Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

A Structural Approach to Non-Ablative Rejuvenation Gary D. Monheit, M.D. Associate Professor Department of Dermatology University of Alabama at Birmingham Birmingham, Alabama Facial Rejuvenation today involves a complex of different procedures designed to reverse or correct the degenerative changes that occur on multiple levels of skin and soft tissue in response to the processes of aging. Intrinsic and photoaging processes cause changes in epidermis, dermal structures and subcutaneous atrophy. These lead to the characteristics of dynamic and static wrinkles, redundant skin and surface changes in color and texture. In the past, major innovations involving face lifting techniques and deep chemical peels involved a morbidity and risk of complications as well as significant recuperative down time. The advent of more conservative “lunch time” procedures to correct these changes are the expected norm for most cosmetic patients. Microdermabrasion, light and medium depth chemical peels, chemodenervation with Botulinum toxin, filling injections with collagen and other implants, vascular and pigmented lesions lasers all play a role in reversing discreet lesions of photoaging. The most recent treatment modality is non-ablative resurfacing, allowing the physician to remodel and control dermal collagen without destructive changes or down time. It fits in well with the other procedures currently used for photoaging skin correction. It is up to the physician to fit this into an individual treatment program where each tool can be used to correct the defects present. Any one tool alone will not give the results needed but by combining these procedures together in a structural approach will accomplish these goals with a safe and effective treatment program with little down time.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The modalities available for treating acne scars remain imperfect. At this time, there are no methods available that will “remove the scar” as most patients wish when they come for consultation. The realistic perspective is to blend or camouflage the scar with surgical tools available to us. Distensible, depressed scars can be elevated with subcision, collagen products, Fibrel or fat, ice-pick scars are punched out and replaced with small grafts, and stellate or jagged scars are replaced with scar revision procedures. Each of these techniques still leaves surface scar and textural change that can be seen or felt. Guttate and fibrotic scars are then resurfaced with available tools such as dermabrasion, the CO2 resurfacing laser or more recently, the Erbium Yag laser. Limitations in resurfacing techniques are determined by depth, contour, and color of the scar. Though blending is an improvement in overall appearance, any one of these procedures usually does not give a perfect result. For this reason, the author proposes a combination of procedures to solve the multiple problems of the acne scar patients.

For nearly fifty years, dermabrasion has been the premiere modality for resurfacing scars. Since Kurtin first promoted the use of a wire brush on a motorized shaft to sand the skin surface for improving skin textural abnormalities, dermabrasion has been the mainstay to plane down surface irregularities of acne scars. The addition of the diamond fraise, the use of refrigerants to firm the skin surface for more even planing, and developments in technique and anesthesia have established dermabrasion as the standard of care for treatment of acne scars and textural changes of facial skin. Over the years, though, there has only been a small core of cosmetic dermatologists and surgeons who have used dermabrasion techniques. This is because the procedure is technique-sensitive with a long learning curve. In addition, it is a major surgical procedure requiring extensive local anesthesia, or tumescent anesthesia along with sedation, and has been condemned for being a “bloody procedure”. Scarring complications have ensued when inadequately trained physicians have attempted to tackle difficult dermabrasion problems, and physicians have been overly aggressive with deeper acne scars.

Most recently, the advent of the resurfacing laser has established a new tool for treatment of photo-aging skin and acne scars. The pulsed CO2 laser vaporizes a controlled depth of skin depth to stimulate the regeneration of new skin. Like the chemical peel, the CO2 laser removes the same uniformed depth of tissue on smooth or irregular skin. Penetration of peel solution and vaporization of tissue occur at a uniform depth throughout the entire area being resurfaced, which is the ideal approach for photo-aging skin. Treatment to a depth of the upper reticular dermis will remove the zone of collagen degeneration and stimulate a new grenz zone of new collagen fibers. Using the laser, the observation was made on the operating table that there is a unique contraction of collagen that occurs as a result of dermal damage. This collagen fiber shrinkage improves the result of treatment by tightening the photo-aging skin. The zone of dermal necrosis necessary to achieve these results, though, has raised a red flag of complications which may include hypopigmentation, textural change, and scarring, similar to that seen with deep phenol peeling.

The use of the CO2 laser for acne scars must differ from those developed for resurfacing photo-aging skin. The irregular mountains and valleys on the skin surface of acne scar patients need to be sculpted or planed rather than uniformly resurfaced. The use of the diamond fraise or wire brush on refrigerated or chilled skin provides the surgeon with tools for which he can take the tops off the mountains and level the skin surface. The CO2 laser, like the chemical peel, uniformly drops the depth of injury on both elevated and depressed areas of skin. Thus, the technique of sculpting scars is more difficult with a resurfacing laser than with the dermabrader. Recently, several authors have reported the benefits of resurfacing lasers for acne scars.

The CO2 laser has made a full-face procedure easier, simpler, and faster, but the results are not as gratifying as expected with dermabrasion. Fulton has emphasized the use of multiple modalities for the treatment of acne scars and has used laser resurfacing and dermabrasion together for the treatment of acne scars. The author has followed this lead in his approach to the patient with acne scars. Combined modalities have a value that will improve the skin texture beyond each alone. For this reason, I have developed a combined technique of laser resurfacing with dermabrasion to utilize the advantages of each technique for use with dermabrasion.

Combination Dermabrasion – CO2 Resurfacing

Combining CO2 resurfacing with dermabrasion allows the surgeon to use the abrasive technique specifically over the scars, and laser resurfacing over those broad areas of skin that do not need sculpting. That is, the entire face will receive two passes of the resurfacing laser to be followed by elective dermabrasion over individual scars. Dermabrasion proceeds in the usual manner until a visual endpoint – the sebaceous lobules – is reached, or the scar is significantly improved. At that point, a last selective CO2 laser pass can be made around the shoulders of the scars to enhance the collagen contraction and further blend the depressed scar. The results with this combined technique seem to be better in some patients or comparable to that of full-face dermabrasion, and does simplify the procedure for the operating surgeon.

Method

All patients are treated prior to the procedure with cosmoceutical agents. Vitamin-A skin conditioning is begun four to eight weeks prior to the procedure. The stimulation of rapid epidermal cell proliferation and new collagen formation encourages faster and more uniform healing. All patients are given an antiviral agent, acyclovir 400 mg. b.i.d. prior to the procedure and this will be continued for ten days post-operatively. Those patients with darker skin – Fitzpatrick type III to V – are treated pre-operatively with hydroquinone 4% to 8% to prevent reactive hyperpigmentation. The bleaching product will be resumed three weeks after surgery.

The patient is prepared pre-operatively in the usual manner for full-face resurfacing or a full-face dermabrasion. The procedure is performed either under general anesthesia or sedation with local skin anesthesia. The level and extent of local anesthesia must be greater than the local nerve block that provides anesthesia for dermabrasion. The refrigerant used for dermabrasion gives added anesthesia that is not present for the resurfacing laser. The patient thus needs either full-face tumescent anesthesia, or multiple local field blocks distributed in quadrants over the facial surface. Eye shields are placed on the patient for protection, and wet drapes are placed around the operative field, preparing for laser resurfacing first. The acne scars are marked and the areas for dermabrasion outlined. Full-face resurfacing passes are first made using the standard CO2 resurfacing technique. Using the Coherent ultrapulsed laser with a computer pattern generator (CPG), the following parameters are used for the first two full face passes: 300 milli-joules, 60 watts, density of five, with a CPG pattern of 38. If the periorbital skin and eyelids are included, the parameters are reduced to 250 millijoules, 50 watts, and a density of 5. The necrotic debris is wiped with damp 4 x 4’s to clean between the passes, and after the second pass the scars become clearly visible to the surgeon.

At this point, the surgeon will switch to dermabrasion. The areas are blocked with square towel drapes, giving a 5-7 cm. area for freezing and sanding. A medium diamond fraise is used with the Bell hand engine for sanding. The skin is chilled for ten seconds with a freon 11/ethyl chloride mixture (Frigiderm). This is a less intense freeze than performed with dermabrasion alone. A denuded papillary dermis is being resurfaced. Dermabrasion is performed at lower RPM and with fewer passes because the damaged collagen can be removed easily. The irregularities in texture are then sculpted and planed. The procedure of freeze-sand is repeated until the endpoint is reached. That is the visual smoothing of the acne scars or the appearance of sebaceous lobules in the dermis. This protocol must be reduced in facials areas more susceptible to scarring such as the forehead, zygomatic arch, temple, jawline and chin where one or two cycles are sufficient. At the conclusion of the dermabrasive portion, saline compresses are placed to control hemostasis. The field is dried and the surgeon then returns to the resurfacing laser. At 250 milli-joules and 50 watts and a density of three with a single spot or linear CPG pattern, a final laser pass is made over the outer perimeter of scars. The touch-up will shrink collagen to further smooth the scar. It is at this depth the surgeon visually appreciates the mauve color-change indicating the thermal effect on the collagen.

At the conclusion of the final laser pass, the non-abraded laser treated skin and surrounding transition zones are dermasanded following the technique of David Harris, M.D.3 Silica combined with sandpaper, (150 gt), is rolled as an instrument to manually sand the transition zones such as jawline and neck, hairline, eyebrows, laser gaps and irregularities in the treated areas. A light manual sanding of the laser areas will remove the necrotic debris as done by Erbium laser – and may promote more rapid healing.

The patient is treated post-operatively in the usual manner with biologic dressings, soaks, and occlusive salves. My approach is to use a biologic dressing – Flexzan, which is changed daily for the first three to five days. At that time, the patient switches to ¼% acetic acid soaks with Vaseline petroleum jelly four times a day. The soaks and ointment create a light debride that will liquefy the crusts during the coagulation phase of wound healing, accelerating epidermal regeneration and wound healing. After 10-12 days, epithelialization is usually complete, and the patient is switched to a non-detergent cleanser, a lighter moisturizing cream, and a mild topical steroid for areas of remaining erythema. The dermabraded portions usually take a little longer to epithelialize than the resurfacing area. Healing is almost always complete within two weeks.

Conclusion

Combining laser resurfacing with dermabrasion achieves a level of improvement beyond what each of these techniques produce individually. The laser resurfacing initially brings the abrasive level of treatment to the dermis, simplifying and speeding up the procedure. The dermabrasion then corrects the scars and the final laser touch-up will shrink dermal collagen around the scars. The combination procedure will produce results beyond what each modality can achieve. The combined procedure seems especially indicated in the older patient with acne scars. This is the patient who notes the acne scars have become worse in middle age as skin laxity has increased and scarring has become more apparent. In this patient, the surgeon is treating both photo-aging skin and acne scars, and the use of both modalities seems to give a superior result to that of resurfacing or dermabrasion alone. For the younger patient with acne scars, this result can be equal to that of dermabrasion, but is usually not superior. The advantages of the combined procedure in this patient are that it simplifies the approach to the operating surgeon. Dermabrasion is a time-intensive procedure and requires the utmost concentration for control of the spinning wheel over the entire face. Limiting the dermabrasive portion to the areas of need simplifies the procedure. The surgeon must be alerted to the fact that he cannot be as aggressive with either procedure when combining the two. Dermabrading of skin that has already received two passes with the resurfacing laser must be performed much more conservatively than full-face dermabrasion de novo. Conversely, the surgeon must use his judgement in placing a last pass over the dermabrasive area. This is dependent upon depth of dermabrasion and skin type and the area treated. Over-aggressive usage of this combined approach can result in scarring, hypopigmentation, and adverse textural changes. The surgeon must temporize his zeal to eradicate the scar with the knowledge that even this approach is an imperfect procedure and cannot “remove the scar”. This combined approach, though, will produce a significant improvement in skin texture and blending of the scars.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The explosion of interest in chemical peeling by cosmetic surgeons and dermatologists has paralleled the general public interest in youthful appearance, photo aging skin and it’s rehabilitation. A number of home treatment programs, cosmetic agents and over the counter chemicals have entered the general market to rejuvenate skin and erase the marks of sun damage and age. Though 90% of these products do little more than abrasive exfoliation and moisturization, the quest for youthful skin continues and the cosmetic surgeon remains at it’s forefront.

Concurrent to the public’s desire for rehabilitation of aging skin has been a new renaissance in chem-exfoliation. Just fifteen years ago, the name chemical peel was associated only with the deep phenol peel and heavy concentrations of trichloracetic acid. There was little understanding of the injury pattern created and its correlation with skin regrowth, potential side effects and complications. Objective analysis by Gordon-Baker, Litton and Kligman documented the histologic depth and injury pattern of the deep peel.1 With the pioneer work of Drs. Reznick and Ayres, a clinical and scientific background for the use of trichloracetic acid was begun.2 Histologic correlation of peel depth with varying concentrations of phenol and trichloracetic acid performed by Dr. Sam Stegman, serves as the scientific basis for our objective understanding of wounding depth and the efficacy of chemical peeling.3 A classification of peeling agents emphasizes depth penetration as a reflection of activity rather than chemical formulas. Thus, labeling a peel as superficial, medium, and deep depth is more meaningful than the chemical names phenol or trichloracetic acid. A new understanding of peel injury and repair has emerged, along with an appreciation of variations in patient skin type, pigmentation, and degree of photo aging. Utilizing the Fitzpatrick,(Table I) and the Glogau system (Table II) of pigmentation and sun damage, one can individualize the strength of chemical agents to match skin types.4 Wounding depth of each agent has been correlated with histology. Trichloracetic acid light and medium depth peeling has been quantitated with depth of injury, morbidity and degree of results. The risks of deep peeling with greater than 50% trichloracetic acid can be weighed against the patient’s need and degree of photo damage.

A new emphasis has been placed on the medium depth peel, the combination peels and repeated lighter peeling regimens. Brody has pioneered the use of 35% trichloracetic acid with carbon dioxide freeze in selective areas.5 The physical and chemical agent used together produces a deeper peel than that found with 35% trichloracetic acid alone. Similarly, a combination of chemical agents, the Jessner – Trichloracetic acid peel has combined wounding agents to create an enhanced level of efficacy.

This brings us to our present usage of peeling agents and the future of chem-exfoliation. The successful usage of the newer agents available depend upon the cosmetic surgeon’s full understanding of photoaging skin and skin types. The photo types are taken into careful consideration in the choice of agents used to prepare the skin, to peel the skin, and for skin after care. The cosmetic surgeon can assess the degree of skin damage and choose the appropriate wounding agent to achieve realistic and desirable results for the patient. Mild photoaging damage may respond better to repeated light TCA peels or the alpha-hydroxy acid (AHA) peels. These should be performed in combination with retinoids, abrasives and sunscreen protection. For this type of patient, an ongoing program of daily skin care, multiple peels and protection against further photo aging is the full package necessary for skin rejuvenation. Physicians and patients must understand that repetitive superficial peels do not produce the same effects of deeper chemical peels as promised by many lay concerns.

Patients with moderate photoaging skin will achieve a more desirable result with a combination medium depth peel. The combination includes either the Jessner 35% trichloracetic acid peel or the CO2 freeze – 35% trichloracetic acid peel. Both of these combinations achieve more desirable results than 35% TCA alone. The combination enhances the depth of the peel to a moderate depth chemical peel (i.e. mid dermis).7 It’s use for pigmentary dyschromia, fine rhytides, weathering of the skin and sallow texture, gives greater results than 35% trichloracetic acid alone. Other choices would include the use of plain phenol, or one of the new combination peels such as additive trichloracetic acid as per Drs. Fulton or Obagi.

Severely damaged photo aged skin including perioral rhagades, deeper rhytides and textural changes require a deeper peel, and the Gordon-Baker phenol peel is my choice. The depth of this peel though, will produce hypopigmentation and a change in texture of the underlying skin in many patients. This is especially important in Fitzpatrick skin types III-VI, and those patients with sebaceous skin.

The cosmetic surgeon, thus, should be familiar with at least two or three chemical peeling agents so that he can use the appropriate tool for the patient’s skin type and degree of photoaging.(Table III) It is impossible to be familiar with all the agents on the market, and I think it is best for the clinician to be proficient in a light, a medium depth and a deep peeling agent. My choices are:

• Light chemical peel 15% to 30% trichloracetic acid, glycolic acid or Jessner’s solution.
• Medium depth chemical peel, Jessner’s – 35% trichloracetic acid.
• Deep chemical peel, Gordon – Baker phenol peel.

The chemical peel procedure itself is not an all or none phenomena, in that the steps taken in the procedure each add a variability to the depth of the peel. This allows the clinician to modify peel depth in patients, and even in regions of the face or neck. For example, a deeper injury may be necessary in the perioral area to improve skin texture and rhagades, while that may not be necessary on the cheeks and temples. The surgeon can choose a Baker-Gordon peel for the lip and Jessner’s TCA 35% for the remainder of the face.

Several stages can be modified to enhance the efficacy of the peel: skin preparation, cleansing and degreasing the skin, application of an adjunct agent and application of active peeling agent.

• Skin preparation. Prior to the peel, patients are begun on retinoic acid, sunscreen protection and moisturization. Retinoic acid increases peel penetration by it’s ability to limit the thickness of the stratum corneum by changing the epidermal kinetics. This prepares the skin to respond to the peel injury with a brisk epidermal regeneration and more lasting changes in collagen synthesis. Patients with pigmentary problems and dyschromias begin using a hydroquinone bleach along with hydrocortisone and Retin A up to six weeks prior to the chemical peel.9 Hydroquinone blocks the tyrosinase enzyme in the creation of new melanin; consequently it will limit the production of new pigmentation and prevent repigmentation from occurring after the chemical peel. It’s usefulness is enhanced by the retinoic acid and hydrocortisone (Table IV). Repeated epidermabrasion, the use of sunscreens, and other light chemical exfoliants all are helpful in preparing the skin for the chemical peel. It’s effect will be to speed up epidermal regenerative kinetics and slow down pigment production.
• Cleansing and degreasing. The degree of degreasing is a variable controlling the depth of peel. Vigorous removal of oils and debris in the dead skin layer increases the effectiveness of the peel by allowing greater penetration. The use of Ingasan (septisol) scrubbed with 4 x 4’s followed by Acetone is repeated until the skin is totally degreased over the entire face. It is especially important for this degreasing to be uniform, as streaks of oil and stratum corneum left behind will produce a blotchy, irregular chemical peel.
• Adjunct agent. In medium depth peels, the use of Jessner’s solution or other chemical or physical adjuncts increase the depth of the trichloracetic acid to be applied later. The Jessner solution is applied evenly with 2 x 2’s producing a light white frosting with erythema. Layering will increase the acid absorption by effectively removing the epidermis as a barrier. The amount of Jessner solution used, the evenness of application, and the degree of frosting and erythema are all quantitative variables in the depth of this peel. The use of CO2, methyl salicylate and tween-40 has also been used to enhance peel strength.
• Application of trichloracetic acid. Both the percentage of trichloracetic acid and the amount applied are variable factors in the depth of the peel. The TCA concentration I prefer is 35%. Instead of using higher concentrations to increase the depth of penetration, I will apply additional layers of 35% TCA since the depth of injury is increased with each application. One can layer a greater quantity of acid in facial areas with more severe photo aging and less over those areas with a greater risk to scarring, such as the lateral cheeks and jawline. An even white frosting is the end point for the chemical peel. I can more precisely control my peel depth by re-applying the medium concentration, rather than using higher concentrations of this acid.

The Jessner – trichloracetic peel will produce excellent results for moderate photo aged skin. However, deeper rhagades and rhytides in the perioral area, in the periorbital area and glabella, show limited response to this level of chemical peeling. For those patients with moderate photo aging on the cheeks and forehead and more severe aging skin in the periorbital area, a combination chemical peel may be the answer. The author has used the Baker’s phenol peel in the periorbital, the perioral and glabellar area while using the Jessner 35% trichloracetic acid peel over the rest of the face. This combination has a distinct advantage in that the clinician has specifically chosen the peel solution to be used for each of these facial areas, and thus will not be over-treating the entire face with a deep chemical peel. He can thus limit the morbidity and complications of the deep chemical peel and simplify the procedure. Because the deep agent is only used on limited portions of the face, the patient would not need IV fluid loading and the necessary monitoring required for a full face phenol peel.10 The medium depth peel used over the rest of the face will blend since deep peels result in hypopigmentation and/or textural changes. The patient will have a softer, more even result when a medium depth peel is on the rest of the face to achieve “blending”. Combining individual agents in distinctive areas in our patients provides the surgeon with more precise tools to treat the many faces of aging skin.

This brings us to the horizon of chem exfoliation, and I feel the future will offer us a greater understanding in the nature of photo damage and it’s early correction. Programs of skin care will be more common and patients will be treated with ongoing protocols to continuely reverse the factors and environmental wear and tear of aging. These will include repeated peelings, as well as using topical pharmacologic agents, home exfoliants, and sunscreen protection. The physician will remain in the forefront in the field of cosmetic pharmacology and surgery. He must function as a guide to his patients who are barraged daily with promises from proprietary companies, cosmetic counters and salons. He must dispel the promised miracles and discuss the benefits of skin care realistically and objectively. This is an exciting time for the cosmetic surgeon to explore the new tools and techniques of chemical peeling.

Fitzpatrick’s Classification of Skin Types

Skin Type Color Reaction to Sun

• Very white or freckled Always burns
• White Usually burns
• White to olive Sometimes burns
• Brown Rarely burns
• Dark brown Very rarely burns
• Black Never burns

Table II
Photo Aging Group – Glogau’s Classification

• Group I Mild (typically age 28-35)
  • Little wrinkling or scarring
  • No keratoses
  • Requires little or no make-up
• Moderate (age 35-50)
  • Early wrinkling; mild scarring
  • Sallow color with early actinic keratoses
  • Little make-up
• Advanced (age 50-65)
  • Persistent wrinkling or moderate acne scarring
  • Discoloration with telangiectasias and actinic keratoses
  • Wears make-up always
• Severe (age 60-75)
  • Wrinkling: photo aging, gravitational and dynamic
  • Actinic keratoses with or without skin cancer or severe acne scars
  • Wears make-up with poor coverage

TABLE III

• Superficial Chemical Peel
  • Agent Ingredients Indications
  • CO2 slash or liquid Physical agent Comedonal or nodular nitrogen spray acne
  • Alpha-hydroxy acids Glycolic or lactic acid Comedonal and 5 to 30% inflammatory acid, mild photo aging
  • Trichloracetic acid Aqueous dilutions of Mild photo aging and 10 to 30% trichloracetic acid comedonal acne
  • Jessner’s solution Resorcinol, salicylic Acne peel acid, lactic acid
  • Tretinoin .01% to .1% cream or Comedonal acne, gel, tretinoin photo aging
• Medium Depth Peel
  • Agent Ingredients Indications
  • Trichloracetic acid 45% Aqueous trichloracetic acid Moderate photo aging skin
  • CO2 + 35% trichloracetic Aqueous trichloracetic acid Moderate photo aging acid skin
  • Jessner’s solution + Aqueous trichloracetic acid Moderate photo aging 35% trichloracetic acid skin
  • 89% Phenol solution, Moderate to severe aqueous photo aging skin
  • Alpha-hydroxy acids Pyruvic acid – 50% in ethanol Moderate photo aging skin
  • “Hot rod” peel (Fulton) 35% trichloracetic acid, Moderate photo aging 5 to 10% methyl salicylate, skin 1% polysorbate 20
  • Obagi peel Trichloracetic acid with Moderate photo aging “unknown additives” skin
• Deep Chemical Peel
  • Agent Ingredients Indications
  • Baker’s formula peel Phenol 88% with water, Severe photo aging septisol and crotin oil skin
  • Trichloracetic acid Aqueous trichloracetic acid Severe photo aging greater than 50% skin

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Case history: a 38-year-old caucasian female had facial laser resurfacing for rejuvenation of photo aging skin. A CO2 laser was used for resurfacing and the patient healed in an uncomplicated fashion. Postoperatively, there was a noticeable hypopigmentation which was especially evident over the jawline in direct contrast to the tan dyscromic coloration of the neck. This bothered the patient because of its unnatural appearance and was referred for treatment.

Discussion, Prevention and Treatment

The unnatural appearance of a laser resurfaced in contra distinction to the photo aging color and texture of neck skin is an unnatural appearance that is not acceptable today. Thought in past decades when deep chemical peeling was in vogue, this was an acceptable difference for which makeup was necessary. In today’s society, there is a demand for a natural blended appearance when cosmetic surgery is performed. Our patients are intolerant of an “operated look” or an artificial juncture from on portion of the skin to another. It is therefore necessary to evaluate the exposed neck, chest, and shoulders of a patient who requests resurfacing for photo aging facial skin. These areas must be addressed for either simultaneous blending procedures or a second procedure to solve the problem of facial resurfacing demarcation lines.

It is best to address the neck issues during the facial resurfacing procedure. Though neck skin cannot tolerate deep laser resurfacing, it, though, can be treated with less aggressive superficial procedures, manual dermasanding, or erbium yag laser. These are epidermal resurfacing procedures that can blend color change and have a softening affect on photo aging skin texture of the next and chest. During consultation the patient must be informed that the changes that will occur in the neck and chest are not as dramatic as though which can be achieved in facial skin that has been resurfaced. In my hand, the procedure of choice if superficial chemical peeling of the chest, shoulders, and neck, along with dermasanding at the jawline juncture descending and blending to the upper third of the neck. This creates a gentle transition from chest to vertical neck to the junction of neck and jawline where deeper resurfacing is present. Neck skin in the upper third can tolerate mild medium depth resurfacing while vertical neck, lower neck and chest will only tolerate superficial resurfacing procedures. If one is too aggressive in these areas, scar formation and pigmentary hypopigmentation will be a consequence. The correct blending of these areas, though, will achieve natural results without demarcation problems.

All patients should be pre-treated with tretinoin, sunscreen protection, and in skin type III-VI, or those with a history of pigmentary dyscromia, a 4-8% hydroquinone bleach in a cream base. These pharmaceutical preparation should be instituted at least three weeks prior to treatment and then restarted approximately 2 – 3 weeks after the surgical procedure when reepithalialization is complete and erythema is decreased. Superficial peeling agents most appropriate for this procedure in clue Jessner’s Solution, 70% glycolic acid solution, 15 – 25% TCA, and 20% lactic acid solution. Manual dermasanding is accomplished with 180 – 220 grit silica carbide sand paper or wall sheeting paper. This method will remove epidermal dyscromias and have a very mild textural change near the jawline to blend facial skin.

To treat this patient who has a demarcation line with neck hyperpigmantation and dyscormia, is a commitment to repetitive superficial chemical peeling, cosmesutical agents, dermal sanding, and, in some cases, laser treatments. It is much more difficult to correct this abnormal pigmentary separation than to prevent it. Treatment instituted should begin with cosmesutical agents including trentinoin and 4 – 8% hydroquinone. Repetitive light chemical peeling with salicylic acid will lighten the dysromic pigmentation and gradually blend the demarcation line. With resistant cases, more aggressive peeling with Jessner’s or TCA can be instituted but with caution. Similarly, dermasanding and erbium yag laser can be an added procedure to blend the pigmentation.

The question arises as to whether the hypopigmentation seen in facial resurfacing is a true hypopigmentation from the laser treatment or pseudohypopigmentation in contrast tot he dyscromic hyperpigmentation. In either event, it is an unnatural, poorly tolerated postoperative result that most patients will complain about. It is, therefore, prudent for the cosmetic surgeon to address the neck issue early on when he is planning his facial procedure.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Synopsis

Chemical peeling remains a valuable tool for the cosmetic surgeon to treat photoaging skin. Choices available include superficial, medium and deep chemical peeling agents along with preparatory cosmoceutical agents to prep the skin and maintain rejuvenation. This chapter will prepare the cosmetic surgeon to include the latest agents in his practice and choose correctly which treatment is best for patients with individual problems of photoaging of the face and body, acne scars and pigmentary problems. These modalities will be compared with other treatment modalities such as laser and dermabrasion.

The explosion of interest in chemical peeling and laser resurfacing on the part of cosmetic surgeons has paralleled the general public’s interest in acquiring a youthful appearance by rehabilitating the photoaged skin. The public’s interest has been further heightened by advertising for cosmetic agents, over the counter chemicals and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Most of these over the counter home do-it-yourself programs have been tried by patients and by the time they consult their plastic surgeon, cosmetic surgeon, or dermatologist, they are ready for a more definitive procedure performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient’s skin type, degree of photoaging skin, and thus prescribe the correct facial rejuvenation procedure that will give the greatest benefit for the least risk factors and morbidity. The cosmetic surgeon should have available for his consumer the options of medical or cosmoceutical topical therapy, dermabrasion, chemical peeling, and lasers available for selective skin destruction and resurfacing. Each of these techniques maintains a place in the armamenteria of the cosmetic surgeon to provide the appropriate treatment for each individual patient and his specific problem.

With an aging baby boomer population expressing an interest in rehabilitating weathered and photoaging skin, the male patient has become a major consumer for the cosmetic surgeon. The approach to photoaging skin has expanded beyond a one-stage procedure to now include preparatory medical therapy and post-treatment cosmoceutical topical therapy to maintain results and prevent further photodamage. Thus, the cosmetic surgeon’s office has become not only a surgical treatment session, but also an educational setting for skin protection and care and a marketplace for the patient to obtain the necessary topicals for skin protection. It is up to the dermatologist, cosmetic surgeon, plastic surgeon to fully understand the nature of skin and sun damage, protective techniques available, and active agents that work as cosmoceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right procedure to restore and rehabilitate their skin.

Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Various classification systems have been available and I would like to present a combination of three systems that would simplify and help the physician define the right program or therapeutic procedure for his patient. The Fitzpatrick skin type system classifies degrees of pigmentation and ability to tan. Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage, and ability for facultative melanogenesis (one’s intrinsic ability to tan). In addition, this system classifies skin as to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin type I and II are pale white and freckled with a high degree of potential to burn with sun exposure. Three and four can burn but usually is an olive to brown coloration. Five and six are dark brown to black skin that rarely ever burns and usually does not need sunscreen protection (see Table I). The patient with type I or II skin with significant photodamage needs regular sunscreen protection prior to and after the procedure. He, though, has little risk for hypopigmentation or reactive hyperpigmentation after a chemical peeling procedure. The patient, though, with type III through VI skin has a greater risk for pigmentary dyschromia – hyper or hypopigmentation, after a chemical peel and may need pre and post-treatment with both sunscreen and bleaching to prevent these complications. Pigmentary risks are generally not a great problem with very superficial and superficial pigment chemical peeling, but may become a significant problem with medium and deep chemical peeling. It can also be a significant risk when regional areas such as lips and eyelids are peeled with a pulsed laser, creating a significant color change in these cosmetic units from the rest of the face. This has been classified as the “alabaster look” seen with taped deep chemical peels in regional areas. The physician must inform the patient of this potential problem, especially if he is of skin type III through VI, justify the benefits of the procedure, outweigh these risks and, in addition, plan for the appropriate techniques to prevent these unwanted changes in color.

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects. The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised for therapeutic intervention in that category I or minimal degree photodamage can be treated with light chemical peeling and medial treatment. Category II and III would entail medium depth chemical peeling while category IV would need those modalities listed plus cosmetic surgical intervention for gravitational changes (see Table II).

