A Blog about Minimally Invasive Cosmetic Procedures and Aesthetic Ancillaries.
The idea of a “skin peel” is not only visually, but also verbally appealing in that it could simply “peel” away all the years of sun worshipping that are apparent on our photodamaged skin.
And actually, there is a lot of science associated with the peel. Here are the important issues to think of when you are considering a skin peel.
1. Chemical Peels
With a chemical peel, acids are utilized to denature the protein in the skin which essentially “wounds” the upper layers of the skin. If the papillary or upper dermis of the skin is wounded, then it is considered a medium depth peel. If the deeper, reticular layer of the dermis is wounded, then it is considered a deep peel.
The acids utilized help to exfoliate the upper layers of skin.
The most common acids that you will find in chemical peels are:
a. Alpha Hydroxy Acids: these penetrate the outermost layer of the skin
b. Trichloroacetic Acid (TCA): typically used in concentrations of 30-50%
c. Phenol: This is utilized for a deep peel.
You can classify the peels as either light, medium or deep peels.
1. Light to Medium Peels
These peels are typically performed by first cleansing the skin with a surfactant which removes skin oils and allows for greater penetration of the acid. Then acetone is usually utilized to further remove oil from the skin. Finally, Jessner’s solution is applied to again aid the penetration of the acid.
After the skin has been prepped and cleaned in this fashion, TCA is applied, usually at 35%. Whitening of the skin can occur in 30 seconds to 2 minutes.
If there is erythema and minimal whiteness, then it is a light peel. A medium depth peel will occur when the skin shows a white frosting with surrounding erythema and finally skin appearance with a deep peel will appear white with no erythema.
2. Deep Chemical Peel
These are typically 50% TCA or Baker Gordon phenol peels.
The Phenol peel was introduced in 1981 and became popular. But, present day, the popularity has waned.
In order to have this peel, IV sedation is necessary as well as cardiac monitoring. The goal is to increase the penetration of the phenol at the skin level, but not in the blood, because phenol can be toxic to the heart and lead to ectopic beats or life threatening cardiac issues.
A study published by Landau in 2007 reviewed 181 patients receiving phenol peels and out of these patients, 6.6% suffered cardiac arrhythmia from the full face peel.
Another reason why deep phenol peels are falling out of favor, is the advent of laser technology which can go deep, but in a more controlled fashion. Fractional CO2 laser is more popular in this day and age compared to deep phenol peels.
Until next time…
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43141
Technorati Tags: AHA peel, chemical peel, Fractional CO2, Jessner's solution, phenol peel, skin peel, TCA peel
The gold standard for treating photodamaged skin, photoinduced facial rhytids, precancerous lesions, dyschromias and atrophic scars has been the carbon dioxide laser. This laser basically vaporizes or ablates the top layer of the skin (epithelium), down to the middle aspect of the dermis.
There is some initial tissue tightening which occurs from the removal of tissue and heat effects, but the predominant tightening and results will start to be appreciated at about 6-8 weeks after the laser treatment.
Last decade, we had standard CO2 resurfacing. This do a great job, but there was a significant “downtime” associated with the laser which could be from 4-6 weeks up to 3 months! Who has the time to heal from this?
Not to mention, the side effect profile was a lot greater with standard ablation. Issues such as infection and pigmentary alterations were too common to embrace this laser.
So for awhile, it was either standard ablation or no laser at all.
Then an exciting thing happened in the aesthetic arena. Fractional technology was created. This meant that pulses of CO2 laser were delivered almost like a pin cushion where small areas were treated and equally small zones that were left untouched etc. Although the results looked like confluent treatment, the small skip areas allowed for much quicker healing while still maintaining nice results.
I have received several comments on the blog and from patients, if I could post photos of what a patient would look like each day following a procedure.
After each photo, I will add comments, so you know what is expected for patient care at each stage of the healing process. I hope this clarifies questions.
What is important to know is that while fractional CO2 has a much decreased “downtime” compared to standard CO2, there is still a “downtime”. This downtime is typically about 4 days and usually by the end of the 4rth day or the beginning of day #5, sunscreen and make-up can be worn again.
This is what the face looks like immediately post fractional CO2 laser. This was done with the Performa Laser (Cynosure, Westford, MA), with good depth of penetration. So what you see is some pinpoint bleeding and the gray, stippled fractional photothermolysis appearance.
