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  • 1. Nonoperative Facial Rejuvenation Andrew Coughlin M.D. Raghu Athre M.D. University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation February 25, 2010
  • 2. Objectives
    • Discuss the history of cosmetic facial rejuvenation
    • Discuss Aging and Photodamage to the skin
    • Discuss treatment options for adynamic facial conditions and their associated complications
  • 3. History of Facial Rejuvenation
    • 3000 BCE Egyptians
      • Manicures, Make-up, Tattoos of the face (1)
    • 1500 BCE Egyptians
      • Used sandpaper for scars as early form of dermabrasion (2)
    • 100 BCE Roman poet Ovid: The Art of Love
      • Facial mask of barley, bean, eggs, hartshorn, narcissus bulbs, balsam, Tuscany seed, honey (3)
    • 200 CE Jewish Talmud
      • Husband must provide 10 dinars for his wife’s cosmetic needs
    • 900 CE Arabic Physicians
      • Crushed rice, seashells, marble, crystal, limes, eggs, beans, ground lentils (dermabrasion)
  • 4. History of Facial Rejuvenation
    • 1905 Kromayer
      • Mechanical dermabrasion with wheels and rasps (4)
    • 1960’s Facial Peels
    • 1990’s CO2 Laser Resurfacing
    • Most recently filler agents have become increasingly popular
    • **Modern techniques are reminiscent of ancient techniques
  • 5. Layers of the Skin
  • 6. Epidermis
    • Stratum Corneum
      • Keratinized cells to be sloughed off
    • Stratum Lucidum
    • Stratum Granulosum
    • Stratum Spinosum
    • Stratum Basale
      • Basal regenerative cells and melanocytes
      • Regeneration every 12-14 days (1)
  • 7. Epidermis
  • 8. Dermal Layers
    • Papillary Dermis
      • Meshwork of fine type III collagen fibers
      • Anchors epidermis down to dermis
    • Reticular Dermis
      • Thick type I collagen bundles
      • Elastic fibers for resiliency
      • Glycosaminoglycans (GAG’s)
        • Ground substance between fibers
        • Can hold up to 1000x their weight in water (5)
      • Hair, sebaceous/sweat glands, nerve receptors and blood vessels
  • 9. Papillary and Reticular Dermis
  • 10. Hypodermis
    • Connects skin and underlying bone/muscle
    • Loose connective tissue and elastin
    • Predominant Cells
      • Fibroblasts
      • Macrophages
      • Adipocytes
  • 11. Damage to the Dermis
    • Age
      • Decreased ratio of Type I : Type III collagen
    • Photodamage and Tobacco Smoke (6)
      • Increase tissue collagenases and gelatinases
      • Further decrease collagen in the dermis
      • Decrease capillary and blood flow to skin
      • Decreased skin integrity
    • **Ultimately leads to decreased skin turgor and elasticity forming wrinkles and sagging skin (7)
  • 12. Initial Evaluation
    • Patient selection is key
      • Unrealistic
      • Psychiatric history or multiple physician visits
      • Smokers have 12 times increased skin sloughing and scarring
    • Must perform proper:
      • Education
      • Counselling
      • Consistent procedural skills
  • 13. Physical Exam
    • Are rhytids dynamic vs adynamic
      • Traction of skin in antagonistic direction
    • Hypo- or Hyperpigmented skin
    • Associated skin conditions
    • Active infection
    • Thickness of skin
    • Glogau System
  • 14. Glogau System (8)
    • Stratifies patients based on amount of aging and skin damage
    • Category I
      • Photoaging down to stratum granulosum or papillary dermis with minimal wrinkles
      • Dermabrasion or superficial chemical peeling
    • Category II
      • Photodamage down to upper reticular dermis and wrinkles with facial gestures
      • Medium depth chemical peeling
    • Category III
      • Photodamage down to upper reticular dermis and wrinkles at rest
      • Medium depth peels
    • Category IV
      • Photodamage to mid reticular dermis, wrinkles, skin discoloration
      • Deep peel required
  • 15. Treatment Options
    • Dermabrasion
    • Laser Resurfacing
    • Chemical Peels
    • Facial Fillers
  • 16. Dermabrasion
    • Purpose is to level the skin and promote re-epithelialization with new collagen deposition.
