facial rejuvenation

1. NON SURGICAL FACIAL
REJUVENATION
Dr Gautam Kalra
Senior Resident
Dept Of Plastic & Reconstructive Surgery
AFMC, Pune

2. CONTENT
• Facial aesthetic unit
• Features of ageing face
• Fitzpatrick skin typing
• Patient directed treatments
• Physician directed treatments
• Chemical peels
• Dermabrasion & microdermabrasion
• Lasers in aesthetics
• Fillers
• Threads
• Micro needling
• Radiofrequency devices
• Platelet rich plasma

3. FACIAL AESTHETIC UNIT (FATTAHI)

4. Ageing changes
1. Forehead and glabella creases.
2. Ptosis of the lateral brow.
3. Redundant upper eyelid skin.
4. Hollowing of the upper orbit.
5. Lower eyelid laxity and wrinkles.
6. Lower eyelid bags.
7. Deepening of the nasojugal groove (Tear trough).
8. Ptosis of the malar tissues.
9. Generalized skin laxity.
10. Deepening of nasolabial folds.
11. Perioral wrinkles.
12. Downturn of oral commissures.
13. Deepening of labiomental crease
14. Jowls.
15. Loss of neck definition and excess fat in neck.
16. Platysmal bands

5. CUTANEOUS FEATURES OF INTRINSIC
AND EXTRINSIC AGEING
INTRINSIC AGEING EXTRINSIC AGEING
Thinning of dermis, stratum corneum
normal, loss of rete ridges
Epidermal hyperplasia
Dermal atrophy with reduction of
collagen and elastin
Thickening Of the dermis & abnormal
elastin fibers leading to coarse dry skin
Atrophy of subcutaneous fat Decrease in collagen fibres and increase
in ground substances  skin laxity and
wrinkles
Atrophy of hair follicles and loss of
melanocytes
Pigmentary changes like solar lentigenes
Decrease in linear nail growth
Decrease in number and function of
sweat glands

6. SKIN TYPE
S
U
N
E
X
P
O
S
U
R
E
Tanning
S
U
N
E
X
P
O
S
U
R
E
Burns
R
X
N
T
O
P
R
O
C
E
D
U
R
E
S
Sensitivity
risk of PIH

7. COMMON SKIN PROBLEMS

8. TREATMENT TECHNIQUES
Patient
directed
techniques
Physician
directed
techniques

9. PATIENT DIRECTED TECHNIQUES
• Sunscreens
• Moisturizers
• Topical retinoids
• Alpha hydroxy acids
• Topical antioxidants
ORGANIC (CHEMICALS) Inorganic
(physical)
UVA FILTERS UVB FILTERS BROAD SPECTRUM
FILTERS
Zinc Oxide
Benzophenones PABA –
padimate O
Ecamsule Titanium dioxide
Avobenzone Cinnamates Silatriazole Calamine
Ecamsule Salicylates Bimotrizinol Iron Oxide
Meradimate Ensulizone Bisoctrizole

10. PHYSICIAN DIRECTED TECHNIQUES
• Chemical peels
• Dermabrasion &
microdermabrasion
• Lasers in aesthetics
• Fillers
• Threads
• Micro needling
• Radiofrequency devices
• Platelet rich plasma

11. chemical peel
Accelerating Exfoliation by using irritant
chemicals
Classified - According to
the level of their injury
• Superficial
• Medium-depth
• Deep

12. SUPERFICIAL
VERY LIGHT
PEELS
Depth of
penetration-
limited to st.
corneum and
only creates
exfoliation
SUPERFICIAL
LIGHT PEEL
Depth of
penetration-
entire
epidermis
down to the
basal layer,
stimulating
regeneration
of fresh new
epithelium
MEDIUM
DEPTH PEELS
Depth of
penetration -
entire
epidermis
and papillary
dermis.
DEEP PEELS
Depth of
penetration-
papillary
dermis , into
the upper-
reticular
dermis and
may extend
to mid –
reticular
dermis
CLASSIFICATION OF PEELS

13. SUPERFICIAL VERY LIGHT PEELS
AHAs
10-15%
TCA
Tretinoin
Salicylic
acid
SUPERFICIAL LIGHT PEEL
1. 70% glycolic acid
J e s s n e r ’ s solution
(resorcinol + salicylic
acid + lactic acid +
ethanol)
2. 20-30% T C A
MEDIUM DEPTH PEELS
35% TCA
Jessner’s +
35% TCA
70% glycolic
acid + 35%
TCA
DEEP PEELS
TCA > 50%
Phenol
containing
preparation