Initially after the treatment, we recommend cool compresses and I have the patient take a pan and place ice in it. Then I have them add water that has been mixed with vinegar (1 cap of vinegar per cup of water) and have them place two small towels in the pan and rotate the cold cloths to their face. The more patients can do this the first day, the less the swelling.
Also, patient should not excercise on the first day and their face should constantly have a sheen of Aquaphor. So typically patients will place a thin layer of aquaphor every 2 hours or four times per day on the skin. There will be heat that the patient will feel for about 2 hours post procedure and then there is no more discomfort.
To the right is day number 1 and 2 after the laser. You can
see that the face is swollen (edema is usually prominant around the eyes). There is a fine layer of aquaphor on the face.
Day 3 and 4 (below) show the skin getting a touch darkeer. Itching can be experienced on day 2-3 as the skin is almost ready to peel. There will be underlying erythema (redness) when the skin begins to peel on day 3 or 4. Now sunscreen and make-up can be worn. 
Baseline and Day number 7.
Here you can see the difference between baseline and day 7. But know that there is still a little bit of swelling so this actually makes the face look as if collagen is already stimulated. But it is important to remember that you will look fantastic at day 7-10 and then the swelling will totally be gone, and you will think your wrinkles are returning! But by 6-8 weeks the skin again begins to go through a process where collagen can now be appreciated clinically and you will start to notice the tightening.
Here is a photo comparing baseline to 10 weeks.
Baseline and 10 weeks post laser.
Now you can appreciate the tightening. Again, it is important to remember that all the wrinkles will not be gone (wrinkles around the mouth are stubborn), but the laser will help to minimize the wrinkling.
Hope that helps.
Until next time…..
GHTime Code(s): 62a9b
43141
Technorati Tags: 1 week after fractional CO2, aquaphor, day, day four, day one, day three, day two, each day, face, fractional CO2 laser, healing, patient, Performa laser, photos, skin, swelling, vinegar, wrinkles
Our ability to address volume depletion has improved significantly since the launch of FDA approved fillers several years ago.
Restylane (Medicis) was one of the first hyaluronic fillers to be FDA approved in the US followed by Juvederm (Allergan) and now several others on the market. The ease of use of fillers has made it a widely acceptable, very minimally invasive procedure in restoring youthfulness.
However, complications can occur. The common issues of bruising and minimal swelling and erythema will be there. Bruising is the most significant around the ocular area as well as around the mouth. Patients can also have issues of overfill, again the culprit area is typically under the eyes. Even a small amount of filler here can in some patients, cause prolonged swelling. Or simply, there is just too much filler placed in a certain location.
If this occurs, what can be done?
We discussed hyaluronidase in a previous post. I have received a lot of questions regarding hyaluronidase, especially under the eyes, but in other areas as well, so I thought I would discuss it in greater detail.
What is Hyaluronidase?
Hyaluronidase is a naturally occurring substance that degrades hyaluronic acid (such as juvederm and restylane). There are 5 different commercially made hyaluronidases:
1. Amphodase (Amphastar Pharmaceuticals, Rancho Cucamonga, CA)
2. Hydase (Prima Pharm, San Diego, CA and distributed by Akorn, Lake Forest, IL), has not been available since 2009.
3. Vitrase (ISTA Pharmaceutical, Irvine, CA): This is the one we use.
4. Wydase (Wyeth-Ayerst, Madison, NJ), has not been available since 2001.
5. Hylenex (developed by Halozyme Theurapeutics, San Diego, CA and distributed by Baxter, Deerfield, IL)
Out of these 5, only 3 are available: Amphodase, Vitrase and Hylenex.
Amphodase is derived from testicular bovine hyaluronidase and does have mercury derivative thimerosol as the preservative.
Vitrase is made from purified ovine (sheep) testicular hyaluronidase and is preservative free. This is the one we utilize at our office.
Hylenex is made from purified recombinant human DNA and is the most expensive out of all three hyaluronidases. This one is rarely used.
Hyaluronidase is FDA approved to be used as an adjunct to increase the absorption and dispersion of other drugs. So for example, in ophthalmology, it is used with a retrobulbar block to help increase the dispersion of the injected drug.
It is used off label to help decrease excess hyaluronic acid fillers or the Tyndall effect which can occur if HA fillers are injected too superficially.