    • Used for:
      • Scar revision
      • Acne scarring
      • Rhinophyma
      • Facial rhytids
    • Contraindicated for Keloids and Hypertrophic Scars
    • Must only injure only the papillary dermis
      • Preserves adnexal structures for re-epithelialization
      • Damage through the reticular dermis (Fat visualized) leads to adverse scarring
  • 17. Dermabrasion
    • Performed with high speed diamond fraise or wire brush.
    • Local anesthesia +/- IV sedation
    • Broad surfaces are frozen to maintain rigid tissue (malar region)
    • Brush strokes are made at right angles to the brush rotation to avoid loss of control and damage to normal tissue
    • Feathering : Edges are slightly brushed for blending
  • 18. Dermabrasion
    • Upper layers of skin are removed resulting in partial thickness wounds
    • Small pinpoint bleeding of the wound
    • Heal by re-epithelialization in 7-10 days
    • Recovery is 2-3 weeks
  • 19. Microdermabrasion
    • Alternative to dermabrasion that attacks just the upper layer of skin
    • Disadvantages
      • Only good for early photodamage and superficial wrinkles
      • Not useful for dermal pathology
    • Uses Aluminum oxide microcrystals
    • Advantages
      • Repeated at short intervals
      • Painless requiring no anesthesia
      • Minimal erythema and side effects
  • 20. Microdermabrasion
    • Freedman 2001 (9)
      • 10 patients treated with 6 treatments
      • Physical exam and tissue biopsy
      • Thickened epidermis and dermis with newly deposited collagen
    • Karimipour 2010 PRSJ (10)
      • Very good for skin contour irregularities such as rhytids
      • Less effective with dyschromias than glycolic acid peels
      • No RCT to evaluate uses in acne but decision should be based on patients expectations
  • 21. Picture of Debridment Instrument
  • 22. Dermabrasion Results
  • 23. Laser Resurfacing
  • 24. Laser Resurfacing
    • Works by targeting chromophores
    • Each laser has a different chromophore:
      • Water, oxyhemoglobin, melanin, etc.
    • Chromophore absorbs the laser heat destroys cells harboring that chromophore
    • Amount of chromophore in a cell is proportional to absorption/destruction
    • Lasers have opened the door for treatment of periocular skin where dermabrasion cannot reach
  • 25. Ablative Lasers
    • Carbon Dioxide (10,600nm)
      • Used with the same indications as dermabrasion
      • Wavelength selectively targets water in soft tissue
      • More collagen production and prolonged redness due to dispersed thermal injury
    • Other advantages
      • Hemostatic properties
      • Depth of treatment is more precise with laser
        • Skin tightening is immediate
        • Skin irregularities are improved immediately
  • 26. Ablative Lasers
    • Erbium:YAG (2,940nm)
      • Reduced thermal damage
        • Less post-therapy redness
        • Less collagen production
    • Newman et al. 1999 (11)
      • Compared Er:YAG and CO2 laser
      • 21 patients with half the upper lip treated by each laser
      • Er:YAG had less days of crusting 3.4 compared to 7.7
      • 63% vs 54% improvement at 2 months favoring CO2
  • 27. Other Lasers
    • Nd:YAG Laser (1,064nm)
      • Infrared, invisible, oxyhemaglobin, deep penetration
      • Good for port-wine stains, telangiectasias, hemangiomas
    • KTP (532nm)
      • Visible, oxyhemaglobin absorption
      • Good for cutaneous lesions
    • Argon (193nm)
      • Visible, broad blue band, oxyhemaglobin
      • Penetrates between CO2 and Nd:YAG
      • Same indications as Nd:YAG
    • Flashlamp Excited Pulsed Dye (595 nm)
      • Visible, yellow light, vascular sensitive
      • Less scarring and hypopigmentation than Nd:YAG & Argon
      • Cutaneous vascular lesions
  • 28. Effectiveness of Lasers
    • Bisson in 2002 evaluated 31 patients (12)
      • At 6 weeks wrinkle depth reduction of 91%
      • At 2 years wrinkle depth reduction of 87%
    • 2001 Lasers are falling out of favor (13)
      • 88% of patients considered post-therapy results very good.
