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  1. 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. 2. Objectives <ul><li>Discuss the history of cosmetic facial rejuvenation </li></ul><ul><li>Discuss Aging and Photodamage to the skin </li></ul><ul><li>Discuss treatment options for adynamic facial conditions and their associated complications </li></ul>
  3. 3. History of Facial Rejuvenation <ul><li>3000 BCE Egyptians </li></ul><ul><ul><li>Manicures, Make-up, Tattoos of the face (1) </li></ul></ul><ul><li>1500 BCE Egyptians </li></ul><ul><ul><li>Used sandpaper for scars as early form of dermabrasion (2) </li></ul></ul><ul><li>100 BCE Roman poet Ovid: The Art of Love </li></ul><ul><ul><li>Facial mask of barley, bean, eggs, hartshorn, narcissus bulbs, balsam, Tuscany seed, honey (3) </li></ul></ul><ul><li>200 CE Jewish Talmud </li></ul><ul><ul><li>Husband must provide 10 dinars for his wife’s cosmetic needs </li></ul></ul><ul><li>900 CE Arabic Physicians </li></ul><ul><ul><li>Crushed rice, seashells, marble, crystal, limes, eggs, beans, ground lentils (dermabrasion) </li></ul></ul>
  4. 4. History of Facial Rejuvenation <ul><li>1905 Kromayer </li></ul><ul><ul><li>Mechanical dermabrasion with wheels and rasps (4) </li></ul></ul><ul><li>1960’s Facial Peels </li></ul><ul><li>1990’s CO2 Laser Resurfacing </li></ul><ul><li>Most recently filler agents have become increasingly popular </li></ul><ul><li>**Modern techniques are reminiscent of ancient techniques </li></ul>
  5. 5. Layers of the Skin
  6. 6. Epidermis <ul><li>Stratum Corneum </li></ul><ul><ul><li>Keratinized cells to be sloughed off </li></ul></ul><ul><li>Stratum Lucidum </li></ul><ul><li>Stratum Granulosum </li></ul><ul><li>Stratum Spinosum </li></ul><ul><li>Stratum Basale </li></ul><ul><ul><li>Basal regenerative cells and melanocytes </li></ul></ul><ul><ul><li>Regeneration every 12-14 days (1) </li></ul></ul>
  7. 7. Epidermis
  8. 8. Dermal Layers <ul><li>Papillary Dermis </li></ul><ul><ul><li>Meshwork of fine type III collagen fibers </li></ul></ul><ul><ul><li>Anchors epidermis down to dermis </li></ul></ul><ul><li>Reticular Dermis </li></ul><ul><ul><li>Thick type I collagen bundles </li></ul></ul><ul><ul><li>Elastic fibers for resiliency </li></ul></ul><ul><ul><li>Glycosaminoglycans (GAG’s) </li></ul></ul><ul><ul><ul><li>Ground substance between fibers </li></ul></ul></ul><ul><ul><ul><li>Can hold up to 1000x their weight in water (5) </li></ul></ul></ul><ul><ul><li>Hair, sebaceous/sweat glands, nerve receptors and blood vessels </li></ul></ul>
  9. 9. Papillary and Reticular Dermis
  10. 10. Hypodermis <ul><li>Connects skin and underlying bone/muscle </li></ul><ul><li>Loose connective tissue and elastin </li></ul><ul><li>Predominant Cells </li></ul><ul><ul><li>Fibroblasts </li></ul></ul><ul><ul><li>Macrophages </li></ul></ul><ul><ul><li>Adipocytes </li></ul></ul>
  11. 11. Damage to the Dermis <ul><li>Age </li></ul><ul><ul><li>Decreased ratio of Type I : Type III collagen </li></ul></ul><ul><li>Photodamage and Tobacco Smoke (6) </li></ul><ul><ul><li>Increase tissue collagenases and gelatinases </li></ul></ul><ul><ul><li>Further decrease collagen in the dermis </li></ul></ul><ul><ul><li>Decrease capillary and blood flow to skin </li></ul></ul><ul><ul><li>Decreased skin integrity </li></ul></ul><ul><li>**Ultimately leads to decreased skin turgor and elasticity forming wrinkles and sagging skin (7) </li></ul>
  12. 12. Initial Evaluation <ul><li>Patient selection is key </li></ul><ul><ul><li>Unrealistic </li></ul></ul><ul><ul><li>Psychiatric history or multiple physician visits </li></ul></ul><ul><ul><li>Smokers have 12 times increased skin sloughing and scarring </li></ul></ul><ul><li>Must perform proper: </li></ul><ul><ul><li>Education </li></ul></ul><ul><ul><li>Counselling </li></ul></ul><ul><ul><li>Consistent procedural skills </li></ul></ul>
  13. 13. Physical Exam <ul><li>Are rhytids dynamic vs adynamic </li></ul><ul><ul><li>Traction of skin in antagonistic direction </li></ul></ul><ul><li>Hypo- or Hyperpigmented skin </li></ul><ul><li>Associated skin conditions </li></ul><ul><li>Active infection </li></ul><ul><li>Thickness of skin </li></ul><ul><li>Glogau System </li></ul>