Monheit and Fulton have devised a system of quantitating photodamage developing numerical scores that would fit into corresponding rejuvenation programs.3 In analyzing photodamage, the major categories include dermal with textural changes and epidermal with skin lesions. Dermal changes include wrinkles, cross-hatched lines, sallow color, leathery appearance, crinkly thin parchment skin, and the pebblish white nodules of milia. Each of these is classified, giving the patient a point score, 1 through 4. In addition, the number and extent of lesions are categorized from freckles, lentigenes, telangiectasias, actinic and seborrheic keratoses, skin cancers, and senile comedones. These also are added in a classification system 1 through 4 and the final score results are tabulated. A total score of 1 through 4 would indicate very mild damage and the patient would adequately respond to a five-step skin care program including sunscreen protection, retinoic acid, glycolic acid peels and selective lesional removal. A score of 5 through 9 would include all of the above plus repetitive superficial peeling agents program such as glycolic acid, Jessner’s solution, or lactic acid peels. A score of 10-14 would include medium depth chemical peeling, and a score of 15 or above would include deep chemical peeling or laser resurfacing. The patient thus could understand during the consultation his degree of photodamage and the necessity for an individual peeling program.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Quickread: The Contour thread™ is a strong and stable barbed thread used in non-surgical face-lifts today, showing very positive cosmetic results. Procedure times are shorter and aesthetic results last longer than non-invasive techniques, possibly setting a new bar for non-invasive mid-face and brow lifting procedures, according to one expert.

Palm Springs – Minimally invasive face lifting procedures using barbed threads seem to be the future in cosmetic face lifts, and are also more aggressive approaches than traditional surgically invasive procedures. Of the barbed threads available on the market today, Contour threads™ seem to be the most popular in terms of durability and positive cosmetic outcome, according to one specialist.

“The Contour thread™ can effectively elevate sagging tissues like the brows, cheeks, and mid-facial areas, and easily reposition the mass and volume in these structures. They can be used to reshape the brow to create a prettier arch, as well as soften the appearance of jowling,” said Gary D. Monheit M.D., Associate Clinical Professor of the Departments of Dermatology and Ophthalmology at the University of Alabama in Birmingham.

Dr. Monheit said that the key points that set the Contour thread™ apart from other barbed threads on the market are its unique barbed design, providing an optimum holding and breaking strength not seen with other threads. The FDA approved Contour thread™ has attached needles to the suture materials for ease and convenience, and a longer thread length for greater control and lifting. Another major benefit is its clear polypropylene material, which is not visible in light skinned patients.

Aptos threads use 3 pathways to direct the threads through the subcutaneous tissue and SMAS of the mid-face to lift the malar fat pad and nasolabial fold. According to Dr. Monheit, the non-approved Aptos threads carry with them several disadvantages, compared to the Contour threads™. He said that the Aptos threads are free-floating which may lead to unwanted thread migration, there can be thread splitting, as well as a questionable longevity and tensile strength of the thread.

The Articulus CT400™ (the next generation of the Contour thread™) is the first knotless fixated barbed suture that combines two unidirectional threads to elevate and fixate sagging facial tissue. Its new and improved suture technology boasts a reduction in procedural time, and increases holding strength in the tissues. This thread is designed to compliment the Contour threads™ as an adjunct lifting procedure.

Dr. Monheit said that when marking the face of the patient just prior to the Contour thread™ procedure, it is crucial to decide on the direction of elevation and visualize the result while palpating the skin. The surgeon should plan from a fixed to a mobile area for optimal results, and also demonstrate to the patient the plan of the procedure.

“Advancing the Contour thread™ is a simple 4 step procedure consisting of incision, deployment of Contour threads™, the fixation of the proximal suture and suspension, and then careful and purposeful contouring of the tissue,” Dr. Monheit said.

He said that immediately post-op, the patient will likely experience some swelling, redness, bruising, discomfort, tightness and pulling. These side effects are more or less expected but are mild and fortunately short-lived.

“The thread lifting procedure can be done in approximately 1 hour under local anaesthesia, and in an in-office ambulatory setting. The patient will not have any visible scars and will experience only a mild discomfort following the procedure. Furthermore, there are little or no dressings post-procedure and the physical recovery time is only a week,” Dr. Monheit said. The patient, though, must contend with folds and dimples for 2 to 3 weeks to maintain corrections.

He said that this is very different from the conventional face-lifting procedures. Here, the procedure lasts anywhere from 2-4 hours and sedation or general anaesthesia are required. Patients will experience some post-op pain and some scarring will occur. Patients must receive a helmet dressing and the recovery time is longer, lasting anywhere from 2-3 weeks.

Dr. Monheit said that he likes to give his patients prophylactic antibiotics to avoid any unwanted complications of infection. He also tapes the face to remind the patient to restrain from facial motion, which helps to achieve a more positive aesthetic outcome. He reminds the patient not to pull down on the facial areas for 3-4 weeks post-op and to minimize facial expression or mimicking. He stressed that patients should sleep on their backs and keep the head elevated for 1 week following the procedure, as well as hold their brows up with their fingers when making facial movements.

Directly following a thread lifting procedure, Dr. Monheit carefully instructs his patients to apply ice-packs for 1-2 days, avoid the sun for a several days, to refrain from smoking pre- and post-op, as well as to steer clear of vitamin E and NSAIDS 2-3 weeks pre- and post-op.

This procedure represents another step in the direction of less aggressive procedures for facial rejuvenation.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Levels of resurfacing reflect depth of skin destruction, vaporization and/or inflammation as performed by chemicals, laser or dermabrasion. Classifying the degree of photoaging skin allows the physician to determine which of his patients require more extensive or deeper resurfacing with each of the modalities. The Glogau system grades photoaging from I to IV, based on intensity and severity of wrinkles. It will guide the physician to the depth of damage to be corrected. The depth of chemical peel penetration has been classified as superficial, medium depth and deep as to level of histologic destruction. Superficial is destructive of partial or complete epidermis; medium depth implies epidermal destruction with the papillary dermis while deep chemical peeling implies inflammation and/or destruction to the mid reticular dermis. Deep chemical peeling is usually reserved for photoaging skin of Glogau III or IV or those with extensive wrinkling and dermal change. (Table I) (Fig 1)

Evaluation of the degree and quantity of wrinkles will direct the physician to the proper level of destruction to correct the condition with minimal morbidity and maximal safety. Deep chemical peeling thus should be reserved for the more severe form of photoaging skin. This is characterized by deep facial rhytids, perioral rhagads, periocular wrinkles and crow’s feet, leathery skin texture with deep creasescreasy skin and loss of elasticity. (Table II) Correction of this same dermal degeneration of collagen and elastic tissue requires destruction of skin to through the mid reticular dermis.3 (Fig 2)

Deep chemical peeling leads to the production of new collagen and ground substance down to a level in proportion to the depth of the peel. Facial skin will rejuvenate itself when damaged to the upper and mid reticular dermis. Injury below that level, though, will produce parallel collagen only with a loss of pilosebaceous apparatus, pigmentation and fine rhytides. This results in the complications of deep peeling – loss of natural skin texture, hypopigmentation and even contractile scar tissue. (Fig 3) It is thus important for the physician to use chemicals with the utmost care as the line of therapeutic efficacy runs very close to over-treatment and complications.

Deep peeling entails the use of either Trichloracetic Acid in concentrations above 50% or phenol-containing preparation. Both chemicals produce protein denaturation of epidermis and dermis with surface characteristics of keratocoagulation. This reaction produces the visual biologic reaction of frosting or an intense whitening of the skin surface. With TCA, the rate of onset and intensity of frosting is dependent on the concentration and quantity applied. TCA above 50% has an erratic and unpredictable level of penetration creating a significant risk for scarring and other complications. The resultant frosting can progress too quickly for the physician to control its safe penetration reliably. For this reason, TCA is not recommended for deep chemical peeling. Thus, solutions containing phenol remain the agents of choice for deep chemical peeling.

The application of pure, undiluted 88% phenol to the skin causes rapid and complete coagulation of epidermal keratin protein and is thought to produce a partial blockade for further chemical penetration. Thus, pure phenol can only penetrate to a medium depth level and is rarely used in chemical peeling because its limited penetration produces an ineffectual peel. The mixtures of phenol thus remain the available chemical solutions for deep chemical peels. There are a number of extemporaneous formulations of phenol, water and other agents but the most reliable and longest used formula is the Baker-Gordon phenol peel.

The Baker-Gordon peel utilizes phenol in a formulation that allows deeper penetration of the chemical reaction into the dermis than full strength phenol. The solution consists of:

• Septisol, (Vestal Laboratories, St. Louis, MO), a detergent, which solubilizes the other agents and breaks the lipid barrier
• Croton Oil, a vesicant epidermolytic agent that enhances phenol absorption
• Phenol, the active keratolytic agent, and
• Water, which reduces the phenolic concentration to 50 or 55% (Table III)

The more dilute solution – 50% – has greater penetration and thus peel potency than the full strength 88% straight phenol preparation. As one dilutes even further with water, the degree of penetration and potency is reduced.

The Baker-Gordon formula is well documented in the scientific literature with animal models; histology, clinical studies and long term follow up as to its efficacy and predictable results. Regeneration of new collagen with resultant skin rejuvenation has been well documented with long-term follow up studies of greater than 20 years. For this reason, the formula has stood the test of time unchanged over these 40 years.

Recent investigations by Hetter into varying the concentrations of both phenol and croton oil have suggested that the efficacy of the reaction is dependent on more than phenol concentration alone. Altering the concentration of croton oil can produce a less penetrant peel and thus reduce the risk of hypopigmentation and “alabaster skin.” (Fig 4) These and other modifications of the present Baker-Gordon formula are currently under investigation.

Phenol is a potential systemic toxin with significant systemic absorption. It is a potential cardio toxin and undergoes hepatic and renal elimination. Serum levels of phenol can rise to dangerous levels with overuse or overzealous application. For this reason, all patients undergoing full-face phenol peeling should have a complete physical examination including EKG, complete blood count with liver and renal function determinations. Any patient who has a history of cardiac arrhythmia and who is taking a medication known to precipitate arrhythmias should not undergo a full face Baker-Gordon phenol peel.

All patients undergoing full face phenol peels should be monitored and given one liter of 0.9% NACI or lactated Ringer solution prior to this peel to initiate renal diuresis dieresis. An additional liter of fluid should be administered during the peel to further eliminate systemically absorbed phenol and lower the serum concentration.

A full face Baker-Gordon phenol peel is conducted in 1-½ hours with a 15-minute waiting period between each cosmetic unit. This will protect the patient from excessive phenol absorption and elevated serum levels. Continuous electrocardiography, pulse oxymmetry, and blood pressure monitoring are mandatory during the entire operative period. If any cardiac arrhythmia occurs, the procedure should be abruptly stopped, toxicity evaluated and the arrhythmia treated. Treatment should include O2 supplementation and anti-arrhythmias.

The day of the procedure, the patient may shave and cleanse, have a light breakfast, but may not apply cosmetics. The skin is marked while the patient is seated to outline the borders of the facial peel. Although deep resurfacing procedures can be accomplished entirely with nerve blocks and anxiolytic sedatives, some patients require deeper conscious sedation during the procedure. The peel solution should be mixed fresh daily for each patient. The formula should be followed carefully and ingredients verified by a second assistant. The accuracy of the formulation is an important determining factor in the efficacy and safety of the peel. The solution is an emulsion and must be stirred prior to application. (Fig 5)

Prior to the application of the peeling solution, the surgeon must vigorously cleanse or debride the skin surface to remove residual oils, debris and excess stratum corneum. The face is initially scrubbed with 4 x 4 gauze pads containing 0.25% Ingrasan (Septisol, Vistal Laboratories, St. Louis, Missouri), then rinsed with water and dried. Acetone is then applied as a defatting and degreasing agent with moist gauze pads. A thorough cleansing and degreasing will ensure equal penetration of peel solution over the face and thus an even peel.

The peel solution is applied with cotton tip applicators, one cosmetic unit at a time. The emulsion is gently stirred and the cotton tip is dipped with a conservative amount of peeling agent. It is applied evenly over the cosmetic unit. (Fig 6) Frosting is immediate and only unfrosted areas are retreated. (Fig 7) The frosting fades rapidly to a gray brawny color and texture. The peel solution is applied over the jawline and worked into the hairline and eyebrows to give an even transition. Using the wood portion of the cotton tip, peel solution is worked into deeper rhytids and perioral rhagades. Aesthetic units are sequentially treated from forehead to cheeks, chin, nose, lips and finally the periorbital skin. Care is taken to protect the globe from peel solution. If there is accidental peel solution spillage, it should be flushed out with mineral oil rather than saline. (Fig 8)

The Peel

After the peel application, a mild emollient can be applied or the tapping procedure is immediately begun. Occlusion of the peeling solution with tape is thought to increase its penetration and extend the injury pattern. This is particularly useful for the deeply lined “weather-beaten” faces but should be done only by the most experienced physicians. The deeper penetration of taping may be responsible for the hypopigmentation and alabaster appearance proceeded in some patients. White waterproof tape (3-M Corporation) is layered by overlapping strips over the entire face. The taped mask is removed in 24 hours. The underlying necrotic tissue is liquefied making tape removal easier, but some patients require anesthesia for this second procedure.

The unoccluded technique as promoted by McCollough, relies on a greater amount of peel solution applied to obtain a similar level of tissue rejuvenation. Careful post-operative cleansing and debridement is necessary to remove the necrotic tissue in the untapped peel. (Fig 9) The incidence of hypopigmentation and “plastic skin appearance” is less with this modification.

The patient experiences an immediate burning sensation as the peel solution is applied but subsides within 20-30 minutes. It returns as a deep burning sensation over the next 6-8 hours. It is for this reason the patient receives pain medication post-operatively and would benefit from local marcaine nerve blocks. Systemic steroids (40 mg. Triamcinolone acetamide IM) are routinely given to reduce inflammation and antiviral agents are taken for 2 weeks.

The peel will take 10-14 days for reepithelialization and post-operative care is labor intensive. The patient is to soak the denuded facial skin with ¼% acetic acid compresses (1 tsp white vinegar with 1 pt warm water) to debride and cleanse 4 times a day. The acetic acid solution is antibacterial, especially against gram-negative organisms, and is aseptic as its mild acidity debrides necrotic tissue. Occlusive ointments are applied after the soaks to prevent scabbing and crusting and for patient’s comfort. (Fig 10)

Frequent post-operative visits are necessary to recognize healing problems early on and thus prevent complications. Difficulties such as post-operative bacterial or viral infection can be recognized and treated appropriately. If left untreated, it will progress to delayed wound healing with a potential for scarring.

As one may consider, patient selection is of critical importance for the deep peel. (Fig 11) The patient undergoing this procedure must be fully informed and willing to accept the inherent risk of complications, the degree of morbidity, as well as a realistic understanding of results. Excessively loose skin of the face and eyelids will not improve with peeling and will only respond to surgery. Similarly, deep grooves, cheek and tear trough “hollows” cannot be fixed by peeling but respond to filling agents. The adjunct of Botox pre-operatively will help improve the dynamic wrinkles of the forehead, glabella and crow’s feet. The Baker’s phenol peel will produce excellent results on advanced photoaging skin with rhytides and rhagades in the perioral and periorbital area. (Fig 12) Long lasting results have been documented by histology over 15 years. Comparable, if not better results than CO2 laser resurfacing in the perioral area have been demonstrated. (Fig 13)

Many patients require deep peeling only in specific cosmetic units such as the perioral and periorbital area. A combination procedure will reduce the operative morbidity by using Baker’s phenol on the perioral and periorbital skin and a medium depth peel – such as the Monheit version Jessner’s 35% TCA – on the isolated cosmetic units so that there will not be pseudo-hypopigmentation in those areas. (Fig 14) This combination will reduce the need for general anesthesia as well as the post-operative morbidity.

In the age of laser resurfacing, the deep chemical peel still offers some unique advantages in the severely photoaged skin. The results appear more complete and longer lasting. It is, thus, to the cosmetic surgeon’s advantage to have this procedure in his armamentarium for those specific patients who need this degree of resurfacing.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Mark A. Chastain, M.D.
Instructor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, AL

Resurfacing techniques popularized in the 20th century began with Kronmayer’s first description of modern dermabrasion as a technique for debriding and for treatment of scars. Kurtain and then Burke later modified it in the 40’s and 50’s and their initial wire brush techniques have been little changed to the present day. During a period of the 60’s and 70’s, deep dermabrasion was the premiere technique for resurfacing photoaging skin, acne scars and dermatologic growths. Wire brush dermabrasion with refrigerants and little usage of anesthesia made this dermatologic technique difficult for the patient to endure. In addition, the dry healing techniques of wet dry debridements and Neosporin powder to create thick crusts prolonged the healing and contributed to post-operative problems such as hypopigmentation and scarring. These problems along with the advent of controlled chemical peeling and then later in the 90’s with pulsed lasers for resurfacing greatly decreased the popularity of dermabrasion. It fell out of favor in the late 80’s and 90’s and only now is it being re-studied as to its value compared to those other techniques for superficial, medium depth and deep resurfacing.

Levels of resurfacing were first popularized by Stegman in his histologic controlled studies with varying concentrations of trichloracetic acid. He was able to divide chemical peel resurfacing into superficial and deep. The definitions became the standard index of measurement for both chemical peeling and laser resurfacing. It not only reflected the histologic level of destruction found but also the consequent degree of improvement to the condition being treated. The adage “the more you get, the deeper you go,” was confirmed with these studies and further investigators have categorized which patients with degrees of photodamage and scarring – Glogau scale, Monheit Index of Photoaging Skin – will respond to levels of skin destruction with specific procedures.

Superficial resurfacing is defined as destruction of or removal of the superficial epidermis or a major portion of the epidermis. Medium depth resurfacing involves removal of or destruction of the epidermis entirely along with a portion of papillary dermis. Deep resurfacing involves removal of or destruction of epidermis, papillary dermis and a portion of reticular dermis to the level of mid reticular dermis. Utilizing this classification, resurfacing lasers, chemical peel solutions and now dermabrasion can be classified as to the injury pattern desired.

The same measuring guide of tissue destruction now can be applied to dermabrasion with the advent of the new less invasive techniques of microdermabrasion and manual dermasanding.

Microdermabrasion involves the removal of the stratum corneum only with little disruption of the lower epidermis or basal cell layer. The most aggressive microdermabrasion may involve penetration to the basal cell layer. It, thus, is classified as a very light resurfacing technique or a superficial method of disrupting the upper epidermis. The theoretical construct of the procedures explains that the removal of stratum corneum and surface debris will stimulate a more rapid epidermal proliferation and thus a freshening in surface feel and appearance. The microdermabrasion unit’s handpiece is a closed system, which propels aluminum oxide crystals at the skin at high speeds and simultaneously removes them with suction. The units were originally developed in Europe in the 1980’s but have become commercially available in the 90’s and are now widespread in physician offices and in non-medical aesthetic spas. It is commonly indicated for superficial epidermal conditions such as acne with open and closed comedones, improving the texture of photoaging skin especially in its early phases of development, stimulating epidermal regeneration for conditions such as pigmentary dyschromias, melasma and superficial epidermal lesions. It is a “lunchtime” procedure with little or no downtime. Postoperatively, it produces erythema, edema and occasionally skin sensitivity for a number of hours. The patient, though, is well able to return to work, use make-up and daily cleansing on a regular basis almost immediately after treatment. Patients and physicians have reported improvement after repeated treatments but there is presently little objective evidence in the scientific literature of documented histologic changes in photoaging skin. Patients seem to appreciate the little downtime and the smooth texture of their skin to feel and there are many anecdotal stories of flattened rhytides, improved acne scars and even changes in striae distensi. Well-documented studies of these conditions must be done to reproduce these findings in a broader population of physicians and patients.

Medium depth abrasive injury is that in which the epidermis is destroyed and the papillary dermis is entered. Though this level of injury can be extended with microdermabrasion equipment medium depth procedures are beyond the reach of these instruments. The injury produced by microdermobrasion is not well controlled at a deeper level and can produce sequelae and side effects. For this reason, medium depth abrasive injury is generally performed with light mechanical diamond fraize dermabrasion and manual dermasanding.

Manual dermasanding involves abrading the skin by hand power using silicone carbide sandpaper or wall screen commercially available at any hardware store. It is gaining popularity for skin resurfacing because it has several advantages over power-driven dermabrasion at this level of injury. Those advantages include a greater control over depth injury, particularly on localized areas such as the lips and orbital rims. Its use in blending borders for other resurfacing techniques such as chemical peeling and laser resurfacing can be done easily as a combined procedure. It, of course, is of lower cost with greater simplicity of instrumentation and set-up than with mechanical dermabrasion or for that matter, erbium YAG laser. In comparison to mechanical dermabrasion, there is no risk of aerosolization of infectious particles during the procedure with less risk of intraoperative injury.

The depth of penetration in manual dermasanding is dependent upon the type of paper or “grit” used, the force applied by the surgeon and the duration of contact with the skin. Although it can be used to produce a wound almost as deep as wire brush dermabrasion with multiple passes, manual dermasanding is most commonly used as a medium depth or minimally deep resurfacing modality. The silicone carbide sandpaper is classified in a variety of grades: fine grade (#400), medium grade (#220-320) and coarse grade (#180). The sandpaper is cut into small pieces and then steam autoclaved. A 1 ½ x 2 inch gauze pad is moistened with saline and sandpaper wrapped around it. The sandpaper is always kept moist with saline so it will glide easily over the skin surface. Back and forth circular motions are used to gradually abrade the skin layer by layer through the epidermis and into the papillary dermis. Blending of traumatic scars, acne scars and post surgical scars can be obtained with dermasanding and without the use of a refrigerant. The skin is stretched tightly and the skin is abraded with both back and forth and circular motions. The surgeon chooses the grade necessary to obtain the results desired. Fine grit sandpaper is used for blending purposes, to remove necrotic debris after laser resurfacing and over demarcation zones of other procedures for blending. This is especially true after laser resurfacing to blend the upper third of the neck, the hairline, the eyebrows and areas of eyelid skin. It is also used after a Jessner – 35% TCA chemical peel in selective areas where deeper injury is necessary to remove and blend perioral rhytids and periorbital crow’s feet. It can also be used to remove the thick epidermal lesions that medium depth chemical peeling cannot remove. The opportunity of using this simple tool as an adjunct in our other skin resurfacing procedures is widespread and open to the imagination of the surgeon.

Deep abrasive resurfacing techniques are mechanical dermabrasion, both diamond fraize and wire brush. A topical refrigerant spray is used to produce anesthesia and harden the skin prior to abrasion. It immobilizes the topographic features so that there is no distortion by the pressure of the abrasive instrument. The wire brush is composed of small caliber stainless steel wires that project from the curved side of the cylindrilical hub producing micro incisions as it removes superficial skin. The diamond fraize consists of a stainless steel cylinder to which industrial grade diamonds are bonded to create an abrasive surface. There continues to be debate over which item is best for which condition but both can be used for deep abrasive resurfacing. The technique is generally accepted as the primary method for treating acne scars. Motorized dermabrasion is best suited for full-face resurfacing though it can be used for localized spot dermabrasion. Conditions amenable and best treated by mechanical dermabrasion include acne scars, surgical or traumatic scars, epidermal growths especially hyperkeratotic actinic keratoses and rhinophyma.

Now that we have a decade of experience with laser resurfacing, the two methods can be compared back to back. Though laser resurfacing does produce better results on thin and atrophic skin such as eyelids, results are comparable to other areas such as photoaging lips and cheeks. A comparable depth dermabrasion will heal faster than a similar laser resurfacing with less postoperative erythema and less risk of post inflammatory hyperpigmentation. This is because abrasive injury does not create thermal damage, which will produce pigmentary dyschromias. It, though, will not have the salutary effect of thermally induced collagen contraction that improves the final phase of laser resurfacing. Thus the resurfacing laser has an advantage in the treatment of photoaging skin with thermally induced collagen contraction. Conversly, dermabrasion can sculpt irregular skin surfaces and is the choice agent for acne scars and surface contour deformities.

In summary, we now have brought dermabrasion into the new millennia. Its purpose and function is well appreciated as both a superficial, medium depth and deep resurfacing technique and its applications will continue to grow as we learn to combine our present resurfacing techniques.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Botulinum type A neurotoxin has been available in the United States and Europe to treat a variety of neuromuscular disorders of spasm, spasticity and muscular rigidity. While Botox has been manufactured and studied in the US since 1985, Dysport has been studied in Europe since 1988. Manufactured by Ipsen Pharmaceutical in the U.K., the toxin is produced from separate incubator vats of clostridium Botulinum than the North American product. The final clostridium Botulinum toxin type A hemogglulinin complex from European vats – Dysport – thus has distinct attributes and characteristics different from that of its North American cousin, Botox. (Table I) The molecular weight of the toxin is the same (150K DA) as well as bulk active substrait of the hemogglulinun complex. The pharmacologic composition, though, differs in that Dysport is accompanied 125-µ gm human serum albumin with 2.5 mg lactose while Botox has 500-µ gm human serum albumin in 0.9 mg sodium chloride. Dysport is currently registered in 60 countries worldwide including all European union countries and currently under investigation in the United States.

In 1990, the toxin was first approved for blepharospasm and hemifacial spasm and in 1992 for spasmodic tortocolis. Leg and arm spasticity approved second in 2000 and 2001 with approval also for cerebral palsy. Approval for cosmetic indications was first granted for glabellar frown lines in 2002 (Argentina, Brazil, Columbia and Uruguay). Further clinical cosmetic studies for glabella, forehead and periorbital rhytids have been performed in Europe and the United States during the last four years. Efficacy and dose ranging studies will be summarized.

Dysport is a Botulinum A hemagglutinin neurotoxin and its action is similar to that of Botox. The toxin is a single chain protein with a light and heavy chain. The heavy chain targets the linking molecule to the cholinergic nerve ending while the light chain cleaves SNAP-25 inhibiting exocytosis of acetylcholine.(Fig 1)

BTX-A toxin is measured in units of physiologic action, as either Botox versus Dysport units. Though the units are not interchangeable, various published reports support a conversion ratio from 1:5 to 1:3. Units of potency and thus dilution should be evaluated independent of the Botox product.

The standard dilution of 500 Dysport units is performed with 2.5 ml saline solution. Dose ranging studies for cosmetic usage have varied this dilution ratio to both a higher and lower concentration. Ascher performed a multicenter, randomized double-blind placebo controlled study of efficacy and safety of each dilutional doses of Botulinum toxin A (Dysport) for the treatment of glabellar lines. The 119 patients were from 18-70 years of age with moderate to severe glabellar frown lines and no prior anesthetic treatment. The dosages used were: placebo, 25, 50 and 75 units in a double-blind control. They were injected in five controlled glabellar sites targeting the obicularis pars frontalis, the corrugators and the procerus muscle, each with appropriate divided units. (Fig 2) Outcome measurements were assessed from blinded standardized photographs, investigator assessments and patient evaluation. These were compared to a rating scale 0-4 of glabellar lines as follows: 0=no lines; 1=mild lines; 2=moderate lines; 3=severe lines.(Fig 3) A responder was defined as 0:1 on the rating scale. The results indicated that all groups except placebo showed a response at one month and at three months. At six months, approximately two-thirds of the BTX-A treated patients were still responders. (Fig 4) Though the primary statistical analysis was performed at rest, the assessment at maximal frown was similar up to three months confirming the activity of BTX on the glabellar musculature.

The safety protocol was favorable with a 7.0% rate of adverse events, all mild and reversible. Headache was the most common with all resolving within two to ten days. There were no reported cases of blepharoptosis or diptopia. The conclusions indicated the BTX-A (Dysport) was an effective cosmetic treatment for glabellar lines as evaluated by independent photographic analysis and investigator assessment. The result suggested that 50 units was the optimal dosage for the glabella and with 10 units injected into each of five glabellar sites. Most interesting was the long-term result indicating that 1/3 of the patients treated were still responders at six months.1 (Fig 5) Other studies by Asher have indicated similar results of efficacy and safety for BTX-A (Dysport) in other locations including the forehead and crow’s feet.

Inamed – Ipsen designed a multicentered North American study to evaluate three doses of BTX-A (Dysport) to determine the optimal dose in reducing the severity of hyperfunctional glabellar lines for efficacy and safety. A total of 373 patients were tested with the following dosages in a double-blind placebo-controlled dose-ranging study: 20, 50 and 75 units – Dysport. A validated scale was developed both at rest and maximal frown. Each scale was comprised of four photographs, grade 0 to 3: 0=no wrinkles; 1=mild wrinkles; 2=moderate wrinkles; 3=severe wrinkles. Live assessment was used in this study as it was considered to have advantages over photographic evaluations. The assessor was able to note the level of effort being made by the patient in the act of frowning and truly note the dynamic nature of frowning. Thus – at maximal frown – the dynamic act of frowning is an indicator of pharmacologic activity of the toxin that cannot be truly evaluated by a static photograph. The live assessment of maximal frown proved more objective than photographs in which factors of lighting and position can blur the accuracy of assessment. An additional assessment at rest was also made on a 0 to 4 scale. The resting phase was felt to represent how the patient appeared in daily life and thus corresponded to treatment efficacy and patient satisfaction. A responder was defined as a patient with a rating of 0-none or 1-mild on day 30. Evaluations though were continued until day 120, or 4 months. (Fig 6, Fig 7)

A further language descriptor of glabellar wrinkles was formulated as much confusion has arisen in the literature concerning wrinkles, lines and grooves. The definitions at maximal frown were as follows:

• Relaxed Skin Tension Line – no wrinkle
• Wrinkle Line – a line visualized on the skin no greater than .2 mm. in diameter and no greater than 2 cm. in length – either dynamic or photoaging with no appreciable visible depth.
• Wrinkle Crease – a wider line visible on skin with diameter .5-1 mm and 1 to 3 cm in length with no noticeable depth as perceived by shoulders on either side of the skin-divided crease.
• Wrinkle Furrow – 1-2 mm. bulging on either side with deformity of surrounding shortening and dynamic movement

The results indicated that all doses of Dysport resulted in a statistically better response in the appearance of glabellar frown lines compared with placebo. Twenty units – the smallest dose – was effective at 30 days and remained apparent at 90 days but not at 120 days. Fifty units Dysport was found to be as effective as 75 units, Dysport for efficacy and duration. Close to half the patients continued to show an effect at 120 days. In this study, greater benefit was found among women than in men.

All doses were well tolerated with only minor side effects including headache, needle pricks and bruising but blepharoptosis was observed in only three patients. Of those reported cases, only one demonstrated to the investigator a true clinical ptosis. Ptosis had been reported in other product studies but not in other studies involving Dysport.

Antibody production has always been of concern with clinical usage of Botulinum toxin, but studied only with cervical dystonia. None of the patients in this study showed any evidence of neutralizing antibodies either at baseline or on follow up evaluations. From these observations, the 50-unit dosage was recommended as the optimal dose for safety and efficacy.

