturizer. A skin bleaching product for hyperpigmentation can also be applied after the treatment. No tanning should be done while undergoing microdermabrasion treatments. Retinol and alpha hydroxy acid usage may be resumed be about 3 days after treatment. Waxing, electrolysis, and depilatories should be avoided for at least a week following treatments.

Complications Complications associated with microdermabrasion are very rare. Microdermabrasion causes minimal discomfort to the patient and does not require anesthesia or recovery time. Patients may return immediately to their daily activities. Microdermabrasion is felt to be safe for all Fitzpatrick skin types. Hypopigmentation and scarring do not result from superficial levels being removed by this technique. Postinflammatory hyperpigmentation and streaking from excessive handpiece pressure can occur, as can petechiae and purpura. As mentioned above, Fitzpatrick Types V and VI may be prone to developing postinflammatory hyperpigmentation and care should be used in these patients to avoid overly aggressive treatment. These signs usually resolve within days of the procedure. Pinpoint bleeding can be elicited with very aggressive technique. Aluminum oxide crystals used in microdermabrasion have been reported to cause eye irritation

Microdermabrasion / 75

with erythema, photophobia, and epiphora. Ophthalmologic examination revealed conjunctival congestion, crystals adherent to the cornea, and superficial punctate keratopathy. Sodium chloride microdermabrasion is theoretically safer in this respect as particles in the eye can be treated with immediate and thorough rinsing, which should dissolve the particles. Adhesive ocular shields are recommended for patients undergoing the procedure in the face. An unusual case of severe urticarial reaction immediately following aluminum oxide microdermabrasion has been reported. The patient responded to immediate treatment with intramuscular betamethasone dipropionate and 25 mg of diphenhydramine. Potential causes were hypothesized to be latex exposure from the microdermabrasion unit, exaggerated dermographism, or pressure-induced urticaria. Minimal exposure to blood, therefore, reducing the risk of blood-borne pathogen transmission, is an advantage of microdermabrasion over traditional dermabrasion techniques. Bloody material was reported on the handpiece following microdermabrasion on a patient with acne scarring by Shelton. It was recommended by the author of the report that the handpiece itself should be sterilized rather than only the distal cap or using disposable caps. While prolonged exposure to aluminum has been associated epidemiologically to impaired cognitive function and the development of Alzheimer’s disease in miners and factory workers, no such effects have been reported in healthcare workers, despite millions of microdermabrasion treatment that have been administered so far. The particle size used in microdermabrasion is about 100 microns. Particles larger than 50 microns are unlikely to be inhaled and reach the alveoli where they can be absorbed systemically. Nevertheless, it is recommended that microdermabrasion providers wear a mask during treatment.

Summary The ideal skin resurfacing modality needs to be efficacious, reliable, technically easy to use, have minimal morbidity, and risk for the patient, and minimal risk of disease exposure for the operator. Well-designed, large sample, controlled studies remain to be performed to clearly demonstrate the efficacy. Several early studies have shown improvement in skin appearance as well as favorable patient

satisfaction. Favorable histologic changes in the epidermis and dermis have also been observed. Compared to chemical peels and lasers, there is minimal patient discomfort, and no “downtime.” Patients perceive immediate improvement in skin tone, texture, and pigmentation. It is safe to continue topical retinoids and other exfoliation therapies up to within a few days of microdermabrasion, unlike peels. Microdermabrasion also appears to have utility as an adjunct to deeper techniques such as laser and deep chemical peels. As a superficial resurfacing technique, it has limited efficacy in treating deep wrinkles and thick scars, emphasizing the fact that no single treatment modality is appropriate for all skin problems. Nevertheless, microdermabrasion has established a solid position in the armamentarium of skin resurfacing techniques.

Suggested Readings Alam M, Omura N, Dover J, Arndt K. Glycolic acid peels compared to microdermabrasion: a right-left controlled trial of efficacy and patient satisfaction. Dermatol Surg 2002;28:475–79. Bernard R, Beran S, Rusin L. Microdermabrasion in clinical practice. Clin Plast Surg 2000;27:571–77. Coimbra M, Rohrich RJ, Chao J, Brown SA. A prospective controlled assessment of microdermabrasion for damaged skin and fine rhytides. Plast Reconstr Surg 2004;113:1438–43. Farris P, Rietschel R. An unusual acute urticarial response following microdermabrasion. Dermatol Surg 2002; 28:606–08. Freedman BM, Rueda-Pedraza E, Waddell S. The epidermal and dermal changes associated with microdermabrasion. Dermatol Surg 2001;27:1031–34. Grimes PE. Microdermabrasion. Dermatol Surg 2005; 31:1160–65. Hernandez-Perez M, Ibiette V. Gross and microscopic findings in patients undergoing microdermabrasion for facial rejuvenation. Dermatol Surg 2001;27: 637–40. Koch RJ, Hanasono MM. Microdermabrasion. Facial Plast Surg Clin North Am 2001;9:377–82. Lloyd J. The use of microdermabrasion for acne: a pilot study. Dermatol Surg 2001;27:943–49. Rubin MG, Greenbaum SS. Histologic effects of aluminum oxide microabrasion on facial skin. J Aesth Derm Cosmetic Surg 2000;1:237–39. Shelton RM. Prevention of cross-contamination when using microdermabrasion equipment. Cutis 2003;72: 266–68. Shim E, Barnette D, Hughes K, Greenway H. Microdermabrasion: a clinical and histopathic study. Dermatol Surg 2001;27:524–30.

76 / Microdermabrasion Spencer JM. Microdermabrasion. Am J Clin Dermatol 2005;6:89–92. Tan MH, Spencer J, Pires L, et al. The evaluation of aluminum oxide crystal microdermabrasion for photodamage. Dermatol Surg 2001;27:943–49.

Tsai R, Wang C, Chan H. Aluminum oxide crystal microdermabrasion: a new technique for treating facial scarring. Dermatol Surg 1995;21:539–42.

8 Chemical Peels Vishal Banthia, MD, Basil M. Hantash, MD, PhD, and R. James Koch, MD

Introduction While lasers have become increasingly popular with technological advances, chemical peels represent a more time-tested and cost-effective tool to use either solo or as an adjunct to surgery in the eternal quest for facial rejuvenation. Chemical peels are agents that induce a controlled caustic injury to the epidermis and/or dermis with resulting exfoliation that renders the underlying and reepithelialized skin refreshed with respect to texture and appearance. Indications for the application of chemical peels are relatively similar to those presented for laser resurfacing and include: photoaging, rhytides, actinic keratoses, pigmentary dyschromias, postinflammatory hyperpigmentation, superficial scarring, and acne vulgaris. Note that unlike for laser resurfacing, certain peels can be useful for the treatment of active acne. The biologic mechanisms accounting for skin enhancement after chemical treatment are similar to those described for laser resurfacing and are extensively discussed in previous chapters. Briefly, insult to the skin stimulates a wound healing response in which the epidermis regenerates from surrounding epithelium, and dermal fibroblasts are induced to synthesize new collagen. These effects lead to an overall more favorable, remodeled dermal matrix with improved elastic and tensile properties.

Facial Analysis and Preoperative Considerations As with any type of resurfacing modality, the aesthetic surgeon must be familiar with basic skin anatomy and the aesthetic facial subunits, which are

described in previous chapters. Chemical peels may be performed within specific facial subunits but are more commonly applied for full facial resurfacing. Once two or more facial subunits are treated, it is generally appropriate to treat the entire face to avoid unwanted areas of demarcation. As with any type of intervention, a thorough history and physical examination is central to the preoperative assessment. A history of previous herpetic infection, chemotherapy, radiation exposure, and previous resurfacing treatments should be noted. No absolute contraindications exist for most peels (except for unrealistic patient expectations) although relative contraindications include connective tissue disorders, keloid predisposition, and active herpetic infection. Patients with cardiovascular, renal, and/or hepatic disorders are not candidates for phenol peels. On examination, skin texture and type should be assessed using Glogau’s classification of photoaging and Fitzpatrick sun reactivity type (Tables 8-1, 8-2) which are of utmost importance when determining which peeling agent to use. Chemical peels are classified according to their histologic depth of injury. As such, understanding the depth of pathology being treated will be helpful in determining the appropriate selection of the peeling agent. Superficial or light peels exfoliate and refresh the skin at the level of the epidermis while medium-depth and deep peels penetrate to the papillary and midreticular dermis, respectively. Table 8-3 lists the commonly used peeling agents according to depth. While peels are used to treat photoaged skin in general, superficial peels are particularly useful in treating melasma and postinflammatory hyperpigmentation in comparison to other

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TABLE 8-1 Glogau Classification of Photoaging

TABLE 8-3 Classification of Chemical Peels

Severity

Age (yrs)

Features

Mild

28-35

–Little wrinkling or scarring –No keratosis –Requires little or no makeup –Early wrinkling, mild scarring –Sallow color with early actinic keratosis –Requires little makeup –Persistent wrinkling –Discoloration with telangiectasias and actinic keratosis –Wears makeup always –Wrinkling - Photoaging, gravitational, dynamic –Actinic keratoses with or without skin cancer –Wears makeup with poor coverage

Depth of Tissue Peel Depth Penetration Common Peels

Moderate

35-50

Advanced

50-65

Severe

60-75

Superficial Epidermis (Granular layer)

Medium

Deep

Papillary – upper reticular dermis Midreticular dermis

• Alpha-hydroxy acids (e.g., glycolic acid 30-70%) • Jessner’s solution: resorcinol 14 g, salicylic acid 14 g, lactic acid 14 mL, QS ethanol 100 mL • TCA 10-20% • Jessner’s solution/ TCA 35% • Jessner’s solution/TCA 25% for type IV skin • Baker-Gordon Phenol peel: 3 mL USP liquid phenol 88%, 2 mL tap water, 8 drops liquid soap (Septisol), 3 drops croton oil

TCA, trichloroacetic acid.

resurfacing modalities. Superficial peels penetrate through the stratum corneum or the entire epidermis depending upon the type of peel being used. Hence, significant improvement in furrows or rhytidosis will not be achieved using superficial peels. The conclusion of the preoperative visit includes standard preoperative photography as well as the institution of preoperative medications. Medications recommended are similar to those prescribed for laser resurfacing and include ciprofloxacin, 500 mg twice per day for 7 days and valacyclovir, 500 mg twice per day for 10 days as well as pain medications. Antibiotics and antiviral agents are commenced 1 and 2 days prior to the procedure, respectively. With regard to anesthetic concerns, superficial and medium depth peels may be performed with-

TABLE 8-2 Fitzpatrick Sun-Reactive Skin Types Skin Type

Skin Color

Tanning Response

I II

White White

III

White

IV V

Brown Dark Brown

VI

Black

Always burns; never tans Usually burns; tans with difficulty Sometimes mild burn; tan average Rarely burns; tans easily Very rarely burns; tans very easily No burn; tans very easily

out intravenous sedation or general anesthesia, although these should be considered with deeper peels. Superficial peels may in fact be performed without any anesthesia; however, medium depth peels require nerve blocks with a local anesthetic. The authors routinely administer 10 mg diazepam for additional comfort. Topical anesthetic creams (i.e., EMLA) are not recommended as it remains uncertain whether this impairs penetration of the peeling agent.