  14. 14. Glogau System (8) <ul><li>Stratifies patients based on amount of aging and skin damage </li></ul><ul><li>Category I </li></ul><ul><ul><li>Photoaging down to stratum granulosum or papillary dermis with minimal wrinkles </li></ul></ul><ul><ul><li>Dermabrasion or superficial chemical peeling </li></ul></ul><ul><li>Category II </li></ul><ul><ul><li>Photodamage down to upper reticular dermis and wrinkles with facial gestures </li></ul></ul><ul><ul><li>Medium depth chemical peeling </li></ul></ul><ul><li>Category III </li></ul><ul><ul><li>Photodamage down to upper reticular dermis and wrinkles at rest </li></ul></ul><ul><ul><li>Medium depth peels </li></ul></ul><ul><li>Category IV </li></ul><ul><ul><li>Photodamage to mid reticular dermis, wrinkles, skin discoloration </li></ul></ul><ul><ul><li>Deep peel required </li></ul></ul>
  15. 15. Treatment Options <ul><li>Dermabrasion </li></ul><ul><li>Laser Resurfacing </li></ul><ul><li>Chemical Peels </li></ul><ul><li>Facial Fillers </li></ul>
  16. 16. Dermabrasion <ul><li>Purpose is to level the skin and promote re-epithelialization with new collagen deposition. </li></ul><ul><li>Used for: </li></ul><ul><ul><li>Scar revision </li></ul></ul><ul><ul><li>Acne scarring </li></ul></ul><ul><ul><li>Rhinophyma </li></ul></ul><ul><ul><li>Facial rhytids </li></ul></ul><ul><li>Contraindicated for Keloids and Hypertrophic Scars </li></ul><ul><li>Must only injure only the papillary dermis </li></ul><ul><ul><li>Preserves adnexal structures for re-epithelialization </li></ul></ul><ul><ul><li>Damage through the reticular dermis (Fat visualized) leads to adverse scarring </li></ul></ul>
  17. 17. Dermabrasion <ul><li>Performed with high speed diamond fraise or wire brush. </li></ul><ul><li>Local anesthesia +/- IV sedation </li></ul><ul><li>Broad surfaces are frozen to maintain rigid tissue (malar region) </li></ul><ul><li>Brush strokes are made at right angles to the brush rotation to avoid loss of control and damage to normal tissue </li></ul><ul><li>Feathering : Edges are slightly brushed for blending </li></ul>
  18. 18. Dermabrasion <ul><li>Upper layers of skin are removed resulting in partial thickness wounds </li></ul><ul><li>Small pinpoint bleeding of the wound </li></ul><ul><li>Heal by re-epithelialization in 7-10 days </li></ul><ul><li>Recovery is 2-3 weeks </li></ul>
  19. 19. Microdermabrasion <ul><li>Alternative to dermabrasion that attacks just the upper layer of skin </li></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Only good for early photodamage and superficial wrinkles </li></ul></ul><ul><ul><li>Not useful for dermal pathology </li></ul></ul><ul><li>Uses Aluminum oxide microcrystals </li></ul><ul><li>Advantages </li></ul><ul><ul><li>Repeated at short intervals </li></ul></ul><ul><ul><li>Painless requiring no anesthesia </li></ul></ul><ul><ul><li>Minimal erythema and side effects </li></ul></ul>
  20. 20. Microdermabrasion <ul><li>Freedman 2001 (9) </li></ul><ul><ul><li>10 patients treated with 6 treatments </li></ul></ul><ul><ul><li>Physical exam and tissue biopsy </li></ul></ul><ul><ul><li>Thickened epidermis and dermis with newly deposited collagen </li></ul></ul><ul><li>Karimipour 2010 PRSJ (10) </li></ul><ul><ul><li>Very good for skin contour irregularities such as rhytids </li></ul></ul><ul><ul><li>Less effective with dyschromias than glycolic acid peels </li></ul></ul><ul><ul><li>No RCT to evaluate uses in acne but decision should be based on patients expectations </li></ul></ul>
  21. 21. Picture of Debridment Instrument
  22. 22. Dermabrasion Results
  23. 23. Laser Resurfacing
  24. 24. Laser Resurfacing <ul><li>Works by targeting chromophores </li></ul><ul><li>Each laser has a different chromophore: </li></ul><ul><ul><li>Water, oxyhemoglobin, melanin, etc. </li></ul></ul><ul><li>Chromophore absorbs the laser heat destroys cells harboring that chromophore </li></ul><ul><li>Amount of chromophore in a cell is proportional to absorption/destruction </li></ul><ul><li>Lasers have opened the door for treatment of periocular skin where dermabrasion cannot reach </li></ul>
  25. 25. Ablative Lasers <ul><li>Carbon Dioxide (10,600nm) </li></ul><ul><ul><li>Used with the same indications as dermabrasion </li></ul></ul><ul><ul><li>Wavelength selectively targets water in soft tissue </li></ul></ul><ul><ul><li>More collagen production and prolonged redness due to dispersed thermal injury </li></ul></ul><ul><li>Other advantages </li></ul><ul><ul><li>Hemostatic properties </li></ul></ul><ul><ul><li>Depth of treatment is more precise with laser </li></ul></ul><ul><ul><ul><li>Skin tightening is immediate </li></ul></ul></ul><ul><ul><ul><li>Skin irregularities are improved immediately </li></ul></ul></ul>