14. AHAs
• Most commonly performed; being safe and non-toxic
naturally occurring compounds
• Glycolic acid is derived from sugar cane
• Lactic acid from sour milk
• Citric acid from citrus fruits
• Phytic acid from rice
• Depth of injury depends on : conc. of free acid, volume
applied, and duration of contact

15. Glycolic Acid
• Most popular & commonly used AHA
• Present in various conc. up to 70%
• Stable for more than two years
• Time of application is critical should be rinsed off with
5% sodium bicarbonate within 2-4 min.
• Can be used weekly for tt. of acne, mild
photoaging & melasma

16. AHAs
• Low conc. decrease the cohesion of
corneocytes at junction of st. corneum &
st. granulosum
• Higher conc. induce complete
epidermolysis
• Daily use of products containing AHA
results in increase
* skin thickness
* density of collagen
* improvement of elastic fiber quality
• Efficient For Treatment of Photoaging

17. BHA
• Salicylic acid (SA) is a BHA; used alone or in
Jessner's solution
• BHA has a stronger comedolytic effect than AHA
• Comedonal acne ; lipophylic & concentrates in
pilosebaceous unit and exfoliates the pores

18. Jessner’s Solution
• Combination of keratolytic ingredients (resorcinol
+ salicylic acid + lactic acid + ethanol)
• Inflammatory & comedonal acne (resorcinol)
• Rosacea (SA)
• Intense keratolytic activity induces loss of
corneocyte cohesion within the st. corneum
• Can be used with other peels because it does
not need neutralization

19. Trichloroacetic Acid Peels
• Different concentrations: 10-35%
• 10-15% TCA: intra epidermal superficial peel.
Improves fine wrinkles and dyschromias to give
smooth healthy appearance
• 30-35% TCA: papillary dermis, medium depth
peel.
Produce epidermal & dermal necrosis
• Be cautious with dark skin. (risk of PIH)

20. TC A
• Not light or heat-sensitive
• Stable for about 6 months
• No need for neutralization
• The clinical end point of tt. is frosting
• Frosting is due to denaturation of proteins
• Frosting appears within 7sec up to 20min
according to the conc. used
• Healing time within a week if used alone , 10
days if used in combination

21. FROSTING SEEN IN TCA PEEL

22. END POINT
• *Minimal erythema +shiny skin--- VL
superficial peel
• *Erythema + streaky frosting------ Superficial
peel
• *Erythema+ level I or II frosting----Medium-
depth peel

23. Phenol Deep Peel
Baker’s Formula
• Pure undiluted 88% phenol + croton oil + septisol
liquid soap + water

24. INDICATIONS
DEPTH OF PEEL INDICATION
VERY SUPERFICIAL Skin glow, Comedonal acne
SUPERFICIAL Dyschromasia, melasma, PIH, Dilated
pores, fine wrinkles, photoageing I
MEDIUM DEPTH Fine wrinkles and photoageing II
DEEP PEELS Deep wrinkles and skin laxity

25. Complications
• Irritant contact dermatitis
• Post inflammatory hyperpigmentation
• Infections
• Scarring

26. MICRODERMABRASION (MDA)
• Introduced by Marini and Lobrutto in 1985
• Types –
– Crystal MDA – mildly abrasive – Uses crystals (
Aluminium oxide)
– Diamond MDA – Used for deeper scars

27. MDA – Mechanism of action
• Gentle mechanical abrasion  Removal of
stratum corneum.
• Also has effect on deeper layers of epidermis and
dermis
– Causes rearrangement of melanosomes in basal layer
– Flattening of rete ridges at DEJ
– Increases collagen fiber density
– Increases transdermal delivery hence MDA
combined with superficial skin peels to enhance
delivery

28. MICRODERMABRASION

29. End point of treatment
• Pin point bleeding and effacement of rhytides

30. INDICATIONS
• Skin rejuvenation – improves skin tone and
texture
• Fine wrinkles
• Scars/acne scars
• Photoageing
• Striae
• Melasma
• Very effective in vertical peri-oral rhytides

31. CONTRAINDICATIONS
• Any bacterial or viral infections at the site
• Allergy to aluminium crystals (use different
crystal/diamond MDA)
• Relative contraindications
– Hypertrophic scars & keloids

32. Limitations of MDA
• Not useful for deep wrinkles, scars or PIH
• Use in melasma is controvertial
• Use with caution in Dark skin people (PIH)