Technique Superficial Chemical Peels As aforementioned, superficial peels, achieve a depth of penetration into the epidermis, specifically the granular layer. Common superficial peeling agents include alpha hydroxy acids (AHAs), beta hydroxy acids (i.e., salicylic acids), and Jessner’s solution. AHAs encompass a group of carboxylic acidic agents derived from fruit and dairy products including glycolic, lactic acid, tartaric, and malic acids. The most commonly used AHA is glycolic acid. Commercial, over-the-counter preparations set at 3-10% concentrations yield a slow exfoliation process with repeat applications over a period of several weeks. Higher strength concentrations (i.e., 30-70%) are reserved for application by supervised aestheticians. The higher the concentration, the greater the depth

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TABLE 8-4 Key Instruments/Materials • • • • • • • •

100% Acetone Balanced salt eye solution (BSS) 4×4” or 2×2” gauze Sterile gloves Cotton-tipped applicators Cooling fan Container with gauze soaked in iced water Emollient (e.g., Aquaphor ointment)

of penetration and efficacy. Salicylic acids have also been associated with skin textural improvements, in particular with comedonal acne and oily skin. Jessner’s solution is a blend of salicylic acid 14%, resorcinol 14%, lactic acid 14%, and ethanol. Jessner’s solution may be used as a mild, superficial peel but is more commonly used as a preparatory peel immediately prior to application of trichloroacetic acid (TCA) peels. The disruption of the epidermis by Jessner’s keratolytic properties allows for a more even penetration of TCA. Salient technical considerations are outlined below for the application of chemical peels. Table 8-4 outlines the key materials commonly required. • The patient is positioned at an incline with head elevated at 30-45 degrees to prevent entry of peeling agents into eyes. Balanced saline solution (BSS) should be available in the event that the chemical inadvertently enters the eyes. If the patient reports a burning sensation in the eyes during the procedure, BSS should be applied with its stream directed towards the medial canthus. • The skin is thoroughly cleansed with acetone on gauze pads to help achieve an even penetration of the peeling agent. Acetone removes the oil from the skin’s outer surface and acts as a keratolytic of the stratum corneum. • Each subunit is treated individually before moving on to the next to avoid under- or overtreatment in particular areas. Subunits may be marked out before peel application or can be mentally noted. • The peeling agent is applied with cotton-tipped applicators or 2×2” gauze to aesthetic subunits with emphasis of working solution into deeper rhytids or folds. The periocular region is usually addressed first and cotton-tipped applicators are used whenever treating this region. Application of the peel should approach within 2-3 mm of the lid margin. Cotton-tipped applicators are held at both medial and lateral canthi in order to soak

Figure 8-1. Chemical peel application in the periocular subunit. Note the placement of the cottontip applicators at the medial and lateral canthi to prevent capillary action towards the eye.

•

•

•

•

tears produced by the eye and to prevent entry of the peeling solution into the eye (Figure 8-1). The upper lids are treated superficially, as the associated skin is very thin in this region. As with laser resurfacing, treatment should be feathered to approximately 1-2 cm into the neck below the cheek and chin subunits to avoid obvious demarcation. Jessner’s solution or a TCA 10-20% peel produces level I frosting after 15-45 seconds which is the appearance of erythema and streaky whitening or a slight whitish frosting. Cool saline-soaked gauze is used to wipe off the peel. Glycolic acid peels need to remain on the skin for 2-4 minutes before being washed off. Glycolic acid peel treatments consist of weekly to monthly applications as clinically indicated. Superficial peels may be used in the neck, whereas deeper peels are not recommended in this area. The neck may be treated with TCA 15-25% peels in a conservative manner. Multiple applications of such superficial peels will eventually equal that of higher concentration and therefore are discouraged. A light, translucent frost signals the endpoint of treatment in the neck.

Medium-Depth Chemical Peels A combination of Jessner’s solution/trichloroacetic acid (TCA) 35% medium depth peel represents the workhorse peel used in the authors’ centers as reliable and consistent clinical improvement has been

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noted with the use of this peel for mild to moderate rhytidosis. Combination Jessner’s/TCA 15-25% has been used successfully in treating patients with Fitzpatrick type IV skin. • After appropriate cleansing, marking, and positioning of the patient, one to two coats of Jessner’s solution are applied as an initial preparatory peel. Approximately 1 minute after the appearance of level I frosting, TCA 35% is applied in a similar fashion into aesthetic units sequentially. • The desired endpoint with the TCA is a level II frost which appears after a few minutes after even application of the peel. This appearance is characterized by a uniform but not completely opaque white-coated frosting with slight permeating erythema. It is important to note the skin color changes from mild erythema initially to the light frost followed by a return to erythema (Figure 8-2). The return to erythema does not represent undertreatment, and the peeling agent should not be applied further, as excess treatment may induce scarring. • A cooling fan is held by an assistant at the region of the patient’s waist and aimed towards the face to mitigate any burning sensation experienced by the patient. • As mentioned above, the peel should be feathered at the jawline for about 1-2 cm to masquerade the transition into untreated skin. In the perioral region, application of peel is carried to 1-2 mm into the vermilion border to prevent obvious demarcation. • Immediately after each subunit is treated, the area is covered with ice water-soaked compresses

Figure 8-2. A patient undergoing medium-depth Jessner’s/TCA 35% peel. Note the characteristic frost signaling the endpoint of treatment.

Figure 8-3. Appearance immediately after Jessner’s/ TCA 35% peel treatment.

which are left on the patient for several minutes. Emollient, such as Aquaphor (Beiersdorf AG, Wilton, CT) is then coated over the treated areas. • Figure 8-3 demonstrates appearance just immediately following application of a chemical peel. Figure 8-4 shows improved skin texture following a medium depth chemical peel.

Deep Chemical Peels Deep peels (phenol and TCA 50% or higher) have largely been abandoned in full facial resurfacing, as phenol peels may induce certain toxicities and require monitoring, while higher-strength trichloroacetic acid (TCA) have high risks of inducing scarring and hypopigmentation. • The Baker-Gordon phenol peel is indicated for severely photoaged skin but, as aforementioned, is rarely used in treating the full face and will not be discussed further. Limited areas of application, however, such as the perioral region for deep perioral rhytids represent contemporary applications for this peel. The mechanical technique of application of this regional peel is similar to that described above; however, the endpoint is a level III frosting characterized by a solid white frosting without penetrating erythema seen shortly after application of the peel. • Full facial resurfacing with the phenol peel requires administration of intravenous fluids prior to the start of treatment to help dilute and excrete absorbed phenol. Additionally, cardiovascular monitoring is required.

Chemical Peels / 81

A

B

Figure 8-4. Pre- (A) and postprocedure (B) photographs of a patient after having had a Jessner’s/TCA 35% peel.

• Deep acne scar pits deserve special mention as the limited, focal application of 100% TCA can yield impressive results. This technique is especially useful for patients with darker skin types. A wooden applicator with 100% TCA soaked within is placed into the depressed ice-pick scar. A frosting ensues signaling the endpoint within 10 seconds. Similar to the fractional photothermolysis concept in laser therapy, the limited application of 100% TCA in this manner permits the surrounding untreated skin to help speed the healing process in treated areas. The high strength TCA stimulates collagen formation within the scar depression to ultimately eliminate the depression altogether. A total of four to six applications spaced at 4-6 week intervals are generally required to achieve noticeable improvement. As with standard peeling, Aquaphor ointment is applied to the treated areas. No anesthetic or monitoring is required for such limited application of this peel. Note that 100% TCA is not advocated for full face treatment.

Postoperative Care An open wound care approach is generally used after chemical peel treatment. For superficial peels, a moisturizer such as Cetaphil (Galderma, Alliance, TX) lotion can be applied immediately after treatment and should be continued for several days until the skin has reepithelialized. The skin can be cleaned at least two times per day with a mild cleanser such as Cetaphil cleanser. Patients should have an adequate expectation of skin sloughing and significant erythema during the wound healing process after the peel treatment. Time to reepithelialize is 3-6 days for superficial peels, while that associated with medium and deep peels is 7-10 days.

For medium and deep peels, Aquaphor is generally applied to treated areas and is continued until reepithelialization. The cleaning regimen is similar to that for laser resurfacing and includes the application of dilute acetic acid soaks (one tablespoon white vinegar in one pint of tap water) which should be applied for at least 15 minutes through the layer of petrolatum at least 4-5 times per day. Following the soaks, the skin should be pat dry with a soft towel and the Aquaphor emollient should be reapplied. Patients should not pick at scabs but rather let them wash off with the soaks. Once reepithelialization is complete, Cetaphil lotion may be used in place of the thicker Aquaphor ointment. Acetic acid soaks may be discontinued; instead, Cetaphil cleanser can be used. After reepithelialization, patients can wear powder-based makeup and sun protection using UV-A/UV-B sunblocks containing titanium dioxide or zinc oxide with an SPF over 30. Sun exposure should be minimized at least for the first few weeks following peel treatment. As with any type of resurfacing procedure, patients should be evaluated frequently to monitor their progress post-peel. Suggested follow-up visits are on postoperative days 1, 7, 14, and 30 at the very least.

Complications As with laser resurfacing, potential complications following chemical peel treatments are a function of the depth of tissue injury. The greater the tissue insult, the greater the risk of complication. Complications after peeling are similar to those after laser resurfacing and are presented in Laser Skin Resurfacing, and the reader is urged to review this section for further details. Common complications after

82 / Chemical Peels

treatment, however, are briefly presented. It should be noted that many complications associated with chemical peels are related to use of an incorrect concentration of the peeling agent and/or its expiration. Thus, it is particularly important to verify the shelf-life and concentration of the reagent prior to its use.

Prolonged Erythema Erythema after superficial and deep peels can persist for 2-4 weeks and 2-3 months, respectively. Erythema lasting beyond these schedules should signal poor wound healing and must warrant ruling out infection and contact dermatitis. Sun avoidance and sunscreen use should be reinforced. For persistent erythema, topical application of corticosteroids (i.e., hydrocortisone 2.5%) twice per day for 3 weeks may be considered. Intralesional and systemic steroids may also be taken into consideration for refractory cases.

Acne and Milia Prolonged use of a thick, occlusive emollient such as Aquaphor can obstruct pores and may predispose to acne and milia eruptions. These blemishes are usually self-limiting; however, persistent milia may be lanced manually using an 18-gauge needle.

Infection Despite adequate prophylaxis, viral (herpetic), bacterial, and fungal infections may surface. Focal areas of pain, crusting, erythema, and possibly discharge herald infection. Cultures should be considered and directed antimicrobial therapy instituted. While ciprofloxacin and valacyclovir doses have been previously described, fluconazole 100-200 mg daily for 7-10 days may be considered for fungal (Candida) infection. Prompt infection eradication is imperative; if left untreated, future scarring may result.