      • 77% would not be willing to have procedure again.
    • **Several studies have shown equivalent results of CO2 lasers compared to dermabrasion (14-16)
  • 29. Laser Resurfacing Results
  • 30. Complications of Dermabrasion/Laser Resurfacing
    • Infection (17)
      • Bacterial infection rates 4.3 to 12%
      • Fungal infection rates 1.8 to 2.2%
    • Hypo/Hyperpigmentary mismatches
      • Dark Skinned Patients
      • Melasma or Cholasma associated with OCP’s
      • Photosensitivity post-procedure should be prevented with UV blocking lotions for 2 months (18-19)
    • Scarring Risk
      • Must stop 13-cis-retinoic acid (Accutane) for 6-12 months prior to therapy (20)
    • Milia Formation
      • Small epidermal cysts common after dermabrasion
      • Can be prevented with occlusive ointments or dressings for 1-2 weeks
      • Can be treated with abrasive cleansers or scalpel
    • Herpes Simplex Risk
      • Roberts et al 1997 (21)
        • Studied 907 patients with CO2 laser treatment and found that HSV infection of 3% was reduced to 1% with acyclovir prophylaxis
        • Therefore patients treated with antivirals for 2-3 days prior and 7-10 days post procedure
  • 31. Laser Resurfacing Redness
  • 32. Melasma/Chloasma
  • 33. Milia
  • 34. Chemoexfoliation
    • Controlled wounding of skin to induce regeneration and a more youthful appearance
    • Most commonly used for photodamage that leads to
      • Thickened Stratum Corneum
      • Thinned Stratum Spinosum
      • Disorganized maturation and elastin
      • Decreased dermal collagen and GAG’s
      • Irregular melanin dispersion
    • Skin is rough, wrinkled and mottled
  • 35. Damaging Levels
    • Stratum Corneum
      • Skin feels smoother
    • Epidermal Basement Membrane
      • Melanocytes live here
      • Lighter and evenly pigmented
    • Upper Reticular Dermis
      • Smoother and lighter skin
      • Deposition of new collagen, elastin, GAG’s
      • Subsequent reduction of fine wrinkles
    • Middle Reticular Dermis
      • More collagen production with reduction of deeper wrinkles
    • Deep Reticular Dermis
      • Collagen production can produce a scar
  • 36. Factors that increase solution penetration
    • Solution Concentration
    • Condition of Skin
      • Pre-treatment tretinoin, electrolysis, surgery, waxing.