33. Complications
• Swelling/tenderness/petechiae
• Bruising in sensitive skin
• Conjuntivitis
• Risk of autoinnoculation of viral cutaneous
lesions (molluscum contagiosum) and
reactivation of HSV
• Deep abrasions can cause PIH

34. LASERS IN FACIAL REJUVENATION
• Light Amplification by Stimulate Emissionof Radiation
• Characteristics: 1)Monochromaticity (samewave length)
2)Coherence- (in same phase - time
and space
3)Collimation-wavesremain parallel

35. MECHANISM OF
ACTION

36. Basic Principles
Laser Tissue Interactions
• Reflected, Scattered, Transmitted or
Absorbed.
• Chromophores- hemoglobin, melanin
tattoo pigment, water

37. Classification of Lasers
Ablative lasers- Carbondioxide laser.
- Er: YAG
Vascular lesion lasers- Yellow dye laser
Green dye laser
KTP laser, diode laser
Pigmented lesion lasers (target melanin)

38. Commonly used Lasers
Medium Laser Wavelength
(nm)
Target Chromophore
Solid Ruby 694 Melanin, tattoo pigment
Neodymium: YAG 1,064 Pigment
KTP 532 Oxyhemoglobin, Melanin
Erbium: YAG 2,940 Water
Diode 800 Melanin, Oxyhemoglobin
Alexandrite 755 Melanin, tattoo pigment
Liquid Yellow dye 595 Oxyhemoglobin
Green dye 510 Melanin

39. Common Lasers in Plastic Surgery
Medium Laser Wavelength
(nm)
Target Chromophore
Gas Argon 488, 514 Oxyhemoglobin, Melanin
Carbondioxide 10,600 Water

40. LASER OUTPUT
⚫ CONTINUOUS MODE- co2 LASER
⚫PULSED MODE- pulseduration in microsecond
⚫QUALITY SWITCHING- pulse duration in
nanoseconds with extremely high peak power

41. DEPTH OF PENETRATION

42. CO2 LASER - 10,600nm
• Infrared invisible LASER
• Target chromophore : water
• Penetration <1 mm
• USES: Focused Mode-skin tags, warts moles
Defocused Mode-skin resurfacing,acnescars,

43. Nd:YAG LASER -1064nm
⚫Infrared invisible LASER in which medium is Nd
in a crystal of YAG.
pigments
⚫Target chromophore:
⚫ Penetration -10-20mm
vessel- 3 mm
⚫USES: tattoo marks
pigmented skin lesions
vascular lesions

44. Er:YAG - 2940nm
⚫Infrared invisible laser
⚫Targetchromophore: water
⚫Tissue penetration less thanco2 laser
⚫USES: skin resurfacing

45. Laser Resurfacing
• Ablation of abnormalities in the epidermis and upper dermis
and stimulation of dermal collagen remodelling diminishing
the effects of photoaging on skin, using a laser.
• CO2 laser Er: YAG laser
• Ideal candidates: Fair skin of Fitzpatrick I- III
: Fine to moderate facial wrinkles

46. Laser Resurfacing
• Photoaging
 Loose and heavily wrinkled skin
 Rough sallow, inelastic
 Histology: elastotic clumping in upper dermis
: Thicker disorganised collagen
 Epidermal thickening with dermal thinning

47. Laser Resurfacing
Absolute contraindications
• Delayed wound healing
 Active/ recent use of isotretinoin
 History of burns/ SSGs
 History of radiation treatment
Relative contraindications
• Fitzpatrick IV-VI
• Active Herpes Simplex
• Sensitive skin

48. Laser Resurfacing- Tissue Interactions
• Water Heat
• Complete ablation of epidermis (90% water)
• Zone of vapourized/ ablated tissue & surrounding thermally damaged
tissue
• Remodelling in less thermally damaged tissue
– Dermal collagen shrinkage & shortening
– Dermal tightening
– Collagen Remodelling/ Elastin fibre proliferation
– Collagen deposition

49. DERMAL FILLERS
• Injectable preparations used for soft tissue
augmentation
• History:
– Dr Arnold Klein (1980) – for lip augmentation
(bovine collagen)
• Hyaluronic acid was approved in 2003
– Natural component of human skin
(glucosaminoglycan)

50. Hyaluronic acid
• HA molecule is identical across all species and
lacks protein component (no immunological
reaction)
• Chemically composed of repeating
disaccharide unit with cross linked hydroxyl
group that binds to water (creates volume,
1000x)

51. • FDA approved various types of HAs and
products like calcium hydroxyapatite, Poly L
lactic acid and polymethylmethacrylate for
dermal fillers.