Skin Dyschromia Some degree of hyperpigmentation should be expected especially in higher Fitzpatrick skin types. Postinflammatory hyperpigmentation may be precipitated by exposure to direct sunlight which stimulates melanocytic activity and sunlight precautions must be once again reinforced. As in laser resurfacing, persistent hyperpigmentation is treated with a cream mixture of hydrocortisone 1%, hydroqui-

none 4%, and Retin A 0.05% twice per day for one month on and one month off, until resolved. While controversial, the authors routinely pretreat patients with Fitzpatrick skin types III or higher with the above combination cream for 4-6 weeks in order to minimize postinflammatory hyperpigmentation. Temporary mild hypopigmentation should also be an expected consequence after peel treatment especially in patients with lower Fitzpatrick skin types. Permanent hypopigmentation is rare but unfortunately can occur as late as several months postprocedure.

Scarring Hypertrophic scarring may result from an overly aggressive or deep peel that yields excessive tissue injury. Contact dermatitis, infection, and prolonged erythema are additional etiologies of scarring and thus should be recognized and treated promptly. Topical application of corticosteroids (i.e., Temovate 0.05%) twice per day for 2 weeks represents initial management; intralesional steroid injections as well as the application of silicone gel or sheeting may also be considered.

Phenol Toxicity Full face resurfacing with a phenol peel carries risks associated with phenol toxicity including cardiac arrhythmias, central nervous system depression, hypotension, and liver and renal failure. Such peels should be performed under monitored conditions with adequate intravenous fluid hydration pre- and intraoperatively. Additionally, each facial subunit should be treated followed by at least a 15 minute break prior to the treatment of the next aesthetic unit. Fortunately, such complications are rare given that full face resurfacing with phenol peels are rarely performed today.

Suggested Readings Camacho FM. Medium-depth and deep chemical peels. J Cosmet Dermatol 2005;4(2):117–28. Erbil H, Sezer E, Tastan B, et al. Efficacy and safety of serial glycolic acid peels and a topical regimen in the treatment of recalcitrant melasma. J Dermatol 2007;34(1):25–30. Glogau RG. Chemical peeling and aging skin. J Geriatr Dermatol 1994;2:30–5. Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Dermatol Surg 1999;25(1):18–22.

Chemical Peels / 83 Hirsch RJ, Dayan SH, Shah A. Superficial skin resurfacing. Facial Plast Surg Clin N Am 2004;12:311–321. Landau M. Cardiac complications in deep chemical peels. Dermatol Surg 2007;33(2):190–3. Landau M. Combination of chemical peelings with botulinum toxin injections and dermal fillers. J Cosmet Dermatol 2006;5(2):121–6.

Monheit GD. Advances in chemical peeling. Facial Plast Surg Clin N Am 1994;2:5–9. Monheit GD. The Jessner’s – TCA peel. Dermatol Clin 1995;13:277–83. Zakopoulou N, Kontochristopoulos G. Superficial chemical peels. J Cosmet Dermatol 2006;5(3): 246–53.

9 Cosmeceuticals Mary Lynn Moran, MD

Introduction The role of the facial plastic surgeon is increasingly challenging as we face many additional demands in order to stay relevant in today’s market. It is not enough to be a skilled surgeon. Patients are sophisticated in their expectations and highly educated about their options. They are giddily optimistic about the possibility of postponing surgery indefinitely by using nonsurgical means of rejuvenation as new technology continues to develop at warp speed. Aggressive marketing by skincare conglomerates and a proliferating “spa” market reinforces their hopes. With mounting economic pressure on physicians from all specialties as well as growing opportunities for non-physicians to capitalize on nonsurgical treatments, competition in the cosmetic medical industry is at an all-time high. The good news is that the growing wealth of technology enables us to better serve our patients in new and different ways. As facial plastic surgeons we are in a unique position to offer our patients the entire spectrum of facial rejuvenation options from sunblock to surgery. It behooves us to have a basic grasp, if not a mastery of all aspects of facial rejuvenation in order to deliver the most comprehensive care that we possibly can. Not every patient who walks in your door for a consultation is an ideal surgical candidate. On the other hand, it is a rare individual who could not benefit from some form of topical skincare. As a medical/surgical expert in all matters of facial rejuvenation, we are in a position to offer them the most effective, potent, and appropriate care for their skin. If you do not guide them as to the best care for their skin, they will obtain guidance elsewhere. Patients in today’s world cannot avoid information about the

latest in skincare. They cannot turn on the television without seeing a news story, commercial, infomercial, or talk show about the latest wrinkle treatment. They cannot open a single woman’s magazine (or almost any magazine for that matter) without being bombarded with ads or article about skincare. You must help them sort out hype from reality which means that you need to understand how topical therapy works. Topical delivery systems are a growing trend in medicine and in the biotechnology industry. Skincare has been around nearly since the beginning of civilization. Cleopatra was notorious for her use of sour milk baths and honey to improve her complexion. The current skincare industry alone is estimated to comprise 11 billion of the 45 billion total dollars spent on beauty each year in the United States. Cosmeceuticals are a sophisticated subset of that industry that is growing ever more crowded under the pressure of a baby boomer population now numbering 78 million strong.

What is a Cosmeceutical? In 1938, Congress passed the Food, Drug, and Cosmetic Act declaring that a topical product must be categorized as either a cosmetic or a drug. The act provides that if a product has the ability to prevent or treat a disease then it must be proven to do so and then categorized as a drug. If the intent of the product is merely to enhance appearance then it must have no demonstrable effect on the structure or function of the skin and it is then labeled a cosmetic. The irony of this law is that, many seemingly inert ingredients can penetrate and alter physiologic properties and function of the skin, such as water, petrolatum and mineral oil. Since the passage of

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this bill, many new substances have been discovered that have significant impact on the structure and function of the skin. Yet, to classify them all as drugs would be unnecessarily restrictive and tedious. Furthermore, it is not in the best economic interests of the producers of theses substances to classify them as drugs and thereby subject themselves to time-consuming and costly testing and regulatory hurdles. Clearly a new class of substances was emerging that had both cosmetic and pharmaceutical properties. At a meeting of the Society of Cosmetic Chemists, Dr. Alfred Kligman first called these substances “cosmeceuticals” 25 years ago. A cosmetic product with medicinal or drug-like benefits as a result of biologically active ingredients is considered a cosmeceutical. They are marketed as cosmetics with physiologic benefits but are not subjected to the regulatory rigor and oversight. Producers of cosmeceuticals are very careful with their claims to avoid triggering action by the Federal Trade Commission and oversight by the FDA. This ambiguity creates a challenge for consumers and cosmetic professionals alike. It can be nearly very difficult assess whether a product will deliver on its promises. It is even more difficult to know if the “special ingredient” is actually causing the perceived changes, or if it is the other more common less expensive ingredients which are responsible. While some peer reviewed studies exists for certain substances, many of them merely allude to benefits without credible substantiation. Consumers, for the most part, are more than willing to believe that the fountain of youth does exist in a jar that they can buy at the drug or department store. Cosmeceutical corporations are more than eager to continue to feed those dreams especially when the risks are low and the financial benefits are staggeringly high. Fortunately for all of us, there exist many ingredients that have a beneficial impact on the health and appearance of the skin. The technological developments on the horizon do indeed seem very promising. Appropriate effective skincare implementation can have an enormous impact on the lives of patients. Cosmeceuticals play a very important role in every facial rejuvenation treatment regimen.

Indications Cosmeceuticals are used in a wide range of applications. They can be used for existing advanced conditions or they can be used proactively and pre-

ventatively. Topical agents commonly address dry skin, oily skin, acne, aging, sun-exposure, hair removal, hair growth, rosacea, pigmentation, tanning, and countless other concerns. For the purposes of this chapter, we will limit our discussion to facial products. We will also focus more on products that relate to rejuvenation. All skin is aging skin. Ideally intervention occurs before irreversible damage occurs. Beginning a cosmeceutical regimen while an individual is in his/her 20s is not too soon. As the patient accumulates more age and sun related pathology, the regimen becomes more intense and layered. Early on, a good moisturizer and sunblock can go a long way to stave off signs of skin aging. As damage begins to show, it is important to initiate rejuvenators and products specific to the patient’s pathology.

Physiology Intrinsic aging and photodamage occur at the level of the molecular pathways. Ultraviolet rays trigger intracellular signals to inhibit procollagen gene expression which results in the breakdown of collagen and other proteins in the extracellular matrix. Reactive oxygen species are produced by ultraviolet light on the skin which also degrades collagen. The histologic markers are compact stratum corneum, atypical keratinocytes, cell necrosis and dysplasia, and irregularity in the epidermal cell organization. Dermal changes include elastosis, increase in reticulin fibers along with amorphous material which replaces broken-down collagen. Loss of elasticity, loss of hydration, pigmentation, irregularity of texture, enlargement of pores, broken capillaries sallow color, loss of translucency, keratoses are among the signs of aging. Skin wrinkling, crepiness, and sagging are manifestations of aging and photodamage.

Function In order for a topical agent to be effective, it must deliver an active ingredient into and across the skin barrier. The stratum corneum is a simple laminar structure that is found on top of the epidermis (Figure 9-1). Corneocytes held together with cosmodesmosomes and intercellular lipids (including fatty acids, ceramides, and cholesterol), form a brick and mortar barrier that keeps in moisture and blocks out chemicals and microorganisms. NMF (Natural Moisturizing Factor) is found within the corneocytes. It is comprised of a mix of low molecular

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Stratum Granulosum Stratum Corneum

Epidermis

Stratum Spinosum Stratum Basale

Papillary Dermis Reticular Dermis

superficial fascia

Figure 9-1. Epidermis.

weight hygroscopic molecules, including 50% ami-no acids and 50% salts. Lactic acid, urea, and sodium PCA are components of NMF, If water is lacking in the stratum corneum because of intrinsic or extrinsic factors, the skin feels dry, flaky, and looses elasticity and looks dull. Many products are targeted at the stratum corneum because a little bit of hydration goes a long way to a better appearance, function, and feel of the skin. If a product is targeted at the epidermis or dermis, it must somehow penetrate through this tough barrier in order to be effective. Many claims are made about a novel ingredient that has a special ability to rejuvenate the skin when in fact, the result that is observed is nothing more that good hydration of the stratum corneum. Nonetheless, cosmeceutical companies will keep trying and consumers will keep buying. In an effort to organize the vast array of topical agents, they will be organized by general function. Some ingredients may be multifunctional. This is by no means, an exhaustive list given that there are many different ingredients classified as cosmeceuticals and more are being added as you read this publication.

Moisturizers Moisturizers have been around nearly since the beginning of recorded civilization. Until recently

they were the only commercially available topical agents. They are still the most widely used topical product by a significant margin. Moisturizers target the stratum corneum comprised of corneocyte/ desmocorneocyte matrix and an intercellular bilipid matrix. The maintenance of the epidermal barrier assures skin integrity water balance and normal corneocyte desquamation. Disruption of either component results in increased transepidermal water loss (TEWL). Ideally, the water content in stratum corneum is between 20-35%. They typically will contain a humectant and an occlusive agent. Most ingredients used in a majority of moisturizers are inexpensive, widely available, and not technically thought of as cosmeceuticals. Often they are nothing more than commercially produced replicas of the components naturally found in the NMF or lipid barrier. Nonetheless, they can be highly effective in the right formulation. Effective common humectants include glycerin, propylene glycol, lanolin, bisabolol, sodium PCA. Commonly used occlusive agents are petroleum, mineral oil, and silicone. The combination of a humectant with a barrier rehydrates the skin thereby minimizing fine lines, dullness, flakiness, and irritation. The moisture/barrier combination also allows for repair of skin damage to occur and can help to mitigate wrinkle formation by increasing the cushion effect of the lipid barrier.