  26. 26. Ablative Lasers <ul><li>Erbium:YAG (2,940nm) </li></ul><ul><ul><li>Reduced thermal damage </li></ul></ul><ul><ul><ul><li>Less post-therapy redness </li></ul></ul></ul><ul><ul><ul><li>Less collagen production </li></ul></ul></ul><ul><li>Newman et al. 1999 (11) </li></ul><ul><ul><li>Compared Er:YAG and CO2 laser </li></ul></ul><ul><ul><li>21 patients with half the upper lip treated by each laser </li></ul></ul><ul><ul><li>Er:YAG had less days of crusting 3.4 compared to 7.7 </li></ul></ul><ul><ul><li>63% vs 54% improvement at 2 months favoring CO2 </li></ul></ul>
  27. 27. Other Lasers <ul><li>Nd:YAG Laser (1,064nm) </li></ul><ul><ul><li>Infrared, invisible, oxyhemaglobin, deep penetration </li></ul></ul><ul><ul><li>Good for port-wine stains, telangiectasias, hemangiomas </li></ul></ul><ul><li>KTP (532nm) </li></ul><ul><ul><li>Visible, oxyhemaglobin absorption </li></ul></ul><ul><ul><li>Good for cutaneous lesions </li></ul></ul><ul><li>Argon (193nm) </li></ul><ul><ul><li>Visible, broad blue band, oxyhemaglobin </li></ul></ul><ul><ul><li>Penetrates between CO2 and Nd:YAG </li></ul></ul><ul><ul><li>Same indications as Nd:YAG </li></ul></ul><ul><li>Flashlamp Excited Pulsed Dye (595 nm) </li></ul><ul><ul><li>Visible, yellow light, vascular sensitive </li></ul></ul><ul><ul><li>Less scarring and hypopigmentation than Nd:YAG & Argon </li></ul></ul><ul><ul><li>Cutaneous vascular lesions </li></ul></ul>
  28. 28. Effectiveness of Lasers <ul><li>Bisson in 2002 evaluated 31 patients (12) </li></ul><ul><ul><li>At 6 weeks wrinkle depth reduction of 91% </li></ul></ul><ul><ul><li>At 2 years wrinkle depth reduction of 87% </li></ul></ul><ul><li>2001 Lasers are falling out of favor (13) </li></ul><ul><ul><li>88% of patients considered post-therapy results very good. </li></ul></ul><ul><ul><li>77% would not be willing to have procedure again. </li></ul></ul><ul><li>**Several studies have shown equivalent results of CO2 lasers compared to dermabrasion (14-16) </li></ul>
  29. 29. Laser Resurfacing Results
  30. 30. Complications of Dermabrasion/Laser Resurfacing <ul><li>Infection (17) </li></ul><ul><ul><li>Bacterial infection rates 4.3 to 12% </li></ul></ul><ul><ul><li>Fungal infection rates 1.8 to 2.2% </li></ul></ul><ul><li>Hypo/Hyperpigmentary mismatches </li></ul><ul><ul><li>Dark Skinned Patients </li></ul></ul><ul><ul><li>Melasma or Cholasma associated with OCP’s </li></ul></ul><ul><ul><li>Photosensitivity post-procedure should be prevented with UV blocking lotions for 2 months (18-19) </li></ul></ul><ul><li>Scarring Risk </li></ul><ul><ul><li>Must stop 13-cis-retinoic acid (Accutane) for 6-12 months prior to therapy (20) </li></ul></ul><ul><li>Milia Formation </li></ul><ul><ul><li>Small epidermal cysts common after dermabrasion </li></ul></ul><ul><ul><li>Can be prevented with occlusive ointments or dressings for 1-2 weeks </li></ul></ul><ul><ul><li>Can be treated with abrasive cleansers or scalpel </li></ul></ul><ul><li>Herpes Simplex Risk </li></ul><ul><ul><li>Roberts et al 1997 (21) </li></ul></ul><ul><ul><ul><li>Studied 907 patients with CO2 laser treatment and found that HSV infection of 3% was reduced to 1% with acyclovir prophylaxis </li></ul></ul></ul><ul><ul><ul><li>Therefore patients treated with antivirals for 2-3 days prior and 7-10 days post procedure </li></ul></ul></ul>
  31. 31. Laser Resurfacing Redness
  32. 32. Melasma/Chloasma
  33. 33. Milia
  34. 34. Chemoexfoliation <ul><li>Controlled wounding of skin to induce regeneration and a more youthful appearance </li></ul><ul><li>Most commonly used for photodamage that leads to </li></ul><ul><ul><li>Thickened Stratum Corneum </li></ul></ul><ul><ul><li>Thinned Stratum Spinosum </li></ul></ul><ul><ul><li>Disorganized maturation and elastin </li></ul></ul><ul><ul><li>Decreased dermal collagen and GAG’s </li></ul></ul><ul><ul><li>Irregular melanin dispersion </li></ul></ul><ul><li>Skin is rough, wrinkled and mottled </li></ul>
  35. 35. Damaging Levels <ul><li>Stratum Corneum </li></ul><ul><ul><li>Skin feels smoother </li></ul></ul><ul><li>Epidermal Basement Membrane </li></ul><ul><ul><li>Melanocytes live here </li></ul></ul><ul><ul><li>Lighter and evenly pigmented </li></ul></ul><ul><li>Upper Reticular Dermis </li></ul><ul><ul><li>Smoother and lighter skin </li></ul></ul><ul><ul><li>Deposition of new collagen, elastin, GAG’s </li></ul></ul><ul><ul><li>Subsequent reduction of fine wrinkles </li></ul></ul><ul><li>Middle Reticular Dermis </li></ul><ul><ul><li>More collagen production with reduction of deeper wrinkles </li></ul></ul><ul><li>Deep Reticular Dermis </li></ul><ul><ul><li>Collagen production can produce a scar </li></ul></ul>