Dysport is best injected for cosmetic indications with Diablo or tuberculin syringes, 1.0 ml or 0.5 ml and using a 30-gauge needle. The standard dilution of 500 units per vial is best performed with 2.5 ml. of saline, bactereostatic. This produces a clinical usage concentration of 10 units Dysport per 0.05/ml, an easily measured quantity in the 1 ml tuberculin syringe. Thus, for the glabellar injection, aliquots of 10 units per 5 sites are easily administered. (Fig 8, Fig 9)

The forehead is best treated through five injection sites located at mid forehead at a distance of at least 2.5 cm above the brow. A dosage of 40 to 60 Dysport units is effective for forehead wrinkle relaxation. The lateral forehead injection site should be above the highest point of the outer one-third of the brow. This will prevent an undesirable lateral brow elevation, the “Mephisto look.”

Laugh lines or crow’s feet are treated with 30 units of Dysport injected lateral to each orbital rim. The injection sites are 1.0 cm lateral to the orbital rim in the three positions, representing the muscle bulges, superior, mid and inferior. Care must be taken not to inject the upper or lower lid obicularis muscles as ptosis or ectropion can result.

Lower eyelid wrinkles formed from an overactive or hypertrophic obicularis muscle can be treated judiciously with 3-4 units Dysport injected in the lower lid at the mid papillary line just below the tarsal plate. This will flatten the bulging muscle and create an image of “open eye.” Overaggressive treatment may, though, create an unwanted ectropion.

Areas of the lower face have been treated with similar results as those found with Botox. These include vertical rhagades of the upper lip, marionette lines at the corners of the mouth and chin wrinkles. Dosages should be conservative relying primarily on dermal fillers and only using chemodenervation as a secondary procedure. (Table II)

The activity of BTX-A for cosmetic usage has been firmly established in North America with Botox. Similarly, the use of BTX-A Dysport is also proving to be an effective agent for cosmetic usage for glabellar, forehead and crow’s feet under objective controlled studies. Most recent studies will show us differences in the two products as to time of onset, longevity, clinical application and technical usage. The objective evaluations in these studies should add much valuable data to our true understanding of Botulinum toxin.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Soft tissue augmentation has increased in popularity as minimally invasive procedures have surged to the forefront in a cosmetically elegant and time-sensitive society. Although many filler substances have been developed for soft tissue augmentation, no perfect filler exists. Each dermal filler has its own niche based on its inherent properties. Different fillers require specific injection techniques as well as amount of correction needed to achieve optimal results. In general, each filler has similar risks as well as its own unique set of risks. It is the physician’s responsibility to know the risks and benefits of each filler substance as well as which filler or fillers is best suited for the patient’s specific contour irregularities. At times in order to obtain the best results, fillers should be layered with denser fillers injected deeper into the dermis and finer fillers in the upper dermis. Correction of contour defects over areas of high movement can be prolonged with underlying muscular paralysis by adjuvant therapy with Botox. It is important that the patient has realistic expectations of what can be achieved with fillers and other adjuvant therapy.

Injectable bovine collagen was developed in the 1970s. Today bovine collagen (Zyplast) remains the gold standard for which other filler products are compared. Permanent injectable collagen, Artecoll, was developed as a long lasting alternative to Zyplast. Recent advances in filler substances include human derived collagen (Cosmoderm and Cosmoplast), hyaluronic acid derivatives (Restylane and Hylaform), calcium hydroxylapatite microspheres (Radiance FN), and polylactic acid microspheres (Sculptra).

Bovine Collagen Derivatives: Zyderm and Zyplast (McGhan Medical Corporation)

Key Points

• Zyderm and Zyplast were the first FDA approved injectable bovine collagen products in the United States, being approved in 1982 for correction of soft tissue deformities of the dermis. Bovine collagen is processed from the hides of isolated herds of domestic Angus/Hereford cattle fed fresh grass or grains in California, thereby negating the possibility of contamination with bovine spongiform encephalopathy virus or prion that causes mad cow disease. Carruthers J and Carruthers A. Mad cows, prions, and wrinkles. Arch Dermatol/Vol 138, May 2002, p667-670.
• Zyderm is a purified bovine dermal collagen that is dispersed in phosphate-buffered physiological saline containing 0.3% lidocaine. It is available in two forms, Zyderm 1 and Zyderm 2 with Zyderm 2 containing almost twice the collagen concentration as Zyderm 1. Zyderm contains 95-98% type I collagen and the remainder is type III collagen. Zyderm is best used for the correction of fine lines. Package insert for zyderm
• Zyplast is a collagen implant composed of purified dermal bovine collagen that is lightly crosslinked with glutaraldehyde and dispersed in a phosphate-buffered physiological saline containing 0.3% lidocaine. Zyplast is best used for augmentation of deeper rhytides or grooves. Package insert for zyplast
• Before administration of the bovine collagen derivatives, a test implantation is required which consists of a 0.1 cc injection of Zyderm into the volar forearm. The test site is monitored over a four week period. If erythema, induration, tenderness, or edema occurs, the patient is considered sensitive to the injection and the use of bovine collagen in contraindicated. If the results are equivocal, a second test syringe should be used on the opposite arm and monitored for four weeks. Elson ML. The role of skin testing in the use of collagen injectable materials. J Dermatol Surg Oncol 1989;15:301-3.
• Approximately 3.0% of those patient’s tested have a sensitivity to bovine collagen and therefore treatment is contraindicated. Approximately 1.3% of patients developed transient localized adverse reactions. If hypersensitivity occurs, it is usually within 1-2 weeks of treatment. Watson W, Kay RL, Klein AW, et al. Injectable collagen: a clinical overview. Cutis 1983;31:543-6.

Reports of adverse events with bovine collagen:

Reactivity to bovine collagen has been noted even with a negative test implantation site. A study done by ML Elson verified that of 188 patients, 3% demonstrated hypersensitivity to the test implant. Further observation concluded that treatment with Zyderm and Zyplast collagens in patients with a negative skin test resulted in 6 hypersensitivity reactions and in these patients reactions were not observed to Zyplast treated sites but to those treated with Zyderm.
Elson ML. Clinical assessment of Zyplast Implant: a year of experience for soft tissue contour correction. J Am Acad Dermatol. 1988 Apr;1894 Pt 1):707-13.

Localized hypersensitivity reactions may occur in 3-35% or treated individuals. Symptoms include erythema, induration, discoloration, or pruritus of the treatment site. Eighty percent of these reactions occur within four weeks after administration.
Rare cases or long-term sequelae including firmness or discoloration have been reported.

Systemic hypersensitivity reactions have rarely been reported generally occurring within 48-72 hours after injection. Fever, malaise, and urticaria are common. Treatment is with systemic steroids and several months of therapy may be needed. Rare granulomatous reactions consisting of palpable nodules have been reported. Rarely the hypersensitivity response has progressed to a cystic reaction which may drain purulent material. These reactions develop weeks to months following injection and may result in scar formation. This type of reaction can occur as multiple and/or recurrent sterile abscesses which tend to be persistent and resistant to drug therapy. Incision and drainage has been a useful treatment.
Stegman SJ, Chu S, Armstrong RC: Adverse reactions to bovine collagen implant: Clinical and histologic features. J Dermtol Surg Oncol 14(Suppl):39-48, 1988

Labow TA, Silvers DN: Late reactionsat Zyderm skin test sites. Cutis35:154-158, 1985. Overhold MA, Tschen JA, Font RL: Granulomatous reaction to collagen implant, light and electron microscopic observations. Cutis 51:95-98, 1993.

Cucin RL, Barek D: Complications of injectable collagen implants .Plast Reconstr Surg 71:731, 1983.

Treatment of Hypersensitivity Reactions

Other case reports in the literature verify that despite adequate pretreatment testing, allergic reactions due to bovine collagen hypersensitivity can develop. Treatment of these reactions includes topical steroids and/or tacrolimus and oral antihistamines. If needed injected steroids or oral steroids can be used. One case report concluded that oral cyclosporine may be a safe and effective treatment for hypersensitivity reactions. As the collagen implant degrades, the hypersensitivity reaction should lessen, however Brooks reported a foreign body granuloma persisting for ten months at a second test implantation site on the forearm after her first test site two weeks earlier showed equivocal results.

Moody BR, Sengelmann RD. Topical tacrolimus in the treatment of bovine collagen hypersensitivity. Dermatol Surg. 2001 Sep;27(9):789-91.
Baumann LS, Kerdel F. The treatment of bovine collagen allergy with cyclosporine. Dermatol Surg. 1999 Mar;25(3):247-9.

Brooks N. A foreign body granuloma produced by an injectable collagen implant at a test site. J Dermatol Surg Oncol. 1982 Feb;8(2):111-4.
Barr RJ, King RD, McDonald RM, et al: Necrobiotic granulomas associated with bovine collagen test site injectio.s. J Am Acad Dermatol 6:867-869, 1982.

Due to the reactivity to injectable bovine collagen, a new injectable collagen was developed, CosmoDerm and CosmoPlast, with the goal of less antigenicity and therefore a better safety profile. A pre-test screening to rule out sensitivity is not required.
Non-bovine collagen: CosmoDerm and CosmoPlast (INAMED Corporation)

Key Points:

• CosmoDerm and CosmoPlast, which were FDA approved in 2003, are made from a human fibroblast derivative. Both products are used similarly to Zyderm and Zyplast respectively.
• Cosmoderm collagen implants are dispersed in phosphate-buffered physiological saline containing 0.3% lidocaine and are available in two forms: CosmoDerm 1 and Cosmoderm 2. Cosmoderm 2 contains approximately twice as much collagen as CosmoDerm1.
  Package insert cosmoderm
• CosmoPlast collagen implant is crosslinked with glutaraldehyde and dispersed in phosphate-buffered physiological saline containing 0.3% lidocaine.
  Package insert CosmoPlast
• Both CosmoDerm and CosmoPlast are human-based collagen implants. These injectable collagen products are less antigenic than their bovine counterparts and safety tests have deemed them free of any pretreatment test injections. Patients should still be counseled as to the risk and benefits of injectable human collagen which may be similar to but much less common than with bovine collagen.

Injection technique of Collagen:

• Zyderm and CosmoDerm
  • Zyderm and CosmoDerm are injected into the superficial papillary dermis into the plane of the deformity with insertion or withdrawal of the needle. The serial puncture technique can also be employed at 1 to 3 mm intervals. Blanching should occur with injection and if this does not occur, the substance is likely being injected too deeply in the dermis. After injection, a transient or minimal amount of edema, erythema, and discomfort is expected with should quickly resolve.
  • When using Zyderm 1 and CosmoDerm 1, overcorrection to 1.5-2.0 times the initial depth of the lesion is recommended due to the loss of saline in the suspension with time.
  • A lesser degree of overcorrection of Zyderm 2 and CosmoDerm 2 is needed to achieve correction. Care should be taken around the periorbital area and vermilion which require less of a correction as the material is slow to resolve.
• Zyplast and Cosmoplast
  • Zyplast and CosmoPlast are injected into the mid to deep dermis and should be injected so that it is more felt than seen. Either can be injected while inserting or withdrawing the needle through this plane. No blanching should occur. The area should be corrected 100% but not more.
    Klein AW. Indications and implantation techniques for the various formulations of injectable collagen. J Dermatol Surg Oncol 1988;14 (Suppl. 1):27-30.
    Package insert for Zyderm, Zyplast, CosmoDerm, CosmoPlast.

Longevity

Studies have shown that after injection of collagen products, the suspended collagen forms a network of fibers that over a period of time becomes colonized by host connective tissue cells taking the texture and appearance of normal tissue.
Correction achieved by collagen lasts 3-5 months with repeat maintenance injections required after this. Longevity of the products is increased if the area injected is static.
Knapp TR, Luck E, Daniels JR. Behavior of solubilized collagen as a bioimplant. J Surg Res 1977;23:96-105.

Pearls and General Information

• Zyplast and Cosmoplast are not recommended for use in the periorbital or glabellar areas. Collagen can initiate platelet aggregation and if implanted into dermal vessels may cause vascular occlusion, infarction, or embolic phenomenon.
• Firm massage of the injection site can reduce lumpiness.
• Reports of connective tissue diseases occurring subsequent to collagen injections in patients with no previous history of these disorders have been written. Conflicting studies have been published regarding the association between polymyositis and dermatomyositis and injectable collagen. A casual relationship has not been established. A thorough history and physical exam should be done on each patient. Caution should be used in a patient who has a family or personal history or collagen vascular disease.
  Cukier J, Beauchamp R, Spindler J, Spindler S, Lorenzo C and Trentham D: Association implants and a dermatomyositis or a polymyositis-like syndrome. Ann Internal Med 118:920-928, 1993.
  Rosenberg M and Reichlin M: Is there an association between injectable collagen and polymyositis/dermatomyositis? Arth Rheum 37:747-753, 1994.

Polymethyl-methacrylate: Artefill (Artes Medical)

With the advent of Zyplast, the popularization of dermal fillers began. One disadvantage noted with Zyplast was the need for frequent reinjections to obtain maximal results. Therefore a filler with more permanency was sought. Polymethyl-methacrylate (PMMA) microspheres, found in bone cement, were purified and combined with a collagen solution acting as the carrier material for the microspheres to avoid lumpiness and aid in injection. These microspheres provide a scaffold to promote our own bodies deposition of connective tissue. Since 1994, this suspension of purified PMMA microspheres in bovine collagen has been distributed under the trade name Artecoll. Clinical trials in the United States were completed in September 2001 and in 2003, the FDA advisory panel recommended marketing approval of Artecoll which will be marketed under the trade name of Artefill in the United States. Artefill is a suspension of 20% PMMA microspheres of 30 to 42 micrometers diameter in 80% bovine collagen solution produced from calf hides. The mixture contains lidocaine.
Lemperle G, Ott H, Charrier U, Hecker J, Lemperle M. PMMA microspheres for intradermal implantation. I. Animal research. Ann Plast Surg 1991:26:57-63.
Lamperle G, Gauthier-Hazan N, Lemperle G. PMMA microspheres (Artecoll) for long-lasting correction of wrinkles: refinements and statistical results. Aesthetic Plast Surg 1998;22:356-65.
Hamilton D. A pilot study of the first patients treated in United States with Artecoll implantation for the aging face. Cosmet Dermatol 200: 147-51.

Artefill is designed for implantation into the deep reticular dermis under areas of well defined wrinkles or furrows. The viscosity of Artefill is three times higher than that of Zyplast and is more technique sensitive than injecting collagen. In addition to adverse events similar to those of bovine collagen there is a low but true risk of allergenicity to the PMMA microspheres. Allergic reaction can occur with Artefill even with a negative test site. Due to the persistence in tissue, patients may have a prolonged allergic response. Patients who form keloids and hypertrophic scars may form scarring at the site of injection due to a tissue reaction around the PMMA microspheres and therefore caution should be heeded in these patients.
Lemperle G, Romano J, Busso M. Soft Tissue Augmentationwith Artecoll: 10-Year History, Indications, Techniques, and Complications. Dermaatol Surg 2003;29:573-587.

Hyaluronic Acid: Restylane (Medicis Aesthetics, Inc) and Hylaform (Genzyme Corporation)

Hyaluronic acid is a glycosaminoglycan polymer found in the skin. It is found ubiquitously in mammalian connective tissue and decreases with aging. Its primary function is to provide volume and pliability to the skin. Hyaluronic acid is a high molecular weight polymer composed of repeating dimers of glucuronic acid and N-acetyl glucosamine on a protein backbone. Its shape is much like that of a bottle brush with each sugar residue radiating outward and densely filling the space around the protein core. A unique characteristic of hyaluronic acid is its binding capacity of water. The repeating sugar moieties can bind 1000 times their own volume of water. Hyaluronic acid is chemically, physically, and biologically identical in the tissues of all species which increases its chance of biocompatability. Its viscoelastic properties make it a desirable agent for soft tissue augmentation. Hyaluronic acid undergoes isovolemic degradation. This type of degradation allows the product to hold more water the less concentrated it becomes, maintaining its correction even in low presence of the material.
Goa KL, Benfield P. Hyaluronic acid. A review of its pharmacology and use as a surgical aid in ophthalmology and its therapeutic potential in joint disease and wound healing. Drugs 1994;47:536-66.

Restylane and Hylaform are injectable hyaluronic acid derivatives. They were developed primarily as an alternative to collagen injections for augmentation. One of the advantages to injectable hyaluronic acid derivatives versus collagen is the potential longevity of the product in tissue. Restylane and Hylaform were approved by the FDA in December 2003 for treatment of facial wrinkles. When seeking FDA approval, the safety and effectiveness of Restylane for the treatment of nasolabial folds was compared to Zyplast in a randomized, controlled study. One nasolabial fold was injected with Restylane and one with Zyplast to optimal correction. Less volume of Restylane was required to achieve optimal correction. The side effect profile after injection between both products was similar. The patients were evaluated at six months to compare longevity of the products. The FDA panel found Restylane comparable to Zyplast. Two independent scales of wrinkle assessment evaluated by a blinded investigator done at six months after injection revealed that Restylane was superior in 57% and 62% of patients while Zyplast was superior in 10% and 8% of patients. This study was published in Dermatologic Surgery where it was concluded that Restylane provided a more durable aesthetic improvement.
Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S. A randomized, double-blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial folds. Dermatol Surg. 2003 Jun;29(6):588-95.

Hylaform was also compared to Zyplast with respect to safety and longevity in FDA trials over a twelve week period. The FDA panel found Hylaform comparable to Zyplast. In the investigational trials, Genzyme excluded patients allergic to avian materials composing the hyaluronic acid gel from their study, and because of this, the FDA panel stipulated that assessment of avian protein allergies should be required before injection, either through a test or confirmation of history. However, this argument was refuted and hyalaform was released onto the market shortly following Restylane and does not require a pre-test injection.

The major difference between the hyalunonic acid injectables is their origin, composition and cross-linkage. Restylane, produced by bacterial fermentation, has a lower molecular weight but a higher concentration (20 mg/ml), and its viscoelastic properties have a more viscous tendency. Hylaform, produced by extraction from rooster combs, has a higher molecular weight but a lower concentration (6 mg/ml) and its viscoelastic properties have a more elastic tendency.
Duranti F, Salti G, Bovani B, Calandra M, Rosati ML. Injectable hyaluronic acid gel for soft tissue augmentation. A clinical and histological study. Dermatol Surg. 1998 Dec;24(12):1317-25.

Restylane is a gel of hyaluronic acid generated by Streptococcus species of bacteria, chemically cross-linked with BDDE, stabilized and suspended in physiologic buffer at pH = 7 and concentration of 20 mg/ml. Restylane is indicated for mid-to-deep dermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds. There are three separate products made from the above streptococcus bacteria: Restylane, Restylane Fine Line, and Perlane. Restylane Fine Line is used for correcting thin superficial lines. Perlane can be used for shaping facial contours, such as the cheeks and chin, correcting deep folds, and for volume augmentation of the lips.

Hylaform (hylan B) is a sterile, nonpyrogenic, transparent gel implant composed of cross-linked molecules of hyaluronan generated from the hyaluronic acid of domestic rooster combs at a concentration of 6.0 mg/ml. Hylaform is indicated for correction of soft tissue contour deficiencies, such as wrinkles an acne scars. There are three products in this line: Hylaform, Hylaform Plus (used for shaping facial contours), and Hylaform Fineline (used for thin superficial lines).

Restylane and Hyalaform are injected in the mid to deep dermal plane. Before injecting, the material should be advanced to the tip of the needle by gently applying pressure to the plunger of the syringe. The needle should be advanced under the area to be filled and the substance should be injected while pulling the needle back. Serial puncture injections and/or the tunnel technique can also be used to achieve the desired affect. The wrinkle should be eliminated after the injection. Correction should be 100% with no overcorrection needed. After injection, the area should be gently massaged and molded into the contour of the surrounding tissues. If overcorrection has occurred, a firm massage can help to mold the contour to a desirable affect. If blanching occurs with injection, downward pressure and firm massage can push the filler more deeply into the tissue. Additional treatment with Restylane may be needed to maintain optimal correction. The patient should return to clinic for evaluation at least two weeks after injection. Occasionally a fairly exuberant inflammatory reaction occurs with injection which subsides within a few days. This is more commonly seen with Restylane than with Hylaform. An ice pack can be used for pain and control of inflammation after injection.

Synergestic affects of cosmetic procedures have been reported. In 2003, an article comparing the treatment of glabellar furrows with Restylane alone versus treatment with both Restylane and Botox was done. This study revealed that the median time for the return of preinjection furrow status occurred at 18 and 32 weeks in the Restylane alone and the Restylane and Botox treated groups respectively. By paralyzing the musculature underlying the glabella, the movement that caused the furrows to occur is eliminated. This musculature movement may decrease the longevity of injectable products by allowing them to shift and be pushed toward the subcutaneous tissue rendering them unable to fill out the dermal tissue.
Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonaminal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg. 2003 Aug;29(8):802-9.

Although the injectable hyaluronic acids seem as though they should be almost free of side effects this has not proven to be true. It is true that there are fewer allergies to hyaluronic acid injectables than with injectable collagen (allergy to bovine-derived collagen: 3-4% ), however side effects are occurring and the question of whether human anti-hyaluronic acid antibodies occur has been raised. In a study done by Lowe et al, of the 709 patients treated with injectable hyaluronic acid, the incidence of allergy was found to be 0.42%. Another study done by Friedman et al, of 144,000 patients who received a hyaluronic implant had an incidence of adverse events of 0.15%. There have been several reports of granulomatous foreign body reaction of the lip after hyaluronic acid injection. Delayed hypersensitivity reactions have been seen in patients and verified by challenge skin testing. Hypersensitivity is an inflammatory reaction has been observed with edema, erythema, tenderness, induration, and rarely acneform papules at the sites of injection. To date, no systemic reactions have been directly correlated to hyaluronic acid injectables. Although no systemic symptoms have been directly linked, some have advocated for a pretreatment skin test to rule out allergy before treatment with these agents can be administered.
Micheels P. Human anti-hyaluronic acid antibodies: is it possible? Dermatol Surg. 2001 Feb;27(2):185-91.
Lowe N, Maxwell CA, Lowe P, Duick M, Shah K. Hyaluronic acid skin fillers: adverse reactions to skin testing. JAAD 2001;45:930-3.
Friedman PM, Mayfong EA, Kauvar AN, Geronemus RG. Safety data of injectable nonamincal stabilized hyaluronic acid for soft tissue augmentation. Dermatol Surg. 2002 Jun;28(6):491-4.
Fernandez-Acenero MJ< Zamora E, Borbujo J. Granulomatours foreign body reaction against hyaluronic acid: resport of a case after lip augmentation. Dermatol Surg. 2003 Dec;29*12):1225-6.
Lupton JR, Alster TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Derm Surg 2000;26:135-7.
Raulin C, Greve B, Hartschuh W, Soegding K. Exudative granulomatous reaction to hyaluronic acid. Contact Dermatitis. 2000 Sep;43(3):178-9.

Calcium Hydroxylapatite (Radiance: Bioform)

Calcium Hydroxylapatite (CaHA) is an inorganic substance that mimics the structure of bone. In the United States, it is marketed as Radiance. Radiance is currently FDA approved for use in oral maxillofacial defects and for soft tissue vocal fold augmentation and as a radiographic tissue marker. CaHA is currently widely used in Europe as a soft tissue filler. Radiance is currently not approved in the United States by the FDA for cosmetic applications and can only be used as an off-label use for soft tissue augmentation.

In its soft tissue injectable form, CaHA microspheres are suspended in a carboxycellulose absorbable gel, and it is injected into the dermis or subcutaneous tissue. As the gel is absorbed, collagen deposition into and around the microspheres causes collagen formation and enhances augmentation. It is expected to last between two to five years and its break down products include calcium and phosphorous.
Sklar JA, White SM. Radiance FN: a new soft tissue filler. Dermatol Surg. 2004 May;30(5):764-8.

Poly-L-lactic Acid: Sculptra/New Fill (Dermik)

Poly-L-lactic acid (PLLA) received conditional FDA approval for treatment of HIV-related lipoatrophy under the trade name Sculptra on March 2004. However, the FDA has not yet approved Sculptra for general cosmetic use in the United States. Studies of this product are currently underway to gain FDA approval. Poly-L-lactic acid has been marketed as New-Fill in Europe since November 1999.

PLLA is a synthetic polymer which is resorbable, biocompatible, and biodegradable. It has been used for several years in multiple medical devices and is a component of vicryl suture. PLLA can be injected into the deep dermal tissue or subcutaneous tissue. The area to be filled should be undercorrected. After injection, gradual degradation takes place by hydrolysis while gradual deposition of collagen occurs. A study by Gogolewski et al was done to assess changes in tissue in rats after subcutaneous implantation of PLLA. Biopsies were taken at 1, 3, and 6 month intervals. It was found that the PLLA degraded by 6%, 32%, and 58% at 1, 3, and 6 months respectively. It was also found that the amount of collagen present in the specimens increased with each progressive biopsy.
Nayak, PL. Biodegradable polymers: opportunities and challenges. JMS Rev Macromol Chem Phys, 1999, C39(3):481-505
Gogolewski S, et al. Tissue response and in vivo degradationof selected polyhydroxyacids: polylactides (PLA), poly(3-hydroxybutyrate) (PHB), and poly(3-hydroxybutyrate-co-3-hydroxyvalerate) (PHB?VA). Jouranl of Biomedical Materials Researach, 1993,27(9):1135-48.

The initial apparent correction, due to implantation of the PLLA decreases over the next few days as the diluent is resorbed. The area treated with PLLA will then slowly refill as the tissue reacts to the implant. A gradual increase in the volume will continue to occur over the next few months.

The side effects of this material are similar to other injectables and include erythema, edema, and bruising at the injection site. Palpable but nonvisible subcutaneous nodules have been noted in some patients which can resolve spontaneously. These nodules may be due to over-correction. Massaging the treated area after injection may reduce the incidence of this side effect. Rare cases of sterile abscess, late granuloma formation and hypersensitivity reactions have been reported.
Moyle GJ, Lysakova L, Brown S, Sibtain N, Healy J, Priest C, Mandalia S, Barton SE. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection.
Lombardi T, Samson J, Plantier F, Husson C, Kuffer R. Orofacial granulomas after injectionof cosmetic fillers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med. 2004 Feb;33(2):115-20.
Valantin MA, Aubron-Olivier C, Ghosn J, Laglenne E. Pauchard M, Schoen H, Bousquet R, Ktz P, Costagliola D, Katlama C. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open label study VEGA. AIDS. 2003 Nov 21;17(17):2471-7.

Biocompatibility and Durability of Ten Injectable Fillers

A study of ten injectable filler substances used for soft tissue augmentation was conducted to assess both biocompatibility and durability of each substance. Each filler was injected deep intradermally into the volar forearm (0.1 cc) and reviewed for clinical reaction and permanence. At 1, 3 ,6, and 9 months the test sites were excised, histologically examined, and graded according to foreign body reactions classification. The histologic grading system consisted of Grades I through IV, with Grade I representing slight reaction with a few inflammatory cells and Grade IV representing granuloma with encapsulated implants and clear foreign body reaction. Collagen (Zyplast) was phagocytosed at 6 months and resulted in a Grade I inflammatory reaction. Hyaluronic acid (Restylane) was completely phagocytosed at 9 months and resulted in a Grade II inflammatory reaction. PMMA microspheres (Artecoll) had encapsulated with connective tissue, macrophages, and sporadic giant cells (Grade III). The injected substance remained visible clinically throughout the study. Polylactic acid microspheres (New-Fill, Sculptra) induced a mild inflammatory response clinically and persisted 9 months in tissue. Calcium hydroxylapatite microspheres (Radiance FN) induced almost no foreign body reaction but were absorbed by the skin at 12 months where it became whitish and shining through the skin. PMS 350 (Silicone) dispersed into the surrounding tissue and resulted in an intense inflammatory response. Reviderm intra (dextran beads) injection caused swelling an erythema continuing for 10 days with edema persisting for more than 3 months. Histologically it also produced the greatest amount of granulation tissue. Dermalive (hydroxyethyl-methacrylate persisted clinically 4 months and showed the least cellular reaction of all implants. Aquamid (clear gel of polyacrylamide) is used for breast augmentation in Ukraine and China. This product remained palpable at 9 months but steadily decreased in size. The histological reaction resembled that of injected fluid silicone. Evolution (polyvinylhidroxide microspheres suspended in acrylamide gel) clinically resembled Artecoll and histologically resembled PLA.

It was noted by the authors that a late or delayed inflammatory reaction could be missed due to an inadequate duration of the study. Lemperle G, Morhenn V, and Charrier U. Human Histologya dn persistence of various injectable filler substances for soft tissue augmentation. Aesthetic Plastic Surgery. Springer-Verlay 2004. Published online: 14 Jan 2004.

As new filler products are approved by the FDA, these products will become more widely used and possibly unreported adverse side effects unveiled. Publishing these events and contacting the company is paramount as these side effects need to be reported and verified as linked or not linked to the product. Also if another physician has had a patient with a similar adverse event, possible treatment modalities can be shared.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The field of Aesthetic Medicine has been changing at such a rapid pace it has become hard to keep up with the latest trends and developments. Each decade has introduced new technologies that have made our practices safer, simpler and more efficacious. The 80’s were the decade of chemical peels; the 90’s the laser; but the two most innovative changes have come about from the aesthetic use of botulinum toxin in the 90’s and now the explosion of fillers in this era of the 21st Century. From one or two fillers available twenty years ago, we now have a full cabinet of filling materials – both biodegradable and permanent – to meet each of our patient’s needs. In the recent few years, fillers are emerging like spring flowers in a profusion of original devices, copycats and injection materials. It has become increasingly difficult for the clinician to sort through the marketing hype to find the real objective science – if it exists – on the newer agents. This is further complicated by the fact that CE certification does not require efficacy and safety data if comparable filling substances are already on the market. The reality is that most new aesthetic devices come from Europe, and it is difficult for us to evaluate what’s new and what’s good.

“Fillers in Aesthetic Medicine” provides a well-needed compendium as a complete yet very hands-on practical approach to the practice of fillers at this time. It fulfills an important niche by gathering information from many sources for the updated volume. Both Drs. Rzany and de Maio are highly respected aesthetic researchers and clinicians. They have sorted through the technical data and marketing hype to provide truthful and practical information for you – the aesthetic clinician – for use in your practice.

The volume is divided into usable chapters encompassing materials, patient selection, preparations, anesthesia, regional injections including techniques, combination therapy and complications with treatment. I highly recommend this compendium for both the novice clinician beginning a filler practice as well as those with long experience needing an update on the latest materials and techniques. This is the next best thing to a “hands-on” course from master clinicians.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The use of temporary yet non-invasive techniques for wrinkle and volume correction has begun an industry of soft tissue and skin fillers. Beginning with collagen in the early 1980’s, techniques for correction of nasolabial folds, forehead and glabella wrinkles and lip augmentation were developed. The quest for other temporary yet biocompatible agents without the necessary skin tests for allergy has begun the development of hyaluronic acid fillers. The hyalurons have specific advantages over collagen and recently a plethora of new products has emerged on the market. This article will discuss the properties of hyaluronic acid filler products, their differences and their uses as soft tissue fillers.