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Water Water is the primary humectant in the majority of products on the market. Dermis is comprised of approximately 80% water. The stratum corneum varies between 10-30%. Hydration of the skin is essential for its most critical functions. Applying water topically is highly effective but it must be coupled with other ingredients that carry and hold it within the dermis and stratum corneum for a prolonged period of time in order for the skin to benefit. Glycerin is one of the most versatile ubiquitous substances around. It is a sugar alcohol with three hydrophilic alcoholic hydroxyl groups that are responsible for its solubility in water and its hygroscopic nature. It is capable of binding water to the skin. Sometimes it appears as PEG in various products. Bisabolol is an alcohol that does occur naturally but is produced synthetically for commercial purposes. It has also been used for hundreds of years in cosmetics because of its perceived skin healing properties. Bisabolol is known to have anti-irritant, anti-inflammatory, and antimicrobial properties. Hyaluronic Acid is a more recent addition to the skincare market. It is one of the most effective humectants available. In the body, it is found in the intercellular matrix of the skin, synovial fluid, as well as in the vitreous of the eye. It allows the vocal cords to vibrate and cushions the joints. It is a mucopolysaccharide that acts as a binding, lubricating, and protective agent. The molecular structure is such that it holds up to several times its weight in water. Hyaluronic acid is found in high concentrations in the skin, however, with age and UV exposure, the amount deteriorates. Topical application is a very efficient way to replace deficiencies and an excellent way to reduce TEWL. Sodium PCA a sodium salt of 2-pyrrolidone5-carboxylic acid occurs naturally in human skin as part of the NMF (Natural Moisturizing Factor) and is responsible for binding moisture to the cells. It is highly water-absorbent, holding several times its weight in water, which makes it an excellent humectant. Urea is also a component of NMF in the corneocytes. It is a crucial humectant and a highly effective keratolytic. In high concentrations it is used to treat disorders of the stratum such as eczema and severe dryness (xerosis and ichthyosis). Panthenol is a very effective humectant. It is also known as vitamin B5, however, it is not absorbed

into the skin effectively, therefore, its topical effects are as a moisturizer, emollient and humectant. It has not been active as a provitamin topically. Botanicals are too numerous to enumerate in this publication, however, many of them are very effective topical agents. Examples include aloe vera, papaya, and soy. Many of them have antioxidant, anti-inflammatory, and antimicrobial properties among other effects. Emollients and occlusive agents play a significant role in the efficacy of skincare products. They act as moisture shield that not only prevent TEWL, but also allow for greater retention of the active ingredients. They can also act as replacement lipids for the lipid barrier. Some of the most common emollients and occlusives include mineral oils and petrolatum. They are perfectly good additives when a heavier barrier is indicated. The molecular weight of these agents is higher than that of sebum and will not likely penetrate the stratum cornea very deeply if at all. Nonetheless, they act very effectively as a moisture seal. Various vegetable, animal and nut oils can be used according to the molecular weight desired for textural and functional reasons. Lower molecular weight oils and emollients tend to be absorbed more easily and are generally less comedogenic. Jojoba and squalene are two oils that are very similar to human sebum and thereby easily absorbed into the skin. Grapeseed and borage oils are very elegant agents with potent antioxidant properties. Lanolin mimics human sebum despite being derived from sheep oil. It causes a relatively high incidence of contact dermatitis so it must be used judiciously. The name “Oil of Olay” was derived from the word lanolin since it was at one time a common ingredient in many of their products. Shea butter is an emollient with anti-inflammatory properties that promotes healing. It provides moderate natural UV sun protection. Shea butter absorbs rapidly into the skin without leaving a greasy feeling. It contains both vitamin A and vitamin E. Cocoa butter is similar and also contains antioxidants. Ceramides are a family of lipid molecules. A ceramide is composed of sphingosine and a fatty acid. They are found in high concentrations within the cell membrane and are one of the component lipids that make up sphingomyelin, one of the major lipids in the lipid bilayer. Ceramides can be released from the cell membrane by enzymes and then act as a signaling molecule to regulate differentiation,

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proliferation, programmed cell death and apoptosis of cells. Topically, however, it acts as an emollient. Waxes and Paraffins are inexpensive and effective ways to reduce TEWL. Silicone reduces TEWL without causing a greasy feel or occluding oil ducts. It acts as an effective barrier to microbes and pollution but allows for oxygenation of the skin. It is a relatively new additive to hair and skincare products and is a very popular for its oil-free emollient properties. In gel-form, silicone is felt to aid in the reduction of scar tissue. The mechanism of action is not completely understood but it is believed that the electrical charge of the gel or sheeting stimulates reorganization by modulating expression of fibroblast growth factors such as bFGF. Cetyl Stearate is one of the most common emollients and is also notable for a nongreasy feel.

Rejuvenators Alpha-hydroxy acids (AHAs) have been utilized for their anti-aging properties for centuries. As mentioned earlier, lactic acids were the active ingredient in Cleopatra’s sour milk baths. Glycolic and lactic acid are the most widely used antiaging cosmeceuticals. They are effective and when used properly have a low incidence of side effects. The concentration and preparation of the acid determines its antiaging capacity. In low concentrations, it is an excellent exfoliant and humectant. The exfoliation occurs as a result of epidermolysis because of desmosomal detachment. Corneocytes become “unglued” thereby enhancing turnover. Stratum corneum becomes thinner, more hydrated, and more translucent. At higher concentrations of at least 5% AHAs have been shown histologically to thicken epidermis and to increase the number of active fibroblasts and the amount of dense collagen in the dermis. They can also decrease pigmentation and act as antioxidants. This may be because of stimulation of transforming growth factor beta (TGF-B). At higher concentrations AHAs can be irritating and cause sunsensitivity. This can be mitigated by adding an anti-irritant such as strontium nitrate which blocks type c nociceptors, thereby minimizing subjective discomfort and inhibiting release of inflammatory mediators. Glycolic acid is a sugar-derived AHA, lactic acid is a milk-derived AHA. There are other AHA cosmeceuticals including malic from apples and pears, tartaric from grapes, citric from lemons. All AHAs can be effective if formulated properly.

Beta-hydroxy acids (BHAs) are similar to AHAs except that they are lipid soluble instead of water soluble. They are excellent agents for the treatment of acne-prone or oily skin. BHAs works mainly as an exfoliant and are particularly effective at penetrating into the sebum-filled pore to exfoliate dead skin cells that have accumulated, thereby unblocking it. BHAs are reported to improve wrinkling, roughness, and pigmentation. They are most effective in a concentration of 1% to 2% and at a pH of 3 to 4. The main BHA used commercially is Salicylic acid and was derived originally from willow bark. Poly-hydroxy acids (PHAs) are a special type of AHA which are thought to penetrate the skin more gently than traditional AHAs in part to their larger size and multiple hydroxyls, resulting in less discomfort for sensitive skin. Because of the additional hydroxyl groups, PHAs may attract more water through hydrogen bonding, making strong humectants. Many polyhydroxy acid salts such as gluconolactone, glucoheptonolactone, glucoheptonate, and lactobionic acid have been shown to function as antioxidants through chelation of oxidation promoting metals.

Retinoids Retinoids are highly effective, well-studied substances that have been used for rejuvenation since the 80s. They are a naturally occurring class of compounds with the same core structure as vitamin A and its oxidized metabolite derivatives. The most widely known of these products are retinoic acid (Retin A, Renova), retinol, retinaldehyde, and retinyl esters. Several synthetic versions have been developed including adapalene (Differin), and tazarotene (Avage and Tazorac). In the skin, retinol is converted to retinaldehyde which is then oxidized to retinoic acid. Retinoic acid regulates gene expression affecting keratinocyte differentiation. Histologically it is shown to cause epidermal thickening, increased granular layer thickness, stratum corneum compaction, and decreased melanin content. They are also beneficial in the treatment of acne, psoriasis, and can be used for actinic keratoses and early cancer prevention. The anti-cancer effects of retinoids are mainly mediated by their nuclear receptors, the retinoic acid (RA) receptors (RARs) and the retinoid X receptors (RXRs) which regulate cell differentiation and growth. Retinoids also promote apoptosis which can inhibit tumor cell growth. Side effects of retinoids include potentially significant irritation and teratogenicity. Irritation is the primary cause of noncompliance among cosmetic patients.

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Antioxidants Vitamin C is the best known of the antioxidant class. Its benefits orally have touted since the days of scurvy and popularized as a supplement by Linus Pauling in the 70s. It is a water soluble vitamin found in both the extra- and intracellular fluids. As an antioxidant, it neutralizes reactive oxygen species (or free radicals) that destroy cells of the skin by attacking cell membranes, proteins such as collagen, and by altering DNA chemistry. These free radicals (including superoxide, singlet oxygen, and hydroxyl radicals) released during oxidative stress are produced on a regular basis as we live and breathe, however, production is stepped up under various conditions, such as UV exposure, stress, smoking, exposure to toxins, high glycemic index, air travel, and excessive exercise.

Physiology Vitamin C is the most prevalent antioxidant found in the skin. It is constantly donating electrons to scavenge free radicals, thereby mitigating damage to cells and DNA. Ultraviolet radiation (UVR), especially UVB, depletes the skin of Vitamin C and E (both crucial antioxidants). Simultaneously, ROS concentration greatly increases upon exposure to UVR, especially UVA. The anti-inflammatory properties of Vitamin C are well documented. The mechanism is by inhibition of production of cytokines such as TNF-a, IL-1, IL-6, and IL-8 by virtue of downregulation of transcription nuclear factor kappa B. Vitamin C also plays an important roll in collagen synthesis. It is a key cofactor in several steps involved in cross-linking and stabilizing collagen. It stimulates production of procollagen mRNA. It is also prevents elastosis.

Topical Application Topical vitamin C protects against certain UVA (320-400) and UVB (290-320) bandwidths by absorbing free radicals released upon exposure thereby mitigating damage. It also assists Vitamin E in its free radical activities within the lipid-soluble parts of the skin. Topical vitamin C also has been shown to improve all aspects of photoaging including increased collagen staining seen histologically, decreased inflammation, and overall improvement in texture, tone, and elasticity.

