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scar management.pdf
This document contains information about Islam Kassem, an oral and maxillofacial surgeon, including his educational background and credentials. It also lists other doctors in the maxillofacial department and discloses no conflicts of interest. The rest of the document discusses topics related to scar management, including different types of skin, ideal patients for peels, goals of conditioning skin, and depths of peels.
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scar management.pdf
- 1. Copy right 2021 Scarmanagement Copy Right 2022
- 2. • BDS AlexandriaDental 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 • IslamKassem • Mohamed Talat • Mohamed Mostafa • Basal Garwani • Ahmed Barbary • Hady hassan • Mohamed Gargaway • Amro Elshieck
- 4. • There isno 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
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- 6. Your face isyour signature
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- 13. !Dermatologists !Cosmetic dentistry !Skin carecenters !Anti –Aging specialist !Professional beauty centers WHICH MARKET SEGMENTS ?
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- 15. 15 Who is the mostbeautiful girl in the world ?
- 17. The Science ofBeauty 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.
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- 24. J of FacioplasticSurg 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
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- 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 epidermisand 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 tostart? 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 agedskin 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) •Watersoluble: 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 has2 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
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- 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: Bakerand 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: Controlledaccelerated 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
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- 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 realisticexpectations • 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 woodslamp to delineate indications of peeling
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- 49. • A detailedconsent 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 andlactation • 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 • Penetrateepidermis 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 Chemicalpeeling
- 56. • Patient restingcomfortably 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 TREATMENTZONES 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 erythemaindicates → 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 importantstep 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 •Mostdiscomfort 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 ofthe 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 systemicabsorption. 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 PEELPROCEDURE
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- 65. •Cleanse skin thoroughlywith 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 cleansewith 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 solutionstarting 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 tocontact 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 carefullyfor erythema •Spot neutralize with cotton bud dabbed with TDF post peel neutralizer •Upon neutralization burning sensation ↓ GLYCOLIC ACID PEEL PROCEDURE
- 70. • Neutralize withgenerous amount of TDF Post-peel neutralizer • Apply with cotton wool in circular motion and slight pressure GLYCOLIC ACID PEEL PROCEDURE
- 71. • Wipe excessneutralizer • Apply cold compresses for 30 seconds • If burning persists re-neutralize GLYCOLIC ACID PEEL PROCEDURE
- 72. GLYCOLIC ACID PEELPROCEDURE
- 73. • Initially use50% 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 willowbark, 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 acid14% • 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 → waitfor 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 theepidermis & 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 necrosisof 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 •Usea 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 Icepick 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 gourmetPeeler •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 ToAvoid 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.
- 85. •Scarring remains themost 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 facewith 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.
- 88. •Developed in Italyin 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 remoldingof 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 mmMicro-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