different startegy in scar managment

1. Copy right 2021
Scar management
Copy Right 2022

2. • BDS Alexandria Dental school 2002
• MSc Oral & Maxillofacial surgery 2008
• MFDS RCS Ed 2005
• MOMS RCPS Glasg 2009
• FFD RCSI OS OM 2011
• AO-CMF Fellowship 2012
• American Aesthetic fellowship diploma 2013
• Implant Diploma Napoli university 2014
• Laser Diploma ALD 2015
• FDS RCSP Glasg
• Oral & Maxillofacial Surgeon
Islam Kassem

3. Maxillofacial Department
• Islam Kassem
• Mohamed Talat
• Mohamed Mostafa
• Basal Garwani
• Ahmed Barbary
• Hady hassan
• Mohamed Gargaway
• Amro Elshieck

4. • There is no conflict of interest in this course
• I have no monetary benefit from this course.
• No implied sponsorship by any company to
the speaker
• all photographed patients were treated by
the speaker and consented for photographing
and public publishing

5. After 6 month

6. Your face is your signature

7. What about laser

10. long list
Botox
dermal
fi
ller
peeling
mesotherapy
prp
mesobotox
Surgery
Subcision

11. 11

12. photo
please

13. !Dermatologists
!Cosmetic dentistry
!Skin care centers
!Anti –Aging specialist
!Professional beauty centers
WHICH MARKET SEGMENTS ?

14. Think globally
act locally

15. 15
Who is the
most beautiful
girl in the world ?

17. The Science of Beauty
Studies have shown that
individuals who feel
good about the way
they look:
➢lead more productive
and happier lives
➢can actually live longer

18. 18
Measurement’s secrets
Cunningham, M. (1986) : Measuring
the physical in physical
attractiveness : Quasi-experiments on
the sociobiology of female facial
beauty. Journal of Personal & social
Psychology. 50 : 925-35.

19. 19
Aesthetic subunits

20. Rule of thirds

21. 21
Langers line equal
Luxury

22. 22
Phi matrix

24. J of Facioplastic Surg
MAGIC 7 OF FACIAL BEAUTY
1. Ovoid symmetric face
2. Forehead height
3. Eye brow shape
4. Eye size and inter eye distance
5. Nose shape
6. Lips
7. Skin clarity

26. FITZPATRICK SKIN
TYPES AND PEELS

27. Type 1 • Burns easily, never tans
• Red & blonde hair. Blue eyes
• Freckles, very fair skin
• MC1R gene risk.
• ↑ risk for skin cancer
• May scar if slow to heal.
• ↑ potential for vascular (veins)
damage.
Type 2 • Burns easily, tans with difficulty
• Fair sandy/red hair, green or blue
eyes
• Some freckles
• MC1R gene risk.
• ↑ risk for skin cancer
• May pigment with trauma and may
scar if slow to heal.
• ↑ potential for vascular damage.
Type 3 • Slow to burn, will tan.
• Brown, fair, sandy hair; green,
hazel, blue eyes
• May have MC1R gene risk.
• Moderate risk for skin cancer
• ↑ risk for all pigmented skin
conditions;
• Higher potential for scarring
• Moderate risk for visible vascular
damage.
FITZPATRICK SKIN TYPES IDEAL FOR PEELS
MAY USE SUPERFICIAL OR DEEP PEELS WITH LESS RISK OF PIH OR SCARRING

28. 28
FitzpatrickSkinTypesnotidealfordeeppeels
Type 4 • Dark brown hair; green, hazel,
brown eyes.
• Slow to burn--tans easily.
• ↑risk for trauma, heat & chemically
caused pigmentation, and moderate
risk for all other pigmented skin
conditions.
• ↑risk for scarring
• Moderate risk for visible vascular
damage.
Type 5 • Dark and black hair; brown and
dark brown eyes.
• May never burn.
• Very high risk for trauma, heat &
chemically caused pigmentation,
• ↓ risk for solar pigmented skin
conditions.
• ↑ risk for scarring (keloid)
• Moderate risk for visible vascular
damage.
Type 6 • Black hair, dark brown eyes.
• May never burn
• Never tan
• Equivalet to SPF 8
• Very high risk for trauma, heat &
chemically caused pigmentation, and
lower risk for solar pigmented skin
conditions.
• Very high risk for scarring (keloid);
• Moderate risk for visible vascular
damage.
MAY USE SUPERFICIAL PEELS LIKE SALICYLIC OR GLYCOLIC PEELS

