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Office-based Restorative Systems

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

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

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

  4. Monochromatic Coherent Collimated

  5. 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)

  6. 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

  7. Laser – tissue interaction • Each tissue differs in absorption characteristics and relaxation time (time necessary to release 50% of energy) • Pulse width <relaxation time = chromophore targeted with little collateral spread of energy • Cutaneous chromophores: water, melanin, hemoglobin • Penetration is influenced by target chromophore (more absorption = less penetration)

  8. Laser spectrum

  9. Laser spectrum • LaserWavelength (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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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.

  16. 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

  17. Laser -- hair removal Anagen Catagen Telogen • 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

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

  19. 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

  20. 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

  21. 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.

  22. Soft tissue augmentation – injectable fillers Restylane

  23. Perlane

  24. 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

  25. Dermabrasion -- results

  26. 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

  27. Microdermabrasion -- results

  28. 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

  29. 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

  30. Peels

  31. 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

  32. 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

  33. Peels -- results

  34. 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

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