    • Pre-peel degreasing with alcohol or acetone
    • Application (brush, swab, sponge)
    • Rubbing
    • Time of contact
    • Occlusion with tape or petroleum jelly
  • 37. Individual Results
    • Some argue that test patching is important because each person reacts so differently to each type of peel
      • Depth of penetration
      • Wrinkling response
      • Scarring
    • Post-therapy care should include ointment to promote healing, sun avoidance, and proper wound care to prevent infection
  • 38. Patient Selection
    • Post-therapy appearance can be frightening
    • Make sure patients are:
      • Psychologically stable
      • Compliant with post-therapy care
      • Willing to stay out of the sun
      • Willing to wear makeup
    • Be sure to perform proper informed consent and document it appropriately
  • 39. Topical Retin-A
    • First line therapy
    • Advantages
      • Reverses all the previously discussed findings of sun damage
      • Also decreases fine wrinkles, evens pigmentary differences, smoothes the skin
    • Disadvantages
      • Photosensitivity
      • Dries the skin out making moisturizers necessary
      • Class C pregnancy media
    • Can be combined with alpha hydroxy acids which are less effective but potentiate tretinoin preparations
  • 40. Process of Skin Peeling
    • Cleansing
      • Septisol and acetone to decrease oil and scaliness of the skin
      • Jessner’s or 70% glycolic solution can be used first to break initial barriers and allow TCA to penetrate deeper (8)
    • Application
      • Superficial  blotchy white and red frost
      • Medium  white frost with surrounding erythema
      • Deep  solid white with no erythema
    • Healing
      • Cool saline presses to decrease inflammation
      • Vinegar soaks Q2 hours while awake for 5-7 days
      • Regular follow up to look for infection
  • 41. Superficial Peels
    • Glycolic Acid
    • Trichloroacetic Acid 10%
    • Jessner Solution (lactate+salicylate+resorcinol+ethanol)
      • Apply for a few minutes then rinse with water or neutralize with bicarbonate solution
      • Stinging sensation and slight flush
      • Smooth glowing skin with no activity restrictions
      • Repeated doses Q week/2 weeks/4 weeks
    • If you want to peels down to the basement membrane
      • Slightly stronger concentration of solution
      • desquamation for 2-3 days
  • 42. Superficial Peel Results
  • 43. Medium Depth Peel
    • Amount of collagen depends on depth of peel and individual variations
    • Scarring occurs with any subepidermal wound but is unpredictable
    • TCA >50% have higher incidence of scarring (22-24)
    • TCA 35% in combo with Jessner or glycolic solution first help with penetration
    • Post treatment
      • Skin turns dark brown
      • Exfoliates for 4-7 days
      • Socially incapacitated for 7 days
      • New skin is very pink
  • 44. Medium Peel Results
  • 45. Deep Peels
    • Baker-Gordon Peel
      • Formulation
        • 3cc 88% phenol
        • 2cc water
        • 8 drops of septisol
        • 3 drops croton oil
      • Treatment
        • Agitate solution prior to usage
        • Cotton tip application to 1 section of face at a time
        • Slow application to regional subunits
          • Prevents systemic absorption and arrhythmias
      • Post Treatment
        • Frosting of skin is immediate
        • Swelling intense and release of epithelium over 1-2 days
        • Re-epithelialization takes over 1 week
        • Constant serous exudate hourly
        • Very red skin for months
        • Hypopigmentation expected
      • Results
        • Robust collagen formation is long-lasting
        • Fine and deep wrinkles respond well
  • 46. Baker’s Peel Progression
  • 47. Complications
    • Landau 2007 (23)
      • 181 patients with full face peels
      • 10-15 minutes between each face section
      • 6.6% arrhythmias
      • Increased with Diabetes, HTN, depression
    • Prevention
      • Sedation
      • IV hydration
      • EKG, LFT’s, Kidney function prior to therapy
      • Monitoring with close follow up
  • 48. Complications
    • Infection
      • Usually result of poor post-procedural care
      • Bacterial, Fungal, or Herpetic
      • Prophylactic antivirals
      • Post-procedure antibiotics
      • Vinegar washes very important
      • Culture any non-healing wounds
  • 49. Complications
    • Hyperpigmentation
      • Dark skin, OCP’s and pregnancy
      • Prophylaxis with hydroquinone
      • Treatment with Tretinoin, alpha hydroxy acid, and steroid cream
      • Sun avoidance before and after treatment plus sunscreen
      • Repeeling is an option if poor results occur
  • 50. Complications
    • Scarring
      • Post-therapy infection
      • Use of oral accutane