29. 29
Goals of Conditioning:
I. Improve texture feel and look
II. Speed up healing
III. Improve results
IV. Reduce complications
Targets:
• Keratinocyte
• Melanocytes
• Fibroblast
• Dermis vascularization
SKIN CONDITIONING

30. Objectives: Affect both
epidermis and dermis
1. Correction
2. Stimulation
3. Exfoliation
4. Bleaching and blending
5. Angiogenesis
Components:
1.Exfoliate
2.Bleach
3.Stimulate
4.Hydrate
5.Protect
6.Prevent
SKIN CONDITIONING

31. • Good penetration
• Restore normal pH of skin 5.4 (cleansers pH should be 4.5 - 5.5)
• Active ingredients (cosmeceuticals)
• Quantified amounts for patients
• Known optimal frequency to achieve best results
• Achieve desired response
IDEAL SKIN CONDITIONING PRODUCTS

32. • When to start? 4-6 weeks before procedure
• When to Pause? 3-5 days before procedure
• When to resume? Use 3-4 weeks after to avoid PIH
• For how long? Twice per week for maintenance
AM:
• Cleanse
• Exfoliate
• HQ+Retin A
• Hydrate
• Sunscreen
PM:
• Cleanse
• Exfoliate
• HQ+Retin A
• Hydrate
SKIN CONDITIONING PROGRAM

33. 33
• In aged skin keratinocytes takes 12 weeks to reach skin surface
• The stratum cornium should be removed to get better product
penetration and better laser treatment outcomes
• Chemoexfoliation is more gentle than mechanical exfoliation
EXFOLIATION

34. AHA: (fruity acids)
•Water soluble: Glycolic/Lactic acids
•Product has to be 5-8% to be effective with pH of 3-4
BHA:
•Oil soluble: Salicylic acid
PHYTIC ACIDS:
•Found in the cereal seeds and, fruits seeds
•For years has been used as an anti-oxidant in the food industry
•Light bleacher
EXFOLIATION

35. • HQ has 2 hydroxyl groups bonded to a benzene ring in a para position.
• Potent melanocyte cytotoxic agent
• Reversible inhibition of DNA and RNA synthesis
• Inhibits tyrosinase by 90% →↓ melanosomes
• Results in 4-6 weeks with plateau at 4 months
• USA , Europe
• Do not use > 10 consecutive weeks
• Side effect: contact dermatitis-Ochronosis (V,VI)
Hydroquinone 2%-6%:
BLEACHING

37. UVAbsorption Spectrum

40. • Ancient Egypt: Cleopatra bathed in sour milk (lactic acid), animal oils, and used
Alabaster to exfoliate skin.
• Middle Ages: (Madame Pompadour France) old wine with tartaric acid as its active
ingredient was used
• Turks: Fire Fire to burn the skin
• Indians: Urine and pumice
• 1882, P.G. Unna A dermatologist first described the properties of salicylic acid,
resorcinol, phenol, and TCA
• 1903: McKee: Chair dermatology NYU used phenol to treat acne scars
The resurrection of Peeling

41. • 1961: Baker and Gordon developed their deep peel to smooth
perioral wrinkles on one patient w follow up result in 3 month
• 1966: Baker publish results on 250 patients
• 1980s: to the present: many peels were introduced.
• 1990s: Peels were most popular aesthetic procedures. With
introduction of lasers and microdermabrasion ↓ in peels
• 2011: 1.1 million peels were performed in USA ↓ by 0.3% from 2010
• 2013: Designer peels, new application methods to improve outcome

42. 42
• Definition: Controlled accelerated skin exfoliation induced by caustic agents causing controlled
damage, followed by the release of cytokines and inflammatory mediators, resulting in
thickening of the epidermis, deposition of collagen, reorganization of structural elements, and ↑
in dermal volume
• At 2 weeks: new collagen formation begins and may continue up to 1 year. New bands of dermis
2- to 3- mm-thick with thin, compact, parallel collagen bundles arranged horizontally along the
epidermal-dermal matrix

43. 43

44. • Medical history: cardiac, hepatic, or renal disease, recurrent herpetic
outbreaks, keloid. Control medical problems (DM/collagen vascular disease)
• Previous cosmetic procedures
• Allergy
• Smoking
• Medications:
• Exogenous estrogens ( OCP, supplements) ↑ photosensitizing → ↑ pigments
• Blood thinners (Plavix, coumadin, warfarin) ↑ bleeding from the peel site →
should be avoid in deep peels . Patients taking aspirin usually do not have
complications, but, if the medication is not necessary, advise them to stop
taking it 1 week prior to a deep peel.
• Oral isotretinoin ↑ photosensitizing and complications

45. • Set realistic expectations
• Before-and-after results should be shown
• Possible complications explained
• Plan the conditioning and peel choice a necessary
chemoprophylaxis
Herpes:
• Acyclovir (400 mg) should be started 2 days prior to the peel and
continued for 5 days after the peel to ↓ risk of recurrent herpes
infection.
• Some dermatologists advise prophylaxis in all patients to avoid the
risks of a herpetic outbreak.