There are three commonly used preparations of Vitamin C including l-ascorbic acid, ascorbyl palmitate, and magnesium ascorbyl phosphate. L-ascorbic acid is water soluble and is the least stable preparation which makes it an effective antioxidant as it willingly attaches itself to free radicals. For ideal efficacy it is formulated at a pH of less than 3.5 and a concentration of 10-20%. This acidic preparation acts as an exfoliant and can be irritating. Ascorbyl palmitate is a fat-soluble derivative of vitamin C which is less irritating and more stable than L-ascorbic acid. Like its fat-soluble counterpart vitamin E, it helps to protect the skin from lipid peroxidation. It may not, however, boost collagen synthesis as much as L-ascorbic acid. Magnesium ascorbyl phosphate is a water-soluble derivative of vitamin C rapidly gaining popularity in skin care because of its higher stability and lower irritation than L-ascorbic acid. It appears to have the same potential as vitamin C to boost skin collagen synthesis at lower concentrations. It does not produce any exfoliating effects because it is less acidic. Ascorbyl tetra-isopalmitate and Tetrahexyldecyl Ascorbate are among the next generation of vitamin C derivatives.

Vitamin E Vitamin E (alpha tocopherol) is the body’s most important fat-soluble antioxidant. It is a stable molecule, however, it cannot be synthesized by the human body so it must be taken orally or topically and it requires vitamin C to replenish itself. It protects cell membranes and lipoproteins by preventing lipid peroxidation. It is necessary for tissue repair, is a natural anticoagulant, and it promotes healing. The predominant form of vitamin E in human and animal tissues is alpha tocopherol. Derivatives of vitamin E do not have the antioxidant benefits of alpha tocopherol but are effective emollients.

Other Topical Antioxidants Ferulic Acid Ferulic acid is a plant phenolic acid that possesses potent antioxidant potential. UV absorption by ferulic acid catalyzes stable phenoxy radical formation which terminates free radical chain reactions. Ferulic acid is a safe nontoxic compound with both hydrophilic and lipophilic properties that is absorbed and metabolized easily. It works synergistically with other antioxidants such as vitamins C and E.

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Coenzyme Q10 and Idebenone Coenzyme Q10 (CoQ10) is a vitamin-like natural compound found in all aerobic organisms, It plays a pivotal role in the cellular energy production and is also an effective antioxidant. CoQ10 is one of life’s most essential biochemicals. It is known as “ubiquinone” in reference to its ubiquitous nature. It is an important antioxidant component of the lipid membranes that surround all cells, as well as the lipid membranes surrounding the various organelles such as mitochondria and microsomes. It is also an important member of the electron transport chain within mitochondria. Idebenone is a synthetic analog of CoQ10. Idebenone is claimed to have antioxidant benefits similar to CoQ10 and is more water soluble. Idebenone is different from CoQ10 in one very important way. During a hypoxic (low oxygen) condition, CoQ10 can switch function from an antioxidant to an autooxidant. This autooxidation produces free radicals which damages the tissues. Idebenone is said to perform the same functions as CoQ10 without the risk of an autooxidation reaction. Both are used in commercially available topical preparations as antioxidant creams. A study by McDaniel, et al compared using a sunburn cell assay test, photochemiluminescence test, and a measure of primary oxidative products, secondary oxidative products, UVB-irradiated keratinocytes. The study showed that idebenone compared very favorably to ubiquinone, lipoic acid, ascorbic acid, tocopherol, and kinetin as an agent that prevented ROS damage in the Jounal of Cosmetic Dermatology (January 2005). Kinetin is a chemical analogue of a class of plant hormone called cytokinins that promote cell division. Miller and Skoog isolated and identified these compounds in 1955. They noted that kinetin prevents senescence (aging) of leaves in plants. Further laboratory studies, using human cell cultures, showed that Kinetin delays the destruction of skin fibroblasts. Lipoic acid, also known as alpha-lipoic acid, is a sulfur-containing fatty acid. It is an antioxidant which is fat and water soluble. It is a co-factor in a key biochemical pathway responsible for energy production in the cells (citric acid cycle). It can, like vitamin C modify gene expression by stabilizing NF kappa B transcription factor. It may help regenerate other antioxidants that have been used up and it inhibits cross-linking proteins or other large molecules which can lead to wrinkling of the skin. It has

a moderate anti-inflammatory effect and can neutralize and remove from the body a variety of toxic metals. There exists a variety of other antioxidants that may provide antiaging benefits including selenium, green tea (containing catechin polyphenols), lycopene (a carotenoid found in tomatoes), betacarotene (a carotenoid found in carrots and other orange and dark green vegetables), and Oligomeric proanthocyanidin complexes (OPCs) made from grape seed or pine bark which are closely related to bioflavonoids.

Peptides Peptides are amino acid short chain sequences that comprise larger proteins. It is felt that proper use of the fragments may be used to enhance production of new collagen and elastin. Signal peptides, such as a pentapeptide known as KTTKS, must be linked to palmitic acid as a carrier to penetrate into the stratum corneum. In the case of carrier peptides such as copper peptide, copper is active co-factor in the production of collagen while the peptide acts as the carrier. Moderate use of copper peptides stimulates collagen synthesis and has antioxidant effects, however, excessive use can have an opposite effect by increasing the levels of free copper and/or by triggering excessive production of metalloproteinases. Free copper promotes free radical damage and collagen breakdown. Metalloproteinases can digest collagen and elastin. A third peptide class is known as neurotransmitter-inhibiting peptides including argireline is known to decrease facial lines and wrinkles when applied topically. This is in contrast to another cosmeceutical DMAE (dimethylaminoethanol) which is believed to enhance facial tone by stimulating muscle activity with topical application. DMAE releases acetylcholine. Keratin peptides are hydrolyzed proteins derived from animal skin or wool. They act almost entirely as a humectant rather than a modifier of cellular activity. They can have a high cystine content, which may impart some antioxidant activity.

Growth Factors Growth factors are naturally occurring proteins capable of stimulating cellular proliferation and cellular differentiation, as well as regulating a variety of cellular processes. Some examples in-

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clude transforming growth factor beta (TGF-B) which stimulates collagen secretion and vascular endothelial growth factor (VEGF) which stimulates new blood vessel formation. Epidermal growth factor (EGF) is released in the body when there is an injury. Hepatocyte growth factor (HGF) and basic fibroblast growth factor (bFGF) stimulate new blood vessel formation. Keratinocyte growth factor (KGF) speeds up skin cell turnover and halts DNA fragmentation. Insulin-like growth factor 1 (IGF1) promotes cell growth and multiplication. Plateletderived growth factor AA (PDGF-AA) regulates cell growth and division. The role of growth factors in wound healing is indisputable. How they impact intact aging skin is not as well established scientifically.

Hormones Hormones play a very large roll in the intrinsic and extrinsic aging of the skin. As estrogen levels drop around menopause, collagen thickness begins to diminish. The skin’s ability to retain moisture also declines as NMF and lipid barriers become less plentiful. Estrogens have a profound influence on skin, however cellular, sub-cellular sites, and mechanisms of estrogen action are still poorly understood. Estrogen receptors (ERs) have been detected in skin. In 1997 in a study at the University of CaliforniaSan Francisco, studying women on systemic hormone replacement therapy, it was discovered that compared to women not on HRT there was less dryness and wrinkling as a result of detection of estrogen receptors in the skin. Because of concerns about breast cancer attributed to HRT, oral replacement therapy is not being recommended by most practitioners to treat aging skin. Perhaps one of the promising selective estrogen receptor modulators under development may be used to target skin aging without the worry of deleterious systemic side effects. Topical hormone creams were among the most popular and effective antiaging creams available long before the term “cosmeceutical” was even in use. Several histologic studies have shown significant increases in collagen after topical application of estrogen cream. Elasticity, moisture, and firmness markedly improve and wrinkle depth and pore sizes are decreased. Unfortunately, telangiectasias are often seen with chronic use. Phytoestrogens, such as genistein found in soy, are among the most popular botanical additives to skincare products. It isn’t clear whether the es-

trogenic effect is producing the observed benefits. Given the current regulatory climate, it is unlikely that studies will be done to clarify that point. As with many cosmeceuticals, we are left only with anecdotal claims. The estrogenic potency of genistein does not hold up against estriol or estradiol measuring in the 10s of thousands of times weaker. It does, however have some anticancer and photoprotective activity.

Pigment Lighteners Melanocytic response to UV Radiation is not clearly understood. Melanocytes are contained within basal keratinocytes. It appears to be a photoprotective defense mechanism. It is largely UVR-dose dependant as you find more dyspigmentation in areas of greatest exposure and none in areas where there is no sun exposure. It is largely influenced by genetics as well hormones, medications, and other health conditions. Hydroquinone 4% is still the gold standard for dyspigmentation. It is a tyrosinase inhibitor which prevents the conversion of tyrosine to melanin. It may also degrade melanocytes. They need to be used with care to avoid ochronosis, a sooty hyperpigmentation which can also be permanent. It is also cytotoxic and potentially mutagenic causing it to be restricted in many countries. Kojic Acid and Azelaic acid are tyrosine inhibitors that are less toxic but less effective. Azelaic acid also inhibits ROS. Licorice extract (glabridin) is a tyrosinase chemical which is shown to be effective without the attendant toxicity. Tretinoin is an effective treatment for dyspigmentation, although the mechanism of action is not well understood. It is believed to inhibit tyrosinase induction but also disperses keratinocyte pigment granules and accelerate epidermal turnover. Corticosteroids are a nonselective suppressor of melanogenesis. Vitamin C interferes with melanin production and multiple oxidative steps. The pigment lightning effects of glycolic acid are largely caused by the epidermolysis of pigmented keratinocytes. The most effective products with the least toxicity combine several ingredients and are used over a long period of time along with sun avoidance and lifestyle changes and perhaps adjunctive nonablative energy treatment.

Sun Blocks Given that Photodamage accounts for up to 90% of premature aging, it would follow that a good sunblock is among the most important of all cosmeceuticals if not the most important. Prevention

Cosmeceuticals / 93

of photoaging is without a doubt the most effective means of managing extrinsic aging. Actinic injury is caused by exposure to ultraviolet radiation of which 90-95% is comprised of UVA (320-400 nm wavelength). UVB (290-320 nm wavelength) makes up the remainder since UVC (100-290 nm wavelength) is mostly filtered out by ozone. Ultraviolet light activates reactive oxygen species which release cytokines and remove phosphate groups, stimulating epidermal growth factor, interleukin, and tumor necrosis factor receptors on keratinocytes and fibroblasts. These receptors then signal transcription of factor AP-1 which subsequently stimulates matrix metalloproteinase genes (MMP) genes and inhibits progocollagen gene expression thereby simultaneously breaking down collagen and suppressing repair. The release of free radicals destroys and mutates collagen, elastin, proteoglycan, and cells. UVA and UVB radiation suppresses local immunity in the skin by depleting Langerhans’ cells ultimately contributing to cancer formation. The mutation of p53 tumor suppressor gene by UVB rays also contributes to the formation of cancers. It is generalized that UVB rays are primarily responsible for sunburns while UVA rays are the predominant cause photoaging and cancer, however this is somewhat of an oversimplification. There are many significant differences in their activities. UVB does not penetrate glass or clouds. The predominant effect of UVB rays is between 10 am and 2 p.m. during summer months. UVB penetration primarily remains at the epidermis level. A large dose of UVB radiation will cause acute sunburn, redness, burning sensation, and blistering. UVB rays stimulate the formulation of melanin, causing a significant pigmentation of the skin. This darkening effect will be evident after approximately 24 hours and is relatively long-lasting. Most sunblocks are very effective at blocking UVB photodamage. Repeated UVB exposures in early life are linked to the development of basal cell carcinoma and possibly melanoma. UVA rays penetrate up to 40 times deeper into the skin’s dermis than UVB rays. They are pervasive and penetrate through glass, clouds, and exist all day and all year long. As few as eight moderate dosages of UVA are necessary before histologic damage is produced. These changes are evidenced by wrinkles, dark blotches, freckles, leathery texture, and loss of elasticity, and xerosis (dryness). Tanning booths contain mostly UVA rays because of the ability to produce tanning without the erythema. UVA rays

comprise 20 times more UVR than UVB rays at sea level.