        • Healing is by re-epithelialization from pilosebaceous units
        • Accutane destroys sebaceous units
      • Recently radiated skin
      • Recently operated skin (undermining)
      • History of keloids
  • 51. Complications
    • Hypopigmentation
      • Occurs after deep peeling
      • More apparent in very dark or very light skin
      • Feathering of the peel with dermabrasion can camouflage the edges
  • 52. Soft Tissue Augmentation
  • 53. Soft-Tissue Augmentation History
    • Began in 1893 Neuber harvested arm fat and injected it into the patients facial defects (24)
    • Fillers now used for
      • Scars from trauma and acne
      • Static or dynamic rhytids
      • Lip augmentations
      • Melolabial fold augmentation
    • 1900s paraffin injection used but fell out of favor due to paraffinomas (granulomatous reactions)
    • 40-50’s Silicone introduced
      • Granulomatous reactions and scarring limited its use
    • 1970’s Stanford used human and animal collagen
      • Still in use today in bovine form (25)
  • 54. Modern Injectable Fillers
    • Research is huge in this area for the ideal filler
      • Inert, long lasting, abundant, low cost, no allergy, not carcinogenic, fixable
    • Patient demand high
      • Outpatient injection
      • No surgery
      • Minimal recovery 48-72 hours
      • Lower short term cost
    • Dermis is the #1 place of injection
      • Fibroblasts that produce type 1 collagen are most abundant in this region
  • 55. Types of Fillers
    • Xenografts
    • Homografts
    • Autografts
    • Synthetics
  • 56. Xenografts
    • Bovine Collagen
    • Most widely used and is the “Gold Standard”
    • All are dissolved in saline and lidocaine and Pepsin proteolysis to decrease antigenicity
      • Zyderm I (35mg/mL)
        • Injected into upper dermis
        • Poor long term effect because of low concentration
        • Overcorrection necessary 100% (26)
      • Zyderm II (65mg/mL)
        • Injected into mid dermis
        • Longer effect with higher concentration
        • Overcorrection necessary 50% (26)
      • Zyplast (35mg/mL)
        • Cross linked with glutaraldehyde to decrease degredation
        • Injected into reticular dermis for longer duration/less resorption
        • No overcorrection recommended
  • 57. Bovine Collagen Complications
    • Hypersensitivity reaction
      • Tenderness
      • Induration
      • Erythema
      • Pruritis
    • Skin testing before definitive use
      • 3-4% with positive skin test (27,28)
    • 20 to 30% may show delayed reaction
      • Must examine skin test site in 4 to 6 weeks prior to initiating therapy
    • Some argue that second skin test necessary as reactions can occur with repeated injections
    • Other complications
      • Tissue necrosis (29)
      • Foreign body reaction
      • Headache/Nausea/Arthralgias (30)
  • 58. Homografts
    • Cosmoderm and Cosmoplast
      • Bioengineered collagen from fibroblasts
        • No antigenicity so no skin testing required
      • Packaged and concentrated analogously to Zyderm I and Zyplast respectively
        • Cosmoderm for superficial wrinkles
        • Cosmoplast for deeper scars and grooves
      • On average they last 3-6 months but duration is less than bovine equivalents (26)
  • 59. Homografts
    • Alloderm (Cymetra = injectable form)
      • Acellular dermal graft from cadaveric skin
      • Freeze drying process removes cells but leaves collagen IV, VII, proteoglycans and elastin
      • Requires reconstitution with lidocaine prior to injection
      • No skin testing required
      • Duration of 3 to 6 months (31)
  • 60. Xenografts
    • Hyaluronic Acid
      • A Glycosaminoglycans (GAG)
      • Can hold 1000x its weight in water leading to increased skin turgor
      • Overcorrection not required
      • Identical in all species leading to minimal immunogenicity
      • <1% chance of hypersensitivity
      • Correction achieved for 6-9 months with HA (32)
      • Hylaform (500 micron, 5.5mg/mL)
        • Purified from rooster combs
        • Few reports of local or systemic reactions from avian protein
        • Shortened lifespan due to lower concentration (33)
      • Restylane (400 micron, 20mg/mL)
        • Bacterial cultures of Equine steptococci
        • Cross linked with epoxides
        • Also has “Fine Lines” and “Perlane” formulations with diffent particle sizes
    • Isovolumetric contraction where matrix does not disperse water until all hyaluronic acid particles are degraded leading to prolonged effects (34)
  • 61. HA Pitfalls
    • Must inject intradermally
      • Injection too deep
        • Decreased duration of action
      • Injection too superficial
        • Unappealing bumps
    • **Undesirable injections can be corrected with hyaluronidase injection.
