Office-based Cosmetic Procedures: Office-based Cosmetic Procedures Glen T. Porter, MD David C. Teller, MD University of Texas Medical Branch at Galveston Dept. of Otolaryngology January 2005


Office-based Cosmetic Procedures: Office-based Cosmetic Procedures Laser applications Intense pulsed light Chemical peels Dermabrasion Microdermabrasion Botox injection Injectable fillers Aesthetician-provided procedures


Laser—basics: Laser— basics Light Amplification by Stimulated Emission of Radiation Coherent photons in phase temporally/spatially Collimated tight beam, parallel paths Monochromatic one wavelength


Slide4: Monochromatic Coherent Collimated


Laser--basics: Laser--basics Fluency = energy per area J/cm2 Power density = energy rate J/second Frequency = wavelength nm Light can be: Reflected (bounces off) Scattered (random dispersal) Transmitted (passes through unchanged) Refracted (change in direction) Absorbed (maximal clinical benefit)


Laser – emission modes: Laser – emission modes Continuous Uninterrupted beam Relatively constant power Pulsed/Superpulsed (microsec) Higher energy/shorter duration pulses Q-switched (nanosec) Extremely high energy/short pulse duration


Laser – tissue interaction: Laser – tissue interaction Each tissue differs in absorption characteristics and relaxation time (time necessary to release 50% of energy) Pulse width

Laser spectrum: Laser spectrum


Laser spectrum: Laser spectrum Laser Wavelength (nm) Application Er:YAG 294 Skin resurfacing Argon 488/514 Vascular lesions KTP:YAG 532 Vascular lesions Copper vapor 578 Vascular lesions FLPPD 585 Vascular lesions Long pulse 595-600 Leg veins Ruby, Q-switched 694 Tattoo removal Long pulse 694 Hair removal Q-switched Alexandrite 755 Tattoo removal Nd:YAG 1064 Deep vascular Q-switched YAG 1064 Tattoo removal CO2 10600 Cut/coag/resurf


Intense Pulsed Light: Intense Pulsed Light Noncoherent Multiple wavelengths (500-1200nm) Different handles with different ranges used for vascular lesions and hair ablation Some reports indicate skin tightening effect Well tolerated as outpatient May require cooling


Slide11: Laser -- vascular lesions Telangiectasias: in order of preference/effectiveness Diode laser (variable-pulsed-width 532nm)-as effective as pulsed-dye without puerperal pulsed-dye laser (puerperal results) IPL Hemangiomas pulsed-dye laser (585nm wavelength) 2-10 treatments spaced 6-8 weeks apart Port-wine stains Pulsed-dye laser (585nm) 2-12 treatments spaced 6-8 weeks apart superficial lesions, red lesions, younger than 10, head and neck lesions respond better


Slide12: Laser – superficial pigmented lesions Superficial lesions (generally shorter-wave-length systems) Freckles: Q-switched 532nm Nd:YAG laser recur frequently Café-au-lait lesions: Q-switched Nd:YAG lasers difficult to treat, recur often Lentigos: Q-switched Nd:YAG lasers CO2, Erbium, KTP recurrence uncommon Peels, topicals


Laser – superficial pigmented lesions: Laser – superficial pigmented lesions Nevi: biopsy if suspicious Q-switched Nd:YAG 532, 694, 755nm lasers respond within 1-3 treatments Melasma: Q-switched Nd:YAG laser hormonal control bleaching agents sun avoidance tend to recur Rosacea: topicals (antibiotics, tretinoin) oral abx IPL KTP laser


Slide14: Laser -- deep pigmented lesions Deep lesions-deeper, therefore treated better with longer wavelength (goes deeper): can use ruby, alexandrite, and Nd:YAG blue nevi: 1064 nm Nd:YAG laser nevus of ota and ito: Q-switched 1064nm Nd:YAG laser multiple treatments recurrence is unusual


Laser -- hair removal: Laser -- hair removal Goal = ablation of hair unit Wavelengths between 600 and 1000 nm most effective Generally want spot size larger than the depth of the target being treated--5mm to 1 cm for hair Optimal situation is dark hair with light skin Thermal relaxation time is key: epidermis = 3- 10 ms, hair follicle = 80-100 ms. Use of pulse duration < 10 millisecond targets hair without skin. May need longer for darker skinned individuals.


Laser -- hair removal: Laser -- hair removal Ruby, alexandrite, diode, 1064nm YAG, IPL Ruby (Fitzpatrick skin types I-III) Diode 810nm can treat darker skinned patients (III-IV) 1064 nm YAG safest for skin types IV-VI. IPL appears equally as effective in skin types IV-VI IPL can be used in all skin types Different spectrum applicators


Laser -- hair removal: Laser -- hair removal Hair follicle must be present Good result = erythema/edema around follicle, burning of hair Bad result = blanching or “graying” of skin Facial hair-- usually requires 5-6 treatments (chin and upper lip) repeated at 4 week intervals Body hair--repeated at 6-8 week intervals 60-95% removal at 6 months. Regrowth usually finer and lighter Anagen Catagen Telogen


Soft tissue augmentation – injectable fillers: Soft tissue augmentation – injectable fillers 1899 Gersuny – paraffin Problems with nearly all injected fillers: Inflammatory response Foreign body reaction Allergy