47. •Exam: Skin Analyzer
woods lamp to delineate
indications of peeling

48. Darker equal
more easy

49. • A detailed consent listing the procedure details and possible
complications should be signed by the patient.
• Should state the limitations of the procedure
• Should clearly mention if more procedures are needed for proper
results
• The patient should be provided with adequate opportunity to seek
information through brochures, presentations, and personal
discussions
• The need to adhere to a strict postpeel regimen should be
emphasized
Consent

50. Pigmentary disorders
• Melasma
• PIH
• Freckles
• lentigines
• Facial melanoses
Acne
• Comedonal acne
• Mild/ moderately severe acne
• Superficial acne scars
• Post acne pigmentation
Aesthetic
• Photoaging
• Dilated pores
• Superficial scars
• Fine superficial wrinkling
Epidermal growths
• Seborrheic keratoses
• Sebaceous hyperplasia
• Actinic keratoses
• Milia
Peels Indications

51. • Pregnancy and lactation
• Allergy
• Active bacterial, viral, fungal, or herpetic infection
• Open wounds
• Photosensitizing drugs
• Inflammatory dermatoses: as psoriasis or atopic dermatitis
• Unrealistic expectations
• Uncooperative patient (patient is careless about sun exposure or
application of medicine)
• For medium-depth and deep peels: history of abnormal scarring,
keloids, atrophic skin, or isotretinoin use in the last 6 months
Contraindications

52. Superficial • Penetrate epidermis only
Medium-depth
• Damage the entire epidermis
and papillary dermis
Deep • Mid-reticular
dermis
Depth of Peel Penetration

53. Cornified Layer
Basal Layer
Superficial
Medium
Deep
• AHAs
• Retinoids
• Salicylic acid
•Jessner’s solution
• Up to 30% TCA
• 35-40% TCA
• Jessner’s solution + 35%TCA
• Phenol peel
• Baker-Gordon
• TCA > 50%
Granular Layer
Squamous Layer
Papillary Dermis
Reticular Dermis
Depth of Peel Penetration

54. 54
• Skin prepping
• Agent type
• Agent concentration
• Number of layers applied
• Application technique
• Patient skin type
• Location of the peel
Factors influencing
depth of Peels

55. 55
Techniques of Chemical peeling

56. • Patient resting comfortably in supine position.
• Hair wrapped with a hair bonnet.
• Occlusive ointment on oral commissures, outer canthus
• Cotton is put in each ear opening during the peel.
• If only face is peeled, the neck and shoulders are draped with towels.
• Eyewear is optional and often interferes with the area to be peeled. Exercise great
care not to drop acid into the eye should this happen water rinse should be
available immediately used generously
• Patients must keep their eyes closed
• The acid should not form pools in the facial folds nor drip from the face
Technique of Chemical peeling

57. 57
• 2
FACIAL TREATMENT ZONES
1
3
4
Face is divided to 6 aesthetic
units
1. Forehead
2. Perioral region
3. Bilateral cheeks
4. Chin
5. Nose
6. Periorbital region
3
5
6
Technique of Chemical peeling

58. • Homogeneous erythema indicates → Epidermal penetration.
• White frost (30 sec-2m) indicates → Coagulative necrosis of the papillary
dermis.
• Gray-white frost indicates → Coagulative necrosis of the reticular dermis. If you
see gray stop peeling and immediately neutralize irrespective of the time
Technique of Chemical peeling
Clinical Response to Peels

59. • An important step once the proper depth of the peel is achieved
determined by either the frost or how much time has elapsed.
• This soothes the tingling discomfort caused by the peeling agent
• Glycolic acid → Only peel to neutralize. Use bicarbonate spray.
• Salicylic acid, Jessner solution, TCA, and phenol → self neutralize.
Technique of Chemical peeling
Neutralization