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43141
Technorati Tags: Amphodase, filler, hyaluronic acid filler, hyaluronidase, Hylenex, Juvederm, Restylane, Tyndall effect, Vitrase
Lipomas are the most common soft-tissue tumor, occurring in 1% of the population. They are benign fatty tumors which form soft masses that can be felt under the skin. .
Lipomas in the subcutaneous location are typically asymptomatic but may be removed for cosmetic purposes.
There is no rhyme or reason why the occur, but there has been speculation regarding a link between trauma and subsequent lipoma formation. One theory suggests that fat may herniate after trauma through tissue planes to create a “pseudolipoma.” Another thought is that trauma releases cytokines which may trigger various chemical factors which allows for fatty cells to differentiate and mature.
But many patients have the presence of multiple lipomas with no antecedent trauma history.
When lipomas appear in areas that are cosmetically unacceptable, patients often desire excision. Depending on the location, the excision itself may leave a visually unacceptable scars.
Liposuction has been documented as a treatment option for lipomas, however, complete removal may still not be possible with aspiration alone.
With the advent of laser lipolysis, SmartLipo has emerged as a treatment option. Pretreating the lipoma with laser lipolysis prior to extraction minimizes complications such as post-operative scarring from excision site, hematoma formation and dimpling seen with liposuction alone.
Mild bruising can occur after extraction of the lipoma, primarily from the digital massage. The addition of the Nd:Yag laser in the multiplex setting of laser lipolysis helps with coagulation thus minimizing bruising. The 1320 nm wavelength helps with emulsification therefore assisting the ease of extraction of the lipomatous material.
This also allows for quick healing and no obvious scarring.
If lipomas are very little, then simple excision may be the quickest option. However, for the medium sized or larger lipomas, know that there are options out there which won’t leave you worse off then your starting point.
Here is a patient that was bothered by his lipomas on his arms. They were mid sized lipomas that gave his arm silhouette a cosmetically notable area. He had some lipomas removed from the trunk of his body by excision, but because of the scarring, he was reluctant to have them excised.
He came to us for consultation on options for lipoma removal with minimal scarring.
We tumesced the lipomas and then did SmartLipo MPX to the lipoma. Finally, the lipomatous material was expressed out with pressure.
Here are photos of his arm before and 5 days after SmartLipo with expression of the fat.
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Technorati Tags: excision, laser, laser lipolysis, lipoma, minimally invasive, option, scarring, SmartLipo
Solar Lentigo
Solar lentigenes are often referred to as “liver spots” and tend to occur primarily on the hands and the face. They are flat areas of pigmentation which occur secondary to prolonged sun exposure on certain skin types. These areas of pigmentation are benign but it is important to distinguish them from pre cancerous lesions.
Pigmentation on the hands and face can be cosmetically unappealing. So what can be done for these liver spots?
1. Topical cream with hydroquinone 4% (bleaching cream) and tretinoin (which is generic retin A). There are several great prescription products, namely Triluma which contains hydroquinone, tretinoin and a mild steroid. The only negative is that it is quite costly.
You can use hydroquinone (generic) and tretinoin and mix them together and utilize on the face or hands at night.
2. Chemical peels
There are many different types of chemical peels and based on the skin type, you may not be able to get overly aggressive. Trichloroacetic acid works quite well on solar lengtigenes, however, make sure you go to someone who does a lot of them.
3. Broad Band Light Source
My practice is in the southeast, so many patients consult us regarding their areas of pigmentation. IPL (Intense pulsed light) is one of the most popular treatments that patients have done. Basically the broad band of light targets several chromophores (targets) from the photodamage. It targets melanin, therefore these “liver spots” can be treated and it targets hemoglobin, so small vessels and skin ruddiness can be treated. My IPL of choice is the Lum One (Lumenis) Depending on the severity of the pigmentation, it may take several treatments (typically about 3).
4. Lasers
There are several lasers which can be utilized.
If the area of pigmentation is discrete, an Alexandrite laser can be used with a small spot size and short pulse duration.
Also Q switched Alexandrite laser (Accolade, Cynosure) Q switched Nd:YAG (Affinity, Cynosure) work brilliantly for discrete areas of pigmentation.
If pigmentation is not superficial, but tends to be deeper, then the Q switched Yag or fractional CO2 laser (SmartSkin, Cynosure) can be employed.