Soft tissue augmentation – injected substances: Soft tissue augmentation – injected substances Synthetics Silicone – outlawed in 1991 Polymethylmethacrylate beads (Artecoll) Injected into subdermis for deeper rhytids Fibroblastic ingrowth/encapsulation Skin test required Permanent Xenografts Bovine collagen (Zyderm, Zyplast) Requires skin test Lasts 3-4 months Zyderm requires overinjection by 30-60% Hyaluronic acid derivatives Does not require skin test (identical across species) Cock’s comb (Hylaform) Microbial culture (Restylane, Perlane) Lasts 9-12 months


Soft tissue augmentation – injectable fillers: Soft tissue augmentation – injectable fillers Homografts Cadaveric dermal tissues (Dermalogen, Cymetra, Cosmoderm) Acellular (little cross-reactivity) Overcorrection required (20-30%) No skin testing required No studies on long-term effects Autografts Fat Inconsistent survival volume Fibroblasts (Isologen, Autologen) Requires skin harvest (up to 2cm2 for 1 ml injectable) Delay of 4-6 weeks for cell growth Expensive 75-100% volume at 5 years No skin test


Soft tissue augmentation – injectable fillers: Soft tissue augmentation – injectable fillers 30-gauge needle Most rhytids effaced by injection into mid-reticular dermis Deeper rhytids require subdermal or deep dermal injection. May require lysis of deep adhesions (defects which will flatten with tension usually do not have deep adhesions) 2 methods of injection: Serial injection (glabella) Threading (lips) Many product lines come in a variety of particle sizes. Smaller particles can be injected in more superficial planes. This can efface shallow rhytids or be used to fine-tune the effects of deeper injections.


Soft tissue augmentation – injectable fillers: Soft tissue augmentation – injectable fillers Restylane


Slide23: Perlane


Dermabrasion: Dermabrasion Time-honored method of skin resurfacing Abrasive brushes and friezes to mechanically remove superficial layers of the skin Results similar to laser/chemical peels Requires experience to perform well—felt to have increased incidence of scarring and hypopigmentation Still the best application for deep scarring, deep rhytids, acne-related pits/scars Requires sedation, assistant, protection from bodily fluids Learning points: Hand dermabrasion of thin-skinned areas Carry dermabrasion across vermillion border Rotation of brush/frieze should be toward nearby vital structures to avoid tearing of tissues


Dermabrasion -- results: Dermabrasion -- results


Microdermabrasion: Microdermabrasion Aluminum oxide crystals pumped at high speeds toward skin surface. Suction applied to remove crystals and debris. Less operator-dependant than dermabrasion Consistent depth of tissue loss (adjustable) Less blood exposure than dermabrasion Usually two passes to remove epidermis (pinpoint bleeding) Results not as dramatic, may need several treatments Erythema resolves after 24 hours Risks of hyper/hypopigmentation and scarring low Indicated for minor degrees of sun damage, wrinkling, acne scarring, blending of treatment boundaries Little outcome data available


Microdermabrasion -- results: Microdermabrasion -- results


Peels : Peels Chemical cutaneous injury to specific level Limitations of facial peeling: Cannot reduce pore size, eliminate telangiectasias, eliminate deep scars, efface deep wrinkles Can improve appearance of sun-damaged skin, flatten mild scarring, smooth out rhytids, destroy epidermal lesions, help with acne, remove pigmented lesions, blend other interventions Lower preoperative Fitzpatrick’s type translates into lower risk of pigmentation problems History of Accutane therapy in last 6 months, XRT, previous facial cosmetic surgery, abnormal scar formation, rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis should give pause


Peels: Peels Multiple formulations with differing peel depths: Superficial = epidermal loss Medium = injury to superficial dermis Deep = mid-dermal injury Depth of peel dictated by level of skin aging Patients with severe aging changes usually best treated with surgical intervention


Peels: Peels


Peels – preoperative intervention: Peels – preoperative intervention Superficial peel: No intervention necessary Medium/Deep peel Antiviral agent (continued x 10d-2wk) Weak tretinoin solution 1-2 wks before 4-8% hydroquinone gel for patients with Fitzpatrick skin types III or higher Evaluate for cardiac status, kidney disease


Peels: Peels Superficial Very light Injure stratum corneum 10-20% TCA Jessner’s Tretinoin Salicylic acid Light Injure entire epidermis 70% glycolic acid (must be rinsed) 25-35% TCA Solid CO2 slush Medium 35% TCA + Jessner’s vs. 70% glycolic acid vs. CO2 Risk of scarring with 50% TCA Deep Baker-Gordon solution Phenol, water, septisol, croton oil Phenol cardiac toxicity precautions Diluent Taped vs. untaped Laser


Peels -- results: Peels -- results


The role of an Aesthetician: The role of an Aesthetician Topical treatments Cleanser, toner, sunblock Tretinoin, exfoliants, bleaching agents Non-ablative procedures IPL Microdermabrasion Light chemical peels Other skin treatments Interval skin evaluation/patient education Post-operative care Makeup application/cosmetic camouflage


Office-based Cosmetic Procedures: Glen T. Porter, MD David C. Teller, MD University of Texas Medical Branch at Galveston Office-based Cosmetic Procedures