52. CLASSIFICATION OF DERMAL FILLERS
Temporary (3–12 Months)
Replace collagen in the skin, which weakens with age
and loses its elasticity.
Collagen has three main sources—bovine, porcine
and human.
Bovine collagen (widely used) is very similar to the
human molecule (telopeptides removed)
Hyaluronic acid is the most commonly used Filler
material of this category.

53. SEMI-PERMANENT FILLERS
Semi-Permanent (1–5 Years)
Calcium hydroxyapatite (creates a stable
scaffold for soft tissues to grow)
Calcium hydroxyapatite may be injected into the
deep dermis (formation of non-scar-tissue
type of collagen that provides volume)

54. Permanent fillers
• Permanent (>5 Years) (Synthetic)
made of Polymethylmethacrylate (PMMA)
microspheres (Inert).

55. INDICATIONS
• Glabellar and Forehead
wrinkles
• Augmentation of
Nasolabial Fold
• Lip Augmentation
• Tear Trough Deformity
• Augmentation of cheek
volume

56. CONTRAINDICATIONS
• Scarring and collagen/connective tissue
disorders
• Infections—e.g.: Viral Herpes
• Pregnant or Lactating women

57. THREADS IN FACIAL REJUVANATION
• Minimally invasive cosmetic procedure,
utilises a biocompatible implant placed into
the deeper layers of face to predictably shift
and realign tissues in a predetermined
direction or vector.
• Introduced by Ruff (Durham) and sulamindze
(Moscow)

58. CLASSIFICATION
• Depending on the modality of their action
a. Redefinition of the facial contours—Barbed
threads
b. Induction of collagen production—Mono
PDO threads

59. • Permanent/Non-resorbable threads-
Polypropylene threads (Aptos threads,
Silhouette lift threads)
• Resorbable threads—Polydioxanone threads
(Alfa aqualift) and Poly-L Lactic acid
(silhouette soft threads)
• Can be anchored or free floating
• Barbed or non barbed

60. BARBED THREADS
• Unidirectional – eg contour thread
• Anchored to a fixed point (eg deep
temporal fascia)
• Bidirectional – eg aptos thread
• Stretch the skin because of their design
• Cogged – can be uni/bi/multi
• Lift towards the direction of entry
(tissues get entangled)

61. Mechanism of action
a. These barbs get entangled in the subcutaneous tissues and as the
thread is pulled backwards, the tissues get squeezed along the
barbs and stay there.
b. At Cellular level
Mechanical transduction happens when the threads
are placed in the tissues
Intracellular signals in the surrounding cells
(mechanical stresses)
metabolic responses results in cellular growth modulates
tissue morphology and architecture

62. INDICATIONS
• Skin Rejuvenation (plain PDS thread)
• Sagging skin (Barbed threads)
– Nasolabial folds
– Eye brow lift
– Upper and lower cheeks
– Neck and jaw lines
– Marionette lines

64. COMPLICATIONS
• Infection
• Hematoma
• Nerve damage
• Procedure related – asymmetry, dimpling,
puckering, palpable thread

65. MICRONEEDLING (PERCUTANEOUS
COLLAGEN INDUCTION)
• Orentreich & Orentriech
• Introduction of needles beneath a retracted
scar/wrinkle stimulates neocollagenesis
• It is a procedure involving superficial and
controlled puncturing using miniature needles

66. • Helps in collaged induction and dermal
remodeling without any damage to epidermis
• Also aids in transdermal delivery of
therapeutic drugs

67. MECHANISM OF ACTION
• Multiple microscopic wounds are made with
minimal superficial bleeding in dermis
Multiple
microscopic
wounds in
dermis
Sets up wound
healing cascade
+ release of
growth factors
Neovascularizati
on and neo
collagenesis by
migration of
fibroblasts

68. NEEDLE LENGTH AND DEPTH OF
PENETRATION

69. INDICATIONS
• Skin rejuvenation
• Acne scars/post
traumatic scars/burns
scars
• Alopecia
• Hyperhydrosis
• Stretch marks
CONTRAINDICATIONS
• Active acne
• Local bacterial and viral
infections
• dermatitis
• Psoriasis
• Keloids
• Bleeding disorders
• Post Chemo/radiation
(relative
contraindications)

70. Device
• Standard Derma roller (depth 0.5-1mm & 1.5
– 2mm)
• Home derma roller (0.5mm)
• Needle diameter is 0.1-0.25mm