  • 62. Autografts
    • Fat
      • Very abundant
      • No antigenic potential
      • Requires additional procedure for harvesting
        • Liposuction
      • Questions regarding how much is reabsorbed
      • Adynamic melolabial folds have prolonged duration of action compared to dynamic glabella (26)
  • 63. Autografts
    • Isolagen (Fibroblasts)
      • Postauricular punch biopsy of patients skin
      • Cultured in vitro with growth factors for 4-6 weeks
      • Overnight delivery for injection the following day
      • Several Treatments required for desired outcome
      • Cost and time considerations make it impractial
      • 6 month histologic evaluation showed integration of fibroblasts but is on hold by FDA due to growth factors and further studies (35)
  • 64. Synthetic Material
    • Silicone
      • Been used for over 50 years
      • Requires multiple microdroplet injections over 4 weeks
      • Injections performed into deep dermis 1 to 3mm apart
      • No overcorrection because innate reaction to the product was part of the process
      • Webster studied 235 pts over 2800 injections (36)
        • Good results and few complications
      • Others have shown extensive reactions (37-39)
        • Chronic inflammation
        • Migration
        • Extrusion ulceration
        • Skin necrosis
        • Granulomatous hepatitis
        • Pulmonary emboli
        • Silicosis (pneumonitis)
    • FDA declared it illegal in 1991 but recent use for retinal detachment is bringing off label use back
    • American Academy of Dermatology (1993) (7)
    • “ There is a wealth of clinical experience in dermatology with the use of liquid injectable silicone by the micro-droplet technique which shows its efficacy and safety in many individuals over many years.”
  • 65. Synthetic Material
    • ArteFill
      • Combined 20% polymethylmethacrylate and 80% bovine collagen
      • Skin testing required
      • As collagen is degraded (4 months) the PMMA is encapsulated to maintain augmentation
      • Injected into the subdermis to prevent persistent painful nodule
      • Individual results are unpredictable so multiple injections are required over 3-4 months with 50 to 75% permanent correction (25)
      • Overcorrection not recommended because each result is different
    • Lemperle (Bailey 37 ) showed good results with minimal complications
    • Others report granulomatous reactions and scarring (Bailey 38 ).
    • Not approved in US but Europe has shown long term correction of >10 years (7)
  • 66. Synthetic Material
    • Radiesse (25 to 45 micron size)
      • 35% synthetic hydroxyapatite particles in water, glycerin, and sodium carboxymethylcellulose
      • Injeted into deep dermis or subdermally due to viscosity
      • Massage is necessary to contour product
      • Produces augmentation in 2 ways
        • Collagen ingrowth by fibroblasts
        • Encapsulation of crystals by fibroblasts to prevent degredation
      • Radiographic evidence of implant for up to 6 years (40)
      • Pitfalls
        • Injection into lips can produce painful nodules
        • Palpable implant for 2 to3 months until the product is replaced by collagen
      • Tzikas studied 90 patients and found 88% patient satisfaction at 6 months (41)
  • 67. Post-therapy Findings
    • Post-injection pain
    • Redness
    • Ecchymosis
    • Swelling
    • Nodularity
    • Palpability
    • **Should be transient and resolve over 1-2 days
  • 68. Complications: 0-2 days
    • Overcorrection
      • Know the properties of the injectable filler and whether to overcorrect or not
    • Implant visibility
      • HA can produce bluish nodule
      • Other fillers cause white nodule