Sunscreens and Sunblocks The first mass produced sunscreens were developed by Benjamin Green in 1944 to protect soldiers in WWII. He tested a cocoa butter and jasmine mixture from his home stove on his own bald head and mixed it with red veterinary petrolatum and called it “red vet pet”. The SPF system was developed in 1972 and indicates the time a person can be exposed to sunlight before getting sunburn with a sunscreen applied relative to the time they can be exposed without sunscreen. An SPF of 5 would afford someone who would normally burn after 12 minutes in the sun a full hour (60 min) before they would burn with sunscreen applied. Unfortunately there is no good indicator of a sunscreen’s ability to prevent UVA damage. A product is considered a sunscreen if it has an SPF of 2 or greater. It must be rated at least SPF 12 to be considered a sunblock. Previously, the nomenclature defined chemical (“organic”) ingredients as sunscreens and physical blocks as sunblocks. That is no longer a relevant distinction. In general, it is felt that an SPF of 30 probably blocks most UVA rays. Most modern sunscreens will indicate whether or not they offer “full spectrum UVA/UVB” protection, however, it is not an accurate indication of efficacy against UVA rays of all wavelengths. In light of new knowledge of the role of UVA irradiation in the pathogenesis of photoaging and cancer, it is important to protect against the full spectrum. Fortunately, there are many new choices available that offer better protection against the sun. The two basic types of sunblocks include organic chemicals and inorganic physical blocks. The chemical blocks which are commonly used include cinnamates (Octyl methoxycinnamate and cinoxate, octinoxate) which are derivatives of cinnamon that provide protection in the range of 280-310 nm. The salicylates (homomenthyl salicylate, octyl salicylate, and triethanolamine salicylate) have been around even before PABA and provide effective protection in the range of 290-315. These chemical ingredients largely protect against UVB (290-320 nm) rays. PABA was formerly among the most commonly used but has been all but discontinued because of a high incidence of hypersensitivity and stinging sensation of the eyes. Some PABA derivatives are still in use, such as padimate A and O (290-315nm). The sunscreens ingredients with protection against

94 / Cosmeceuticals

UVAII (320-340 nm) as well as some UVB are oxybenzone (benzophenone-3), octocrylene, and more recently avobenzone known as Parsol 1798 (Butyl Methoxydibenzoylmethane). Because of concerns about the instability of avobenzone in sunlight newer products have emerged pairing it with stabilizing chemicals. Recently a product known as “Helioplex” combining avobenzone, oxybenzone and a photostabilizing solvent Hallbrite TQ was introduced. The most recent addition to the FDAapproved armamentarium is Mexoryl also known as ecamsule (chemical name Terephthalylidene Dicamphor Sulfonic Acid) which is a UVA blocker known for its excellent photostability. It is available in Europe as both Mexoryl SX (water soluble) and Mexoryl XL (oil soluble). Used together they show a synergistic effect in protection. Mexoryl was FDAapproved for use in one product so far by L’Oreal called Anthelios-SX, which combines Mexoryl SX with Avobenzone and Octocrylene to provide additional protection against UVB as well as photostabilization. In Europe, the Anthelios products are combined with the physical block Titanium to further enhance photoprotectivity throughout the UVR spectrum. Many products combine sunblock ingredients based on their peak wavelength absorption to optimize coverage. Physical blocks provide a very broad spectrum protection throughout both UVB and UVA ranges. They were among the earlier sunblocks in the 1950s when it was not uncommon to see lifeguards with white zinc oxide paste on their noses and lips. The new micronized formulations of zinc oxide and titanium dioxide are more cosmetically acceptable and pragmatic. Titanium dioxide is a pigment used in white paint that scatters light. It has a broad range of protection throughout the UVR spectrum but does not protect at the longest UVA range. Zinc Oxide has been used topically for centuries as a skin protectant and wound healing adjuvant for hemorrhoids diaper rash, and dermatitis. Its ability to protect in the long UVA range is higher than titanium dioxide. It has the broadest spectrum of protection of all available sunblocks.

Tinosorb A new class of sunblock has been developed by the Ciba Corporation and is used widely in Europe and is used in fabric here in the United States. This sunblock is named Tinosorb and comes in two formulations (bis-ethylhexyloxyphenol methoxyphenol triazine and methylene bis-benzotriazolyl

TABLE 9-1 Sunscreens and Sunblocks UVB 290-320 PABA esters 290-315 (310) Salicylates 290-320 (307) Cinnamates 270-320 (300)

UVAII 320-340 UVA1 340-400 Avobenzone Octocrylene 310-400 (358) 290-375 (303) Benzophenones Zinc 250-380 250-350 (285-325) ecamsule 320-340 Titanium 250-340

tetramethylbutylphenol). Ciba trade named the two Tinosorb S and Tinosorb M, respectively. They are broad-spectrum, organic microfine UV-A and UV-B blockers that combine qualities of chemical and physical sunblocks that absorb radiation like an organic compound and scatter and reflect radiation like an inorganic material. (See Table 9-1)

Conclusion Aging is inevitable. Intrinsic aging is at this time in history unavoidable. Extrinsic aging is as difficult to manage as is human behavior. Fortunately for our bad fortune with genetics and/or bad behavior, there are an ever increasing number of options for treatment. Given the growing demand, the ever increasing fund of knowledge and understanding, and the growing profit margins associated with the industry, it is not likely that the trend will reverse. Cosmeceuticals are an exciting subject and a valuable tool in your ability to serve your patients.

Suggested Readings Draelos ZD. Procedures in Cosmetic Dermatology: Cosmeceuticals. Elsevier, 2005. Dunn LB, Damesyn M, Moore AA, Reuben DB, Greendale GA. Does estrogen prevent skin aging? Results from the First National Health and Nutrition Examination Survey Arch Dermatol. 1997 Mar;133(3):339–42. FDA monograph on sunscreen, 2006 http://vm.cfsan.fda.gov/~lrd/fr990521.html. Histopathological and ultrastructural effects of glycolic acid on rat skin. - Inan S - Acta Histochem - 01-JAN-2006; 108(1):37–47). Verdier-Sévrain S, Bonté F, Gilchrest B. Biology of estrogens in skin: implications for skin aging Experimental Dermatology 2006;15(2), 83–94. U. S. Food and Drug Administration Center for Food Safety and Applied Nutrition Office of Cosmetics and Colors Fact Sheet February 3, 1995; revised February 24, 2004.

Index

Note: Page references with f indicate figures; page references with t indicate tables. A Ablative skin resurfacing modalities, 33. See also Chemical peels; Dermabrasion; Laser skin resurfacing, ablative Abobotulinumtoxin A (Dysport), 21 Acetylcholine, 17, 18f, 91 Acne. See also Scars, acne-related as contraindication to laser skin resurfacing, 34–35 emollient-related, 82 laser skin resurfacing-related, 42 microdermabrasion treatment for, 71 nonablative laser treatment for, 58 Adapalene (Differin), 89 Aesthetic subunits, of the face, 33f Aging, of skin, 86. See also Photoaging Allergic reactions to botulinum toxin, 31 to soft tissue fillers, 15 Allergies, as contraindication to botulinum toxin, 21, 21t to soft tissue fillers, 3, 3t Aloe vera, 88 Alpha-hydroxy acid (AHA) peels, 69, 70–71 anti-aging properties of, 88–89 depth of penetration of, 78, 78t discontinuation prior to microdermabrasion, 72 Aluminum oxide microdermabrasion device, 72f, 73, 74–75 Alzheimer’s disease, 75 American Academy of Cosmetic Surgery, 69 Aminoglycosides, 21, 21t Amyotrophic lateral sclerosis, 21, 21t Angiofibroma, 69 Antibiotic prophylaxis for chemical peel patients, 78 for laser skin resurfacing patients, 35

Antioxidants, topical, 90-91 Antiviral agent prophylaxis for chemical peel patients, 78 for laser skin resurfacing patients, 35 Aquaphor®, 40, 80, 81 Aramis lasers, 50 Argireline, 91 Arrhythmias, botulinum toxin-related, 31 Ascorbyl palmitate, 90 Ascorbyl tetra-isopalmitate, 90 Aspirin, 35 Atrophy, temporal, soft tissue filler treatment for, 3t Autoimmune disorders, as contraindication to botulinum toxin, 21 microdermabrasion, 72 soft tissue fillers, 3, 3t Azelaic acid, 92 B Bacterial infections in chemical peel patients, 82 Pseudomonas, 35, 42 Barker-Gordon phenol peel, 78t, 80 Bell’s palsy, 17, 20, 30 Beta-hydroxy acid (BHA) peels, 78, 89 Beta-naphathol, 70 Bisabolol, 87 Blackheads, 71 Bleaching agents, 47, 92 Blistering, nonablative laser treatment-related, 47, 48, 58 Blood-borne pathogen exposure laser skin resurfacing-related, 35 microdermabrasion-related, 75 Blood-thinner medications, 35 Botanicals, 88 Botox Cosmetic (onabotulinumtoxin A), 21

96 / Index Botulinum toxin (Btx) injections, 17–31 action mechanism of, 17, 18f, 19 advantages of, 17 in combination with soft tissue fillers, 10, 11, 18, 28 complications of, 19, 31 contraindications to, 20–21, 21t “off-label” use of, 21 postoperative care for, 30-31 preoperative considerations for, 20–21, 21t preparation and dosing considerations for, 21-22 procedure setup for, 22, 22f product considerations for, 19, 31 targeted treatment sites for, 20, 20t technique of, 22–30 for cervical region, 29-30, 30f for periocular region, 26–27, 27f for perioral region, 27–29, 27f, 28f for special applications, 30 for upper one-third of face, 22–24, 23f, 24f type A, 17, 19 type B, 17, 19Breast feeding, as contraindication to botulinum toxin, 21, 21t Brow elevation with botulinum toxin injections, 25-26, 20t, 26f with nonablative laser treatment, 59 with ThermaCool™ System, 65–66, 67 Brow enhancement, with soft tissue fillers, 3t C Calcium hydroxylapatite beads, as soft tissue filler, 2t Candida, 42, 82 Cardiovascular disorders, as contraindication to botulinum toxin, 21, 21t chemical peels, 77 Ceramides, 88 Cervical region. See also Neck botulinum toxin injections in, 29-30, 29f, 30f Cetaphil, 40, 81 Cetyl stearate, 88 Cheek, as facial aesthetic subunit, 33f Chemical peels, 33, 77-83. See also specific types of chemical peels action mechanism of, 70 advantages and disadvantages of, 36t, 70 in combination with microdermabrasion, 71 comparison with microdermabrasion, 69 complications of, 70, 81–82 contraindications to, 77 deep, 77, 78t, 80–81 definition of, 77 facial analysis for, 77 indications for, 77 medium-depth, 77, 78t, 79–80, 80f postoperative care for, 81 preoperative considerations for, 77 superficial, 77–79, 78t, 79f, 79t technique of, 78–81