71. End point
• Fine punctate bleeding at the site

72. Complications
• Transient edema, erythema, bruising
• Rare – folliculitis, tram track scars & PIH

73. RADIOFREQUENCY DEVICES
• Non ablative
• MECH OF ACTION
– electrothermal energy to generate heat in tissues by
rapid movement of charged particles
– At a critical temp. of 65-76º it leads to collagen
denaturation and tissue contraction

74. • Depth of penetration ∝ 1/frequency
• Amount of collagenesis ∝ amount of heat
generated but beyond 65º it plateaus
downtime and complications

75. • The dissipated heat leads to formation of
coagulated columns in dermis
• Cellular infiltration, neo collagenesis,
neovascularization and remodeling occurs
• In contrast to laser devices here the
temperature gradient is inverse hence RF has
minimal downtime

76. Mechanism of action of non-ablative
radiofrequency.

77. MICRONEEDLING RF
• Introduced by Hantash
• Advantage – delivers heat at a greater depth
than laser (> 3mm)

78. INDICATION
• Rhytides, acne scars, cellulite & stretch marks
CONTRAINDICATION
• Active infections at the site
• Pacemaker
• Keloidal tendency
• Anticoagulants
• Epilepsy

79. DEVICES
• NON INSULATED NEEDLE
– Larger coagulum zone
– More downtime
– More PIH
– Increased epidermal
injury
INSULATED NEEDLE
Delivers energy only at
tip

80. DEPTH OF NEEDLE USED
• 0.5-1mm – Pore reduction
• 1.2mm – wrinkles
• 2-3.5mm – acne scars and stretch marks
• END POINT OF PROCEDURE
– Minimal punctate bleeding

81. COMPLICATIONS
• Petechiae, bruising, flare up of acne
• PIH
• Superficial burns
• Rare – scarring and altered skin texture

82. PLATELET RICH PLASMA
• Autologous serum therapy  delivers high
concentration of platelet growth factors
• MECH OF ACTION
– ⍺-granules contain PDGF, VEGF, TGF-β, IGF
– Promote stem cell regeneration, soft tissue
remodeling, angiogenesis and cell proliferation
– Result – angiogenesis, neo-collagenesis and
adipogenesis
– Also improves fat survival

83. • PDGF (platelet-derived growth factor)
• TGF-β1 & β2 (transforming growth factor
• VEGF (vascular endothelial growth factor
• EGF (epidermal growth factor)
• HGF (hepatocyte growth factor)
• FGF (fibroblast growth factor)

84. INDICATION
• Superficial wrinkles – esp. periorbital and neck
rhytides
• Improves skin texture and tone
• Reduces healing time when combined with
other modalities and CO2 fraction laser.
CONTRAINDICATION
• Platelet dysfunction syndrome
• Chronic liver disease (debatable)
• Local systemic infections
• Anticoagulant use
• Relative C/I – corticosteroids/immunosuppression

85. Therapeutic PRP
• Concentration – 1 million per ml of platelet
concentration
• Method of preparation
• Around 30ml of blood
sample gives 3 to 5 ml
of PRP
• Activation by calcium
gluconate

86. • There are 4 major families:
• P-PRP - Pure Platelet-rich plasma without Leukocytes.
It has low-density fibrin network after activation.
liquid solutions or an activated gel form and can be injected.
P-PRP is commonly used aesthetic medicine.
• L-PRP - Leukocyte and PRP is a preparation with leukocytes in
it.
low-density fibrin network after activation.
liquid solutions or an activated gel form and can be
injected.
L-PRP is used in aesthetic medicine & trichology, etc.

87. • P-PRF - Pure Platelet-rich fibrin is a preparation without
leukocytes.
It has a high-density fibrin network and exists as a
strongly activated gel form.
It cannot be injected
commonly used in dentistry & maxillofacial surgery
today.
• L-PRF - Leukocyte and PRF is a preparation with
leukocytes.
It has a high density of fibrin network
strongly activated gel
It cannot be injected
used in implant dentistry, periodontal surgeries,
oral surgeries, treatment of skin wound ulcers.

88. USES
• PRP can be repeated at interval of 4-6 weeks
• Can be infected or can be used with micro
needling
• Reduces erythema, improves healing and
reduces downtime
COMPLICATIONS
• Bruising at the site
• Single case of skin necrosis at the site of
injection and blindness in one eye has been
reported

89. THANK YOU
• References
– Grabb and Smith's Plastic Surgery (7th Ed.)
– Plastic Surgery - Peter C. Neligan (Vol-2)
– Non-surgical Modalities of Facial Rejuvenation and
Aesthetics - Oral and Maxillofacial Surgery for the
Clinician