  36. 36. Factors that increase solution penetration <ul><li>Solution Concentration </li></ul><ul><li>Condition of Skin </li></ul><ul><ul><li>Pre-treatment tretinoin, electrolysis, surgery, waxing. </li></ul></ul><ul><li>Pre-peel degreasing with alcohol or acetone </li></ul><ul><li>Application (brush, swab, sponge) </li></ul><ul><li>Rubbing </li></ul><ul><li>Time of contact </li></ul><ul><li>Occlusion with tape or petroleum jelly </li></ul>
  37. 37. Individual Results <ul><li>Some argue that test patching is important because each person reacts so differently to each type of peel </li></ul><ul><ul><li>Depth of penetration </li></ul></ul><ul><ul><li>Wrinkling response </li></ul></ul><ul><ul><li>Scarring </li></ul></ul><ul><li>Post-therapy care should include ointment to promote healing, sun avoidance, and proper wound care to prevent infection </li></ul>
  38. 38. Patient Selection <ul><li>Post-therapy appearance can be frightening </li></ul><ul><li>Make sure patients are: </li></ul><ul><ul><li>Psychologically stable </li></ul></ul><ul><ul><li>Compliant with post-therapy care </li></ul></ul><ul><ul><li>Willing to stay out of the sun </li></ul></ul><ul><ul><li>Willing to wear makeup </li></ul></ul><ul><li>Be sure to perform proper informed consent and document it appropriately </li></ul>
  39. 39. Topical Retin-A <ul><li>First line therapy </li></ul><ul><li>Advantages </li></ul><ul><ul><li>Reverses all the previously discussed findings of sun damage </li></ul></ul><ul><ul><li>Also decreases fine wrinkles, evens pigmentary differences, smoothes the skin </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Photosensitivity </li></ul></ul><ul><ul><li>Dries the skin out making moisturizers necessary </li></ul></ul><ul><ul><li>Class C pregnancy media </li></ul></ul><ul><li>Can be combined with alpha hydroxy acids which are less effective but potentiate tretinoin preparations </li></ul>
  40. 40. Process of Skin Peeling <ul><li>Cleansing </li></ul><ul><ul><li>Septisol and acetone to decrease oil and scaliness of the skin </li></ul></ul><ul><ul><li>Jessner’s or 70% glycolic solution can be used first to break initial barriers and allow TCA to penetrate deeper (8) </li></ul></ul><ul><li>Application </li></ul><ul><ul><li>Superficial  blotchy white and red frost </li></ul></ul><ul><ul><li>Medium  white frost with surrounding erythema </li></ul></ul><ul><ul><li>Deep  solid white with no erythema </li></ul></ul><ul><li>Healing </li></ul><ul><ul><li>Cool saline presses to decrease inflammation </li></ul></ul><ul><ul><li>Vinegar soaks Q2 hours while awake for 5-7 days </li></ul></ul><ul><ul><li>Regular follow up to look for infection </li></ul></ul>
  41. 41. Superficial Peels <ul><li>Glycolic Acid </li></ul><ul><li>Trichloroacetic Acid 10% </li></ul><ul><li>Jessner Solution (lactate+salicylate+resorcinol+ethanol) </li></ul><ul><ul><li>Apply for a few minutes then rinse with water or neutralize with bicarbonate solution </li></ul></ul><ul><ul><li>Stinging sensation and slight flush </li></ul></ul><ul><ul><li>Smooth glowing skin with no activity restrictions </li></ul></ul><ul><ul><li>Repeated doses Q week/2 weeks/4 weeks </li></ul></ul><ul><li>If you want to peels down to the basement membrane </li></ul><ul><ul><li>Slightly stronger concentration of solution </li></ul></ul><ul><ul><li>desquamation for 2-3 days </li></ul></ul>
  42. 42. Superficial Peel Results
  43. 43. Medium Depth Peel <ul><li>Amount of collagen depends on depth of peel and individual variations </li></ul><ul><li>Scarring occurs with any subepidermal wound but is unpredictable </li></ul><ul><li>TCA >50% have higher incidence of scarring (22-24) </li></ul><ul><li>TCA 35% in combo with Jessner or glycolic solution first help with penetration </li></ul><ul><li>Post treatment </li></ul><ul><ul><li>Skin turns dark brown </li></ul></ul><ul><ul><li>Exfoliates for 4-7 days </li></ul></ul><ul><ul><li>Socially incapacitated for 7 days </li></ul></ul><ul><ul><li>New skin is very pink </li></ul></ul>
  44. 44. Medium Peel Results