Chin region botulinum toxin injections in, 27–29, 28f, 29f cleft, 29 soft tissue filler use in, 2f, 2t, 10, 12f Ciba Corporation, 94 Cinnamate, 93, 94t Citric acid peels, 70, 89 Cleopatra, 85, 89 Clostridium botulinum, 17. See also Botulinum toxin (Btx) injections Coenzyme Q10 (CoQ10), 91 Collagen microdermabrasion-related deposition of, 70 as soft tissue filler, 2t synthesis of, 92 ultraviolet light-related breakdown of, 86, 93 Commissures, soft tissue filler augmentation of, 12 Connective tissue disorders, as contraindication to chemical peels, 77 laser skin resurfacing, 34–35 Contact dermatitis, 42, 82 Contour™ Er:YAG laser system, 39, 39f, 41f CoolTouch CT3™ laser system, 49–50, 57–58, 57f Corneocytes, 86, 87 effect of alpha-hydroxy acids on, 89 Corticosteroids, 42, 82, 92 Cosmeceuticals, 85–94 antioxidants, 90-91 definition of, 85–86 estrogens, 93 function of, 86–87 growth factors, 91-92 indications for, 86 moisturizers, 87–88 peptides, 91 pigment lighteners, 92 skin rejuvenators, 88 sunblocks and sunscreens, 86, 92–94 Cosmetics, with physiologic benefits. See Cosmeceuticals Cosmodesmosomes, 87 Creutzfeldt-Jakob disease, 21 Crow’s feet botulinum toxin-related exacerbation of, 24 botulinum toxin treatment for, 26–27, 27f chemical peel treatment for, 70 definition of, 26 Curare-like depolarizing blockers, 21, 21t D Dermabrasion, 33. See also Microdermabrasion action mechanism of, 70 advantages and disadvantages of, 36t comparison with microdermabrasion, 70 results of, 70 Dermatologic disorders, as contraindication soft tissue fillers, 3, 3t

Index / 97 Dermatologic disorders, as contraindication to botulinum toxin, 21 Dermis, 33–34, 34f acellular, 2t Diabetes mellitus, as contraindication to laser skin resurfacing, 35 microdermabrasion, 72 Dimethylaminoethanol (DMAE), 91 Dressings, occlusive, 41, 41f Dry eye, as contraindication to botulinum toxin injections, 27 E Ectropion, 27, 43 Eczema, 88 Edema nonablative laser treatment-related, 61 soft tissue filler-related, 8 Elastosis severity classification of, 56 solar, 34, 86 Electromagnetic spectrum, 46f Electro-optical synergy (ELOS™), 61 Emollients, 88 Epidermal growth factor (EGF), 91 Epidermis, 33–34, 34f Epinephrine, 35–36 Epiphora, microdermabrasion-related, 74–75 Erythema causes of chemical peels, 80, 82 laser skin resurfacing, 41–42, 43 microdermabrasion, 74–75 nonablative lasers, 60–61 nonablative laser treatment for, 46, 47 Estrogens, use as cosmeceuticals, 91–92 Exfoliants, 89 Eye irritation, microdermabrasion-related, 74–75 Eyelid lower ectropion of, 27, 43 hypertrophy of, 26–27 ptosis of botulinum toxin-related, 24, 25 as contraindication to botulinum toxin, 21, 21t upper, ptosis of, 27 F Face, aesthetic subunits of, 33f Facelifts, with ThermaCool™ System, 66f, 67 Facial analysis of botulinum toxin patients, 19, 21, 20f, 20t of chemical peel patients, 77 of laser skin resurfacing patients, 33–34, 33f of microdermabrasion patients, 71 of nonablative laser treatment patients, 46–47, 55–56 of soft tissue filler patients, 2, 2t, 3t

Facial asymmetry, botulinum toxin treatment for, 20 Facial expression, muscles of, 20f Fat, 2t Fat pads, orbital, pseudoherniation of, 5, 8 Federal Trade Commission (FTC), 86 Ferulic acid, 90 Food, Drug, and Cosmetic Act, 85 Food and Drug Administration (FDA), 1, 69, 86 Forehead region botulinum toxin injections in, 22–24, 23f, 24f as facial aesthetic subunit, 33f ThermaCool™ System use in, 65 Fraxel™ Laser System, 35, 40, 49, 51f, 52f, 60–61, 60f action mechanism of, 50–51 results of, 42f, 53f “Frown lines,” 24-25 Fungal infections Candida, 42, 82 in chemical peel patients, 82 in laser skin resurfacing patients, 42 G Genistein, 92 GentleWave light-emitting diode system, 53 GentleYAG® laser system, 58–59, 58f Glabellar region botulinum toxin injections in, 21, 24–25, 24f, 25f soft tissue filler use in, 2f, 2t, 5, 7f Glabridin (licorice extract), 92 Glaucoma, 31 Glogau’s classification, of photoaging, 55, 77, 78t Glycerin, 88 Glycolic acid peels, 35, 43, 70–71, 78, 89 comparison with microdermabrasion, 69–70 pigment lightening effect of, 92 technique of, 79 Granulomas, soft tissue fillers-related, 15 Green, Benjamin, 93 Growth factors, use as cosmeceuticals, 91-92 H Helioplex, 93 Hematomas botulinum toxin-related, 31 soft tissue fillers-related, 15 Hepatic disorders, as contraindication to chemical peels, 77 Hepatocyte growth factor (HGF), 92 Herbal therapies, 35 Herpes virus infections as contraindication to chemical peels, 77 microdermabrasion, 72 reactivation of laser skin resurfacing-related, 42–43 nonablative laser treatment-related, 48

98 / Index Humectants. See Moisturizers Hyaluronic acid, 2t, 87–88 Hydroquinone, 47, 92 Hyperkeratinization, 70 Hyperpigmentation causes of chemical peels, 82 laser skin resurfacing, 35, 43 microdermabrasion, 70, 74 nonablative lasers, 47, 48, 56, 58 treatment for chemical peels, 77–78 intense pulsed light, 52 microdermabrasion, 71 Hypodermis, 33–34, 34f Hypopigmentation chemical peel-related, 80, 82 laser skin resurfacing-related, 43 microdermabrasion-related, 70 I Ichthyosis, 88 Idebenone, 91 Infections. See also Bacterial infections; Fungal infections; Viral infections botulinum toxin-related, 31 chemical peel-related, 82 as contraindication to soft tissue fillers, 3 laser skin resurfacing-related, 42–43 nonablative laser treatment-related, 48 soft tissue fillers-related, 15 Informed consent for botulinum toxin treatment, 21 for soft tissue filler treatment, 3 Infrared devices and lasers, 45, 47 1320-1550 nm, 49–51 Insulin-like growth factor (IGFI), 91 Intelligent Optical Tracking™ System, 60 Intense pulsed light (IPL) devices, 45, 46, 47, 51–53 Isotretinoin, 34–35, 72 J Jessner’s solution/trichloroacetic acid peels, 78t, 79–80, 80f, 81f Jojoba, 88 K Keloids as contraindication to soft tissue fillers, 13 predisposition to, 34–35, 77 Keratinocytes, 34 as photodamage histologic markers, 86 Keratin peptides, 91 Keratosis, 86 actinic, 46 Kinetin, 91 Kligman, Alfred, 86

Koebner phenomenon, 3, 3t, 21 Kojic acid, 92 KTP lasers, 45, 46, 48, 49 L Lactic acid peels, 70, 78, 79, 88–89 Lagophthalmos, 27 Lambert-Eaton syndrome, 21, 21t Langerhans cells, 34 Lasers, wavelengths of, 46f Laser skin resurfacing. See also Nonablative lasers and lights ablative, 33–44 action mechanism of, 71 advantages and disadvantages of, 35, 36t anesthesia for, 35-37 comparison with nonablative laser treatment, 55 complications of, 41–43 contraindications to, 34–35 disadvantages of, 55 fractional, 35, 40, 42f instruments and materials for, 37, 37t postoperative care in, 40–41, 41f preoperative assessment for, 34–37 pulsed carbon dioxide lasers, 37–38, 38f, 39–40 pulsed erbium:yttrium-aluminum-garnet (Er:YAG) lasers, 37, 38–40, 39f, 41f technique of, 37 Licorice extract (glabridin), 92 Lidocaine, 35–36, 48 Light-emitting diodes, 45, 51, 53 Lipids, intercellular, 87, 88 Lipodystrophy, with soft tissue fillers, 14 Lipoic acid, 91 Liposuction, of neck, 66, 66f Lips botulinum toxin injections in, 27–29, 27f, 28f natural convexity of, 3t soft tissue filler use in, 2, 3t, 11–12, 13f “Lipstick bleeding,” 28 LumiPhase-R, 53 M Magnesium oxide microdermabrasion, 73 Malic acid peels, 78, 89 Marcaine, 35–36 Marionette lines, soft tissue filler treatment for, 2f, 2t, 10, 10f Melanocytes, 34, 92 Melasma, 51, 61, 77–78 Melolabial folds, soft tissue filler use in, 2f, 2t, 8–9, 8f Mentalis muscle, as botulinum toxin injection site, 29 Merkel cells, 34 Metalloproteinase-1, 53 Mexoryl, 94 Microdermabrasion, 69–76 action mechanism of, 70