60. After Peel Instructions
•Most discomfort in the first 4-8 hours after peel
•Most of swelling in the first 3 days
•Most crusting and peeling in 5-7 days
1. Aquaphore applied lightly TID for the first 5 days only.
2.Following this, apply 0.5% hydrocortisone cream OTC BID for the next 3 days only if needed. ( ↓ redness
and irritation)
3.Hypoallergenic moisturizers applied after healing7-10 days post peel.
4.After full completion of healing process apply aloe vera
8.Resume normal skin care 10 days post peel
9.Desmeporo compresses if lot of oozing TID
10.If very dry scabbing use Cetaphil solution on scabs
11.Apply sun block SPF 30
12.First follow up visit will be approximately 5-7 days after the peel.
13.Direct and indirect sunlight should be avoided for at least 12 months

61. • Necrosis of the epidermis
• Healing time from 1-4 days
• Improve: Pigmentary irregularities / Minor surface changes
• For best results use a series of peels performed every 2-6 weeks
•Agents:
• Jessner's solution
• Glycolic acid: 50%-70% → Keratinocyte dyscohesion Epidermolysis
• α-hydroxy acid peels : lactic acid, tartaric acid, and malic acid
• TCA: 10-20%
Superficial peels

62. 1.Safe. No systemic absorption.
2.Low cost. No big ticket
investment
3.Little or no down time
4.Immediate visible results
5.Minimal discomfort
6.Performed by aestheticians
GLYCOLIC ACID

63. GLYCOLIC ACID PEEL PROCEDURE

64. Bruffin 800 mg
retards
2 tab

65. •Cleanse skin thoroughly with TDF
Non Drying Cleansing lotion or TDF
wash-off cleansing lotion to remove
all traces of impurities and make up
GLYCOLIC ACID PEEL PROCEDURE

66. • Double cleanse with cotton wool
dabbed in TDF Mild astringent.
• Preempt the patient that she will
experience a stinging or burning
sensation upon application of GAP
GLYCOLIC ACID PEEL PROCEDURE

67. •Apply GAP solution starting at the forehead,
down to the sides of the face to chin, nose and
lastly the cheeks
•Criss-cross the application to ensure no area is
over looked and the solution is spread evenly
over all skin
•Application should be completed within 20
seconds
GLYCOLIC ACID PEEL PROCEDURE

68. •Allow GAP to contact skin for 3-5
min
•Set timer to keep track of time
•Ask patient for feedback.
•Ensure patient tolerates the peel
•Sensitivity varies between
patients
•Use fan to help tingling or burning
sensation
GLYCOLIC ACID PEEL PROCEDURE

69. •Observe skin carefully for erythema
•Spot neutralize with cotton bud
dabbed with TDF post peel
neutralizer
•Upon neutralization burning
sensation ↓
GLYCOLIC ACID PEEL PROCEDURE

70. • Neutralize with generous amount
of TDF Post-peel neutralizer
• Apply with cotton wool in circular
motion and slight pressure
GLYCOLIC ACID PEEL PROCEDURE

71. • Wipe excess neutralizer
• Apply cold compresses for 30 seconds
• If burning persists re-neutralize
GLYCOLIC ACID PEEL PROCEDURE

72. GLYCOLIC ACID PEEL PROCEDURE

73. • Initially use 50% left on for a carefully timed 3 minutes.
• For very sensitive skin the peel may be started at 2-2.5 minutes.
• Repeat peels every 2-4 weeks:
• ↑ time by 30 seconds each chemical peel procedure
• ↑ concentration up to 70%
• Some patients may tolerate peels lasting up to 10 minutes,
especially if they have severe chronic sun damage.
• To treat acne, it is usually left on for only 1-2 minutes
GLYCOLIC ACID PEEL PROCEDURE

74. • From willow bark, wintergreen leaves and sweet
birch
• Hydroxyl derivative of benzoic acid
• Have the OH group in β position
• Safe, well tolerated
• End point: SA crystal formation
• Common concentrations: 20-30%
• Have a larger molecule > α-hydroxy acids with the
following advantages:
1. Less irritation than α-hydroxy acids → good alternative
for sensitive skin.
2. The β-hydroxy acid stays longer on the skin surface →
penetrate more effectively
Salicylic Acid(β-hydroxy Acid)

75. Mechanisms of Action
1. Dissolve intercellular cement → ↓ stratum corneum adhesion → Keratolysis
2. Lipid-soluble → strong comedolytic effect → penetrate and remove sebum in the hair
follicle, and unclog pores
3. Affects the arachidonic cascade → anti-inflammatory action → useful in both
treatment of acne and rosacea. The anti-inflammatory and anesthetic effects → ↓
erythema & discomfort associated with chemical peels
Salicylic Acid Peel
(β-hydroxy Acid)