Hyaluronic acid is a naturally occurring linear polysaccharide found in the extracellular matrix of connective tissue, synovial fluid and other tissues. There is no antigenic specificity for species or tissues and thus has no potential for allergic or immunogenic reaction in humans. In humans, it serves as the ground substance of dermis, fascia and most fluid mediums because of its viscoelastic properties. It is found in all vertebrate animals and as a “biofilm” around bacteria. It has high concentrations in soft connective tissue extracellular matrix, vitrous of eye, hyaline cartilage, synovial joint fluid, disc nucleus, umbilical cord and skin dermis. It has specific physical and biochemical properties in normal tissue. As a physical background, it functions as space filling, lubrication, shock absorption and protein exclusion. Its biochemical properties include modulation of inflammatory cells, interaction with the proteoglycans of the extracellular matrix and as a helper in free radical scavenging. (Figure 1)

Hyaluronic acid was first isolated 70 years ago and the name hyalos (Greek – glassy) along with uro (uric acid) was used for the space filling and viscoelastic properties. Natural hyaluronic acid has a half life in tissue for only one to two days undergoing aqueous dilution and enzyme degradation in the liver to carbon dioxide and water. For use as a dermal filler, a longer tissue residue time is needed.

Cross-linking native hyaluronic acid forms stable larger molecules with similar biocompatibility and viscoelastic filling properties yet longer residue time in tissues. The bonding creates a larger macromolecule transforming the hylan fluid to a more cohesive gel which is hygroscopic, thus swelling with absorption of water. Particulate cross-linking thus creates water insoluble gels that will remain stable in tissue as they are slowly resorbed over months.1 (Figure 2) The physical properties of these bonded molecules give hylan fillers their unique qualities. They include:

• Gel hardness or rheological (flow) properties as measured by energy stored as the gel is deferred by passage through a syringe and then restored to an expanded viscoelastic state.
• Particle size within the gel
• HA concentration of particles and gel in each milliliter
• Swelling – the gel’s ability to resist dilution, thus a factor in the filler longevity
• Soluble versus insoluble HA – particulated versus fluid components.

Each of these factors are a determinant in the properties of each of the individual HA’s and how they produce clinical effects for soft tissue augmentation.2 (Figure 3)

Medically useful hyaluronic acid was first isolated and purified in 1962 and licensed by the FDA to Pharmacea as Healon® for ophthalmic use. In the 1980’s, cross-linking was perfected to support the stability and viscoelastic properties as a “hyaluronan”. Biomatrix developed hylaform (hylan B) as the first hyaluronic acid skin filler which was released in Europe 1996.2

At present, there are four hyaluronic acid skin fillers FDA approved in the United States: Hylaform, Hylaform Plus, Captique and Restylane. Hylaform and Hylaform Plus are derived from the body of rooster combs which is purified and cross-linked with divinyl sulfone. It has been available worldwide since 1998 and recently in the United States in 2004.3

Clinical phase III studies were completed in the United States – 2002 – demonstrating non-inferiority to collagen for correction of nasolabial folds up to four months in a double blind randomized study carried out in eight sites with over 300 patients. There were very few adverse events with no evidence of immunogenic or allergic reactions with very little inflammatory response. Since then, the filler has favorable results for the treatment of facial wrinkles, folds and grooves, acne scars and used as a volume lip filler.4

Restylane is a bacterial derived, cross-linked hyaluronic acid gel produced from cultures of streptococcus equi. Though hylaform is avian derived and Restylane from a bacterial source, there is no significant allergy or immunogenicity found in either product. Initial European studies of this Sweedish product revealed excellent correction of the nasolabial folds with sustained correction in over 60% of patients over six months. (Olenius)5 An Italian study in which injections were at multiple sites including glabellar lines, nasolabial folds, marionette lines, lips and depressed acne scars resulted in good patient satisfaction with moderate improvement at eight months.6

The major U.S. study by Narins et al. was a randomized double-blind split face study with Restylane and Zyplast for efficacy and safety. At six months, Restylane was found to be superior to Zyplast in 60% of patients, and less Restylane was needed to reach full correction than Zyplast.7

Side effects noted for Restylane in all three studies included erythema, induration, edema and bruising. The induration and swelling were most problematic during the first few days but could last up to a week. Inflammatory reactions of the lips have been symptomatic enough to require a short course of systemic corticosteroids.5,6,7

There have been a number of reports, documenting allergic hypersensitivity reactions to both Restylane and Hylaform (Michaels, Lowe, Alster). Friedman presented a retrospective review of Restylane reactions in 2000 including patients worldwide. The larger series revealed one out of 1400 developed a documented hypersensitivity reaction with localized induration and swelling at the treatment site. Special attention was given to reactions of necrosis in the glabella area which has been reported in the past from Zyplast. This is thought to be due to embolization of particulate material in the subdermal plexus of vessels. None developed systemic allergic responses. Comparing this report to prior adverse event reporting, it was found there was less hypersensitivity reactions in 2000 which was thought to be due to the reformulation of Restylane in 1999 with less protein.

Though the above reviewed hyaluronic acid fillers are available in the United States, many more HA fillers are on the market in Europe. (Table I) These are of variable concentration, gel viscosity, particulate size and some with adjunctive agents. Very few have rigorous clinical testing though they have CE approval. Without FDA approval, there is significant risk for a clinician to import and use these products. Some, though are now undergoing clinical investigation in the United States for FDA approval. Juvederm is a hyaluronic acid filler developed by Corneal Industries (Paris, France) with CE approval since 2000. It presently is undergoing clinical investigation in the United States by Inamed and marketed in Europe under the name Hydrafil. Juvederm differs from the other FDA approved HA products as it is a homogeneous gel rather than particulate-based, giving it less exposure for inflammation and degradation. It is available in three forms: Juvederm-18 for superficial wrinkles; Juvederm-24 used in the mid and upper dermis; and Juvederm-30 which is longer lasting for medium and deeper dermal injections.8 Phase III clinical trials are presently underway in the United States. This and other new HA products are referred to as monophasic as the gel phase predominates rather than particles. The clinical advantages of longevity and less inflammation is yet to be established.

Patient treatment with hyaluronic acid fillers.

In evaluating a patient for an HA filler, one must conduct a full evaluation of what the patient desires and whether the product can fulfill their wishes. One must evaluate the depth of the fold or wrinkle, the area to be treated (eyelid skin versus nasolabial) prior treatments, allergies, pain tolerance, down time, tolerance and financial impact with those variables the clinician then must objectively evaluate the wrinkle, fold or groove to be treated as to depth, how much filler needed, asymmetry and skin type.

Choosing the correct filler is important for natural results. Restylane or Hylaform will give natural and biocompatible results filling nasolabial folds or lip volume filling but will not produce good results for treatment of fine lines in eyelids or vertical fine lines on lips. Zyderm or Cosmoderm is our available filler for the upper dermis. Deeper grooves or folds can be treated with the larger particle hyaluronic acid, Hylaform Plus, but can also be treated with Restylane or Captique. (Table II) (Table III)

After a full pretreatment consultation and the decision for the appropriate hyaluronic acid filler is made, the patient’s face is cleaned with disinfectant and pretreatment photographs are taken. It is important for the patient to be seated in an upright position to visualize the gravitational effect of the wrinkles and folds. It is preferred that the patient’s head is supported with a headrest.

Hyaluronic acid preparations do not contain lidocaine thus separate anesthesia is necessary. The choices include: topical anesthetics, field block, and peripheral nerve block. These may be accompanied by anxiolytics if needed and “talkesthesia”. (Table IV)

Topical anesthesia can provide adequate anesthesia for many patients, especially with limited treatment on the nasolabial folds or marionette lines. Lip augmentation or coverage of multiple areas in the perioral region invariably requires lidocaine injection for infraorbital and mental nerve blocks. The proper use of an infraorbital nerve block will give good anesthesia for the upper lip supplemented by a lower lip mental block and the extended mucosal miniblock for the lateral commissure and surrounding perioral skin. (illustration) Using this technique, full anesthesia of the perioral area can be obtained.9 (Figure 4)

Hylans are generally injected through a 30 gauge needle though the larger particle materials may require a 27 gauge needle. For hylans, more pressure is required through the plunger of the 1 cc. syringe than injecting collagen because of the intrinsic rheological properties of the gel as it is deformed through the needle. It then expands within the tissue giving a greater volume swell than seen with collagen. The needle bevel can be either up or down but the physician must direct the filler into the mid to deep dermis. This can be monitored by the back pressure felt on the plunger. Injecting into the subcutaneous tissue will release the filler too quickly through the needle and the needle should be pulled back until appropriate positioning is established.

Injection techniques include linear threading, serial puncture and fanning. (Figure 5) While serial puncture is most commonly used for collagen injections, retrograde linear threading is most appropriate for hyaluronic acid injections, especially in nasolabial folds and lip filling. The needle is placed in mid to deep dermis at 30 to 60 degree angle and then advanced horizontally below the wrinkle or groove. The filler is released as the needle is withdrawn, monitoring its placement within mid dermis. Placed too high, a blanch or “peau d’orange” will occur and too deep the filler will be in the subcutaneous tissue. This technique is repeated until the volume defect is fully corrected. One should ensure full correction is achieved yet overcorrection is not produced. This technique is commonly used for glabellar furrows, forehead wrinkles, nasolabial folds and lip augmentation.10

Fanning technique is a variation of linear threading in which the needle is redirected in a triangular or a circular volume defect until it is corrected. It is commonly used for filling the labial triangle at the superior aspect of the nasolabial fold, the lower lip and marionette, deeper lip filling and brow augmentation. Serial puncture, though used less for hylans – is helpful for the deep filling of tear troughs, touching up lips and nasolabial folds. Injecting too superficially can produce nodules and sausage-like deformity on the skin surface with depot induration that may last for weeks. (Figure 6)

After injection, the clinician can use massage to smooth irregularities or nodules and move material to the most aesthetic position. An icepack is used after injections to relieve discomfort and reduce swelling. HA fillers are hygroscopic and may increase correction 10-15% after injection unlike collagen which loses volume. (Figure 7)

Areas most amenable to hyaluronic acid fillers include nasolabial folds, marionette lines, lip augmentation, brow augmentation and forehead and glabellar folds not amenable to botulinum toxin.

The following approaches are used in specific areas:

• Nasolabial Folds – Folds are variable from deep furrows to superficial wrinkles, dependent on whether the folds are induced by strong facial muscles and those induced by SMAS ptosis. Each requires different injection techniques and variable viscosity of filler. (Figure 8, 9)
  • Deep furrows
    • Restylane or Hylaform Plus
    • Linear threading and fanning the superior triangle
  • Superficial wrinkles
    • Restylane, Hylaform or Captique
    • Linear threading and serial puncture
  • Technical pearls
    • Stretch and compress skin to visualize the fold
    • Inject medial to fold to avoid further cheek ptosis
    • Avoid multiple punctures to reduce the incidence of bruising
• Lips – Hyaluronic acid filler treatments are performed for lip augmentation in younger patients and lip reshaping for the older patient who has a loss of volume, while collagen can be used at the vermilion and for the correction of the radial grooves. The lower lips should be filled evenly with upper lips as the central lower lip normally protrudes slightly beyond the upper lip. (Figure 10)

Lip injections are painful and a full perioral nerve block should be performed as described previously. Lips are filled in three distinctive planes:

• The vermilion
• The wet-dry junction of the red lip
• The dental arcade giving superior lip volume through the mucosa

Hyaluronic acid is especially useful as a lip filler because of its hygroscopic property and the natural viscoelastic feel and appearance. Fine vertical lines may not be correctable with presently approved HA and need a more superficial filler such as Cosmoderm or Zyderm I. Other techniques to correct older or dynamic lips include botulinum toxin, non-ablative or ablative laser resurfacing and chemical peeling.

Hylaform and Captique are less inflammatory than Restylane for which erythema, induration and lip edema may last as long as one week. Nodules and asymmetry may occur which can be corrected by touch-up and massage.10

It is important not to overfill lips, especially when patients ask for it. This is especially important at the medial tubercle of the upper lip as it may present a “duck-bill” appearance. (Figure 11)

• Marionette Lines – Filling the marionette lines lift the corners of the mouth offsetting the sad or aging oral appearance. The lines are formed by the muscle depressor anguli oris and the platysma with a loss of overlying volume. Filling the depression involves injecting the line and the medial triangle from the lateral lower lip skin and vermilion to the modeolus. A stiff hyaluronic acid filler such as Restylane will deliver volume as well as lift the lip commissures. The clinician can use a combination of retrograde linear threading and fanning technique to give the necessary mid and deep volume filling. It is important to keep the injection under and medial to the fold as a lateral injection will increase the appearance of the fold. The patient with significant elastosis would benefit from injecting multiple layers using serial puncture technique as well to give full filling and prevent deep lumps. (Figure 12)
• Facial Shaping – Deeper volume filling can be used for facial shaping. Though large volume results are best achieved with fat or Sculptra, hyaluronic acids can be used for limited areas such as brow elevation, tear troughs and localized cheek defects. The brow and cheeks are to be injected in deep dermis and subcutaneous tissue while tear trough deformities of the lower eyelids are approached with an HA injection along the bony orbital rim below the orbicularis muscle but not penetrating the orbital septum. This injection should be reserved for those with extensive filling experience. (Figure 13)

Hyaluronic acid fillers are today the most popular skin agent for filling wrinkles and grooves caused by facial aging. It, though, should be considered one of many tools available to the physician for correction of facial aging skin.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The explosion of interest in chemical peeling and laser resurfacing on the part of cosmetic surgeons has paralleled the general public’s interest in acquiring a youthful appearance by rehabilitating the photoaged skin. The public’s interest has been further heightened by advertising for cosmetic agents, over the counter chemicals and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Most of these over the counter home do-it-yourself programs have been tried by patients and by the time they consult their dermatologist, plastic surgeon or cosmetic surgeon, they are ready for a more definitive procedure performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient’s skin type and the degree of photoaging skin, and thus prescribe the correct facial rejuvenation procedure. This should be the procedure or combination of procedures that will give the greatest benefit for the least risk factors and morbidity. The cosmetic surgeon should have available for his consumer the options of medical or cosmoceutical topical therapy, dermabrasion, chemical peeling, and lasers available for selective skin destruction and resurfacing. Each of these techniques maintains a place in the armamenteria of the cosmetic surgeon to provide the appropriate treatment for each individual patient and his specific problem.

The approach to photoaging skin has expanded beyond a one-stage procedure to now include preparatory medical therapy and post-treatment cosmoceutical topical therapy to maintain results and prevent further photodamage. Thus, the cosmetic surgeon’s office has become not only the site for a surgical treatment session, but also an educational setting for skin protection and care and a marketplace for the patient to obtain the necessary topicals for skin protection. It is up to the physician to fully understand the nature of skin and sun damage, protective techniques available, and active agents that work as cosmoceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right procedure to restore and rehabilitate their skin.

Chemical peeling involves the application of a chemical exfoliant to wound the epidermis and dermis for the removal of superficial lesions and improve the texture of skin. Various acidic and basic chemical agents are used to produce the varying effects of light to medium to deep chemical peels through differences in their ability to destroy skin. The level of penetration, destruction and inflammation determines the level of peeling. The stimulation of epidermal growth through the removal of the stratum corneum without necrosis consists of light superficial peel. Through exfoliation, it thickens the epidermis with qualitative regenerative changes. Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Further destruction of the epidermis and induction of inflammation within the papillary dermis constitutes a medium-depth peel. Then, further inflammatory response in the deep reticular dermis induces new collagen production and ground substances which constitutes a deep chemical peel.1 These have now been well classified and usage has been categorized for various degenerative conditions associated with photoaging skin based on levels of penetration. The physician, thus, has tools capable of solving problems that may be mild, moderate or severe with agents that are very superficial, superficial, medium-depth, and deep peeling chemicals. The physician must choose the right agent for each patient and condition.

Indications and Patient Selection

Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Various classification systems have been available and I would like to present a combination of three systems that would simplify and help the physician define the right program or therapeutic procedure for his patient. The Fitzpatrick skin type system classifies degrees of pigmentation and ability to tan.2 Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage, and ability for facultative melanogenesis (one’s intrinsic ability to tan). In addition, this system classifies skin as to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin type I and II are pale white and freckled with a high degree of potential to burn with sun exposure. Three and four can burn but usually is an olive to brown coloration. Five and six are dark brown to black skin that rarely ever burns and usually does not need sunscreen protection (see Table I). The patient with type I or II skin with significant photodamage needs regular sunscreen protection prior to and after the procedure. He, though, has little risk for hypopigmentation or reactive hyperpigmentation after a chemical peeling procedure. The patient, though, with type III through VI skin has a greater risk for pigmentary dyschromia – hyper or hypopigmentation, after a chemical peel and may need pre and post-treatment with both sunscreen and bleaching to prevent these complications.3 Pigmentary risks are generally not a great problem with very superficial and superficial pigment chemical peeling, but may become a significant problem with medium and deep chemical peeling. It can also be a significant risk when regional areas such as lips and eyelids are peeled with a pulsed laser, creating a significant color change in these cosmetic units from the rest of the face. The porcelain white shiny skin seen after taped deep chemical peels in regional areas has been classified as the “alabaster look.” This is an objectionable side effect of deep taped phenol peeling and should be avoided now as patients demand a natural look. The physician must inform the patient of this and other potential problems, especially if the skin type is III through VI. He must justify whether the benefits of the procedure outweigh these risks and, in addition, plan for the appropriate techniques to prevent these unwanted changes in color.

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects.4 The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised to project which patients need therapeutic intervention. Category I or minimal degree photodamage can be treated with light chemical peeling and medial treatment. Category II and III would entail medium-depth chemical peeling while category IV would need deep peeling or resurfacing plus cosmetic surgical intervention for gravitational changes (see Table II). Monheit and Fulton have devised a system of quantitating photodamage developing numerical scores that would fit into corresponding rejuvenation programs.5 In analyzing photodamage, the major categories include dermal with textural changes and epidermal with skin lesions. Dermal changes include wrinkles, cross-hatched lines, sallow color, leathery appearance, crinkly thin parchment skin, and the pebblish white nodules of milia. Each of these is quantitated, giving the patient a point score, 1 through 4. In addition, the number and extent of lesions are categorized from freckles, lentigenes, telangiectasias, actinic and seborrheic keratoses, skin cancers, and senile comedones. These also are added in a classification system 1 through 4 and the final score results are tabulated. A total score of 1 through 4 would indicate very mild damage and the patient would adequately respond to a five-step skin care program including sunscreen protection, retinoic acid, glycolic acid peels and selective lesional removal. A score of 5 through 9 would include all of the above plus repetitive superficial peeling agents program such as glycolic acid, Jessner’s solution, or lactic acid peels. A score of 10-14 would need a medium-depth chemical peeling, and a score of 15 or above would include deep chemical peeling or laser resurfacing. The patient thus understands during the consultation his degree of photodamage and the necessity for an individual skin rejuvenative program. (see table III)

The peeling agent is a chemical eshcarotic that damage the skin in a therapeutic manner. It is important that the physician understand the patient’s skin and its ability to withstand this damage. The epidermis and stratum corneum have a barrier function against noxious chemicals and some skin types withstand the damage to a greater degree than others while particular skin disorders have a greater tendency to produce side effects and complications from chemical peels, due to poor barrier function or exaggerated inflammatory reactions. Patients with skin disorders such as atopic dermatitis, seborrheic dermatitis, psoriasis, contact dermatitis may find their disease exacerbated in the post-operative period or even develop problems with post-operative healing such as prolonged wound healing, post-erythema syndrome, or contact sensitivity during a post-operative period. Rosacea is a disorder of vasomotor instability in the skin and may develop an exaggerated inflammatory response to the peeling agents. Other important factors include a history of radiation therapy to the proposed facial skin as chronic radiation dermatitis decreases the body’s ability to heal properly. A general rule of thumb is to examine the facial hair in the area treated by radiation and if it is intact, there are enough pilosebaceous units to heal the skin properly after medium or even deep chemical peeling. This, though, is not absolute and one should find in history the dates of radiation treatment and how many rads were used for each individual treatment. Some of our patients with the greatest amount of radiation dermatitis, though, had treatments that were given for acne in the mid fifties and over the years the skin developed the resultant degenerative changes.6 On the other hand, patients with extensive photodamage may require stronger peeling agents and repeated applications of medium-depth peeling solutions to obtain therapeutic results. It is for this reason a careful evaluation of skin types and problems must be assessed.

Herpes simplex can be a post-operative problem with significant morbidity. Patients susceptible should be pre-treated with antiherpetic agents such as acyclovir or valcyclovir to prevent herpetic activation. These patients can be identified in the pre-operative consultation and placed on appropriate therapy at the time of the chemical peel. All anti-herpetic agents act by inhibiting viral replication in the intact epidermal cell. The significance of this in peeling is that the skin must be reepithelialized before the agent has its full effect. Thus, the antiviral agent must be continued in deep chemical peeling for the entire two weeks, or in medium-depth peeling for at least ten days.7

The chief indications for medium and deep chemical peeling are associated with the reversal of actinic changes such as photodamage, rhytides, actinic growths, pigmentary dyschromias, and acne scars.8 The physician thus can use his classification systems to quantitate and qualitate the level of photodamage and prescribe the appropriate chemical peeling combination.

Medium-depth chemical peeling

Medium-depth chemical peeling is defined as controlled damage from a chemical agent to the epidermis and papillary dermis resulting in specific regenerative changes that can be performed in a single setting. Agents currently used include combination products – Jessner’s solution, 70% glycolic acid, and solid carbon dioxide with 35% trichloroacetic acid. The benchmark for this level peel was 50% trichloroacetic acid. It has traditionally achieved acceptable results in ameliorating fine wrinkles, actinic changes, and pre neoplasia. However, since TCA itself is an agent more likely to be fraught with complications, especially scarring, in strengths of 50% or higher, it has fallen out of favor as a single agent chemical peel.9 It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of control damage without the risk of side effects.

Brody first developed the use of solid CO2 applied with acetone to the skin as a freezing technique prior to the application of 35% trichloroacetic acid. The preliminary freezing appears to break the epidermal barrier for a more even and complete penetration of the 35% trichloroacetic acid.10

Monheit then demonstrated the use of Jessner’s solution prior to the application of 35% trichloroacetic acid. The Jessner’s solution was found effective in destroying the epidermal barrier by breaking up individual epidermal cells. This also allows a deeper penetration of the 35% TCA and a more even application of the peeling solution.11 Similarly, Coleman has demonstrated the use of 70% glycolic acid prior to the application of 35 % trichloroacetic acid. Its effect has been very similar to that of Jessner’s solution.12 (Table IV)

All three combinations have proven to be as effective as the use of 50% trichloroacetic acid with a greater safety margin. The application of acid and resultant frosting are better controlled with the combination so that the “hot spots” with higher concentrations of TCA can be controlled, creating an even peel with less incidence of dyschromias and scarring. The combination peel produces an even, uniform peel. The Monheit version of the Jessner’s solution – 35% TCA peel is a relatively simple and safe combination. The technique is used for mild-to-moderate photoaging including pigmentary changes, lentigines, epidermal growths, dyschromias, and rhytids. It is a single procedure with a healing time of seven to ten days. It is useful also to remove diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy. Topical chemotherapy is applied for three weeks creating erythema, scabs and crusts for up to six weeks.13 The combination peel will produce similar therapeutic benefits within ten days of healing. It thus reduces the morbidity significantly and gives the cosmetic benefits of improved photoaging skin.

The procedure is usually performed with mild preoperative sedation and nonsteroidal antiiflammatory agents. The patient is told that the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours if the patient can tolerate the medication. Its inflammatory effect is especially helpful in reducing swelling and relieving pain. If given before surgery, it may be all the patient requires during the postoperative phase. For full-face peels, though, it is useful to give preoperative sedation (diazepam 5 to 10 mg orally) and mild analgesia, meperidine 25 to 50 mg (Demerol – Winthrop, New York), and hydroxyzine hydrochloride 25 mg intramuscularly (Vistaril – Lorec, New York). The discomfort from this peel is not long lasting, so short acting sedatives and analgesics are all that are necessary.14

Vigorous cleaning and degreasing is necessary for even penetration of the solution. The face is scrubbed gently with Ingasam (Septisol – Vestal Laboratories, St. Louis, Missouri) four-inch by four-inch gauze pads and water, then rinsed and dried. Next, an acetone preparation is applied to remove residual oils and debris. The skin is essentially debrided of stratum corneum and excessive scale. A thorough degreasing is necessary for an even penetrant peel. The physician should feel the dry, clean skin to check the thoroughness of degreasing. If oil is felt, degreasing should be repeated. A splotchy peel is usually the result of uneven penetration of peel solution due to residual oil or stratum corneum, and a result of inadequate degreasing.

After thorough cleaning, the Jessner’s solution is applied with either cotton-tip applicators or 2” x 2” gauze. (Table V) The Jessner’s solution is applied evenly with usually one or two coats to achieve a light but even frosting. The frosting achieved with Jessner’s solution is much lighter than that produced by TCA and the patient is usually uncomfortable, feeling only heat. A mild erythema appears with a faint tinge of splotchy frosting over the face. Even strokes are used to apply the solution to the unit area covering the forehead to the cheeks to the nose and chin. The eyelids are treated last creating the same erythema with blotchy frosting. (Fig 1)

The TCA is painted evenly with one to four cotton-tipped applicators that can be applied over different areas with light or heavier doses of the acid. Four cotton-tipped applicators are applied in broad strokes over the forehead and also on the medial cheeks. Two mildly soaked cotton-tipped applicators can be used across the lips and chin, and one damp cotton-tipped applicator on the eyelids. Thus, the dosage of application is technique dependent on the amount used and the number of cotton-tipped applicators applied. The cotton-tipped applicator is useful in quantatiting the amount of peel solution to be applied.

The white frost from the TCA application appears complete on the treated area within 30 seconds to 2 minutes. Even application should eliminate the need to go over areas a second or a third time, but if frosting is incomplete or uneven, the solution should be reapplied. TCA takes longer to frost than Baker’s formula or straight phenol, but a shorter period of time than the superficial peeling agents do. The surgeon should wait at least 3 to 4 minutes after the application of TCA to ensure the frosting has reached its peak. He then can document the completeness of a frosted cosmetic unit and touch up the area as needed. Areas of poor frosting should be retreated carefully with a thin application of TCA. The physician should achieve a level II to level III frosting. Level I frosting is erythema with a stringy or blotchy frosting, seen with light chemical peels. Level II frosting is defined as white-coated frosting with erythema showing through. A level III frosting, which is associated with penetration through the papillary dermis, is a solid white enamel frosting with little or no background of erythema.15 A deeper level III frosting should be restricted only to areas of heavy actinic damage and thicker skin. Most medium-depth chemical peels use a level II frosting and this is especially true over eyelids and areas of sensitive skin. Those areas with a greater tendency to scar formation, such as the zygomatic arch, the bony prominences of the jawline, and chin, should only receive up to a level II frosting. Overcoating trichloroacetic acid will increase its penetration so that a second or third application will drive the acid further into the dermis, creating a deeper peel. One must be careful in overcoating only areas in which the take up was not adequate or the skin is much thicker. (Fig II)

Anatomic areas of the face are peeled sequentially from forehead to temple to cheeks and finally to the lips and eyelids. The white frosting indicates keratocoagulation or protein denaturation of keratin and at that point the reaction is complete. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the line demarcation between peeled and nonpeeled areas. The perioral area has rhytids that require a complete and even application of solution over the lip skin to the vermilion. This is accomplished best with the help of an assistant who stretches and fixates the upper and lower lips which the peel solution is applied.

Certain areas and skin lesions require special attention. Thicker keratoses do not frost evenly and thus do not pick up peel solution. Additional applications rubbed vigorously into the lesion may be needed for peel solution penetration. Wrinkled skin should be stretched to allow an even coating of solution into the folds and troughs. Oral rhytides require peel solution to be applied with the wood portion of a cotton-tipped applicator and extended into the vermilion of the lip. Deeper furrows such as expression lines will not be eradicated by peel solution and thus should be treated like the remaining skin.

Eyelid skin must be treated delicately and carefully. A semidry applicator should be used to carry the solution within 2 to 3 mm of the lid margin. The patient should be positioned with the head elevated at 30 degrees and the eyelids closed. Excess peel solution on the cotton tip should be drained gently on the bottom before application. The applicator is then rolled gently on the lids and periorbital skin. Never leave excess peel solution on the lids because the solution can roll into the eyes. Dry the tears with a cotton-tipped applicator during peeling because they may pull peel solution to the puncta and eye by capillary attraction. (Fig III) The solution should be diluted immediately with cool saline compresses at the conclusion of the peel. The Jessner’s-TCA peel procedure is as follows:

• The skin should be cleaned thoroughly with Septisol to remove oils.
• Acetone or acetone alcohol is used to further debride oil and scale from the surface of the skin.
• Jessner’s solution is applied.
• Thirty-five percent TCA is applied until a light frost appears.
• Cool saline compresses are applied to dilute the solution.
• The peel will heal with 0.25% acetic acid soaks and a mild emollient cream.

There is an immediate burning sensation as the peel solution is applied, but this subsides as frosting is completed. Cool saline compresses offer symptomatic relief for a peeled area as the solution is applied to other areas. The peel reaction is not neutralized by saline solution as the reaction is completed when frosting occurs.16 The compresses are placed over the face for 5 to 6 minutes after the peel until the patient is comfortable. The burning subsides fully by the time the patient is ready to be discharged. At that time, most of the frosting has faded and a brawny desquamation is beginning.

Postoperatively, edema, erythema, and desquamation are expected. With periorbital peels and even forehead peels, eyelid edema can occur and may be enough to close the lids. For the first 24 hours, the patient is instructed to soak four times a day with a 0.25% acetic acid compress made of 1 tablespoon white vinegar in 1 pint of warm water. A bland emollient is applied to the desquamating areas after soaks. After 24 hours, the patient can shower and clean gently with a mild nondetergent cleanser. The erythema intensifies as desquamation becomes complete within 4 to 5 days. Thus, healing is completed within 1 week to 10 days. At the end of 1 week, the bright red color has faded to pink and has the appearance of a sunburn. This can be covered by cosmetics and will fade fully within 2 to 3 weeks.

The medium-depth peel is dependent on three components for therapeutic effect: (1) degreasing, (2) Jessner’s solution, and (3) 35% TCA. The amount of each agent applied creates the intensity and thus the effectiveness of this peel. The variables can be adjusted according to the patient’s skin type and the areas of the face being treated. It is thus the workhorse of peeling and resurfacing in my practice as it can be individuated for most patients we see.