  45. 45. Deep Peels <ul><li>Baker-Gordon Peel </li></ul><ul><ul><li>Formulation </li></ul></ul><ul><ul><ul><li>3cc 88% phenol </li></ul></ul></ul><ul><ul><ul><li>2cc water </li></ul></ul></ul><ul><ul><ul><li>8 drops of septisol </li></ul></ul></ul><ul><ul><ul><li>3 drops croton oil </li></ul></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Agitate solution prior to usage </li></ul></ul></ul><ul><ul><ul><li>Cotton tip application to 1 section of face at a time </li></ul></ul></ul><ul><ul><ul><li>Slow application to regional subunits </li></ul></ul></ul><ul><ul><ul><ul><li>Prevents systemic absorption and arrhythmias </li></ul></ul></ul></ul><ul><ul><li>Post Treatment </li></ul></ul><ul><ul><ul><li>Frosting of skin is immediate </li></ul></ul></ul><ul><ul><ul><li>Swelling intense and release of epithelium over 1-2 days </li></ul></ul></ul><ul><ul><ul><li>Re-epithelialization takes over 1 week </li></ul></ul></ul><ul><ul><ul><li>Constant serous exudate hourly </li></ul></ul></ul><ul><ul><ul><li>Very red skin for months </li></ul></ul></ul><ul><ul><ul><li>Hypopigmentation expected </li></ul></ul></ul><ul><ul><li>Results </li></ul></ul><ul><ul><ul><li>Robust collagen formation is long-lasting </li></ul></ul></ul><ul><ul><ul><li>Fine and deep wrinkles respond well </li></ul></ul></ul>
  46. 46. Baker’s Peel Progression
  47. 47. Complications <ul><li>Landau 2007 (23) </li></ul><ul><ul><li>181 patients with full face peels </li></ul></ul><ul><ul><li>10-15 minutes between each face section </li></ul></ul><ul><ul><li>6.6% arrhythmias </li></ul></ul><ul><ul><li>Increased with Diabetes, HTN, depression </li></ul></ul><ul><li>Prevention </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>IV hydration </li></ul></ul><ul><ul><li>EKG, LFT’s, Kidney function prior to therapy </li></ul></ul><ul><ul><li>Monitoring with close follow up </li></ul></ul>
  48. 48. Complications <ul><li>Infection </li></ul><ul><ul><li>Usually result of poor post-procedural care </li></ul></ul><ul><ul><li>Bacterial, Fungal, or Herpetic </li></ul></ul><ul><ul><li>Prophylactic antivirals </li></ul></ul><ul><ul><li>Post-procedure antibiotics </li></ul></ul><ul><ul><li>Vinegar washes very important </li></ul></ul><ul><ul><li>Culture any non-healing wounds </li></ul></ul>
  49. 49. Complications <ul><li>Hyperpigmentation </li></ul><ul><ul><li>Dark skin, OCP’s and pregnancy </li></ul></ul><ul><ul><li>Prophylaxis with hydroquinone </li></ul></ul><ul><ul><li>Treatment with Tretinoin, alpha hydroxy acid, and steroid cream </li></ul></ul><ul><ul><li>Sun avoidance before and after treatment plus sunscreen </li></ul></ul><ul><ul><li>Repeeling is an option if poor results occur </li></ul></ul>
  50. 50. Complications <ul><li>Scarring </li></ul><ul><ul><li>Post-therapy infection </li></ul></ul><ul><ul><li>Use of oral accutane </li></ul></ul><ul><ul><ul><li>Healing is by re-epithelialization from pilosebaceous units </li></ul></ul></ul><ul><ul><ul><li>Accutane destroys sebaceous units </li></ul></ul></ul><ul><ul><li>Recently radiated skin </li></ul></ul><ul><ul><li>Recently operated skin (undermining) </li></ul></ul><ul><ul><li>History of keloids </li></ul></ul>
  51. 51. Complications <ul><li>Hypopigmentation </li></ul><ul><ul><li>Occurs after deep peeling </li></ul></ul><ul><ul><li>More apparent in very dark or very light skin </li></ul></ul><ul><ul><li>Feathering of the peel with dermabrasion can camouflage the edges </li></ul></ul>
  52. 52. Soft Tissue Augmentation
  53. 53. Soft-Tissue Augmentation History <ul><li>Began in 1893 Neuber harvested arm fat and injected it into the patients facial defects (24) </li></ul><ul><li>Fillers now used for </li></ul><ul><ul><li>Scars from trauma and acne </li></ul></ul><ul><ul><li>Static or dynamic rhytids </li></ul></ul><ul><ul><li>Lip augmentations </li></ul></ul><ul><ul><li>Melolabial fold augmentation </li></ul></ul><ul><li>1900s paraffin injection used but fell out of favor due to paraffinomas (granulomatous reactions) </li></ul><ul><li>40-50’s Silicone introduced </li></ul><ul><ul><li>Granulomatous reactions and scarring limited its use </li></ul></ul><ul><li>1970’s Stanford used human and animal collagen </li></ul><ul><ul><li>Still in use today in bovine form (25) </li></ul></ul>
  54. 54. Modern Injectable Fillers <ul><li>Research is huge in this area for the ideal filler </li></ul><ul><ul><li>Inert, long lasting, abundant, low cost, no allergy, not carcinogenic, fixable </li></ul></ul><ul><li>Patient demand high </li></ul><ul><ul><li>Outpatient injection </li></ul></ul><ul><ul><li>No surgery </li></ul></ul><ul><ul><li>Minimal recovery 48-72 hours </li></ul></ul><ul><ul><li>Lower short term cost </li></ul></ul><ul><li>Dermis is the #1 place of injection </li></ul><ul><ul><li>Fibroblasts that produce type 1 collagen are most abundant in this region </li></ul></ul>
  55. 55. Types of Fillers <ul><li>Xenografts </li></ul><ul><li>Homografts </li></ul><ul><li>Autografts </li></ul><ul><li>Synthetics </li></ul>