76. Composition:
• Salicylic acid 14%
• Lactic acid 14%
• Resorcinol 14%
• Ethanol 95% 100mL
• Also called Coombe formual or Horvath’s concoction
• Should be stored in dark bottle hence discoloration
Advantages:
• One concentration
• No timing
• No neutralization necessary
Jessner Peels

77. •Apply → wait for a light frost
•Apply with gloves in patients with thin, sensitive skin or
is rubbed in with gauze squares in patients with thick
sebaceous skin
•The depth of the peel depends on the # of coats
Jessner Peels

78. Necrosis of the epidermis & inflammation within the papillary dermis
• Removes of epidermal or superficial lesions:
• Improve depressed scars
• Actinic keratoses
• Repair mild rhytides
• Improve dyschromias
• Agents:
• 35-40% TCA
• Jessner’s solution + 35%TCA
Medium Peels

79. 79
• Coagulative necrosis of cellular proteins in
the epidermis and necrosis of collagen in
the papillary to upper reticular dermis.
• Over several days the necrotic layers slough
• Skin re-epithelializes from the adnexal
structures
Mechanism of Action

80. •Easy to use
•Use a solid block of carbon dioxide ice dipped
in an acetone-alcohol mixture
•The block is then applied to the skin for 5-15
seconds, depending upon the desired depth.
•The depth of the peel can be controlled more
easily than with liquid nitrogen; carbon dioxide
is at -78°C, while liquid nitrogen is at -196°C.
Carbon Dioxide Peels

81. • For Ice pick scars
• ↑ the effects of TCA and ↓
complications
• Focal application of higher
TCA concentrations by
pressing hard on the entire
depressed area of atrophic
acne scars using a tipped
applicator
• It produces multiple, frosted
white spots on each acne scar
Chemical Reconstruction of Skin Scars (CROSS)

82. •Be a gourmet Peeler
•Cookbook medicine is dangerous
•Technique matters
•Look for and trust end points
•Don’t over do things
•Find a mentor
•Be NICE

83. Complication How To Avoid Treatment
Disappointed patients • Manage realistic expectations
Erythema • Transient 3-90 days • Antihistamine and oral steroids
AHA Burns • Treat younger patients carefully
Hyperpigmentation • Transient with medium peels
• Long term with burns
• Sun screen
• Hydoquinone/kojic/phytic
Hypopigmentation • Experience/drugs: minocycline.Benzoil
peroxide. Thiazides. St,. Johns wort
• Avoid deep peeling if necessary
Scarring • experience • Topical steroids
Milia • Avoid emollients after peel • Topical retinoids
Periorbital edema • Avoid deep peels • Steroids
Infection • Prophylaxis • Antiviral antibacterial
Demarcation lines • Feathering • Light peeling
Toxicity: salicylic /
Resorcinol
• Avoid treating large areas

84. HYPERPIGMENTATION

85. •Scarring remains the most dreaded complication of
chemical peels.
•The contributing factors are not well understood.
•By matching the patient and peeling agent properly,
the risk of scarring can be ↓
•To ↓ risk of scarring, the patient should refrain from
picking at the healing skin.
•History of keloids: should not undergo medium or
deep peels
•Weaker superficial peels that only exfoliate the
stratum corneum or superficial epidermis can be
used.
SCARRING

86. • Cleanse face with a povidone wash
• Use bacitracin for medium peels
• Cold sores can be prevented with acyclovir (400 mg PO bid), beginning 2
days prior to the peel and continuing 7 days after the peel.
• For Candidiasis infection use fluconazole
• Cultures need to be taken, and appropriate antibiotics should be
administered.
• Toxic shock syndrome has been reported after a chemical peel.
INFECTION

87. Physical Peeling

88. •Developed in Italy in 1985; widespread in Europe
prior to its introduction and popularity in the US.
•A mechanical medium used
for exfoliation along with adjustable suction to
produce a superficial epidermal ablation of
stratum corneum
•Only effective for superficial scars
Microdermabrasion

89. •Increase the remolding of the skin by creating thousands of
microscopic channels in the skin
•Increase the formation of new tissue by activating the body’s
healing cascade
Micro-needling

90. • 0.5 mm Micro-needling
• Aged and sun damaged skin
• Hair loss
• Craw feet/ Upper lip
• Hyper pigmentation
• 1.0 mm Micro-needling
• Scars
• Stretch marks / Cellulites
• 1.5mm to 2.5 mm Micro-needling
• Acne scars
• Burn scars
• Sacked (aged) connective tissues
• Deeper wrinkles
Micro-needling Indications