The medium-depth chemical peel thus has five major indications:

• destruction of epidermal lesions – actinic keratoses
• resurfacing the level II or III moderate photoaging skin
• pigmentary dyschromias
• mild acne scars
• blending photoaging skin with laser resurfacing and deep chemical peeling

Actinic keratoses

This procedure is well suited for the patient with epidermal lesions such as actinic keratoses which has required repeated removal with either cryosurgery or chemoexfoliation (5-fluoruracil). The entire face can be treated as a unit or subfacial cosmetic unit such as forehead, temples, and cheeks, and can be treated independently. Active lesions can be removed, as well as incipient growths as yet undetected, will be removed as the epidermis is sloughed. Advantages for the patient with photodamaged skin include a limited recovery period – 7 to 10 days, with little post operative erythema after healing. There is little risk of pigmentary changes either hypopigmentation or hyperpigmentation, thus, the patient can return to work after the skin has healed.(Fig IV)

Moderate photoaging skin

Glogau level II or III damage responds well to this peeling combination with removal of the epidermal lesions and dermal changes that will freshen photoaging characterized as sallow, atrophic skin with fine rhytides. This peel is favored over deeper resurfacing procedures such as laser and deep peel in that it will heal in ten days with minimal risk of textural or color complications. It, though, is only designed for medium-depth damage. (Fig V)

Pigmentary dyschromias

Though color change can be treated with repetitive chemical peeling, the medium-depth peel will be a single treatment preceded and followed by the use of bleaching agents and retinoic acid.17 In most cases, the pigmentary problems are resolved with this single peel as an adjunct to the skin care program. (Fig VI)

Blending other resurfacing procedures

In a patient in which there is advanced photoaging changes such as crow’s feet and rhytides in the periorbital and/or perioral area with medium-depth changes on the remaining face, a medium-depth peel can be used to integrate these procedures together. That is, laser resurfacing or deep chemical peeling can be performed over the periorbital and perioral areas that has more advanced photoaging changes, while the medium-depth chemical peel is used for the rest of the face. This will blend the facial skin as a unit so that the therapeutic textural and color changes will not be restricted to one area. The patients requiring laser resurfacing in a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth chemical peel. Patients having laser resurfacing or deep peeling to the perioral or periorbital areas alone develop a pseudo hypopigmentation that is a noticeable deformity. The patient requiring laser resurfacing at a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth peel. The alternative – a full-face deep peel or laser resurfacing has an increased morbidity, longer healing and risk of scarring over areas such as the lateral jaw line, malar eminences, and forehead. If deep resurfacing is needed only over localized areas such as perioral or periorbital face, a blending medium-depth peel does reduce morbidity and healing time.18 (Fig VII)

Deep chemical peeling

Glogau Level III and IV photodamage requires deep chemical peeling. This entails the use of either trichloroacetic acid above 50%, or the Gordon-Baker phenol peel. Laser resurfacing can also be used to reliably reach this level of damage. TCA above 45% has been found to be unreliable and dangerous with a high incidence of scarring and postoperative complications. For this reason, it is not included as a preferred treatment method for deep chemical peeling. The Baker-Gordon phenol peel has been used successfully for over 40 years for deep chemical peeling and produces reliable results.(Table VI) It is a labor-intensive procedure that must be taken seriously as all major surgical procedures are.

The patient requires preoperative sedation with an intravenous line and preoperative IV hydration. Usually a liter of fluid is given preoperatively and in addition, a liter of fluid is given during the procedure. This is helpful in decreasing the phenol concentration from the serum. For this reason, one must be concerned with phenol absorption through the skin and the resultant serum concentration of phenol through cutaneous absorption.

Methods to limit this include:

• IV hydration prior to the procedure and during the peel to flush the phenolic products through the serum.
• Extending the time of application for a full-face peel over one and one-half hours. Baker’s solution is applied to each cosmetic unit with a fifteen-minute wait in between each unit. That is, the forehead, cheeks, chin, lips, and eyelids are each given a fifteen-minute period of time for a total of an hour to an hour and a half for the procedure.
• All patients are monitored and if there is any electrocardiographic abnormality, i.e. PVC, or PAC, the procedure is stopped and the patient is watched carefully for other signs of toxicity.
• Many physicians believe that O2 given during the procedure can be helpful in preventing arrhythmic complications.
• Any patient with a history of cardioarrhythmia, hepatic or renal compromise, or on medications that give a propensity for arrhythmias, should not undergo the Baker-Gordon phenol peel.19

The patient undergoing deep chemical peeling must recognize the significant risk factors, the increased morbidity, and possible complications involved in this procedure so that the benefits can be weighed positively against these particular factors. In the hands of those that do this technique regularly, it is a reliable and safe method of rejuvenating advanced to severe photoaged skin including deeper perioral rhytids, periorbital rhytids and crow’s feet, forehead lines and wrinkles, as well as the other textural and lesional changes associated with the more severe photoaging process.

There are two methods for deep chemical peeling; Baker’s formula phenol unoccluded, and Baker’s formula phenol occluded with tape. Occlusion is accomplished with the application of waterproof zinc oxide tape such as one half inch Curity tape. The tape is placed directly after the phenol is applied to each individual cosmetic unit. Tape occlusion increases the penetration of the Baker’s phenol solution and is particularly helpful for deeply lined “weather-beaten” faces. A taped Baker’s formula phenol peel creates the deepest damage in mid-reticular dermis and this form of chemical peeling should only be performed by the most knowledgeable and experienced cosmetic surgeons who understand the risks of over penetration and deep damage to the reticular dermis.20 The unoccluded technique as modified by McCollough involves more skin cleansing and application of more peel solution. On the whole, this technique does not produce as deep a peel as the occluded method.21

When the Baker’s peel was first popularized in the seventies, taping and dry healing would produce both color and textural changes on most patients. This included hypopigmentation with alabaster skin texture. Most patients were told that they would need make-up to disguise the color and textural changes. Today, this is unacceptable in this day when natural appearance of skin texture is so important. The Baker-Gordon formula for this peel was first described in 1961, and since then has been used successfully for over 25 years. The Baker-Gordon formula of phenol (See table IV) penetrates further into the dermis than full-strength undiluted phenol because full-strength phenol allegedly causes an immediate coagulation of epidermal keratin proteins and self blocks further penetration. Dilution to approximately 50 to 55 % in the Baker-Gordon formula causes keratolysis and keratocoagulation resulting in greater penetration. The liquid soap, Septisol, is a surfactant that reduces skin tension allowing a more even penetration. Croton oil is a vesicant and epidermolytic agent that enhances phenol absorption. The freshly prepared formula is not miscible, but rather is a suspension and must be stirred in a clear glass medicine cup immediately before application to the patient. Though the mixture can be stored in an amber glass bottle for short periods, this is usually unnecessary and should be reformulated on a regular basis.

Techniques

Before the administration of anesthesia, the patient’s face is marked in seated position noting landmarks such as the mandibular angle, the chin, the preauricular sulcus, the orbital rim, and the forehead. The markings delineate the borders of the peel throughout the limits of the face and slightly over the mandibular rim to blend any color change. This peel does require sedation. An intravenous combination such as fentanyl citrate (Sublimaze) and midazolam (Versed) can be administered intravenously by an anesthetist while the patient is monitored and given intravenous sedation. It is helpful to use local nerve blocks along the supraorbital, infraorbital nerve, and mental nerve with Marcaine, which should provide some local anesthesia for up to four hours. This is helpful with post-operative pain.

The patients should arrive n.p.o., and have shaved and cleansed their face the morning of surgery. The face then is cleansed and degreased with a keratolytic agent such as hexochlorophine with alcohol (Septisol) over the entire face with emphasis placed on oily areas such as the nose, the hairline, and mid facial cheeks. A thorough and evenly distributed cleansing or degreasing of the face will assure a more uniform peel without skipped areas.

The phenol chemical agent is then applied sequentially to the six aesthetic units: forehead, perioral, right and left cheeks, nose, and periorbital areas. Each cosmetic area takes 15 minutes for application, allowing 60 to 90 minutes for the entire procedure. Cotton-tipped applicators are used with a similar technique as discussed on the medium-depth Jessner – 35% TCA peel. Less agent, though, is used because frosting occurs very rapidly. The last area for the peel is the periorbital skin on which the chemical is applied with only damp cotton-tipped applicators taken care to keep the drops away from the eye and keep tears off the skin. Tearing may allow the peel solution to reach the eye by capillary attraction. It is important to remember that water dilution of this chemical may increase the absorption; therefore, if the chemical does get into the eye, these should be flushed with mineral oil rather than water. An immediate burning sensation is present for 15 to 20 seconds, and then subsides. The pain returns in 20 minutes and persists for 6 to 8 hours.

Following the full application of peel solution, the white frosting gradually develops a brawny brown color and the tape can be applied for an occluded peel. Ice packs can be applied at the conclusion of the peel for comfort, and if this is an untaped peel, petrolatum is used. A biosynthetic dressing such as Vigilon or Flexzan can be used for the first 24 hours. The patient is usually seen in 24 hours to either remove the tape or the biosynthetic dressing and to monitor the healing. It is at this time the patient is again reinstructed in the method of compresses and occlusive ointments or dressings. It is important to keep the skin crust-free.

The four stages of wound healing are apparent after a deep chemical peel. They include: (1) inflammation, (2) coagulation, (3) reepithelializaiton, and (4) fibroplasia.23 At the conclusion of the chemical peel, the inflammatory phase has already begun with a brawny, dusky erythema that will progress over the first 12 hours. This is an accentuation of the pigmented lesions on the skin as the coagulation phase separates the epidermis producing serum exudation, crusting, and pyoderma. It is during this phase that it is important to use debridant soaks and compresses as well as occlusive salves. These will remove the sloughed, necrotic epidermis and prevent the serum exudate from hardening as crust and scab. I prefer the use of ¼ % acetic acid soaks found in the vinegar/water preparation (1 teaspoon white vinegar, 1 pint warm water), as it is antibacterial, especially against pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue, and mildly debridant, as it will dissolve and cleanse the necrotic material and serum. I prefer to use bland emollients and salves such as Vaseline petrolatum, Eucerin, or Aquaphor, as the skin can be monitored carefully day by day for potential complications.

Reepithelializtaion begins on day 3 and continues until day 10 to 14. Occlusive salves promote faster reepithelialization and less tendency for delayed healing, which may occur with dry crusting. The final stage of wound healing – fibroplasia, will continue well beyond the initial closure of the peeled wound and continues with neoangiogenesis and new collagen formation for 3 or 4 months. Prolonged erythema may last 2 to 4 months in unusual cases of sensitive skin or with contact dermatitis. New collagen formation can continue to improve texture and rhytides for a period up to 4 months during this last phase of fibroplasia.

Complications

Many of the complications seen in peeling can be recognized early on during healing stages. The cosmetic surgeon should be well acquainted with the normal appearance of a healing wound and its time frame for both medium and deep peeling. Prolongation of the granulation tissue phase beyond a week to ten days may indicate delayed wound healing. This could be the result of viral, bacterial, or fungal infections, contact dermatitis interfering with wound healing, or other systemic factors. A red flag should alert the physician to carefully investigate and institute prompt treatment to forstall potential irrepairable damage that may result in scarring.24

Complications can be caused either intraoperatively or postoperatively. The two inherent erros that lead to intraoperative complications are (1) incorrect peel pharmacology and (2) accidental solution misplacement. It is the physician’s responsibility to know the solution and its concentration is correct. Trichloroacetic acid concentrations should be measured weight by volume as this is the standard for measuring depth of peel. Glycolic acid and lactic acid solutions as well as Jessner’s solution must be checked for expiration date as the potency decreases with time. Alcohol or water absorption may inappropriately increase the potency, so one must assure the shelf life is appropriate. The peel solution should be applied with cotton-tipped applicators and in medium and deep peels, it is best to pour the peel solution in a secondary container rather than apply the solution spun around the neck of the bottle. Intact crystals may give the solution a higher concentration of solution as it is taken directly from its container. One should be careful to apply the solution to its appropriate location and not to pass the wet cotton-tipped applicator directly over the central face where a drop may inadvertenly get on sensitive areas such as the eyes. Saline and bicarbonate of soda should be available to dilute TCA or neutralize glycolic acid if inappropriately placed in the wrong area. Likewise, mineral oil should be present for Baker’s phenol peels. Postoperative complications can result from local infection or contact dermatitis. The best deterrent for local infection is the continuous use of soaks to debride crusting and necrotic material. Strep and staph infection can occur under biosynthetic membranes or thick occlusive ointments. The use of ¼ % acetic acid soaks seems to deter this as well as the judicious removal of the ointment with each soak. Staph, e. coli, or even pseudomonas may result from improper care during healing and should be treated promptly with the appropriate oral antibiotic.

Frequent postoperative visits are necessary to recognize the early onset of a bacterial infection. It may present itself as delayed wound healing, ulcerations, build up of necrotic material with excessive scabbing, crusting, purulent drainage, and odor. Early recognition and institution of appropriate antibiotics will prevent the spread of infection, heal the skin, and prevent scarring.

Herpes simplex infection is the result of reactivation of the herpes simplex virus on the face and most commonly on the perioral area. A history of previous HSV infection should necessitate the use of prophylactic oral antiviral medications. Patients with a positive history can be treated with 400 mg of acyclovir three times a day beginning on the day of the peel and continuing for 7 to 14 days, depending on whether it is a medium-depth or deep chemical peel. I prefer to treat all patients with antiviral agents irregardless of a positive history as many patients do not remember prior herpes simplex infection that may have occurred years ago. The mechanism of action of all antiviral agents is to inhibit viral replication in the intact epidermal cell. This would mean that the drug would not have an inhibitory effect until the skin is reepithelialized, which is 7 to 10 days in medium and deep peels. In the past, these agents were discontinued at 5 days and in treated patients, clinical infection became apparent in 7 to 10 days.24

Active herpetic infections can easily be treated with antiviral agents and caught early, they usually do not scar.

Delayed wound healing and persistent erythema are signs that the peel is not healing normally. The cosmetic surgeon must know the normal time table for each of the healing events so that he may recognize what time healing is delayed or the erythema has not fading adequately. Delayed wound healing may respond to physician debridement if an infection is present, corticosteroids if due to contact allergic or contact irritant dermatitis along with the change of the offending contact agent, or protection with a biosynthetic membrane such as Flexzan or Vigilon. When this diagnosis is made, these patients must be followed daily with dressing changes and a close watch on the healing skin.

Persistent erythema is a syndrome where the skin remains erythematous beyond what is normal for the individual peel. A superficial peel loses its erythema in 3 to 5 days, a medium-depth peel within 15 to 30 days, and a deep chemical peel within 60 to 90 days. Erythema and/or pruritus beyond this period of time is considered abnormal and fits this syndrome. It may be contact dermatitis, contact sensitization, reexacerbation of prior skin disease, or a genetic susceptibility to erythema. It though is a red flag that also indicates a sign of potential scarring. Erythema is the result of the angiogenic factors stimulating vasodilation which indicates the phase of fibroplasia is being stimulated for a prolonged period of time. For this reason, it can be accompanied by skin thickening and scarring. It should be treated promptly and appropriately with topical steroids, systemic steroids, intralesional steroids if thickening is occuring, and skin protection which would eliminate the factors of irritancy and allergy. If thickening or scarring becomes evident, other measures that be helpful include the daily use of silicone sheeting and the dye pulsed vascular laser to treat the vascular factors. With prompt intervention, scarring in many cases can be averted.

Conclusion

The physician has the responsibility of choosing the correct modality to treat skin conditions such as photoaging skin, scars, dyschromias, and the removal of skin growths. There are many agents available including the three levels of chemical peels reviewed. It is the responsibility of the physician to have thorough knowledge of all of these tools to give each patient the correct treatment his condition warrants.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Synopsis
Medium Depth Chemical Peeling
Gary D. Monheit, M.D.

The combination medium depth chemical peel – Jessner’s solution + 35% TCA, has been accepted as a safe, reliable and effective method for the treatment of moderate photoaging skin.

Chemical peeling involves the application of a chemical exfoliant to wound the epidermis and dermis for the removal of superficial lesions and improve the texture of skin. Various acidic and- basic chemical agents are used to produce the varying effects of light to medium to deep chemical peels through differences in their ability to destroy skin. The level of penetration, the nature of destruction and the inflammatory response determines the level of the peel. The stimulation of epidermal growth through the removal of the stratum corneum without necrosis consists of light superficial peel. Through exfoliation, it thickens the epidermis with qualitative regenerative changes. Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Further destruction of the epidermis and induction of inflammation within the papillary dermis constitutes a medium-depth peel. Then, further inflammatory response in the deeper reticular dermis induces new collagen production and ground substances which constitutes a deep chemical peel.1 These have now been well classified and usage has been categorized for various degenerative conditions associated with photoaging skin based on levels of penetration. The physician, thus, has tools capable of solving photoaging skin problems that may be mild, moderate or severe with agents that are very superficial, superficial, medium-depth, and deep peeling chemicals. The physician must choose the right agent for each patient and condition.

Medium depth peeling is thus defined as the use of a chemical agent to wound skin through papillary dermis. It is most useful for the removal of epidermal or superficial lesions and to improve skin texture in moderate photodamaged skin (grade II Glogau photoaging skin)2. Medium depth peeling agents create changes through necrosis of the epidermis and part or all of the papillary dermis with an inflammatory reaction in the upper reticular dermis. The procedure is performed to remove actinic keratoses, mild photoaging of the skin including rhytides, treat pigmentary dyschromias, and improve depressed scars.3 (Table I)

Trichloracetic acid has been the gold standard in quantitating chemical peel strength and depth. Ten to 30% has been quantitated as superficial wounding while above 50% is deep chemical peeling. The level, 35-50% trichloracetic acid is the spectrum of medium depth peeling. It is standard to think of 45 or 50% trichloracetic acid corresponding to a wounding level of mid to deep reticular dermis. This concentration of trichloracetic acid, though, has been found unreliable and associated with a higher incidence of pigmentary dyschromia, textural change, and even scarring.4 In an attempt to reduce the morbidity of higher concentration trichloracetic acid, a combination of products have been devised that improve the absorption of the lower concentration of trichloracetic acid without the associated complications.5 The combination peels include:

• Solid carbon dioxide freezing with trichloracetic acid 35%.
• Jessner’s solution + 35% trichloracetic acid.
• Glycolic acid 70% plus 35% trichloracetic acid.

The combinations produce a more even peel with deeper penetration of the wounding agent without the associated complications of higher concentration trichloracetic acid. This chapter will review the scope of medium depth peeling, the patients and conditions most commonly treated, the techniques of application, wound healing, and complications.

Trichloracetic Acid

Trichloracetic acid has become the gold standard of chemical peeling agents for its long history of usage, its versatility in peeling, and its chemical stability. It has been useful in many concentrations because it has no systemic toxicity and can be used to create superficial, medium or even deep wounds in the skin. Trichloracetic acid is naturally found in crystalline form and is mixed weight-by-volume with distilled water. It is not light sensitive, does not need refrigeration and is stable on the shelf for over six months. The standard concentrations of trichloracetic acid should be mixed weight-by-volume to accurately assess the concentration. That is, 30 gm. trichloracetic acid crystals mixed with 100 cc. distilled water will give an accurate 30% concentration, weight by volume. Any other dilutional system – volume dilutions and weight by weight, are inaccurate in that they do not reflect the accepted weight by volume measurements.

Since TCA itself is an agent more likely to be fraught with complications, especially scarring, in strengths of 50% or higher, the higher concentration has fallen out of favor.6 It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of control damage without the risk of side effects.

Brody first developed the use of solid CO2 applied with acetone to the skin as a freezing technique prior to the application of 35% trichloroacetic acid. The preliminary freezing appears to break the epidermal barrier for a more even and complete penetration of the 35% trichloroacetic acid.7

Monheit then demonstrated the use of Jessner’s solution prior to the application of 35% trichloroacetic acid. The Jessner’s solution was found effective in destroying the epidermal barrier by breaking up individual epidermal cells. This also allows a deeper penetration of the 35% TCA and a more even application of the peeling solution.8 Similarly, Coleman has demonstrated the use of 70% glycolic acid prior to the application of 35 % trichloroacetic acid. Its effect has been very similar to that of Jessner’s solution.9 (Table II)

All three combinations have proven to be as effective as the use of 50% trichloroacetic acid with a greater safety margin. The application of acid and resultant frosting are better controlled with the combination so that the “hot spots” with higher concentrations of TCA can be controlled, creating an even peel with less incidence of dyschromias and scarring. The combination peel produces an even, uniform peel. The Monheit version of the Jessner’s solution – 35% TCA peel is a relatively simple and safe combination. The technique is used for mild-to-moderate photoaging including pigmentary changes, lentigines, epidermal growths, dyschromias, and rhytids. It is a single procedure with a healing time of seven to ten days. It is useful also to remove diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy. Topical chemotherapy is applied for three weeks creating erythema, scabs and crusts for up to six weeks.10 The combination peel will produce similar therapeutic benefits within ten days of healing. It thus reduces the morbidity significantly and gives the cosmetic benefits of improved photoaging skin.

Skin preparation is of vital importance to encourage correct healing and avoid complications. Agents used prior to the peel to prepare the skin correctly include:11 (Table III)

• Sunscreen
• Exfoliations – abrasive cleansers, 5-10% glycolic acid lotion
• Tretinoin .05% used six weeks to three months prior to the peel
• Bleaching products – hydroquinone 4-8% used in patients with pigmentary dyschromias and those with type III-VI Fitzpatrick skin pigmentation.
• Anti-viral agents in selected patients with history of facial HSV I infections.

The procedure is usually performed with mild preoperative sedation and nonsteroidal antiiflammatory agents. The patient is told that the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours if the patient can tolerate the medication. Its inflammatory effect is especially helpful in reducing swelling and relieving pain. If given before surgery, it may be all the patient requires during the postoperative phase. For full-face peels, though, it is useful to give preoperative sedation (diazepam 5 to 10 mg orally) and mild analgesia, meperidine 25 to 50 mg (Demerol – Winthrop, New York), and hydroxyzine hydrochloride 25 mg intramuscularly (Vistaril – Lorec, New York). The discomfort from this peel is not long lasting, so short acting sedatives and analgesics are all that are necessary.12

Vigorous cleaning and degreasing is necessary for even penetration of the solution. The face is scrubbed gently with Ingasam (Septisol – Vestal Laboratories, St. Louis, Missouri) four-inch by four-inch gauze pads and water, then rinsed and dried. Next, an acetone preparation is applied to remove residual oils and debris. The skin is essentially debrided of stratum corneum and excessive scale. A thorough degreasing is necessary for an even penetrant peel. The physician should feel the dry, clean skin to check the thoroughness of degreasing. If oil is felt, degreasing should be repeated. A splotchy peel is usually the result of uneven penetration of peel solution due to residual oil or stratum corneum, and a result of inadequate degreasing.

After thorough cleaning, the Jessner’s solution is applied with either cotton-tip applicators or 2” x 2” gauze. (Table V) The Jessner’s solution is applied evenly with usually one or two coats to achieve a light but even frosting. The frosting achieved with Jessner’s solution is much lighter than that produced by TCA and the patient is usually comfortable, feeling only heat. A mild erythema appears with a faint tinge of splotchy frosting over the face. Even strokes are used to apply the solution to the unit area covering the forehead to the cheeks to the nose and chin. The eyelids are treated last creating the same erythema with blotchy frosting. (Fig 1). The application of Jessner’s solution alone is equal to a superficial or light chemical peel.13

After the Jessner’s solution has dried, the TCA is applied. The TCA is painted evenly with one to four cotton-tipped applicators that can be applied over different areas with light or heavier doses of the acid. Four cotton-tipped applicators are applied in broad strokes over the forehead and also on the medial cheeks. Two mildly soaked cotton-tipped applicators can be used across the lips and chin, and one damp cotton-tipped applicator on the eyelids. Thus, the dosage of application is technique dependent on the amount used and the number of cotton-tipped applicators applied. The cotton-tipped applicator is useful in quantitating the amount of peel solution to be applied. Care must be taken to ensure the acid is not dripped inadvertently over unwanted areas such as neck or eyes.

The white frost from the TCA application appears complete on the treated area within 30 seconds to 2 minutes. Even application should eliminate the need to go over areas a second or a third time, but if frosting is incomplete or uneven, the solution should be reapplied. Thirty-five percent TCA takes longer to frost than Baker’s formula or straight phenol, but a shorter period of time than the superficial peeling agents do. The surgeon should wait at least 3 to 4 minutes after the application of TCA to ensure the frosting has reached its peak. He then can document the completeness of a frosted cosmetic unit and touch up the area as needed. Areas of poor frosting should be retreated carefully with a thin application of TCA. The physician should achieve a level II to level III frosting. Level I frosting is erythema with a stringy or blotchy frosting, seen with light chemical peels. Level II frosting is defined as white-coated frosting with erythema showing through. A level III frosting, which is associated with penetration through the papillary dermis, is a solid white enamel frosting with little or no background of erythema.14 A deeper level III frosting should be restricted only to areas of heavy actinic damage and thicker skin. Most medium-depth chemical peels use a level II frosting and this is especially true over eyelids and areas of sensitive skin. Those areas with a greater tendency to scar formation, such as the zygomatic arch, the bony prominences of the jawline, and chin, should only receive up to a level II frosting. Overcoating trichloroacetic acid will increase its penetration so that a second or third application will drive the acid further into the dermis, creating a deeper peel. One must be careful in overcoating only areas in which the take up was not adequate or the skin is much thicker. (Fig 2)

Anatomic areas of the face are peeled sequentially from forehead to temple to cheeks and finally to the lips and eyelids. The white frosting indicates keratocoagulation or protein denaturation of keratin and at that point the reaction is complete. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the line demarcation between peeled and non-peeled skin. The perioral area has rhytids that require a complete and even application of solution over the lip skin to the vermilion. This is accomplished best with the help of an assistant who stretches and fixates the upper and lower lips while the peel solution is applied.

Certain areas and skin lesions require special attention. Thicker keratoses do not frost evenly and thus do not pick up peel solution. Additional applications rubbed vigorously into the lesion may be needed for peel solution penetration. Wrinkled skin should be stretched to allow an even coating of solution into the folds and troughs. Oral rhytides require peel solution to be applied with the wood portion of a cotton-tipped applicator and extended into the vermilion of the lip. Deeper furrows such as expression lines will not be eradicated by peel solution and thus should be treated like the remaining skin.

Eyelid skin must be treated delicately and carefully. A semidry applicator should be used to carry the solution within 2 to 3 mm of the lid margin. The patient should be positioned with the head elevated at 30 degrees and the eyelids closed. Excess peel solution on the cotton tip should be drained gently on the bottom before application. The applicator is then rolled gently on the lids and periorbital skin. Never leave excess peel solution on the lids because the solution can roll into the eyes. Dry the tears with a cotton-tipped applicator during peeling because they may pull peel solution to the puncta and eye by capillary attraction. (Fig 3) The solution should be diluted immediately with cool saline compresses at the conclusion of the peel. The Jessner’s-TCA peel procedure is as follows:

• The skin should be cleaned thoroughly with Septisol to remove oils.
• Acetone or acetone alcohol is used to further debride oil and scale from the surface of the skin.
• Jessner’s solution is applied.
• Thirty-five percent TCA is applied until a light frost appears.
• Cool saline compresses are applied to dilute the solution.
• The peel will heal with 0.25% acetic acid soaks and a mild emollient cream.

There is an immediate burning sensation as the peel solution is applied, but this subsides as frosting is completed. Cool saline compresses offer symptomatic relief for a peeled area as the solution is applied to other areas. The peel reaction is not neutralized by saline solution as the reaction is completed when frosting occurs.15 The compresses are placed over the face for 5 to 6 minutes after the peel until the patient is comfortable. The burning subsides fully by the time the patient is ready to be discharged. At that time, most of the frosting has faded and a brawny desquamation is beginning.

Postoperatively, edema, erythema, and desquamation are expected. With periorbital peels and even forehead peels, eyelid edema can occur and may be enough to close the lids. For the first 24 hours, the patient is instructed to soak four times a day with a 0.25% acetic acid compress made of 1 tablespoon white vinegar in 1 pint of warm water. A bland emollient is applied to the desquamating areas after soaks. After 24 hours, the patient can shower and clean gently with a mild nondetergent cleanser. The erythema intensifies as desquamation becomes complete within 4 to 5 days. Thus, healing is completed within 1 week to 10 days. At the end of 1 week, the bright red color has faded to pink and has the appearance of a sunburn. This can be covered by cosmetics and will fade fully within 2 to 3 weeks.

The medium-depth peel is dependent on three components for therapeutic effect: (1) degreasing, (2) Jessner’s solution, and (3) 35% TCA. The amount of each agent applied creates the intensity and thus the effectiveness of this peel. The variables can be adjusted according to the patient’s skin type and the areas of the face being treated. It is thus the workhorse of peeling and resurfacing in my practice as it can be individuated for most patients we see.

The medium-depth chemical peel thus has five major indications:

• destruction of epidermal lesions – actinic keratoses
• resurfacing the level II or III moderate photoaging skin
• pigmentary dyschromias
• mild acne scars
• blending photoaging skin with laser resurfacing and deep chemical peeling

Actinic keratoses

This procedure is well suited for the patient with epidermal lesions such as actinic keratoses which has required repeated removal with either cryosurgery or chemoexfoliation (5-fluoruracil). The entire face can be treated as a unit or subfacial cosmetic unit such as forehead, temples, and cheeks, and can be treated independently. Active lesions can be removed, as well as incipient growths as yet undetected, will be removed as the epidermis is sloughed. Advantages for the patient with photodamaged skin include a limited recovery period – 7 to 10 days, with little post operative erythema after healing.16 There is little risk of pigmentary changes either hypopigmentation or hyperpigmentation, thus, the patient can return to work after the skin has healed.(Fig 4)

Moderate photoaging skin

Glogau level II or III damage responds well to this peeling combination with removal of the epidermal lesions and dermal changes that will freshen photoaging characterized as sallow, atrophic skin with fine rhytides. This peel is favored over deeper resurfacing procedures such as CO2 laser and deep peel in that it will heal in ten days with minimal risk of textural or color complications. It, though, is only designed for medium-depth damage. (Fig 5)

Pigmentary dyschromias

Though color change can be treated with repetitive chemical peeling, the medium-depth peel will be a single treatment preceded and followed by the use of bleaching agents and retinoic acid.17 In most cases, the pigmentary problems are resolved with this single peel as an adjunct to the skin care program.