        • Massage can help
        • Hyaluronidase or mechanical deroofing of nodule
    • Vascular compromise
      • Arterial: Immediate skin blanching with necrosis (glabella)
        • Aspiration, massage, warm compress, 2% nitropaste
        • +/- hyperbaric oxygen for impending necrosis
      • Venous: violaceous discoloration with dull ache
        • Nitropaste and warm compresses
    • **Skin breakdown treated with Abx and gentle debridment
  • 69. Venous Injury
  • 70. Complications: 3-14 days
    • Noninflammatory Nodules
      • Observation, gentle massage, reassurance
    • Early Inflammatory Nodules
      • Treat with antibiotics for 4-6 weeks
        • Macrolide and Tetracycline
      • I&D plus culture if fluctuance is observed
      • Close f/u visit at 48 hours
        • If no response to therapy get tissue culture
  • 71. Tissue Infection Immediate Day 2
  • 72. Complications: >14 days
    • Hypersensitivity
      • Bovine collagen 3-4% + skin test
      • HA <1%
    • Nodules
      • Saline injection and vigorous massage
    • Inflammatory nodules
      • Evaluate for infection and treat as necessary
      • No infection but no response at 7-10 days  add intralesional steroid injection to avoid resistant granuloma
      • Still no response  biopsy and culture
    • True Granulomas (0.01-1%)
      • Massage and Intralesional steroids
  • 73. Summary
    • There are a variety of treatment options available
    • Proper knowledge of the product or procedure is necessary to avoid complications
    • Patient expectations, informed consent, and proper patient selection is paramount
  • 74. References
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    • J.M. Stuzin, Phenol peeling and the history of phenol peeling, Clin Plast Surg 25 (1998), p. 1
    • F. Blanco-Davila, Beauty and the body: the origins of cosmetics, J Am Soc Plast Reconstruct Surg 105 (3) (2000), pp. 1196–1204
    • J. Golan and N. Hai, JetPeel: a new technology for facial rejuvenation, Ann Plast Surg 54 (4) (2005), pp. 369–374
    • J. Uitto, E.F. Bernstein and J.A. McGrath, The dermis vol. 1. In: C.R. White Jr, M. Bigby and O.P. Sangueza, Editors, Cutaneous Medicine and Surgery: An Integrated Program in Dermatology , W.B. Saunders Company, Philadelphia (1996), pp. 857–881
    • S. Brooke and J. Griffiths, Interventions for photodamaged skin, Cochrane Database Syst Rev 1 (2005) CD001782
    • Athre RS. Facial filler agents. Operative Techniques in Otolaryngology 2007; 18: 243-247.
    • G. Monheit, Chemical peels, Skin Ther Lett 9 (2) (2004), pp. 6–11
    • B.M. Freedman, E. Rueda-Pedraza and S.P. Waddell, The epidermal and dermal changes associated with microdermabrasion, Dermatol Surg 27 (12) (2001), pp. 1031–1033
    • Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: An Evidence-Based Review. Plast Reconstr Surg. 2010 125(1):372-377
    • J. Newman, J. Lord and K. Ash et al. , Variable pulse erbium:YAG laser skin resurfacing of perioral rhytides and side-by-side comparison with carbon dioxide laser, Lasers Surg Med 25 (2) (1999), pp. 208–214
    • Bisson MA, Grover R, Grobbelaar AO. Long-term results of facial rejuvenation by carbon dioxide laser resurfacing using a quantitative method of assessment. Br J Plast Surg 2002;55(8):652–656.
    • Trelles MA, Pardo L, Ayliffe P, et al. Patients' answers to a postoperative questionnaire related to laser resurfacing. Facial Plast Surg 2001;17(3):187–192
    • J. Chew, I. Gin and K. Rau et al. , Treatment of upper lip wrinkles: a comparison of 950 usec dwell time carbon dioxide laser with unoccluded baker's phenol chemical peel, Dermatol Surg 25 (4) (1999), pp. 262–266
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