But with all that said, make sure you wear sunblock to protect yourself from sun exposure while undergoing the treatments (and afterwards, to maintain the cleared skin).
Until next time….
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Technorati Tags: Accolade Laser, Affinity Laser, Cynosure, fractional CO2 laser, IPL, liver spots, Lumenis One, pigmentation, q-switched laser, SmartSkin, solar lentigo, triluma
More options are present today for minimizing photodamage to the skin which occurs after long term sun exposure. Although caucasian skin has a tendency to show more photodamage, ethnic skin too can exhibit changes in vascularity, pigmentation, dyschromia and elastin and collagen changes from years of sun exposure.
In the recent several years, laser technology has advanced where lasers now have the capability of treating ethnic skin while protecting the epidermis from injury during the treatment.
Why is this important?
Ethnic skin represents the majority of the world’s population. This includes East Asians (Chinese, Japanese, Koreans), SouthEast Asians (Indonesians, Malaysians, Singaporeans, Thais, Cambodians, Vietnamese) and South Asians from Bagladesh, India, Pakistan and Sri Lanka.
Standard CO2 laser was not an option for ethnic skin because the risk of pigmentary complications. With the advent of fractional CO2 laser, darker skin types may be treated at lower settings, however, when skin is darker then Fitzpatrick skin type V, fractional CO2 or ablative lasers are not recommended.
What laser would be recommended for ethnic skin tightening?
Fractional nonablative lasers have provided a nice alternative to darker skin types. The objective of the laser is to improve aesthetic concerns of photoaged skin including the appearance of pigmentation, static fine wrinkles, course texture and prominant pores along with recontouring of mild surface irregularities via dermal collagen remodeling.
What are the different nonablative fractional lasers available?
There are several different fractional nonablative lasers on the market today. The lasers use light in the mid infrared spectrum for deep heating of the tissue. Microscopic areas of thermal injury are created on the skin, without ablation, meaning that the epidermis is intact. Because melanin is not a target, patients with darker skin types can be treated.
What to expect during and post treatment?
The laser that we employ in our clinic is an Affirm laser (Cynosure, Westford, MA). This laser has two different wavelengths (1320 nm and 1440 nm) which can be used in a multiplex fashion for additional heating of the skin.
Sometimes, I will numb a patient for 10 to 20 minutes with topical EMLA, but the majority of patients will not need numbing. There is cold air which circulates over the skin as the laser is being performed, adding to patient comfort and protecting the epidermis even further.
After the treatment, the face will be erythematous (red) for about 24-36 hours. The redness has the circular configuration reflecting the circular laser tip. Make-up can be applied, because the epidermis is intact (unlike fractional CO2 laser where the skin surface has been ablated).
We typically do treatments every 4 weeks and patients will need 3-6 treatments depending on the baseline evaluation of their skin. After hours, this is the laser that I use on my skin.
Until next time….
GHTime Code(s): nc
Technorati Tags: Affirm laser, collagen, Cynosure, ethnic skin, fractional nonablative, skin tightening
Homeopathic arnica montana has been used for its anti-ecchymotic (anti bruising) properties. But what is it and does it really help?
Arnica montana is also known as “leopards bane” and is a perennial which is indiginous to central Europe and England. It has been used in many different formulations over the years for such ailments as anxiety and motion sickness.
Its claim to fame in the past decade has been through its purported anti ecchymotic effect (anti bruising effect). It has been used during the perioperative period in aesthetic surgery and in cases of trauma to minimize bruising.
The homeopathic formulation, SinEcch (Alpine Pharmaceuticals, San Rafeal, CA) has been endorsed by surgeons before elective surgery.
It is also commonly recommended for patients who have a tendency to bruise with injectables such as restylane, juvederm, radiesse, etc.
But does it work, is it worth the extra expense?
A study done by Dr. Seely published in the Archives of Facial Plastic Surgery looked at the effects of homeopathic arnica montana on bruising after face lifts.
A total of 26 patients were evaluated. 12 patients were a control, while 14 patients received arnica on the day of the surgery followed by 4 days after the surgery dosed at three times per day.
What was found was that at each data point, the arnica montana group did show less bruising, especially on days 1 and 7 post procedure which were statistically significant. By day 10, bruising in both groups resolved.