Blending other resurfacing procedures

In a patient in which there is advanced photoaging changes such as crow’s feet and rhytides in the periorbital and/or perioral area with medium-depth changes on the remaining face, a medium-depth peel can be used to integrate these procedures together. That is, laser resurfacing or deep chemical peeling can be performed over the periorbital and perioral areas that has more advanced photoaging changes, while the medium-depth chemical peel is used for the rest of the face. This will blend the facial skin as a unit so that the textural and color changes will not be restricted to one area. The patients requiring laser resurfacing in a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth chemical peel. Patients having laser resurfacing or deep peeling to the perioral or periorbital areas alone develop a pseudo hypopigmentation that is a noticeable deformity. The patient requiring laser resurfacing at a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth peel. The alternative – a full-face deep peel or laser resurfacing has an increased morbidity, longer healing and risk of scarring over areas such as the lateral jaw line, malar eminences, and forehead. If deep resurfacing is needed only over localized areas such as perioral or periorbital face, a blending medium-depth peel does reduce morbidity and healing time.18 (Fig 6)

Results

This medium depth peel will produce superior results for the conditions listed.(Table III) Removal of actinic keratoses, both present and incipient, affords the patient a single procedure with healing time within one week to ten days, as a preventive therapeutic modality for the removal of precancerous growths over the face.(Fig 4) A comparison study of the efficacy of Jessner’s solution plus 35% trichloracetic acid with 5-Fluorouracil documented superior effectiveness of this single procedure with a significant reduction in morbidity.19 It is, thus, an effective, safe and simple single procedure that can be used to remove actinic keratoses and epidermal growths as both a therapeutic and cosmetic procedure.

Glogau grade II photoaging skin can be effectively treated for improvement in both texture, color change, and epidermal growths with a medium depth Jessner’s – TCA peel. Of equal importance to the procedure is choosing the correct patient for the procedure. Patients with superficial textural changes and those with epidermal growths seem to respond best to this peel. Fine wrinkles, cross-hatched lines, sallow color changes of photoaging along with the crinkly appearance are the textural changes that will respond to this peel. Additionally, epidermal growths such as freckles, lentigenes, actinic keratoses, and seborrheic keratoses will also respond well.(Fig 5) The more advanced changes seen with deeper grooves and wrinkles, pebbly appearance of the skin and more pronounced gravitational changes of Glogau III and IV photoaging skin require either deep chemical peeling or laser resurfacing. Using trichloracetic acid or any of its combinations as a deep chemical peel for these more advanced indications will only risk potential side effects and complications.

Pigmentary dyschromias such as melasma, blotchy hyperpigmentation, and pigmentary growths do respond well to medium depth chemical peeling. This is especially suited for those problems which have not resolved well with medical treatment or repeated light chemical peeling. Epidermal pigment seems to respond the best and this can be identified with Wood’s light examination. Dermal pigment will show some response but not as effective as epidermal pigment. This combination peel is effective in that it will fully remove the epidermis as well as have an effect on melanocytes in the pilar apparatus during reepithelialization. It is important that these patients be prepared correctly with 4-8% hydroquinone, tretinoin and sunscreen begun at least six weeks prior to the peeling procedure. The bleaching agent is reinstituted after reepithelialization and tretinoin six weeks later. It should be continued for up to three months after the chemical peel and sunscreen used for longer period of time to insure the dyschromia does not return. There are many bleaching agents on the market today which have some lightening effect, but hydroquinone is the most effective.

When localized areas of the face have advanced or severe photoaging such as deeper wrinkles around the eyelids and rhagades on the lips, the combination Jessner’s trichloracetic acid peel can be used to blend the remaining areas of the face if they have only moderate photoaging of the skin. Thus, eyelids and lips can be resurfaced with a pulsed carbon dioxide laser and the remainder of the face treated with the Jessner’s – trichloracetic acid peel. In this instance, the peel should be performed first in the manner described above and then appropriate anesthesia, eye protection and preparation be used to laser the designated areas. Healing will occur in the usual manner for either laser or peel with soaks and occlusive ointments. This is an effective method of reducing morbidity with deeper agents to areas that don’t need them. It will also blend the photoaging skin, texture, color and appearance to that of the laser treated skin.(Fig 6)

Post-Operative Care and Complications

The four stages of wound healing are apparent after a medium depth chemical peel.20 They include:

• Inflammation
• Coagulation
• Reepithelialization
• Fibroplasia

At the conclusion of the chemical peel, the inflammatory phase has already begun with a brawny, dusky erythema that will progress over the first twelve hours. With the medium depth peels, the epidermis will begin to separate, creating a leathery, dry, cracking appearance to the epidermis. This is an accentuation of pigmented lesions on the skin as the coagulation phase separates the epidermis, producing serum exudation, crusting and pyoderma. It is during this phase that it is important to use debrident soaks and compresses as well as occlusive salves. These will remove the sloughed necrotic epidermis and prevent the serum exudate from hardening as crust and scab. I prefer the use of 1/4% acetic acid soaks found in the vinegar water preparation (one teaspoon white vinegar, one pint warm water), as it is antibacterial, especially against pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue, mildly debrident, as it will dissolve and cleanse the necrotic material and serum. Occlusive dressings including bland emollients and salves and biosynthetic membranes. For medium depth peeling, I prefer the occlusive salves as these can be monitored carefully day by day for potential complications.

Reepithelialization begins on day three and continues until day seven to ten. Occlusive salves promote faster reepithelialization and less tendency of delayed healing.21 The final stage of fibroplasia continues well beyond the initial closure of the peeled wound and continues with neoangiogenesis and new collagen formation for three or four months. Prolonged erythema may last two to four months in unusual cases of sensitive skin or with contact dermatitis. New collagen formation can continue to improve texture and rhytides for a period up to four months during this last phase of fibroplasia.

Many of the complications seen in peeling can be recognized early on during healing stages. The cosmetic surgeon should be well acquainted with the normal appearance of a healing wound in its time frame for medium depth peeling. Prolongation of the granulation tissue phase beyond one week may indicate delayed wound healing. This could be the result of viral, bacterial or fungal infection, contact irritants interfering with wound healing, or other systemic factors. A red flag should alert the physician that careful investigation and prompt treatment should be instituted to forestall potential irreparable damage that may result in scarring. Thus, it is vitally important to understand the stages of wound healing in reference to medium depth peeling. The physician then can avoid, recognize and treat any and all complications early on. Specific complications will be discussed in the appropriate chapter.

Longterm care of peeled skin would include sunscreen protection for up to six months along with reinstitution of medical treatment such as low strength hydroxy acid lotions and tretinoin. Re-peeling areas should not be performed for six months from the previous peel. If any erythema or edema persists, the peel should not be performed as the re-injury may create complications. This peel should not be performed on undermined skin such as facelift or flap surgery performed up to six months prior to the peel.22

The evolution of medium depth chemical peeling has changed the face of cosmetic surgery. It has introduced new techniques into the armamateria of the cosmetic surgeon to treat problems that previous have been approached with tools inadequate to obtain the results for moderate photoaging skin or with overly-aggressive treatment using deep peeling agents. The combination peels have provided some of the more popular tools needed to approach a burgeoning population with photoaging skin.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

A classification of peeling agents emphasizes depth of penetration as a reflection of activity rather than chemical formulation. The labeling a peel as superficial, medium or deep depth is more meaningful than using chemicals or brand names.1 A new understanding of peeling injury and repair has emerged along with an appreciation of the variation in patient’s skin type, pigmentation and degree of photoaging. Utilizing the Fitzpatrick and Glogau system of pigmentation and sun damage, one can individualize the strength of chemical agents to match the skin types.2,3

Medium depth peeling is thus defined as the use of a chemical agent to wound skin through papillary dermis. It is most useful for the removal of epidermal or superficial lesions and to improve skin texture in moderate photodamaged skin (grade II Glogau photoaging skin). Medium depth peeling agents create changes through necrosis of the epidermis and part or all of the papillary dermis with an inflammatory reaction in the upper reticular dermis. The procedure is performed to remove actinic keratoses, mild photoaging of the skin including rhytides, treat pigmentary dyschromias, and improve depressed scars.4 (Table I)

Medium-depth chemical peeling

Medium-depth chemical peeling is defined as controlled damage from a chemical agent to the epidermis and papillary dermis that can be performed in a single setting. The benchmark for this level peel was 50% trichloroacetic acid. It has traditionally achieved acceptable results in ameliorating fine wrinkles, actinic changes, and pre neoplasia. However, since higher concentration TCA itself is an agent more likely to be fraught with complications, especially scarring, in strengths of 50% or higher, it has fallen out of favor as a single agent chemical peel.5 It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of control damage without the risk of side effects. Agents currently used include combination products – Jessner’s solution, 70% glycolic acid, and solid carbon dioxide with 35% trichloroacetic acid.6 (Table II)

Brody first developed the use of solid CO2 applied with acetone to the skin as a freezing technique prior to the application of 35% trichloroacetic acid. The preliminary freezing appears to break the epidermal barrier for a more even and complete penetration of the 35% trichloroacetic acid.

Monheit then demonstrated the use of Jessner’s solution prior to the application of 35% trichloroacetic acid. The Jessner’s solution was found effective in destroying the epidermal barrier by breaking up individual epidermal cells. This also allows a deeper penetration of the 35% TCA and a more even application of the peeling solution.8 Similarly, Coleman has demonstrated the use of 70% glycolic acid prior to the application of 35 % trichloroacetic acid. Its effect has been very similar to that of Jessner’s solution.9

All three combinations have proven to be as effective as the use of 50% trichloroacetic acid with a greater safety margin. The application of acid and resultant frosting is better controlled with the combination products. The “hot spots” that result from higher concentrations of TCA can be controlled, creating an even peel with less incidence of dyschromias and scarring. The combination peel produces an even, uniform peel with much less a risk of complications.10 The Monheit version of the Jessner’s solution – 35% TCA peel is a relatively simple and safe combination. This technique is used for mild-to-moderate photoaging including pigmentary changes, lentigines, epidermal growths, dyschromias, and rhytids. It is a single procedure with a healing time of seven to ten days. It is useful also to remove diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy. Topical chemotherapy is applied for three weeks creating erythema, scabs and crusts for up to six weeks.11 The combination peel will produce similar therapeutic benefits within ten days of healing. It thus reduces the morbidity significantly and gives the cosmetic benefits of improved photoaging skin.

The procedure is usually performed with mild preoperative sedation and nonsteroidal antiiflammatory agents. The patient is told that the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours if the patient can tolerate the medication. Its anti-inflammatory effect is especially helpful in reducing swelling and relieving pain. If given before surgery, it may be all the patient requires during the postoperative phase. For full-face peels, though, it is useful to give preoperative sedation (diazepam 5 to 10 mg orally) and mild analgesia, meperidine 25 to 50 mg (Demerol – Winthrop, New York), and hydroxyzine hydrochloride 25 mg intramuscularly (Vistaril – Lorec, New York). The discomfort from this peel is not long lasting, so short acting sedatives and analgesics are all that are necessary.12

Vigorous cleansing and degreasing is necessary for even penetration of the solution. The face is scrubbed gently with Ingasam (Septisol – Vestal Laboratories, St. Louis, Missouri) with four-inch by four-inch gauze pads and water, then rinsed and dried. Next, an acetone preparation is applied to remove residual oils and debris. The skin is essentially debrided of stratum corneum and excessive scale. A thorough degreasing is necessary for an even penetrant peel. The physician should feel the dry, clean skin to check the thoroughness of degreasing. If oil is felt, degreasing should be repeated. A splotchy peel is usually the result of uneven penetration of peel solution due to residual oil or stratum corneum, and a result of inadequate degreasing.

After thorough cleaning, the Jessner’s solution is applied with either cotton-tip applicators or 2” x 2” gauze. (Table III) The Jessner’s solution is applied evenly with usually one or two coats to achieve a light but even frosting. The frosting achieved with Jessner’s solution is much lighter than that produced by TCA and the patient is usually uncomfortable, feeling only heat. A mild erythema appears with a faint tinge of splotchy frosting over the face. Even strokes are used to apply the solution to the unit area covering the forehead to the cheeks to the nose and chin. The eyelids are treated last creating the same erythema with blotchy frosting. (Fig 1)

The TCA is painted evenly with one to four cotton-tipped applicators that can be applied over different areas with light or heavier doses of the acid. Four cotton-tipped applicators are applied in broad strokes over the forehead and also on the medial cheeks. Two mildly soaked cotton-tipped applicators can be used across the lips and chin, and one damp cotton-tipped applicator on the eyelids. Thus, the dosage of application is technique dependent on the amount used and the number of cotton-tipped applicators applied. The cotton-tipped applicator is useful in quantatiting the amount of peel solution to be applied.

The white frost from the TCA application appears complete on the treated area within 30 seconds to 2 minutes. Even application should eliminate the need to go over areas a second or a third time, but if frosting is incomplete or uneven, the solution should be reapplied. TCA takes longer to frost than Baker’s formula or straight phenol, but a shorter period of time than the superficial peeling agents do. The surgeon should wait at least 3 to 4 minutes after the application of TCA to ensure the frosting has reached its peak. He then can document the completeness of a frosted cosmetic unit and touch up the area as needed. Areas of poor frosting should be retreated carefully with a thin application of TCA. The physician should achieve a level II to level III frosting. Level I frosting is erythema with a stringy or blotchy frosting, seen with light chemical peels. Level II frosting is defined as white-coated frosting with erythema showing through. A level III frosting, which is associated with penetration through the papillary dermis, is a solid white enamel frosting with little or no background of erythema.13 A deeper level III frosting should be restricted only to areas of heavy actinic damage and thicker skin. Most medium-depth chemical peels use a level II frosting and this is especially true over eyelids and areas of sensitive skin. Those areas with a greater tendency to scar formation, such as the zygomatic arch, the bony prominences of the jawline, and chin, should only receive up to a level II frosting. Overcoating trichloroacetic acid will increase its penetration so that a second or third application will drive the acid further into the dermis, creating a deeper peel. One must be careful in overcoating only areas in which the take up was not adequate or the skin is much thicker. (Fig II)

Anatomic areas of the face are peeled sequentially from forehead to temple to cheeks and finally to the lips and eyelids. The white frosting indicates keratocoagulation or protein denaturation of keratin and at that point the reaction is complete. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the line demarcation between peeled and nonpeeled areas. The perioral area has rhytids that require a complete and even application of solution over the lip skin to the vermilion. This is accomplished best with the help of an assistant who stretches and fixates the upper and lower lips which the peel solution is applied.

Certain areas and skin lesions require special attention. Thicker keratoses do not frost evenly and thus do not pick up peel solution. Additional applications rubbed vigorously into the lesion may be needed for peel solution penetration. Wrinkled skin should be stretched to allow an even coating of solution into the folds and troughs. Oral rhytides require peel solution to be applied with the wood portion of a cotton-tipped applicator and extended into the vermilion of the lip. Deeper furrows such as expression lines will not be eradicated by peel solution and thus should be treated like the remaining skin.

Eyelid skin must be treated delicately and carefully. A semidry applicator should be used to carry the solution within 2 to 3 mm of the lid margin. The patient should be positioned with the head elevated at 30 degrees and the eyelids closed. Excess peel solution on the cotton tip should be drained gently on the bottom before application. The applicator is then rolled gently on the lids and periorbital skin. Never leave excess peel solution on the lids because the solution can roll into the eyes. Dry the tears with a cotton-tipped applicator during peeling because they may pull peel solution to the puncta and eye by capillary attraction. (Fig III) The solution should be diluted immediately with cool saline compresses at the conclusion of the peel. The Jessner’s-TCA peel procedure is as follows:

• The skin should be cleaned thoroughly with Septisol to remove oils.
• Acetone or acetone alcohol is used to further debride oil and scale from the surface of the skin.
• Jessner’s solution is applied.
• Thirty-five percent TCA is applied until a light frost appears.
• Cool saline compresses are applied to dilute the solution.
• The peel will heal with 0.25% acetic acid soaks and a mild emollient cream.

There is an immediate burning sensation as the peel solution is applied, but this subsides as frosting is completed. Cool saline compresses offer symptomatic relief for a peeled area as the solution is applied to other areas. The peel reaction is not neutralized by saline solution as the reaction is completed when frosting occurs.16 The compresses are placed over the face for 5 to 6 minutes after the peel until the patient is comfortable. The burning subsides fully by the time the patient is ready to be discharged. At that time, most of the frosting has faded and a brawny desquamation is beginning.

Postoperatively, edema, erythema, and desquamation are expected. With periorbital peels and even forehead peels, eyelid edema can occur and may be enough to close the lids. For the first 24 hours, the patient is instructed to soak four times a day with a 0.25% acetic acid compress made of 1 tablespoon white vinegar in 1 pint of warm water. A bland emollient is applied to the desquamating areas after soaks. After 24 hours, the patient can shower and clean gently with a mild nondetergent cleanser. The erythema intensifies as desquamation becomes complete within 4 to 5 days. Thus, healing is completed within 1 week to 10 days. At the end of 1 week, the bright red color has faded to pink and has the appearance of a sunburn. This can be covered by cosmetics and will fade fully within 2 to 3 weeks.

The combination medium-depth peel is dependent on three components for therapeutic effect: (1) degreasing, (2) Jessner’s solution, and (3) 35% TCA. The amount of each agent applied creates the intensity and thus the effectiveness of this peel. The variables can be adjusted according to the patient’s skin type and the areas of the face being treated. It is thus the workhorse of peeling and resurfacing in my practice as it can be individuated for most patients we see.

The medium-depth chemical peel thus has five major indications:

• destruction of epidermal lesions – actinic keratoses
• resurfacing the level II or III moderate photoaging skin
• pigmentary dyschromias
• mild acne scars
• blending photoaging skin with laser resurfacing and deep chemical peeling

Actinic keratoses

This procedure is well suited for the patient with epidermal lesions such as actinic keratoses which has required repeated removal with either cryosurgery or chemoexfoliation (5-fluoruracil). The entire face can be treated as a unit or subfacial cosmetic unit such as forehead, temples, and cheeks, and can be treated independently. Active lesions can be removed, as well as incipient growths as yet undetected, will be removed as the epidermis is sloughed. Advantages for the patient with photodamaged skin include a limited recovery period – 7 to 10 days, with little post operative erythema after healing. There is little risk of pigmentary changes either hypopigmentation or hyperpigmentation, thus, the patient can return to work after the skin has healed.(Fig IV)

Moderate photoaging skin

Glogau level II or III damage responds well to this peeling combination with removal of the epidermal lesions and dermal changes that will freshen photoaging characterized as sallow, atrophic skin with fine rhytides. This peel is favored over deeper resurfacing procedures such as laser and deep peel in that it will heal in ten days with minimal risk of textural or color complications. It, though, is only designed for medium-depth damage. (Fig V)

Pigmentary dyschromias

Though color change can be treated with repetitive chemical peeling, the medium-depth peel will be a single treatment preceded and followed by the use of bleaching agents and retinoic acid.17 In most cases, the pigmentary problems are resolved with this single peel as an adjunct to the skin care program. (Fig VI)

Blending other resurfacing procedures

In a patient in which there is advanced photoaging changes such as crow’s feet and rhytides in the periorbital and/or perioral area with medium-depth changes on the remaining face, a medium-depth peel can be used to integrate these procedures together. That is, laser resurfacing or deep chemical peeling can be performed over the periorbital and perioral areas that has more advanced photoaging changes, while the medium-depth chemical peel is used for the rest of the face. This will blend the facial skin as a unit so that the therapeutic textural and color changes will not be restricted to one area. The patients requiring laser resurfacing in a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth chemical peel. Patients having laser resurfacing or deep peeling to the perioral or periorbital areas alone develop a pseudo hypopigmentation that is a noticeable deformity. The patient requiring laser resurfacing at a localized cosmetic unit will have the remaining areas of their face blended with this medium-depth peel. The alternative – a full-face deep peel or laser resurfacing has an increased morbidity, longer healing and risk of scarring over areas such as the lateral jaw line, malar eminences, and forehead. If deep resurfacing is needed only over localized areas such as perioral or periorbital face, a blending medium-depth peel does reduce morbidity and healing time.12 (Fig VII)

Coleman Version Glycolic Acid and Trichloracetic Acid Peel

The combination of glycolic acid 70% and trichloracetic acid 35% is another combined peel designed to improve the efficacy of 35% trichloracetic acid without the risks and complications of higher strength TCA.(21) Chemicals, methodology and techniques are different so that one must have a thorough understanding of this peel and not utilize the methods of the preceding combination peel or the use of trichloracetic acid alone. This combination peel produces less wounding depth than the previous combination peels as demonstrated in histologic studies, but a significantly greater wound level than 35% trichloracetic acid alone. It has also demonstrated the ability to stimulate new collagen production with a comparable Grenz zone to the other medium depth peels.13 Application of the glycolic acid prior to the TCA peel allows for an even debridement of the stratum corneum equal to that obtained with a degreasing procedure and the Jessner’s solution.9

In this procedure, no cleansing or degreasing procedure is done. After washing the face with soap and water, 70% glycolic acid is applied directly to the patient’s facial skin with a rectal swab and after a strict 2 minute contact period, the solution is removed with tap water. Next, the 35% trichloracetic acid is applied in a sequential pattern with either cotton tip applicators or 4 x 4 inch gauze pads to the entire face. The usual frosting is obtained and cool compresses are placed to alleviate the stinging and burning.

This combination peel has also been found effective in the treatment of actinic keratoses and epidermal growths, Glogau grade II photoaging skin, and pigmentary dyschromias. The same skin preparations are used as well as similar post-operative wound care. Advantages of this peel are that most physicians are already familiar with the use of glycolic acid and its time-dependent action. It is a fairly simple learning curve to add the 35% trichloracetic acid onto this already established chemical peel. Drawbacks may be the uneven nature of glycolic acid peeling and the possibility of accentuating “TCA hot spots.” In addition, the use of saline to neutralize the glycolic acid may inhibit some of the absorption of trichloracetic acid for the second part of this combination peel. Though these are theoretical points, in practicality, Dr. Coleman has demonstrated excellent results with this combination medium depth peel.

Other medium depth peels include:

• Full strength unoccluded phenol peel
• Pyruvic acid (alpha-keto acid)
• Jessner’s-glycolic acid peel

Eighty-nine percent phenol has the ability to wound through the papillary dermis similar to other peeling strengths discussed. Its disadvantage is inherent in the absorption of phenol with significant cardiac and hepato renal toxicity. For this reason, the other peels discussed have significant advantages.

Pyruvic acid is an alpha-keto acid which is a very potent chemical peeling agent and has been used experimentally for photoaging skin. The rapid dermal penetration has the potential for scarring and side effects and though some results have been demonstrated by Griffin to be excellent, its safety and efficacy has not been well established.14

The Jessner’s Solution and Glycolic Acid Peel

This combination peel has been studied by Dr. Larry Moy with the intent of two theoretical advantages.

• Jessner’s solution allows for deeper penetration of the glycolic acid.
• The glycolic acid will be a greater stimulant for collagen regeneration without further exfoliation.

Though this technique is both time-dependent and restricted to visual endpoints, the chances for overtreating are great which may create potential side effects and complications.15

Post-Operative Care and Complications

The four stages of wound healing are apparent after a medium depth chemical peel.16 They include:

• Inflammation
• Coagulation
• Reepithelialization
• Fibroplasia

At the conclusion of the chemical peel, the inflammatory phase has already begun with a brawny, dusky erythema that will progress over the first twelve hours. With the medium depth peels, the epidermis will begin to separate, creating a leathery, dry, cracking appearance to the epidermis. This is an accentuation of pigmented lesions on the skin as the coagulation phase separates the epidermis, producing serum exudation, crusting and pyoderma. It is during this phase that it is important to use debrident soaks and compresses as well as occlusive salves. These will remove the sloughed necrotic epidermis and prevent the serum exudate from hardening as crust and scab. I prefer the use of 1/4% acetic acid soaks found in the vinegar water preparation (one teaspoon white vinegar, one pint warm water), as it is antibacterial, especially against pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue, mildly debrident, as it will dissolve and cleanse the necrotic material and serum. Occlusive dressings including bland emollients and salves and biosynthetic membranes. For medium depth peeling, I prefer the occlusive salves as these can be monitored carefully day by day for potential complications.

Reepithelialization begins on day three and continues until day seven to ten. Occlusive salves promote faster reepithelialization and less tendency of delayed healing.17 The final stage of fibroplasia continues well beyond the initial closure of the peeled wound and continues with neoangiogenesis and new collagen formation for three or four months. Prolonged erythema may last two to four months in unusual cases of sensitive skin or with contact dermatitis. New collagen formation can continue to improve texture and rhytides for a period up to four months during this last phase of fibroplasia.

Many of the complications seen in peeling can be recognized early on during healing stages. The cosmetic surgeon should be well acquainted with the normal appearance of a healing wound in its time frame for medium depth peeling. Prolongation of the granulation tissue phase beyond one week may indicate delayed wound healing. This could be the result of viral, bacterial or fungal infection, contact irritants interfering with wound healing, or other systemic factors. A red flag should alert the physician that careful investigation and prompt treatment should be instituted to forestall potential irreparable damage that may result in scarring. Thus, it is vitally important to understand the stages of wound healing in reference to medium depth peeling. The physician then can recognize, treat and avoid any and all complications early on.

Long-term care of peeled skin would include sunscreen protection for up to six months along with reinstitution of medical treatment such as low strength hydroxy acid lotions and tretinoin. Re-peeling areas should not be performed for six months from the previous peel. If any erythema or edema persists, the peel should not be performed as the re-injury may create complications. This peel should not be performed on undermined skin such as facelift or flap surgery performed up to six months prior to the peel.18

The evolution of medium depth chemical peeling has changed the face of cosmetic surgery. It has introduced new techniques into the armamateria of the cosmetic surgeon to treat problems that previous have been approached with tools inadequate to obtain the results for moderate photoaging skin or with overly-aggressive treatment using deep peeling agents. The combination peels have provided some of the more popular tools needed to approach a burgeoning population with photoaging skin.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Derm projects that HA products will provide all the many tools needed for lunch-time filling.

By Rebecca Bryant, Staff Correspondent

Boston – Although hyaluronic acid (HA) fillers have become the treatment of choice in the U.S., according to Gary D. Monheit, M.D., many questions remain: Can Hylaform, Restylane, and Juvederm be improved to achieve more than a three- to six-month longevity? How will the fillers compare, after more extensive head-to-head testing? And where will HA products ultimately fit in an armature, ranging from bovine collagen to polylactic acid? Those questions notwithstanding, he says, “Looking toward the future, I think the full family of HA products—Restylane, Hylaform, and Juvederm—will gives us all the necessary tools we need for lunch time filling.”

HA vs. Collagen An associate professor of dermatology at the University of Alabama in Birmingham, Dr. Monheit has conducted dozens of clinical trials on fillers. He attributes the most favored status of HA products partly to the allure they’ve gained as the latest generation of proven technology. But they do have an significant position in relation to theadvantage over the collagen products they’ve succeeded. “The HA molecule is hydroscopic,” he says, “and its ability to bind water gives it a viscoelastic feel. After injection the product will swell, adding more volume. This is in contrast to collagen, which loses water suspension after injection.” Even after the cosmetic benefit dissipates, a substantial amount of hyaluronic acid remains in the skin for up to a year. Thus, a second, follow-up treatment will often induce a larger and longer lasting benefit than the first. On the other hand, the HA generation lacks some of collagen’s advantages. Hylaform, Restylane, and Juvederm inhibit the clotting cascade and are formulated without lidocaine. “It’s a good idea to use very fine needles, like the 30-guage Maxflo, to minimize trauma, bruising, bleeding, and discomfort when injecting HA products,” says the dermatologist. He adds, “I find that vibration produces excellent analgesia when injecting the nasolabial folds.” Because HA products are crystal clear, they can appear blue if injected close to the surface due to the Tyndall effect. “HA products should be injected 1-2 mm below the surface to avoid creating the blue color,” he says. “This is not a big deal or something to worry about; it’s just something derms need to be aware of.”

Distinguishing HA products “Both Hylaform and Restylane, which have FDA approval, are particles of HA bonded together and suspended in a gel,” says Dr. Monheit. “Juvederm, which is in the clinical trial phase, is a homogeneous gel-based HA.” Thus, when compared to Juvederm, Hylaform and Restylane have increased surface area exposure with increased susceptibility to enzymatic degradation. There is also more friction upon injection and increased exposure to free radicals. Approved for correction of soft tissue contour deficiencies, such as wrinkles or acne scars, Hylaform binds to water up to 1,000 times its volume, resists degradation, feels natural, and does not clump. The family of products—Hylaform Fine Line, Hylaform, and Hylaform Ultra—correlate to superficial, mid, and deep levels of dermal filling. Dr. Monheit often uses Hylaform in combination with Cosmoplast. The collagen provides structure, while the HA adds volume. The combination (achieved either by mixing the products and injecting them together or by injecting Cosmoplast first) also causes less pain and bruising than the use of Hylaform alone. Produced via a bacterial fermentation process, the Restylane family line tailors particle size to tissue matrix. Use Restylane Fine Lines (reformulated in January 2004) for treatment of superficial lines and wrinkles around the eyes, forehead, and smile lines. Restylane is for treatment of moderate lines, wrinkles and folds, and lips, while Perlane targets deep tissue improvements, such as enhancement of lips, chin, and cheeks. Inject Restylane products as superficially as possible within the recommended tissue depth. Techniques include serial puncturing, linear threading, fanning, and cross-hatching. Also manufactured via bacterial fermentation, Juvederm gained CE approval in 2000 and is distributed as Hydrafil in Europe. As a single-phase gel without particles, it is homogenous, more resistant to in situ degradation, more pliable and viseoelastic, and less inflammatory than its FDA-approved counterparts. “Of the two product lines now approved by the FDA, I find Restylane very favorable for nasolabial folds and marionette lines where volumetric filling is needed,” says Dr. Monheit. “Restylane, though, can produce moderate inflammation for two to five days, and this must be explained to the patient. “If you need a non-inflammatory HA filler, I would recommend Hylaform, as it produces very little inflammation. It is also useful in the lips where inflammation and lumpiness can be a problem. “Mid-dermal fillers can be improved with a lighter filler injected above. I use Cosmoderm above HA to eradicate the fine line wrinkle usually found below deeper grooves on the nasolabial folds, lip lines, and marionette lines.”

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Abstract

The keratoacanthoma (KA) can cause a therapeutic conundrum due to its relationship and at times difficult distinction from squamous cell carcinoma both clinically and histopathologically. Some have described this entity as a benign squamous neoplasm advocating watching and monitoring the lesion until regression has occurred while others have described their metastatic potential. We present a case of an aggressive metastatic keratoacanthoma in a healthy Caucasian male with no prior history of skin cancer or trauma to the area of the primary lesion.

The keratoacanthoma (KA) is a tumor that is characterized by a rapid proliferative stage followed by a stable mature stage leading to spontaneous involution leaving in its wake a scar. It is a relatively common tumor occurring mainly on sun-exposed areas in actinically damaged skin. The following case report involves an atypical aggressive keratoacanthomatous exhibiting behavior worthy of this report. Its peak incidence is between the ages of 50 and 69 and the lesions typically occur as a solitary tumor. While there is a strong suggestion of UV light playing an inciting role in their development, other related factors such as genetics, immunosuppression, chemical carcinogens, viruses, and trauma have also been postulated.1,2 Multiple cases of keratoacanthomas associated with previous trauma have been reported.3

Typically KAs are solitary, however multiple KAs have been characterized. Multiple keratoacanthomas occurring at a young age occurs in the inherited disorder of the Ferguson-Smith type. Generalized eruptive KAs of Grzybowski is characterized by thousands of small, disseminated KAs. KAs also occur more commonly in patients with Muir-Torre syndrome and xeroderma pigmentosum.