  56. 56. Xenografts <ul><li>Bovine Collagen </li></ul><ul><li>Most widely used and is the “Gold Standard” </li></ul><ul><li>All are dissolved in saline and lidocaine and Pepsin proteolysis to decrease antigenicity </li></ul><ul><ul><li>Zyderm I (35mg/mL) </li></ul></ul><ul><ul><ul><li>Injected into upper dermis </li></ul></ul></ul><ul><ul><ul><li>Poor long term effect because of low concentration </li></ul></ul></ul><ul><ul><ul><li>Overcorrection necessary 100% (26) </li></ul></ul></ul><ul><ul><li>Zyderm II (65mg/mL) </li></ul></ul><ul><ul><ul><li>Injected into mid dermis </li></ul></ul></ul><ul><ul><ul><li>Longer effect with higher concentration </li></ul></ul></ul><ul><ul><ul><li>Overcorrection necessary 50% (26) </li></ul></ul></ul><ul><ul><li>Zyplast (35mg/mL) </li></ul></ul><ul><ul><ul><li>Cross linked with glutaraldehyde to decrease degredation </li></ul></ul></ul><ul><ul><ul><li>Injected into reticular dermis for longer duration/less resorption </li></ul></ul></ul><ul><ul><ul><li>No overcorrection recommended </li></ul></ul></ul>
  57. 57. Bovine Collagen Complications <ul><li>Hypersensitivity reaction </li></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Induration </li></ul></ul><ul><ul><li>Erythema </li></ul></ul><ul><ul><li>Pruritis </li></ul></ul><ul><li>Skin testing before definitive use </li></ul><ul><ul><li>3-4% with positive skin test (27,28) </li></ul></ul><ul><li>20 to 30% may show delayed reaction </li></ul><ul><ul><li>Must examine skin test site in 4 to 6 weeks prior to initiating therapy </li></ul></ul><ul><li>Some argue that second skin test necessary as reactions can occur with repeated injections </li></ul><ul><li>Other complications </li></ul><ul><ul><li>Tissue necrosis (29) </li></ul></ul><ul><ul><li>Foreign body reaction </li></ul></ul><ul><ul><li>Headache/Nausea/Arthralgias (30) </li></ul></ul>
  58. 58. Homografts <ul><li>Cosmoderm and Cosmoplast </li></ul><ul><ul><li>Bioengineered collagen from fibroblasts </li></ul></ul><ul><ul><ul><li>No antigenicity so no skin testing required </li></ul></ul></ul><ul><ul><li>Packaged and concentrated analogously to Zyderm I and Zyplast respectively </li></ul></ul><ul><ul><ul><li>Cosmoderm for superficial wrinkles </li></ul></ul></ul><ul><ul><ul><li>Cosmoplast for deeper scars and grooves </li></ul></ul></ul><ul><ul><li>On average they last 3-6 months but duration is less than bovine equivalents (26) </li></ul></ul>
  59. 59. Homografts <ul><li>Alloderm (Cymetra = injectable form) </li></ul><ul><ul><li>Acellular dermal graft from cadaveric skin </li></ul></ul><ul><ul><li>Freeze drying process removes cells but leaves collagen IV, VII, proteoglycans and elastin </li></ul></ul><ul><ul><li>Requires reconstitution with lidocaine prior to injection </li></ul></ul><ul><ul><li>No skin testing required </li></ul></ul><ul><ul><li>Duration of 3 to 6 months (31) </li></ul></ul>
  60. 60. Xenografts <ul><li>Hyaluronic Acid </li></ul><ul><ul><li>A Glycosaminoglycans (GAG) </li></ul></ul><ul><ul><li>Can hold 1000x its weight in water leading to increased skin turgor </li></ul></ul><ul><ul><li>Overcorrection not required </li></ul></ul><ul><ul><li>Identical in all species leading to minimal immunogenicity </li></ul></ul><ul><ul><li><1% chance of hypersensitivity </li></ul></ul><ul><ul><li>Correction achieved for 6-9 months with HA (32) </li></ul></ul><ul><ul><li>Hylaform (500 micron, 5.5mg/mL) </li></ul></ul><ul><ul><ul><li>Purified from rooster combs </li></ul></ul></ul><ul><ul><ul><li>Few reports of local or systemic reactions from avian protein </li></ul></ul></ul><ul><ul><ul><li>Shortened lifespan due to lower concentration (33) </li></ul></ul></ul><ul><ul><li>Restylane (400 micron, 20mg/mL) </li></ul></ul><ul><ul><ul><li>Bacterial cultures of Equine steptococci </li></ul></ul></ul><ul><ul><ul><li>Cross linked with epoxides </li></ul></ul></ul><ul><ul><ul><li>Also has “Fine Lines” and “Perlane” formulations with diffent particle sizes </li></ul></ul></ul><ul><li>Isovolumetric contraction where matrix does not disperse water until all hyaluronic acid particles are degraded leading to prolonged effects (34) </li></ul>
  61. 61. HA Pitfalls <ul><li>Must inject intradermally </li></ul><ul><ul><li>Injection too deep </li></ul></ul><ul><ul><ul><li>Decreased duration of action </li></ul></ul></ul><ul><ul><li>Injection too superficial </li></ul></ul><ul><ul><ul><li>Unappealing bumps </li></ul></ul></ul><ul><li>**Undesirable injections can be corrected with hyaluronidase injection. </li></ul>