So the take home message would be: Yes, arnica may help minimize bruising seen in the first week post injection, but by day 10, there is not really much difference in bruising whether you take the arnica or not. So the choice is yours, if you have a tendency to bruise quite a bit, then this may be an option.
There are different formulations available:
Capsules taken by mouth or topical gels.
I will try to pull an article comparing the capsules to the gels to see if there is a difference in effect. Without a study to corroborate, my feeling is that the capsules may work better because they are started prior to the injection and are therefore within your system at the time of the injection to prevent the bruising.
Until next time….
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Technorati Tags: arnica gel, arnica montana, bruising, injection, leopards bane, SinEcch
With time the aging process becomes noted with facial aging, especially around the mouth area (perioral). The skin begins to loose collagen and elastin and the decreased laxity, along with the continued use of the muscles around the mouth, leads to wrinkles.
Over time, marionette lines can form. The marionette lines are the vertical lines right at the edge of the lips (the oral commissure) which gives the expression of a sad puppet. They occur for several reasons:
1. Muscle hyperactivity (the depressor angularis oris)
2. Volume loss in the area below the lip can accentuate these lines.
Certainly extrinsic factors like smoking and sun damage only add to the aging, so make sure to take your antioxidants, don’t smoke and wear your sunscreen.
How else do we target the marionette lines?
Since the depressor angularis oris muscle is what pulls the edge of the mouth downward, a little botox or dysport to this area will relax this muscle and will improve the downward vertical line. It will then allow for the unopposed muscles (zygomaticus) to work and allow for the elevation of the corners of the mouth. However, this is not enough if there is also volume loss to the area.
The way that I target this is with filler. I like the hyaluronic acid fillers because it is smooth and easy to place. I typically use either Restylane or Juvederm ultra if the area shows minimal volume loss, or Juvederm Ultra Plus or Perlane which is a bit thicker of a hyaluronic acid for more pronounced volume loss.
For some patients that need more structure to this area with more significant loss, I will use Radiesse. I have found that Radiesse has a tendency to bruise more than the HA fillers. Deep injection of Sculptra can also be used in this area to build up the area of volume loss throught the chin (mental) area.
The fillers will typically last from 6-10 months depending on which one was selected. Also it is important to make sure enough of the filler has been placed so that the volume deficit is corrected.
Here are some results:
GHTime Code(s): bff20
Technorati Tags: botox, depressor anguli oris, dysport, facial aging, hyaluronic acid, Juvederm, marionette lines, Perlane, Radiesse, Restylane, volume loss
Venous Lakes
Venous lakes are a benign collection of dilated vessels which look like a blue blood blister. They are compressible and typically solitary and are dark blue to violaceous in color.
They are typically found on sun exposed areas such as the ears, lips or neck area.
Although these lesions may resemble a nodular melanoma, the fact that they lighten with compression and are slow growing are important distinguishing details.
Cause:
The cause of a venous lake is unknown, however, as mentioned previously, the link to sun exposure seems to be present.
Treatment:
The important point is to know that these are not malignant, so treatment is based on cosmetic concerns. There are several methods of treatment that can be utilized for these lesions such as:
1. Surgical excision: this can leaving scarring to the area
2. Sclerotherapy to the lesion: consists of injection of sclerosing material
3. Electrocautery: this too can leave some scarring
4. Laser treatment: typically takes one treatment, but if large, may take two treatments.
Laser Treatment
This is the treatment that I employ because it is quite simplistic to rid the patient of this type of lesion. I use a combined pulsed dye laser with sequential emission of Nd:YAG (Cynergy laser, Cynosure, Westford, MA) and will numb the area with topical application of Hurricane gel for about 5-10 minutes.
I then use my 7 mm spot size handpiece and set my PDL to 7 joules/cm2 with 10 ms pulse duration with a short delay and typically set my Nd:YAG at 30 joules/cm2 with 15 ms duration.
The lesion will turn a darker blue with a slight whitening color. I have the patient use aquaphor if the surface of the area begins to peel, for about 3 days.
I typically will see the patient back at 4-6 weeks and 95% of the lesions are resolved. Rarely do venous lakes need a second treatment, but if they do, they are performed at the 6 week follow up appointment.
Here are some examples:
GHTime Code(s): nc nc
Technorati Tags: blood blister, Cynergy Laser, laser treatment, pulsed dye laser, venous lake