Conservative yet complete excision is advocated as the treatment of choice by the majority due to the potential for aggressive, yet typical non-aggressive behavior of the keratoacanthoma. The authors agree with this treatment of choice, however, the treatment of each KA should be individualized based on its clinical behavior and the patient’s general health.

Case Report

A 58-year-old Caucasian male presented with an asymptomatic erythematous papule on his nasal tip beginning as an erythematous macule two weeks earlier. Physical examination revealed a firm red dome-shaped papule 0.6 cm in size. The patient was a healthy individual with no prior history of trauma to this area. The lesion was diagnosed as folliculitis and the patient was begun on an antibiotic regimen. The lesion continued to grow and the patient was seen two weeks later at which time the lesion was 2.0 cm in size and had a keratinacious core. The lesion was treated with shave electrodessication and curettage and the specimen sent to pathology.(Fig 1) The histopathology was consistent with well-differentiated squamous cell carcinoma-keratoacanthomatous type.

Two weeks later the patient presented to our clinic. On physical examination, the patient was found to have a 4.0 X 4.0 X 3.0 cm red firm exophytic tumor with keratinacious ulcerated center extending from his nasal tip onto the nasal dorsum.(Fig 2) No lymphadenopathy, pain, or neurological deficits were noted and the patient was feeling well. The Mohs procedure was preformed on this patient, and the tumor was cleared in three Mohs layers. The end defect resulted in loss of full thickness soft tissue with some collagen loss of the nasal tip, supratip, and dorsum, extending to but not encompassing the ala. There was partial loss of both lateral cartilages and nasal mucosa of the nasal tip with reconstruction.(Fig 3)

Histologic review of the tumor revealed large pink epithelial cells with few mitoses. A tendency for maturation of the keratinocytes occurred at the sides and base of the lesion. A large central keratin plug was noted in the center with whirls of keratin appearing throughout the lesion.(Fig 4)

Within two weeks of the Mohs procedure, the patient presented to our office with a 1.3 cm recurrent lesion on the columella which was cleared in two Mohs layers.(Fig 5, Fig 6) The histology showed an exophytic mass of large well-differentiated keratinocytes with horn pearl formation.(Fig 7) The patient had no lymphadenopathy, no neurological deficits, and was feeling well.

Two weeks later the patient first noted a blurring of his vision and ptosis of his right upper eyelid.(Fig 8) He stated he was seeing double. No pain was noted although the patient was experiencing occasional headaches. No lymphadenopathy was present. Also at this time a 0.7 cm recurrence of the tumor was noted on his nasal dorsum.(Fig 9) The tumor was cleared in 2 Mohs layers and the histology was similar to the histology of the columella recurrence showing an exophytic mass of large well-differentiated keratinocytes with horn pearl formation.

The patient was referred to a neuroophthalmologist. On physical examination the visual acuity of the right eye was 20/30 and the left eye was 20/20. Both pupils were equal and reactive to light and accommodation. Extraocular movements of the right eye were 10% of normal for all gazes. Extraocular movements of the left eye were normal. Cranial nerves 5 and 7 were intact bilaterally. A diagnosis of unilateral cranial nerves 3, 4, and 6 palsy was made and a mass in the cavernous sinus was suspected. An MRI was obtained to determine the etiology. The MRI revealed an increase in contrast uptake surrounding the carotid flow void in the right cavernous sinus. There was no evidence of parenchymal involvement in the brain.(Fig 10) Due to the acute and unilateral nature of the symptoms and the patient’s previous history of aggressive keratoacanthoma, a diagnosis of metastatic squamous cell carcinoma-keratoacanthomatous type to the apex of the cavernous sinus was made. A PET scan also demonstrated intense hypermetabolic uptake in the right cavernous sinus with an SUV of 11.7. No other uptake was noted in the head, neck, or chest.

A tumor panel was held, and it was decided that the best method of treatment would be palliative chemotherapy and radiation treatment. Fractionated radiotherapy was decided upon due to the proximity of the tumor to the optic nerve. The poor prognosis was discussed with the patient. Interestingly the patient’s eye movement and double vision began to improve before therapy was begun. Even with this improvement in symptoms before treatment, the decision for radiation and chemotherapy was made due to the very poor prognosis of tumor in the cavernous sinus.

The patient underwent chemotherapy utilizing Carbo/Taxol on a weekly bases for a total of 4 weeks and radiotherapy receiving a total of 60 Gy. He currently has no ptosis of the right eye and his extraocular movements are intact bilaterally. Figure 11 He states that his double vision no longer occurs regularly, however he will notice occasional double vision late in the evening when he feels his eyes are fatigued.

A repeat MRI done 6 weeks after finishing therapy (3 ½ month after original MRI) revealed an interval decrease in size of the right cavernous sinus mass with only subtle asymmetrical thickness and more intense enhancement of the right cavernous sinus versus the left. This represents improvement in the metastatic disease.

Discussion

The keratoacanthoma is a tumor that is characterized by three clinical stages: proliferative stage, mature stage, and involutional stage. The proliferative stage is characterized by rapid growth over a two to four week period often achieving a size of 2 cm or more with histology similar to a well-differentiated squamous cell carcinoma with many mitotic cells. The mature stage is typically characterized as a dome-shaped nodule with a keratinous core. The histopathological findings of a mature lesion are typically exoendophytic with an invaginating mass of keratinizing, well-differentiated squamous epithileum at the sides and bottom of the lesion. A central keratin-filled crater is present with lipping of the edges of the lesion which overlap the central crater, giving a symmetrical appearance. The epithelial cells are large with a eosinophilic hue to their cytoplasm. A mixed inflammatory infiltrate is present. The involutional stage tends to take place after a few months with tumor resorption leaving a scar. During the involutional stage the lesion flattens, keratinocytes become shrunken and stain intensely with eosin. Granulation tissue and fibrosis occur at the base of the lesion. Although some lesions may persist for more than a year, the typical course usually takes about 4 to 6 months.1 The mechanism that is responsible for the regression of KAs is poorly understood, but is thought to be an immunologically mediated response.4 Activated CD4-positive T lymphocytes are present in the infiltrate along with an increase in Langerhans cells.5 There is increased apoptosis of the keratinocytes and it has been noted that expression of bcl-2 is lost in regressing KAs.6

It is difficult to distinguish absolutely between keratoacanthoma and squamous cell carcinoma both clinically and histopathologically. Rapid growth and a keratin core help to distinguish the two clinically. However both can grow rapidly and when rapid growth occurs in squamous cell carcinomas, central necrosis of the tumor can lead to ulceration and scabbing which at times can be somewhat similar in appearance to the keratin core. Histological features which favor the diagnosis of KA over SCC include a symmetric exoendophytic lesion with lipping and a central keratin plug, as well as the pattern of cell keratinization with large central cells that have slightly paler eosinophilic cytoplasm.7,8,9 At the current time there is no immunohistologic staining pattern which easily and definitively distinguishes between the two diagnoses.

Malignant transformation and metastasis of KAs have been reported in the literature as rare but serious and at times life ending events. These reports lend themselves to the belief that the KA is in actuality an expression of squamous cell carcinoma and should not be considered a benign entity. The most evidential cases, reported by Hodak et al describe 3 cases of metastasizing KAs.10 Each case report includes a clinical and histopathologic diagnosis of primary KA treated with excision and a histologic diagnosis at the site of metastases consistent with metastatic KA. The first case described an immunologically competent 86-year-old female with diagnoses of KA on her cheek and resultant metastatic disease diagnosed in the ipsilateral parotid a few months later. She was treated with radiation therapy with no evidence of recurrence or further metastasis observed over a 2 year period. The second case describes an immunologically competent 86-year-old man with a diagnosis of KA on his left shoulder. Four months later, a left axillary mass was noted and was consistent with metastatic disease. The patient died several months later with the cause of death due to metastatic squamous cell carcinoma. The third case describes an immunologically competent 77-year-old man with a KA on his neck and a subsequent metastatic lymph node 2 cm from the primary lesion. Six months after the node was excised in total, no recurrence or metastatic disease was noted.10 Another example of aggressive KA in the literature is reported by Piscioli et al describing a 9 cm KA in a patient with impairment of cellular immunity which recurred locally and metastasized to regional lymph nodes. No follow up on the patient was given.11

One other case of invasive KA with metastatic disease to the cavernous sinus has been reported. Grossniklaus et al reported 3 patients with a diagnosis of superficially invasive (extending into muscle and with perineural invasion) keratoacanthoma in the periorbital region. One tumor exhibited late perineural extension into the cavernous sinus which was confirmed histologically. No follow up on the patient was given.12

Our patient presented with an aggressive KA which metastasized to the cavernous sinus causing signs and symptoms consistent with cavernous sinus syndrome. The cavernous sinus is a small but complex structure housing a venous plexus, the carotid artery with its periarterial sympathetic plexus, and several cranial nerves. The abducens nerve (CNVI) runs lateral to the internal carotid artery, the oculomotor nerve (CNIII) runs in the most superior and lateral border of the sinus, the trochlear nerve (CNIV) runs just inferiorly to CNIII. More inferior but still within the lateral dural border of the cavernous sinus runs the ophthalmic division of the trigeminal nerve.

Cavernous sinus syndrome is characterized by multiple cranial nerve neuropathies. Deficits in these nerves can lead to impairment of ocular movements, Horner’s syndrome (miosis, ptosis, apparent enophthalmos, and hemianhidrosis), and sensory loss of more commonly the ophthalmic division of the trigeminal nerve and less commonly the maxillary division of the trigeminal nerve. The pupil can be involved or spared and pain associated with this syndrome is variable.

Several disease states other than neoplasms can cause a cavernous sinus syndrome. These include infections, noninfectious inflammatory disorders such as Tolosa-Hunt Syndrome, and vascular lesions.13

The most common neoplastic lesions in the cavernous sinus are caused by direct invasion of intracranial tumors such as pituitary adenoma.13 Less commonly, perineural spread of a head and neck malignancy or hematogenous spread from distant sites can occur. Most metastatic lesions to the cavernous sinus, orbital, or intracranial areas occurring from a primary lesion on the head and neck are thought to be due to perineural spread of squamous cell carcinoma.14,15 However, the diagnosis of an intracranial metastases in patients with head and neck squamous cell carcinoma is rare and carries with it a very poor prognosis.16,17 Zhu et al reported a case in which a 70-year-old male with multiple cutaneous SCCs of the head and neck developed metastatic disease of the cavernous sinus and leptomeninges, and cauda equina during a 5 year period histologically consistent with moderately differentiated SCC. Veness et al advocate adjunctive radiotherapy if perineural involvement is present in aggressive tumors on the forehead or periorbital area to prevent orbital spread.15

Our patient revealed an acute onset of diplopia due to a limited range of motion of the right eye as well as ptosis of the right eyelid. Due to the patient’s recent history of aggressive KA with two recurrent lesions on his nose, the acute nature of the deficits, and the unilaterality of the findings, a metastatic lesion was diagnosed and the need for a biopsy to verify diagnosis was not felt to be necessary. The MRI visually localized the lesion, however due to the patient’s findings of multiple CN deficits, the location of the lesion without MRI could be deduced. Our patient’s findings were consistent with a right sided CN III, IV, and VI palsy, with sparing of the pupil, vision, and sensation to the upper face. The cavernous sinus is the location where these three cranial nerves are in the closest proximity. CN III acts on the levator palpebrae muscle allowing elevation of the eyelid. Therefore a palsy of CN III can cause ptosis of the upper eyelid, however, if CNIII were the only nerve affected, the patient would have a fixed “down and out” gaze due to the unopposed action of the superior oblique and lateral rectus muscles. The patient had only 10% of normal ocular movement and double vision of all gazes. Therefore palsy of the CN IV and VI were also suspected. The sparing of the pupil is consistent with sparing of the papasympathetic fibers which run with CN III innervating the sphincter muscles of the iris and the ciliary muscle. Normal sensation to the V1 distribution of the face is consistent with sparing of the ophthalmic branch of CN V. Therefore localization of the metastatic lesion to a position just lateral and superior to the carotid artery in the cavernous sinus is possible without MRI.

We do believe that the two lesions occurring 2 weeks and 4 weeks after the initial Mohs procedure were recurrences of the original KA and stand by the diagnosis of KA as opposed to SCC. Rook and Champion reported that excision of KAs in the growth phase can be followed by “recurrence”.18 The authors agree with Haws et al and Griffiths that such recurrences are likely to represent a reactive process in the phase of proliferation rather than a neoplastic change of a KA to a SCC.19,20 This is further supported by the fact that trauma can induce KA lesions.3 It is possible that both the trauma from the excision and the fact that the KA excised was in the proliferative phase contributed to the recurrence or reactive proliferation of the primary lesion. This is further supported by the observation that local recurrence of invasive SCC after complete excision is extremely rare and when recurrence does occur, it occurs either months to years later within the scar of the excision site or as a regional lymph node metastases. It typically does not occur as a metastatic lesion to the skin somewhat near the primary lesion.

It is interesting to note that our patient was beginning to have improvement in his ocular symptoms and headaches before therapy was begun. The beginning of the regression in symptoms occurred 2 ½ months after the original red macule was noted on his nose. Even with this improvement in symptoms before treatment, the decision for radiation and chemotherapy was made due to the very poor prognosis of tumor in the cavernous sinus. Typically, squamous cell carcinoma metastatic to the cavernous sinus holds a survival time of under 6 months. It has currently been 3 ½ months since the patient first noted symptoms of cavernous sinus syndrome and his symptoms continue to improve.

The patient has since undergone chemotherapy and radiation treatment with recovery of his eye movement and resolution of his diplopia. Could it be that the keratoacanthoma had reached the involutional stage even before therapy was begun which could explain this improvement in symptoms with out therapy? A repeat MRI is scheduled in 6 months. The patient will continue to be followed closely.

Conclusion

The difficulty in definitive diagnosis and at times rare but aggressive behavior of this tumor can result in difficulty in treatment decision as well as patient counseling. Due to this difficulty most people advocate conservative excision, although many treatment plans have been tried for KAs. It is important that each lesion and patient is evaluated individually to ascertain the best treatment. KAs behaving aggressively must be respected and treated with early intervention and possibly adjunctive.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Abstract

The public’s interest in acquiring a youthful appearance by rejuvenating their skin has popularized the use of an array of cosmetic procedures. Due to the advances in the field of cosmetics, physicians have many cosmetic products in their armamentarium from which to choose. Deciding which product and procedure will attain the most pleasing results requires in depth knowledge of the products themselves, their proper uses, and the patient’s wishes.

The ageing face shows signs of dryness, fine lines, wrinkles, actinic changes, dyspigmentation, and loss of subcutaneous tissue. Over time both collagen and elastin are degraded and when regenerated do so in a haphazard way leading to loss of resilience and tone of our skin leaving it more susceptible to gravities pull with formation of jowls and the double chin. Our facial expressions are solely dynamic early in life, but due to multiple factors over time, they begin having a static appearance which is accentuated by expressivity. Over time repetitive motion and changes in the skin and subcutaneous tissue can lead to deepening of the nasolabial folds and permanent rhytides of the glabella. Actinic damage leads to irregular maturation of the epidermis, hastening of dermal haphazardness, and dyspigmentation of the skin. Loss of subcutaneous fat of the face also occurs beginning from the cheeks and eventually affecting the temples. With loss of this tissue, more lines are noticeable both statically and with expression.

When evaluating a patient, two objectives must be met for excellence in care: the patient’s desires must be understood and the physician’s evaluation of the patient must be accurate. It is important that the physician understands what the patient perceives as their problem area which seems simple, but can take time. An effective method of conveying information efficiently is by having the patient create a “wish list” of five things they would change about their appearance with the most important feature first on the list. This list should be reviewed with the patient having them demonstrate in the mirror exactly what is meant by each topic on their list, and adding our own suggestions as appropriate. Asymmetries should be pointed out to the patient, recorded in the chart, and recorded photographically before any treatment if received. Changes in the skin due to inherent aging, actinic damage, and loss of subcutaneous tissue with respect to the patient’s skin should be reviewed with the patient. Sometimes this is best done while a patient is looking into a mirror. Rhytides caused by recurrent movement verses changes in the skin caused by increased laxity and gravity and the treatment for these separate issues should be distinguished. It is important that the patient have realistic expectations and are educated on which treatment would be best for their particular concern and why. Treatment options are then reviewed with the patient beginning with simple procedures and combined simple procedures with little down time and ending with more long lasting procedures requiring significant down time. Prior cosmetic procedures are reviewed with the patient. If the patient has not had augmentation procedures before, we typically recommend beginning with a product that lasts the least amount of time so that the patient can decide if augmentation if right for them and whether they would like a degradable or permanent filler. Although permanent fillers have the advantage of fewer injection sessions to maintain a desired affect, there is less of a margin of error when injected and the products can shift over time and with muscular movement. Also as the face ages, the site first injected may not be the ideal site for injection five or ten years later in life leaving an unnatural appearance to the area. The cost of each procedure is reviewed with the patient and written information is given to the patient. They can either proceed with treatment or can schedule a future appointment after considering their treatment options.

The ideal patient for any cosmetic procedure is one that understands the risks and benefits of the procedure and has realistic expectations. If a patient wants more improvement than soft tissue augmentation can offer or has a prominent cheek overhanging the nasolabial fold, a better option may be a face lift or a feather lift. On the other hand, a patient who has almost no perceivable signs of skin aging and wants augmentation may better be treated with a good skin care regimen and possibly a noninvasive laser or microdermabrasion procedure.

Analyzation of the patient with photoaging skin must include skin color and skin type as well as degree of photoaging. Evaluation of the skin needs to be done in a systematic manner. Various classification systems are available and a combination of three systems to help the physician define the right program or therapeutic procedure for the patient will be presented here. The Fitzpatrick skin type system classifies degrees of pigmentation and ability to tan. (Fitzpatrick TB. The validity and practicality of sunreactive skin types I through VI. Arch Dermatol 124:869-871, 1988) Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage, and ability of facultative melanogenesis. In addition, this system classifies skin according to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin types I and II are pale white and freckled with a high degree of potential to burn with sun exposure. Skin types III and IV can burn but usually have an olive to brown coloration. Skin types V and VI are dark brown to black skin that rarely ever burn and usually do not need sunscreen protection. See Table 1

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects. (Glogau RG. Chemical peeling and aging skin. J Geriatr Dermatol 2(1):30-35, 1994.) The categorization is I through IV, ranging from mild, moderate, advanced, and severe photodamaged skin. These categories are devised for therapeutic intervention. Category I or minimal-degree photodamage can be treated with light chemical peeling and medical treatment. Categories II and III would entail the above and medium-depth chemical peeling, soft tissue augmentation and /or Botox, and category IV would need those modalities listed plus cosmetic surgical intervention for gravitational changes including aptos threads. See Table 2.

Monheit has devised a system of quantitating photodamage, developing numerical scores that would fit into corresponding rejuvenation programs. In analyzing photodamage, the major categories include dermal with textural changes and epidermal with skin lesions. Dermal changes include both dynamic and static rhytides, fine lines, sallow color and dyschromia, leathery, thin and parchment-like, pebbly or nodular skin, and pore size and number. Epidermal changes incude number of freckles, lentigenes, telangiectasias, seborrheic keratosis, actinic keratosis, skin cancers, and senile comedones. Each section is given a score and the final score is tabulated. A score of 1-6 represents very mild damage and the patient would adequately respond to a skin care program including sunscreen protection, retinoic acid, glycolic acid peels, and selective lesion removal. A score of 7-11 would include all of the above plus a repetitive superficial peeling agents program such as glycolic acid, Jessner’s solution, or lactic acid peels and laser therapy for pigmented or vascular lesions. A score of 12-16 would include medium-depth chemical peeling with the addition of skin fillers and/or Botox when needed, and a score of 17 or more would include the above plus deep chemical peeling or laser resurfacing. (Figure X: Index of Photoaging)

Most patients have a skin care regimen in place having tried many over the counter products by the time they make an appointment with their physician and are ready for a “procedure”. In every patient seen, skin care should be reviewed and the importance of a daily sunscreen and sun avoidance techniques should be stressed. To avoid eventual deep furrowing of the skin, smoking should be ceased if applicable. When appropriate the strongest tolerated Retin-A product should be prescribed to the patient and glycolic acid skin care products can also be used to contribute towards a youthful appearance.

Need chart for surgery course for AAD per Monheit

The areas to be rejuvenated should then be reviewed with the patient. According to the patient’s desires and scores on the above scales, modalities of treatment should be selected. Table X (chart for surgery course for AAD per Monheit) When photoaging is the primary concern of the patient, lunchtime procedures including microdermabrasion, superficial peels, radiofrequency skin tightening, and intense pulsed light can be used. More aggressive forms of treatment with significant down-time include medium depth peeling, laser resurfacing, and dermabrasion. When dynamic rhytides are attaining permanency or Crow’s feet are of concern, chemodenervation methods such as with Botox or Dysport can be used with no down-time. When static rhytides have formed or folds have become deeper or more prominent or contour irregularities of aging are present, a filler substance can be used. Choosing a filler substance to best suit the patient is imperative. If the cheeks or marionette lines are prominent with gravitational pull, aptos threads or a lifting procedure would best suit the patient. A combination of procedures may increase the effectiveness and longevity of each procedure preformed. The amount of time to recover from the procedure is a trade-off of the procedures efficacy and may dictate which procedure or procedures are preformed. A realistic treatment goal should also be discussed with the patient.

Fillers

Natural youthful contouring of the face can be achieved with soft tissue augmentation. The improvement achievable with soft tissue augmentation depends on the amount of the implant used, the type of implant, the frequency of implantation, and the intrinsic qualities of the contour defect. A single implant or multiple implants can be used to attain the desired affect. For example, if a patient presents with fine lines radiating from the nasolabial folds, the best treatment would be one utilizing an injectable filler specific for fine lines and filling the nasolabial folds with a more appropriate filler for deeper furrows. This method works best when a few of the fine lines are treated followed by filling of the folds, then returning to finish the filling of the fine lines. At times after filling the deeper folds, certain fine lines become more noticeable or new ones occur. Another injection method is to inject both collagen and hyaluronic acid at the same visit and into the same treatment sites. This method is best used to treat deeper furrows, and by layering the two, a synergistic affect may take place lengthening the time of degradation of the products compared to the time of degradation of individual injections. With some products benefits are noticeable the day they are injected, with others, 1-2 weeks are needed before the product has maximum benefit. Some products last for four-six months while others last six to nine months or are permanent. While the cosmetic benefits of filler substances have been proven, the risks and benefits ratio should be reviewed with the patient. Side effect profile of each injectable chosen should be presented to the patient who if sensitivity to the product occurs, will likely have the side effect till degradation of the product is complete.

A thorough medical history, family history, and physical exam should be done with each patient when considering treatment with a filler substance. Any history of collagen vascular diseases (CVD) should be noted. There have been conflicting studies associating injectable collagen to certain CVDs, however, no causal relationship between collagen injections and CVDs has been established. Bleeding disorders or anticoagulation medications should be noted. Bruising occurs more frequently when an anticoagulant is used and the patient should be aware of this possibility. Ice and pressure are good methods to decrease the amount of bruising and pain. Any asymmetries in the patient’s appearance should be noted and brought to the attention of the patient. Asymmetries should also be documented in the chart for legal purposes.

Injectable bovine collagen was developed in the 1970s. Today bovine collagen (Zyplast) remains the gold standard for which other filler products are compared. Permanent injectable collagen, Artecoll, was developed as a long lasting alternative to Zyplast. Recent advances in filler substances include human fibroblast derived collagen (Cosmoderm and Cosmoplast), hyaluronic acid derivatives (Restylane and Hylaform), calcium hydroxylapatite microspheres (Radiance FN), and polylactic acid microspheres (Sculptra). Autologous fat transfer leads to a more permanent result with no chance for allergy or hypersensitivity to one’s own fat, but with significant down-time.

In general, the collagen derivative filler substances last three to four months. The bovine collagen derivatives (Zyderm and Zyplast) require a test implantation before treatment and approximately 3% of the population are sensitive to the product with the sensitivity lasting the longevity of the product. (Elson ML. The role of skin testing in the use of collagen injectable materials. J Dermatol Surg Oncol 1989;15:301-3 and Watson W, Kay RL, Klein AW, et al. Injectable collagen: a clinical overview. Cutis 1983;31:543-6.) There have also been some reports of adverse events with bovine collagen even with a negative test implantation site including systemic hypersensitivity and granuloma formation at the injection site. ( Stegman SJ, Chu S, Armstrong RC: Adverse reactions to bovine collagen implant: Clinical and histologic features. J Dermtol Surg Oncol 14(Suppl):39-48, 1988
Labow TA, Silvers DN: Late reactionsat Zyderm skin test sites. Cutis35:154-158, 1985. Overhold MA, Tschen JA, Font RL: Granulomatous reaction to collagen implant, light and electron microscopic observations. Cutis 51:95-98, 1993.
Cucin RL, Barek D: Complications of injectable collagen implants .Plast Reconstr Surg 71:731, 1983.)

Artecoll consists of bovine collagen and purified polymethyl-methacrylate (PMMA) microspheres. In addition to adverse events similar to those of bovine collagen there is a low but true risk of allergenicity to the PMMA microspheres which can cause a prolonged allergic response due to the permanence of this product. (Lemperle G, Romano J, Busso M. Soft Tissue Augmentationwith Artecoll: 10-Year History, Indications, Techniques, and Complications. Dermatol Surg 2003;29:573-587.)

Nonbovine collagen (Cosmoderm and Cosmoplast) is also available. These collagen products are less antigenic than their bovine counterparts and safety tests have deemed them free of any pretreatment test sites.

Restylane and Hylaform are injectable hyaluronic acid derivatives. They were developed primarily as an alternative to collagen injections for soft tissue augmentation. One of the advantages to injectable hyaluronic acid derivatives versus collagen is the potential longevity of the product in tissue typically lasting 6-8 months. Another advantage is the increased biocompatibility. Although the injectable hyaluronic acids seem as though they should be free of side effects, reported sensitivity to the products have been published and therefore patients should be warned of these potential sensitivities. Micheels P. Human anti-hyaluronic acid antibodies: is it possible? Dermatol Surg. 2001 Feb;27(2):185-91.
Lowe N, Maxwell CA, Lowe P, Duick M, Shah K. Hyaluronic acid skin fillers: adverse reactions to skin testing. JAAD 2001;45:930-3.
Friedman PM, Mayfong EA, Kauvar AN, Geronemus RG. Safety data of injectable nonamincal stabilized hyaluronic acid for soft tissue augmentation. Dermatol Surg. 2002 Jun;28(6):491-4.
Fernandez-Acenero MJ Zamora E, Borbujo J. Granulomatours foreign body reaction against hyaluronic acid: resport of a case after lip augmentation. Dermatol Surg. 2003 Dec;29*12):1225-6.
Lupton JR, Alster TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Derm Surg 2000;26:135-7.
Raulin C, Greve B, Hartschuh W, Soegding K. Exudative granulomatous reaction to hyaluronic acid. Contact Dermatitis. 2000 Sep;43(3):178-9.

Calcium Hydroxylapatite (CaHA) is an inorganic substance that mimics the structure of bone. In the United States, it is marketed as Radiance where it is used off label for soft tissue augmentation. In its soft tissue injectable form, CaHA microspheres are suspended in a carboxycellulose absorbable gel, and it is injected into the dermis or subcutaneous tissue. As the gel is absorbed, collagen deposition into and around the microspheres causes collagen formation and enhances augmentation. It is expected to last between two to five years and its break down products include calcium and phosphorous. Sklar JA, White SM. Radiance FN: a new soft tissue filler. Dermatol Surg. 2004 May;30(5):764-8.

Poly-L-lactic acid (PLLA) received conditional FDA approval for treatment of HIV-related lipoatrophy under the trade name Sculptra on March 2004. The FDA has not yet approved Sculptra for general cosmetic use in the United States, however, studies of this product are currently underway to gain FDA approval. Poly-L-lactic acid has been marketed as New-Fill in Europe since November 1999.

PLLA is a synthetic polymer which is resorbable, biocompatible, and biodegradable. It has been used for several years in multiple medical devices and is a component of vicryl suture. PLLA can be injected into the deep dermal tissue or subcutaneous tissue to correct generalized contour defects. The area to be filled should be undercorrected. After injection, gradual degradation takes place by hydrolysis while gradual deposition of collagen occurs. Nayak, PL. Biodegradable polymers: opportunities and challenges. JMS Rev Macromol Chem Phys, 1999, C39(3):481-505

The initial apparent correction, due to implantation of the PLLA decreases over the next few days as the diluent is resorbed. The area treated with PLLA will then slowly refill as the tissue reacts to the implant. A gradual increase in the volume will continue to occur over the next few months.

The side effects of this material are similar to other injectables and include erythema, edema, and bruising at the injection site. Palpable but nonvisible subcutaneous nodules have been noted in some patients which can resolve spontaneously. These nodules may be due to over-correction. Massaging the treated area after injection may reduce the incidence of this side effect. Rare cases of sterile abscess, late granuloma formation and hypersensitivity reactions have been reported.

Moyle GJ, Lysakova L, Brown S, Sibtain N, Healy J, Priest C, Mandalia S, Barton SE. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection.
Lombardi T, Samson J, Plantier F, Husson C, Kuffer R. Orofacial granulomas after injectionof cosmetic fillers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med. 2004 Feb;33(2):115-20.
Valantin MA, Aubron-Olivier C, Ghosn J, Laglenne E. Pauchard M, Schoen H, Bousquet R, Ktz P, Costagliola D, Katlama C. Polylactic acid implants (New-Fill) to correct facial lipoatrophy in HIV-infected patients: results of the open label study VEGA. AIDS. 2003 Nov 21;17(17):2471-7.

Autologous fat transplantation can be an effective treatment for subcutaneous augmentation that may produce permanent results in some cases. Fat transplantation can be used to treat generalized contour defects of the face. Typically swelling, bruising, and soreness will last from 3-7 days after the procedure depending on how much and where the fat is injected. Fat is harvested from a donor site and different techniques can be used to inject the fat into the contour deficiencies. Four injection techniques are used: immediate injection into the subdermis, immediate injection into multiple tissue planes from the periostium upwards, freezing and storage of fat for monthly low-volume augmentation with or without immediate injection, and emulsifying of fat and injection into the dermis with or without immediate subdermis injection. Overcorrection is necessary as the unviable fat will be resorbed. Small and repeated implantation results in less down-time.
(Fournier PF. Fat Grafting: My Technique. Dermatol Surg 2000;26:1117-1128
Markey AC, Glogau RG. Autologous Fat Grafting: Comparison of Techniques. Dermatol Surg 2000;26:1135-1139.)