  62. 62. Autografts <ul><li>Fat </li></ul><ul><ul><li>Very abundant </li></ul></ul><ul><ul><li>No antigenic potential </li></ul></ul><ul><ul><li>Requires additional procedure for harvesting </li></ul></ul><ul><ul><ul><li>Liposuction </li></ul></ul></ul><ul><ul><li>Questions regarding how much is reabsorbed </li></ul></ul><ul><ul><li>Adynamic melolabial folds have prolonged duration of action compared to dynamic glabella (26) </li></ul></ul>
  63. 63. Autografts <ul><li>Isolagen (Fibroblasts) </li></ul><ul><ul><li>Postauricular punch biopsy of patients skin </li></ul></ul><ul><ul><li>Cultured in vitro with growth factors for 4-6 weeks </li></ul></ul><ul><ul><li>Overnight delivery for injection the following day </li></ul></ul><ul><ul><li>Several Treatments required for desired outcome </li></ul></ul><ul><ul><li>Cost and time considerations make it impractial </li></ul></ul><ul><ul><li>6 month histologic evaluation showed integration of fibroblasts but is on hold by FDA due to growth factors and further studies (35) </li></ul></ul>
  64. 64. Synthetic Material <ul><li>Silicone </li></ul><ul><ul><li>Been used for over 50 years </li></ul></ul><ul><ul><li>Requires multiple microdroplet injections over 4 weeks </li></ul></ul><ul><ul><li>Injections performed into deep dermis 1 to 3mm apart </li></ul></ul><ul><ul><li>No overcorrection because innate reaction to the product was part of the process </li></ul></ul><ul><ul><li>Webster studied 235 pts over 2800 injections (36) </li></ul></ul><ul><ul><ul><li>Good results and few complications </li></ul></ul></ul><ul><ul><li>Others have shown extensive reactions (37-39) </li></ul></ul><ul><ul><ul><li>Chronic inflammation </li></ul></ul></ul><ul><ul><ul><li>Migration </li></ul></ul></ul><ul><ul><ul><li>Extrusion ulceration </li></ul></ul></ul><ul><ul><ul><li>Skin necrosis </li></ul></ul></ul><ul><ul><ul><li>Granulomatous hepatitis </li></ul></ul></ul><ul><ul><ul><li>Pulmonary emboli </li></ul></ul></ul><ul><ul><ul><li>Silicosis (pneumonitis) </li></ul></ul></ul><ul><li>FDA declared it illegal in 1991 but recent use for retinal detachment is bringing off label use back </li></ul><ul><li>American Academy of Dermatology (1993) (7) </li></ul><ul><li>“ 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.” </li></ul>
  65. 65. Synthetic Material <ul><li>ArteFill </li></ul><ul><ul><li>Combined 20% polymethylmethacrylate and 80% bovine collagen </li></ul></ul><ul><ul><li>Skin testing required </li></ul></ul><ul><ul><li>As collagen is degraded (4 months) the PMMA is encapsulated to maintain augmentation </li></ul></ul><ul><ul><li>Injected into the subdermis to prevent persistent painful nodule </li></ul></ul><ul><ul><li>Individual results are unpredictable so multiple injections are required over 3-4 months with 50 to 75% permanent correction (25) </li></ul></ul><ul><ul><li>Overcorrection not recommended because each result is different </li></ul></ul><ul><li>Lemperle (Bailey 37 ) showed good results with minimal complications </li></ul><ul><li>Others report granulomatous reactions and scarring (Bailey 38 ). </li></ul><ul><li>Not approved in US but Europe has shown long term correction of >10 years (7) </li></ul>
  66. 66. Synthetic Material <ul><li>Radiesse (25 to 45 micron size) </li></ul><ul><ul><li>35% synthetic hydroxyapatite particles in water, glycerin, and sodium carboxymethylcellulose </li></ul></ul><ul><ul><li>Injeted into deep dermis or subdermally due to viscosity </li></ul></ul><ul><ul><li>Massage is necessary to contour product </li></ul></ul><ul><ul><li>Produces augmentation in 2 ways </li></ul></ul><ul><ul><ul><li>Collagen ingrowth by fibroblasts </li></ul></ul></ul><ul><ul><ul><li>Encapsulation of crystals by fibroblasts to prevent degredation </li></ul></ul></ul><ul><ul><li>Radiographic evidence of implant for up to 6 years (40) </li></ul></ul><ul><ul><li>Pitfalls </li></ul></ul><ul><ul><ul><li>Injection into lips can produce painful nodules </li></ul></ul></ul><ul><ul><ul><li>Palpable implant for 2 to3 months until the product is replaced by collagen </li></ul></ul></ul><ul><ul><li>Tzikas studied 90 patients and found 88% patient satisfaction at 6 months (41) </li></ul></ul>
  67. 67. Post-therapy Findings <ul><li>Post-injection pain </li></ul><ul><li>Redness </li></ul><ul><li>Ecchymosis </li></ul><ul><li>Swelling </li></ul><ul><li>Nodularity </li></ul><ul><li>Palpability </li></ul><ul><li>**Should be transient and resolve over 1-2 days </li></ul>