Index / 99 in combination with chemical peels, 71 comparison with traditional dermabrasion, 70 complications of, 72, 74–75 contraindications to, 72 definition of, 69 efficacy of, 69 facial analysis for, 71 Food and Drug Administration approval for, 69 indications for, 69 postoperative care for, 74 preoperative considerations for, 71–72 technique of, 72–74, 72f, 73f, 74f MicroLaserPeel™, 40 Milia chemical peel-related, 82 laser skin resurfacing-related, 42 Mineral oils, 85–86, 88 Moisturizers, 86, 87-89 use in chemical peel patients, 81 use in microdermabrasion patients, 74 use in nonablative laser treatment patients, 48 Myasthenia gravis, 21, 21t, 31 Myocardial infarction, 31 N β-Naphathol, 70 Nasal region, soft tissue filler use in, 12–13, 13f Nasal tip natural convexity of, 3t soft tissue filler use in, 2, 3t Nasojugal grooves, soft tissue filler use in, 2f, 2t, 5, 7f, 8, 8f Nasolabial folds. See Melolabial folds Natural moisturizing factor (NMF), 86–87, 88, 92 Neck chemical peels of, 79 laser skin resurfacing of, 39 liposuction of, 66, 66f Nerve blocks, 35–36, 48 Neuromuscular disorders, as contraindication to botulinum toxin, 21, 21t Neuromuscular junction, 17, 18f, 19 NMF (natural moisturizing factor), 86–87, 88, 92 Nonablative lasers and lights, 33, 45–62 action mechanism of, 33, 55 advantages and disadvantages of, 36t alexandrite lasers, 45, 49 comparison with ablative laser treatment, 55 complications of, 48, 57 diodes, 46, 49, 50 erbium-doped fibers lasers, 49, 50 erbium:glass lasers, 46–47, 48, 49, 50 facial analysis for, 46–47, 55–56 flashlamp-pumped pulsed dye lasers (FLPDLs), 48–49 fractional, 50–51 Fraxel™ Laser System, 35, 40, 42f, 49, 50–51, 52f, 53f, 60–61, 60f infrared devices, 45, 47, 49–51

intense pulsed light (IPL) devices, 45, 46, 47, 51–53 KTP lasers, 45, 46, 48, 49 light-emitting diodes, 45, 51, 53 mid-infrared lasers (1320-1550 nm), 49–51 Nd:YAG lasers, 45, 48, 49 1064 nm, 58–59, 58f 1100 nm, 59–60, 59f 1320 nm, 45, 46, 49–50, 57–58, 57f postoperative care in, 48, 57 preoperative considerations for, 47 pulsed dye lasers, 45, 46, 48–49 technique of, 47–48, 56–57 vascular lasers (532-1064 nm), 48–49 Noninvasive cosmetic surgery, advantages of, 1 Nonsteroidal anti-inflammatory drugs (NSAIDs), 35 Nose. See also Melolabial folds; Nasal tip; Nasojugal grooves as facial aesthetic subunit, 33f O Occlusive agents, 88 “Oil of Olay,” 88 Oils, as moisturizing agents, 88 Omnilux, 53 Onabotulinumtoxin A (Botox Cosmetic), 21 Orbicularis oculi muscle, pretarsal, hypertrophy of, 26 Orbicularis oris muscle, botulinum toxin injections in, 29 P Pain, nonablative laser treatment-related, 48 Panthenol, 88 Para-aminobenzoic acid (PABA), 93, 94t Paraffins, use in moisturizers, 89 Paralysis, hemifacial, 30 Patient expectations, 85 Pauling, Linus, 90 Peptides, use as cosmeceuticals, 91 Periocular region botulinum toxin injections in, 26-27, 27f chemical peel application in, 79, 79f Perioral region botulinum toxin injections in, 27–29, 27f, 28f as facial aesthetic subunit, 33f laser skin resurfacing of, 38, 38f rhytidosis severity assessment of, 56 soft tissue filler use in, 2f, 2t, 9–10, 9f Periorbital region as facial aesthetic subunit, 33f nonablative laser treatment of, 60 rhytidosis severity assessment of, 56 ThermaCool™ System use in, 65 Petrolatum, 88 Phenol peels, 70, 80 Barker-Gordon, 78t, 80 contraindications to, 77 for full-face resurfacing, 80, 82 toxicity of, 82

100 / Index Photoaging chemical peel treatment for, 70 Glogau’s classification of, 55, 77, 78t Photodamage, 86 microdermabrasion treatment for, 69–70 severity classification of, 46 Photographs, pre- and postoperative of botulinum toxin patients, 21 of chemical peel patients, 78, 80f, 81f of Fraxel® resurfacing patients, 52f of laser skin resurfacing patients, 35 of microdermabrasion patients, 72f of soft tissue filler patients, 3 Photomodulation, 53 Photophobia, microdermabrasion-related, 74–75 Photothermolysis fractional, 40, 60, 81 action mechanism of, 46 Fraxel® Laser System, 35, 40, 42f, 49, 50–51, 51f, 52f, 53f, 60–61, 60f thermal necrosis in, 50f selective, 45, 45f Physician-patient relationship, 3, 20 Phytoestrogens, 92 Pigmentation. See also Hyperpigmentation; Hypopigmentation ultraviolet radiation B-induced, 93 Pigment lighteners, 92 Platelet-derived growth factor, 92 Platysmal banding, 29, 30f Poikiloderma, 51 Polaris WR™, 61, 61f Poly-hydroxy-acid (PHA) peels, 89 Poly-L-lactic acid, as soft tissue filler, 2t Polymethylacrylate beads, as soft tissue filler, 2t Pregnancy as contraindication to botulinum toxin injections, 21, 21t laser skin resurfacing, 35 nonablative laser treatment during, 48 Pre-jowl sulcus, 11 ProFractional™ laser, 40 Pseudomonas, 35, 42 Psoriasis, as laser skin resurfacing contraindication, 35 Ptosis, of eyelid, 21, 20t, 24, 25, 26-27 Pulsed carbon dioxide lasers, 37–38, 38f, 39–40, 71 Pulsed erbium:yttrium-aluminum-garnet (Er:YAG) lasers, 37, 38–40, 39f, 41f, 71 R Radiofrequency/diode laser system, 61, 61f Radiofrequency tissue tightening. See ThermaCool™ System Reactive oxygen species (ROS), 86, 90, 93 Renal disorders, as contraindication to chemical peels, 77 Resorcinol, 70

Retinoic acid, 89 Retinoids as bleaching agents, 47 discontinuation prior to microdermabrasion, 72 skin rejuvenating properties of, 89 Revitalight, 53 Rhinoplasty primary injection, 12 soft tissue filler use following, 3t, 14, 14f Rhytids facial animation-related, botulinum toxin treatment for, 17–30 forehead, botulinum toxin treatment for, 22–24, 23f, 24f glabellar botulinum toxin treatment for, 21, 24–25, 24f, 25f soft tissue filler treatment for, 2t, 5, 7f microdermabrasion treatment for, 71 nonablative laser treatment for, 58 positive aspects of, 2 radial lip, botulinum toxin treatment for, 27–29 severity grading of, 35, 56 Rosacea, 52, 72 S Salicylates, sun blocking properties of, 93, 94t Salicylic acid peels, 70, 78, 78t, 79–80, 80f, 89 Scars acne-related chemical peel treatment for, 81 microdermabrasion treatment for, 69, 71 nonablative laser treatment for, 51, 58, 61 soft tissue filler treatment for, 13 ThermaCool™ System treatment for, 65 burn-related microdermabrasion treatment for, 69 nonablative laser treatment for, 51 chemical peel-related, 80 depressed, soft tissue filler treatment for, 13–14, 14f hypertrophic chemical peel-related, 82 laser skin resurfacing-related, 43 microdermabrasion-related, 70, 72 nonablative laser treatment for, 51 microdermabrasion treatment for, 69 nonablative laser treatment-related, 48, 58 soft tissue filler treatment for, 3t surgical, microdermabrasion treatment for, 69 traumatic, microdermabrasion treatment for, 71 Schwannoma, vestibular, 20, 30 Seizures, botulinum toxin-related, 31 Shea butter, 88 Silicone, 88 Skin layers of, 33–34, 34f regeneration of, 34

Index / 101 Skin cancer as contraindication to microdermabrasion, 72 ultraviolet radiation-related, 92–93 Skin rejuvenators, 86, 89 Skin types, Fitzpatrick Sun-Reactive of chemical peel patients, 82 of laser skin resurfacing patients, 35, 35t of microdermabrasion patients, 71, 72, 74 of nonablative laser treatment patients, 47, 51, 52, 56, 58 of radiofrequency skin tightening patients, 66 tanning response in, 78t “Smile lines,” 27 Smoking, as laser skin resurfacing contraindication, 35 Smoothbeam laser system, 49, 50 SNARE protein, 17, 18f Society of Cosmetic Chemists, 86 Sodium bicarbonate microdermabrasion, 73 Sodium chloride microdermabrasion, 73, 75 Sodium 2-pyrrolidone-5-carboxylic acid (PCA), 88 Soft tissue fillers (STFs), 1–15 biodegradability of, 1 in combination with botulinum toxin injections, 10, 11, 18, 28 complications of, 15 contraindications to, 3 extrusion of, 15 Food and Drug Administration approval for, 1 “off-label” use of, 3 perioral, 28 postoperative care for, 14–15 preoperative considerations for, 3, 3t procedure setup for, 3, 4f special applications of, 13–14, 13f, 14f technique of, 3–14, 14t cross-hatching, 5, 6f, 9, 9f, 14 fanning, 5, 6f, 9, 9f, 14 layering, 5, 6f, 8–9, 11, 14 linear threading, 5, 6f, 8, 9, 10–11 for natural facial convexities, 11–13, 12f, 13f for natural facial rhytids and depressions, 5, 7–11, 7f, 9f, 10f, 11f serial puncture, 5, 6f, 9, 14 types of, 1, 2t Solar elastosis, 34, 86 SPF system, 93 Squalene, 88 Stratum basale, 34, 34f Stratum corneum, 34, 34f aging-related changes in, 71 as cosmeceutical target, 87 effect of alpha-hydroxy acids on, 89 effect of microdermabrasion on, 70, 71 hydration of, 87 as photodamage histologic marker, 86 structure of, 86, 87f

Stratum granulosum, 34f Stratum spinosum, 34f Stretch marks, 71–72 Sunblocks and sunscreens, 86, 92–94 use in chemical peel patients, 81 use in microdermabrasion patients, 74 use in nonablative laser treatment patients, 48, 52f, 57 Sunburn, 92–93 Superficial musculoaponeurotic system (SMAS), 29-30 Syncope, botulinum toxin-related, 31 T Tanning booths, 93 Tartaric acid peels, 78, 89 Tazarotene (Avage and Tazorac), 89 Telangiectasia, 46, 52 Tetrahexydecyl ascorbate, 90 ThermaCool™ System, 63–67 action mechanism of, 63 complications of, 66 components of, 63–64, 64f postoperative care for, 66 preoperative considerations for, 64 results of, 65–66, 66f technique of, 64–65, 65f Thermascan, 57 Tinosorb, 94 Titanium dioxide, 48, 57, 81, 94 Titan™ laser system, 59–60, 59f Topical skincare products. See Cosmeceuticals Transepidermal water loss (TEWL), 87, 88 Transforming growth factor-beta (TGF-β), 89, 91-92 Tretinoin, 92 Trichloroacetic acid/Jessner’s solution peels, 78t, 79–80, 80f, 81, 81f Trichloroacetic acid peels, 70 Tri-Luma, 47 Tyrosine inhibitors, 92 U Ubiquinone, 91 Ultraviolet radiation (UV) adverse effects of, 90, 92–93 melanocytic response to, 92 Ultraviolet radiation A (UVA), 92-93, 94 Ultraviolet radiation B (UVB), 92-93, 94 University of California-San Francisco, 92 Urea, 88 Urticaria, microdermabrasion-related, 75 V Vascular disorders, as laser skin resurfacing contraindication, 34–35 Vascular endothelial growth factor (VEGF), 91-92

102 / Index Vascular lasers, 48–49 Vascular lesions, intense pulsed light treatment for, 52 Vermilion border laser skin resurfacing of, 38 soft tissue filler augmentation of, 12 Viral infections. See also Herpes virus infections in chemical peel patients, 82 Vitamin C, 90, 92 Vitamin E, 35, 88, 90

W Waxes, use in moisturizers, 88 White line, soft tissue filler augmentation of, 12 Wrinkles. See Rhytids X Xerosis, 88 Z Zinc oxide, 48, 57, 81, 94