  68. 68. Complications: 0-2 days <ul><li>Overcorrection </li></ul><ul><ul><li>Know the properties of the injectable filler and whether to overcorrect or not </li></ul></ul><ul><li>Implant visibility </li></ul><ul><ul><li>HA can produce bluish nodule </li></ul></ul><ul><ul><li>Other fillers cause white nodule </li></ul></ul><ul><ul><ul><li>Massage can help </li></ul></ul></ul><ul><ul><ul><li>Hyaluronidase or mechanical deroofing of nodule </li></ul></ul></ul><ul><li>Vascular compromise </li></ul><ul><ul><li>Arterial: Immediate skin blanching with necrosis (glabella) </li></ul></ul><ul><ul><ul><li>Aspiration, massage, warm compress, 2% nitropaste </li></ul></ul></ul><ul><ul><ul><li>+/- hyperbaric oxygen for impending necrosis </li></ul></ul></ul><ul><ul><li>Venous: violaceous discoloration with dull ache </li></ul></ul><ul><ul><ul><li>Nitropaste and warm compresses </li></ul></ul></ul><ul><li>**Skin breakdown treated with Abx and gentle debridment </li></ul>
  69. 69. Venous Injury
  70. 70. Complications: 3-14 days <ul><li>Noninflammatory Nodules </li></ul><ul><ul><li>Observation, gentle massage, reassurance </li></ul></ul><ul><li>Early Inflammatory Nodules </li></ul><ul><ul><li>Treat with antibiotics for 4-6 weeks </li></ul></ul><ul><ul><ul><li>Macrolide and Tetracycline </li></ul></ul></ul><ul><ul><li>I&D plus culture if fluctuance is observed </li></ul></ul><ul><ul><li>Close f/u visit at 48 hours </li></ul></ul><ul><ul><ul><li>If no response to therapy get tissue culture </li></ul></ul></ul>
  71. 71. Tissue Infection Immediate Day 2
  72. 72. Complications: >14 days <ul><li>Hypersensitivity </li></ul><ul><ul><li>Bovine collagen 3-4% + skin test </li></ul></ul><ul><ul><li>HA <1% </li></ul></ul><ul><li>Nodules </li></ul><ul><ul><li>Saline injection and vigorous massage </li></ul></ul><ul><li>Inflammatory nodules </li></ul><ul><ul><li>Evaluate for infection and treat as necessary </li></ul></ul><ul><ul><li>No infection but no response at 7-10 days  add intralesional steroid injection to avoid resistant granuloma </li></ul></ul><ul><ul><li>Still no response  biopsy and culture </li></ul></ul><ul><li>True Granulomas (0.01-1%) </li></ul><ul><ul><li>Massage and Intralesional steroids </li></ul></ul>
  73. 73. Summary <ul><li>There are a variety of treatment options available </li></ul><ul><li>Proper knowledge of the product or procedure is necessary to avoid complications </li></ul><ul><li>Patient expectations, informed consent, and proper patient selection is paramount </li></ul>
  74. 74. References <ul><li>S. Friedman and J. Lippitz, Chemical Peels, Dermabrasion, and Laser Therapy. Dis Mon 55(4);2009: 223-235 </li></ul><ul><li>J.M. Stuzin, Phenol peeling and the history of phenol peeling, Clin Plast Surg 25 (1998), p. 1 </li></ul><ul><li>F. Blanco-Davila, Beauty and the body: the origins of cosmetics, J Am Soc Plast Reconstruct Surg 105 (3) (2000), pp. 1196–1204 </li></ul><ul><li>J. Golan and N. Hai, JetPeel: a new technology for facial rejuvenation, Ann Plast Surg 54 (4) (2005), pp. 369–374 </li></ul><ul><li>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 </li></ul><ul><li>S. Brooke and J. Griffiths, Interventions for photodamaged skin, Cochrane Database Syst Rev 1 (2005) CD001782 </li></ul><ul><li>Athre RS. Facial filler agents. Operative Techniques in Otolaryngology 2007; 18: 243-247. </li></ul><ul><li>G. Monheit, Chemical peels, Skin Ther Lett 9 (2) (2004), pp. 6–11 </li></ul><ul><li>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 </li></ul><ul><li>Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: An Evidence-Based Review. Plast Reconstr Surg. 2010 125(1):372-377 </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>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 </li></ul><ul><li>J. Kitzmiller, M. Visscher and D. Page et al. , A controlled evaluation of dermabrasion versus CO2 laser resurfacing for the treatment of perioral wrinkles, Plast Reconstruct Surg 106 (6) (2000), pp. 1366–1372 </li></ul><ul><li>K. Holmkvist and G. Rogers, A comparison of dermabrasion and superpulsed carbon dioxide laser, Arch Dermatol 136 (2000), pp. 725–731 </li></ul><ul><li>S. Gilbert, Improving the outcome of facial resurfacing—prevention of herpes simplex virus type 1 reactivation, J Antimicrob Chemother 47 (2001), pp. 29–34 </li></ul><ul><li>Hinman CD, Maibach H. Effects of air exposure and occlusion on skin wounds. Nature 1963;200:377 </li></ul><ul><li>Farrior RT. Dermabrasion in facial surgery. Laryngoscope 1985;95:534 </li></ul><ul><li>Stegman SS. Avoid dermabrasion soon after Accutane therapy. Schoch Lett 1984;34:44 </li></ul>
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