Injectable implants are typically as effective as the product packaging claims as long as the products are injected as directed on the package insert. Variables in efficacy can be noted if the material is injected into the subcutaneous tissue causing much less augmentation compared to when it is injected correctly into the dermis. If the injectable implants are injected too superficially, a beading look to the skin can occur. The beading will eventually decrease with time, decreasing fastest in areas with the most movement. At times when injecting into the dermis and inserting the needle in a forward fashion, the injectable material can be extruded into an area of the dermis that is not the ideal site. Firm massage of the injected sites can help to smooth the contour of the injectable filler and guide the filler to a more optimal location albeit minimally.

Injecting material can cause considerable discomfort in some patients especially when injecting into the nasolabial folds, with maximal discomfort occurring at the superior aspect of the nasolabial folds. Some injectables contain an anesthetic which helps with the pain of injection. Countermeasures to avoid pain include topical anesthetic, ice, infraorbital nerve block, or simultaneous stimulation with a massaging apparatus. While it may be tempting to inject an anesthetic into the area to be treated, this can distort normal contours and should be avoided. Topical anesthetics help to decrease the pain of the needle puncture, but help minimally with the injection itself or the forward motion of the needle through the dermis. Infraorbital nerve blocks or counter nerve stimulation have mixed results, but do help to lessen the pain.

Peeling and Resurfacing

The Fitzpatrick type skin classification allows for easy identification of which patients may experience pigmentary abnormalities after a resurfacing procedure. The side effect profile increases both with depth of peel and darkness of skin. As with all patients receiving a peel or other resurfacing procedure, the patient with Fitzpatrick type I or II skin with significant photodamage needs regular sunscreen protection before and after resurfacing procedures. The patient does, however, have only a small risk for hypopigmentation or reactive hyperpigmentation after a chemical peeling or resurfacing procedure. The patient with type III through VI skin has a greater risk for pigmentary dyschromia-hyperpigmentation or hypopigmentation, after a chemical peel and may need post-treatment bleaching agents in addition to sun prevention to prevent these complications. Pigmentary risks are generally not a great problem with superficial chemical peeling but may become a significant problem with medium and deep chemical peeling. Chemical peeling can also be a significant risk when regional areas such as lips and eyelids are peeled with a resurfacing laser, creating a significant color change in these cosmetic units compared to the rest of the face. This has been classified as the “alabaster look” seen with taped deep chemical peels in regional areas. Avoidance can be achieved if a blending medium depth chemical peel is used in regions abutting the laser resurfaced area. The chemical peel should be preformed first as to not place the peeling agent into denuded skin leading to greater penetration. The physician must inform the patient of this potential problem, especially if the patient is of skin type III through VI; justify the benefits of the procedure; outweigh these risks; and plan for the appropriate techniques to prevent these unwanted changes in color.

Chemical peeling and a laser resurfacing can lead to accentuation or new development of telangiectasias. Dermabrasion is the only resurfacing method that can decrease the number of telangiectasias during treatment, however as the skin rejuvenates, telangiectasias can develop as a natural part of the healing process.

Significant healing time is needed after a medium or deep resurfacing procedure. The patients must be reliable and able to make follow-up appointments for evaluation of the healing process, follow the directions of topical wound care, and take antibiotics and antivirals as prescribed. Patients with current or history of neurotic excoriations or aggressive picking behaviors should be treated with caution if at all with a resurfacing procedure since during the healing time the epidermis should not be disturbed except when doing wound care to ensure proper healing. Picking of the skin and infection can both lead to scarring. Patients should be aware that during the healing process, pruritus is a common symptom and cool compresses can be used with an antihistamine for treatment. Occasionally candida has been cultured out of wounds and should be treated, however, a moderate amount of staphylococcus will colonize any wound.

To minimize edema, we treat our resurfacing patients with 40 mg IM Kenalog after the procedure. This does not seem to slow wound healing and in fact likely speeds healing to the decrease in inflammation and edema.

Botulinum toxin used in conjunction with resurfacing techniques may lead to greater collagen deposition and therefore better post-operative results. This could be do to the lack of movement of the injected areas causing less collagen resorption . Treatment with botulinum toxin should take place at least one week before the resurfacing procedure to ensure full effect of the toxin.

Botox

For cosmetic use, Botox is most commonly injected in the upper face for smoothing out the glabella and forehead and lifting the brow. Evaluation of individuals for symmetry, brow ptosis, and underlying musculature is crucial when treating forehead rhytides and lifting the brow. If asymmetry is present, it should be brought to the attention of the patient. Photographs not only help to track objective changes with treatment but also help to remind the patient of their progress or prior asymmetries. In order to decrease the incidence of brow ptosis it is important to identify those patients who compensate for brow ptosis by recruiting the use of the frontalis muscle to subconsciously lift their brows to a natural level. In those patients who recruit the frontalis muscle to prevent brow ptosis, injection of low dose BOTOX approximately 2.5 cm above the brow lessens this potential side effect.(Goodman G: Botolinum toxin for the correction of hyperkinetic facial lines. Aust J Dermatol 39:158-163, 1998 and Carruthers and Carruthers; Seminars in Cutaneous med and surg. Botulinum Toxin Type A: History and Current Cosmetic Use in the Upper Face) Brow elevation occurs by contraction of the frontalis and/or relaxation of the brow depressor muscles. The goal of treatment of the forehead rhytides is to soften these lines without causing brow ptosis or complete loss of facial expression. There have been several studies done to determine optimal dosage and treatment sites.

When injecting the lower face, it is important to ask the patients if a weakness in their oral aperture will be acceptable as weakening of the orbicualris oris can lead to lessened ability to play a wind instrument, kiss, or enunciate certain sounds. Botulinum Toxin typically last three to four months when injected. Upon repeat injections, muscular atrophy can occur and toxin tends to last approximately four to six months.

Redraping procedures

Aptos

Miniface lift

Conclusions

The key to successful cosmetic treatments include both the patient’s viewpoint and the clinician’s expertise. Many products are available and if used correctly lead to excellent cosmetic results. The recovery time and product cost allowed by the patient can dictate which procedures can be preformed. Synergism between products has been noted and multiple products can be used at the same or interval visits. Starting slow with short lasting products can allow the patient to evaluate a particular look without permanency allowing movement to longer lasting products and procedures as desired. In our youth driven society, cosmetic procedures will continue to thrive, and skilled, educated physicians can continue to develop and better the field of cosmetics.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

For Horizontal Forehead Lines

Horizontal forehead lines are primarily caused by the action of the frontalis muscle. This muscle, lying just below the subcutaneous tissue, is a vertically oriented muscle that is continuous with the galea aponeurotica superiorly and interdigitates with the procerus, orbicularis oculi, corrugator supercilli, depressor supercilli, and the skin of the eyebrow inferiorly. Frontalis contraction causes brow elevation. The temporal branch of the facial nerve is responsible for the action of this muscle with denervation resulting in brow ptosis and loss of forehead motion. The width of this muscle can be noted clinically by the extent of the forehead crease.

For Brow Lift

Brow depression can be perceived as an angry or scowling expression. The brow depressor muscles include the corrugator supercilii, procerus, and the supramedial and supralateral portions of the orbicularis oculi. These three muscles work together to close the eyes and squint creating transverse and oblique glabellar lines. The corregator supercilli muscle is a paired muscle originating at the medial end of the superciliary arch and inserting into the frontalis and skin of the brow. It acts via the temporal nerve to pull the brow together and downward causing vertical glabellar frown lines. The procerus muscle, innervated by the zygomatic branch of the facial nerve, attaches to the nasal root skin primarily acting to shorten the nose causing “rabbit lines” by drawing the forehead skin and eyebrows inferiorly. The orbicularis oculi muscle is divided into orbital and palpebral portions. It inserts into the medial palpebral ligament and circumferentially surrounds the eye. The superior portion of the orbicularis oculi is innervated by the temporal nerve. The orbital component allows tight closure of the eye while the palpebral portion allows gentle eye closure.

For references:

• Bolognia, Jorizzo, Rapini et al. Dermatology (It’s the new big derm text)
• Clemente. Anatomy. A regional Atlas of the Human Body. 4th ed. Williams and Wilkins1997.

Tx Sites and Dosage – Site Studies

Evaluation of individuals for symmetry, brow ptosis, and underlying musculature is crucial when treating forehead rhytides and lifting the brow. If asymmetry is present, it should be brought to the attention of the patient. Photographs not only help to track objective changes with treatment but also help to remind the patient of their progress or prior asymmetries. In order to decrease the incidence of brow ptosis it is important to identify those patients who compensate for brow ptosis by recruiting the use of the frontalis muscle to subconsciously lift their brows to a natural level. In those patients who recruit the frontalis muscle to prevent brow ptosis, injection of low dose BOTOX approximately 2.5 cm above the brow lessens this potential side effect.(Goodman G: Botolinum toxin for the correction of hyperkinetic facial lines. Aust J Dermatol 39:158-163, 1998 and Carruthers and Carruthers; Seminars in Cutaneous med and surg. Botulinum Toxin Type A: History and Current Cosmetic Use in the Upper Face) Brow elevation occurs by contraction of the frontalis and/or relaxation of the brow depressor muscles. The goal of treatment of the forehead rhytides is to soften these lines without causing brow ptosis or complete loss of facial expression. There have been several studies done to determine optimal dosage and treatment sites.

Carruthers et al describes a well accepted method of injection of 10 to 20 U BTX-A, diluted 100U Botox with 1 ml sterile saline, distributed in 4-5 injection sites horizontally across the midbrow 2-3 cm above the eyebrows. Four injection sites are used if the brow is less that 12 cm and 5 for greater that 12 cm. (1. Carruthers and Carruthers; Seminars in Cutaneous med and surg. Botulinum Toxin Type A: History and Current Cosmetic Use in the Upper Face). The Carruthers believe that the brow depressors should be treated at the same time as the frontalis to aid in the prevention of brow ptosis. Even with this cautious approach, a minor degree of brow ptosis or swelling of the upper eyelids is seen in a few patients. In a prospective, double-blind, randomized, parallel-group, dose-ranging study of BOTOX in females with horizontal forehead rhytides, Carruthers et al also observed that higher BOTOX A doses resulted in greater efficacy and longer duration of effect in the reduction of horizontal rhytides when injections of 16, 32, or 48 units of BOTOX A into the brow elevators and depressors. There was a higher incidence of brow ptosis seen in the 32-U and 48-U groups, 21% and 10% respectively than seen in the 16-U group, 0%. (Dermatology Surgery 2003 May 29(5) 461-7)

Keen et al conducted one of the first double-blind placebo-controlled studies of BTX-A use in facial wrinkles. In this study, 11 subjects were treated including 9 for forehead lines and 2 for periorbital wrinkles, the toxin was diluted to a concentration of 2.5 or 5 IU/ml and electromyography was utilized to find the most active portion of the muscle injected. Forehead injections included 8 injection sites totaling 10U of BTX-A on one hemiforehead with normal saline injected on the opposite side of the forehead. Injections into the periorbital wrinkles with 5-U of Botox in two separate sites was done on 2 subjects with normal saline injection on the opposite side. Specific injection sites were not noted. The patients were both self evaluated and evaluated by a physician on a scale from 0 to 3, with 0 reflecting no facial wrinkles and 3 reflecting severe facial wrinkling. Both the forehead and periorbital scores were averaged together. At repose, a mean reduction in wrinkles of 1.3 rating points was seen by the patients while the physicians rated the mean reduction to be 1.5. When the subjects were asked to contract the injected muscles, a mean reduction of 2.0 and 1.5 were seen by the subjects and physicians respectively. Two of the 11 patients in this study felt that their eyebrow had dropped slightly while 3 or 11 thought the injection was painful. One reported a changed in the shape of her brow. There were no physician comments noted about the above changes. (Keen M, Blitzer A, Aviv J et al. Botulinum toxin A for hyperkinetic facial lines: results of a double-blind placebo-controlled study. Plast Reconstr Surg 1994:94:94-9)

In a study conducted by Goodman, 1-2 U of Botox was injected into the ridges created between the forehead lines when the subjects were asked to raise their eyebrows. All injections were made at least 2 finger-breadths above the brow. A concentration of 10 U/ml was used and 1 to 2 units were injected into 2 sites on each ridge. Two of his four patients had complete elimination of their forehead lines with none having brow ptosis. The most common complications included bruising and minor discomfort with injection. (Goodman G, Australas J Dermatol. 1998 Aug; 39(3):158-63)

Another study conducted by Guerrissi and Sarkissian used 12-20 U BTX-A in a 25 U/ml dilution. A pattern of injection was used based on the number of rhytides and lateral extension of the frontalis muscle, however all sites injected were 2.5 cm above the brow. Of the 17 patients in the study, all were satisfied with the results, however, 2 patients developed eyebrow palsy that lasted for 55 to 70 days, 2 patients developed a skin rash (not elaborated on in the article) and edema, and 1 patient developed ecchymosis. (Guerissi J, Sarkissian P. Local injection into mimetic muscles of Botulinum toxin A for the treatement of facial lines. Ann Plast Surg. 1997 Nov; 39(5):447-53)

It is difficult to compare each of these studies due to variability of concentration of Botox used, number of units injected per site, site injection variability, patient population, and lack of specific documentation of injection sites however, most studies agree with the use of 10-20 U of Botox approximately 2 cm above the eyebrow to prevent ptosis of the brow. In our clinic, patients are treated with a total of 10-30 U BTA-A diluted 100 U in 1 ml normal saline in 4-5 injection sites 1-3 U across the midbrow about 2 cm above the eyebrows. A second row of injections of 1-3 U is then placed approximately 1 cm above this. Women are treated with fewer units of botox in the lateral forehead position if lateral elevation of the eyebrow or a more open central face is desired. Men are typically treated with the same number of units across the brow in two rows as above with care paid to lateral injection so that they will not have an elevated lateral brow. Typically men have a more developed musculature, so they receive more units of botox than women. We agree with Carruthers et al and typically inject the brow depressors when treating horizontal rhytides. Our percentage of eyebrow ptosis is approximately 2%.

Decreased activity of the brow depressor muscles can lift the brow and alleviate a scowling or angry expression caused by overactivity of these muscles. It is important to remember that the inferior portion of the frontalis interdigitates with the corrugator supercilii, procerus, and the medial portion of the orbicularis oculi. Clinical observation of the skin lines overlying these muscles is a result of the equilibration of the individual opposing muscular forces developed due to facial expression. Injecting into the areas of muscular overlap can affect each of the underlying muscles, however the bulk of the frontalis lies above this area of overlap. Injecting into the middle of the muscle bellies of the brow depressor muscles or the upper and middle frontalis leads to the most consistent results of brow elevation without ptosis.

In 1998, Frankel et al injected the corrugators and procerus with a total of 20 U of BOTOX-A to determine if the medial brow could be elevated. Of the 30 patients in the study, subjective comparison found 62% to have a mean increase in height of the medial brow of 10% above baseline and a 48% to have a mean increase in height of the midpupillary brow of 14% above baseline after treatment. In 59% of the patients, a measurement of the interbrow distance also showed an increase. In this study however, no side effects of treatment were mentioned and no statistically significant analysis was preformed. (Frankel AS, Kamer FM, Chemical Browlift. Arch Otolaryngol HeadNeck Surg. 1998 Mar; 124(3):321-3)

In 1999, Huilgol et al injected the glabellar area with 7-10 U Botox and the supralateral eyebrow with 0-2.5 U of BOTOX-A bilaterally, to a total dose of 10-14U. Five of the seven women in the study showed brow elevation of 1-3 mm with a mean elevation of 1 mm. Two of the individuals showed no change. There were no significant adverse effects. (Huilgol SC, Carruthers A, Carruthers JD. Raising eyebrows with botulinum toxin. Dermatol Surg. 1999 May;25(5):373-5)

Huang et al evaluated 11 women for alteration in brow position after BOTOX-A treatment of the brow depressor muscles. In this study the concentration of botulinum toxin used was 5 U/0.1 ml (2 ml normal saline in a 100 U vial). Is this correct??? It seems like the concentration would be .5/0.1 ml. Botulinum toxin injections were placed intramuscularly along both orbital rims with four equally spaced sites beginning from the midpupillary line and extending horizontal to the lateral canthus. Each site received 2.5 U of the toxin, for a total of 10U per eyebrow. Five units were injected into the corrugator muscle at each medial brow bilaterally with the injection needle aimed in an upward and horizontal direction. Brow position was then measured at relaxed and elevated positions from the pupil to the nasal, central and temporal brow. Elevation of the brow occurred in both the relaxed and elevated positions with the largest elevation taking place in the central brow region. The largest mean elevations were noted in the right central brow position (relaxed 1.86mm, elevated 2.09 mm) and the left central brow position (relaxed 3.06 mm, elevated 2.86 mm). No adverse effects such as ptosis, bruising, or hematoma were noted in this study. However, in this study, a few patients had negative changes in the brow distance. These changes were not severe enough to be classified as clinical ptosis and were thought to be attributed to diffusion of the toxin into the frontalis muscle. (Huang W et al. Browlift with Botox. Dermatol Surg. 2000 Jan;26(1):55-60)

Ahn et al injected the lateral orbicularis oculi bilaterally with 7-10 U of Botox to measure the efficacy of botox injection for a temporal brow lift. They found an average brow elevation from the midpupil was 1.02 mm and the average brow elevation from the lateral canthus was 4.83 mm when evaluated at 2 weeks after treatment. (Ahn MS et al. Temporal brow lift using botox A. Plast Reconstr Surg. 2000 Mar;105(3):1129-35.

Upon reviewing the literature, there are multiple proven studies to lift the brow. Injection into individual brow depressor muscles alone or several brow depressor muscles can lead to lifting of the brow and the technique used should be based upon the effect needed by the patient. The goal with treatment of the brow depressors with botox is complete or near complete paralysis of these muscles as these muscles aid only in frowning and are not necessary for other important activity. In our clinic, we begin by injecting 3-7 U/side into the corrugator with the needle aimed in a superior fashion and 3-7 units/side approximately 1 cm above this. We then inject the procerus just below the level of the brow centrally with 5-10 U. The procerus is then gently massaged in a horizontal fashion to aid in the diffusion of botox to the depressor supercilli. 3-7 U Botox is injected just inferior to the lateral brow as well as 1 cm above the brow at the pupillary line. We honor the area of the midbrow as to not create an eyelid ptosis. This injection method not only lifts the brow, but it also treats glabellar lines and can lead to the perception of a more open central face. Our percentage of eyebrow and brow ptosis is approximately___________________.

Complications

Adverse reactions associated with Botox A include antibody resistance, idiosyncratic flu like symptoms, distant electromyographic changes, dry mouth, brow and lid ptosis, pain, localized reactions including urticaria, erythema, and edema, ecchymosis, headache, and short-term hypesthesia. (Sadick. Complicaitons of Cosmetic Surgery; Yearbook of Dermatology and Dermatologic Surgery 2002. p 19-41) The most significant complication of treatment of the frontalis is brow ptosis. Each patient’s Botox treatment should be individually based on their underlying anatomical musculature and inherent propensity to elevate their brow to prevent ptosis. Treatment of the brow depressors may be necessary after brow ptosis has occurred. To prevent brow ptosis, a cautious approach to the lower frontalis should be used with injections staying approximately 2 cm above the brow. Injections should be made directly into the muscle is a controlled manner with Botox that has been appropriately diluted. The areas in general should not be massaged. Patients should be instructed to stay upright for 3-4 hours and not to manipulate the area that has been injected. We also recommend that the patients contract their musculature for 1-3 hours after treatement. Injecting the glabella and entire forehead can increase the chance of ptosis. (Klein. Complications and Adverse Reactions with the use of Botox. Seminars in Cutaneous Med and Surg, Vol 20, No2 (June), 2001: pp 109-120)

The most common complication in treatment of the glabellar complex is ptosis of the upper eyelid secondary to the diffusion of Botox through the orbital septum where it can affect the upper eyelid levator muscle. It occurs between a 24 hour to 10 day period and can persist up to four weeks. Eyelid ptosis can be treated by alpha adrenergic agonists eyedrops, Iopidine 0.5% and/or Neosynephrine hydrochloride 2.5%. Neosynephrine acts via Muller’s muscle which is a smooth muscle located beneath the levator muscle of the upper eyelid. To avoid eyelid ptosis, treat conservatively in those patients who may have a reduced orbital septum such as the elderly. Treat accurately with low volumes of Botox. Injection above the midpupillary line should be at least 1 cm above the supraorbital rim. (Klein. Complicaitons and Adverse Reactions with the use of Botox. Seminars in Cutaneous Med and Surg, Vol 20, No2 (June), 2001: pp 109-120)

There is evidence that patients undergoing cosmetic treatment with Botox can produce circulating neutralizing immunoglobin G anitbotulinum toxin A antibodies. This is much more common in patients being treated for neurologic conditions thus requiring larger amounts of the toxin to be injected. The factors causing antibodies to develop are unknown. (Matarasso SL: Complications of Botulinum A exotoxin for hyperfunctional lines. Dermatol Surg 24:1249-1254, 1998.)

Idiosyncratic flu like symptoms are most likely secondary to the proteins in the Botox mixture as opposed to the Botox itself and likely are a mild type of serum sickness. Techniques such as distraction, concurrent muscle stimulation, or application of ice can be used to reduce the pain of the local injection. Localized reactions such as urticaria, edema, and erythema have been reported and are a nonsystemic form of hypersensitivity likely related to local histamine and cytokine release. Bruising can be minimized by avoidance of NSAIDs, aspirin products as well as other anticoagulants. There have been sporadic reports of headache occurring after Botox injection, but more commonly, chronic tension and migraine headaches are improved after the injection. If headache occurs, OTC analgesics may be used. Short-term hyperesthesia is a rare portinjection sequela which remits spontaneously in 48-72 hours. (Klein. Complicaitons and Adverse Reactions with the use of Botox. Seminars in Cutaneous Med and Surg, Vol 20, No2 (June), 2001: pp 109-120)

Patients must be aware of the decreased facial expressivity and the potential change in the brow shape and position when the frontalis and brow depressors are tx with Botox. Multiple small doses injected at 1-2 cm intervals across the forehead will help to weaken, rather than paralyze the frontalis letting facial expression occur while rhytides are treated. Careful placement of the Botox to shape the brow in a pleasing fashion should be done. The dosage is dependent upon the individual but usually ranges from 10-40 U for the brow lift and forehead treatment. The quizzical brow occurs when injection of botox into the lateral fibers of the frontalis is neglected causing weakening of the central forehead without weakening of the lateral forehead. This can be corrected by injecting 1-5 U of Botox laterally.

Contraindications to the use of botulinum toxin include pregnancy, nursing, and pre-existing neuromuscular condition. Medication such as aminoglycosides, penicillamine, quinine, and calcium channel blockers can potentiate the effects of BOTOX and should not be used concomitantly.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The upper face is a visual portal for human communication. In our society where first impressions are important in forming relationships, when one is in contact with a new individual, our first assessment are facial expressions and most particularly around the eyes. Upon greeting, one looks directly into another’s eyes for an initial meeting that will relate to an individual an early message of the encounter to be expected. The periorbital structures and skin gives non-verbal messages as to one’s expectations of the encounter. For example, an open-eyed, smooth glabella and raised brow most commonly indicates receptivity, friendship, friendliness, while a lower brow and scowl can indicate lack of interest, anger, hostility, haughtiness or aloofness. The hanging medial brow, wrinkles and scowl can also indicate disinterest and fatigue. In our rough society with brief meetings, we depend heavily upon visual contact and many times, miscued messages are given by overused and aging muscle structures.

The glabella, forehead and brow control the periorbital units of expression in the upper face. Due to repeated contracture, the photoaging brow ptosis, and concentration lines, a shown or dropped brow may become a permanent fixture giving miscues.

Lucrative brow muscles will cause the skin to crease and repeated movement of specific muscles over time creates visible lines and wrinkles in areas of muscle movement. In particular, the corrugator, the procerus and orbicularis muscles have a major effect for frowning and brow placement.

The orbicularis oculi orbitalis is the “sphincter of the eye” responsible for squinting and blinking. The superior fibers along the brow and above are responsible for brow movement involved in this complex voluntary eyelid closure. The corrugator muscle extends from the base of the nose to the medial brow and forehead area; its function to draw the brow medial and downward and is responsible for the vertical lines in the glabellar area. The procerus muscle, which begins at the nasal base and extends upward to the forehead, wrinkles the nose and pulls the forehead downward. The procerus supercilli ocularis is a smaller muscle in the medial canthus and side of the nose to the infrabrow area medially. It compresses the medial brow, hooding the orbital area. It also is responsible for the wrinkle and frown lines through the glabella. The frontalis muscle which laterally extend upward to the galea from the brow on both sides, have an indirect influence on the glabella but also control brow position and create horizontal wrinkle lines across the brow itself.

In treating the glabella, the muscle sites for Botox treatment are the orbicularis, the corrugator and the procerus. Each should be entered superficially by direct skin injection near the sites of origin. It is best to inject the orbicularis 1 cm. above the supraorbital notch in the suprabrow area. The corrugator is located above the medial-most point of the brow approximately 1 cm. above. The procerus is located midline between the brows and extending down on it. Each muscle may respond to a different dosage of botulinum toxin based on muscle size and strength of movement. These are categorized into mild, moderate and severe frowning forms. Proper doses of each of these have been worked out in dose ranging studies. A 2002 Dose Ranging Study performed by Carruthers, et.al. demonstrated the effectiveness of botulinum toxin A in doses of 10 units to 40 units. The ideal dose range was between 25-40 with an onset within the first week, a peak value at 2 weeks, and longevity between 3-4 months. The mild glabellar wrinkle profile will need approximately 25 units botulinum toxin divided within the 3 muscle groups with 5 injection sites. This can be divided equally but can also be nitrated as to muscle size. Many times, the procerus will need the larger dosage because of its mass and action. This should be evaluated individually on each patient. The moderate glabellar frown has greater muscle bulge and more medial deviation from both the corrugator and orbicularis. A secondary orbicularis injection can be given near the primary to hit bulging fibers. Similarly, a heavier dose to the corrugator can be given, upping the dose to 30 units. The severe form, which has multiple bulges in the glabella, corrugator and orbicularis, may not fully respond due to concomitant photoaging skin and prominent sebaceous skin. Thirty-five to 40 units should be used in controlling the over activity of these muscle groups.

Thus, individual factors affect the Botox dosage in the upper face. These include:

• Muscle size and location – the clinical should watch carefully the movement of frown in each of their patients pre-treatment. This will tell him which muscle strength is being used for each of the components of frown. These include vertical movement, oblique movement and horizontal brow movement with brow depression. Thus, the dosage can be judged by the action and by the muscle size. In addition, males usually require more of a dosage than females because of muscle size and muscle contracture. The older patient requires a larger dosage than the younger patients and one must also take into account skin quality.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Answers

1. The explosion of interest in chemical peeling and laser resurfacing, on the part of physicians has paralleled the general public’s interest in acquiring a youthful appearance by rehabilitating the photoaging skin. The public’s interest has been furthered heightened by advertisements for cosmetic agents, over-the-counter chemicals, and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Most of these over-the-counter, home, do-it-yourself programs have been tried by patients, and by the time they consult their dermatologist or cosmetic surgeon, they are ready for more definitive procedures performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient’s skin type, the degree of photoaging skin and thus prescribe the correct facial rejuvenation procedure that will give the greatest benefit with the least risk factors and morbidity. Major indications when the patient requests improvement include photoaging skin for the correction of rhytides, lentigines, actinic keratoses, and age-related chronological changes of the skin that alter texture and color.

2. Pre-cancerous lesions have been defined as early epidermal changes that are predecessors to skin cancer. These include actinic keratoses, bowenoid keratoses, and even Bowen’s disease. Actinic keratoses can be treated by many different modalities including cryosurgery and topical 5-fluorouracil. Medium depth chemical peeling is well suited for these epidermal lesions as the entire face or a particular subunit of the face, such as the forehead, temples and cheeks can be treated fully within a week to ten days. Active lesions can be removed as well as incipient growths as yet undetected will be removed as the epidermis is sloughed. Advantages for the male patient include a limited recovery time – seven to ten days, with little post-operative erythema after healing. There is little risk of pigmentary change with either hypo or hyperpigmentation. Thus, the patient can return to work rather quickly after healing. There is a long remission period where the patient can expect few if no actinic keratoses to recur.

Deep chemical peels or laser resurfacing will produce a wound deeper than needed for the removal of epidermal lesions; thus, the physician should choose medium depth injury. This includes erbium:YAG laser resurfacing or medium depth chemical peel.

3. In reference to pre-cancerous skin growths such as actinic keratoses, the methods in use today include:

• Topical chemotherapy – 5-fluorouracil
• Cryosurgery
• Electrosurgery
• Retinoic acid – there are no definitive studies that demonstrate the production of actinic keratoses with the use of tretinoin.

4. Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Various classification systems have been available and I would like to present a combination of three systems that would simplify and help the physician to find the right program or therapeutic procedure for his patient. The Fitzpatrick skin type system classifies degree of pigmentation and ability to tan. Graded I through VI, it prognosticates sun sensitivity, susceptibility to photodamage and ability for facultative melanogenesis (one’s intrinsic ability to tan). In addition, this system classifies skin as to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin type I and II are pale, white and freckled with a high degree for potential to burn with sun exposure. Three and IV can burn but instead usually tan to an olive or brown coloration. Five and six are dark brown/black skin that rarely ever burns and usually does not need sunscreen protection. The patient with skin type I or II skin with significant photodamage needs regular sunscreen protection prior to and after resurfacing procedures. He, though, has little risks for reactive hyperpigmentation after a chemical peel. The patient, though, with type III through VI skin has a greater risk for pigmentary dyschromia – hyper or hypopigmentation after a chemical peel and may need pre and post-treatment with both sunscreen and bleaching to prevent these complications.

The Glogau system classifies severity of photodamage taking into account the degree of epidermal and dermal degenerative effects. The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised for therapeutic intervention in that category I with minimal degree of photodamage can be treated with light chemical peeling and medical treatment. Category II and III would entail medium depth chemical peeling or erbium:YAG laser resurfacing or dermabrasion, while category IV would require deep chemical peeling or laser resurfacing and may need those other cosmetic surgical interventions for gravitational changes.

Monheit and Fulton have devised a system of quantitating photodamage, helping numerical scores that would fit into corresponding rejuvenation programs. In analyzing photodamage, the major categories include dermal changes with texture and epidermal with skin lesions. Dermal changes include wrinkles, cross-hatched lines, sallow color, weathery appearance, crinkly-think parchment skin, and pebbly white nodules of milia. Each of these is evaluated and given a point score one through four. In addition, the number and extent of epidermal lesions are evaluated from freckles, lentigines, telangiectasias, actinic and seborrheic keratoses, skin cancers and senile comedones. These are also added in the classification system one through four and a final scoring result is tabulated. The patient then can see which treatment is necessary by the height of score produced. A total score 1-4 would indicate mild damage and the patient would adequately respond to a five-step skin care program including sunscreen protection, retinoic acid, glycolic acid, and selective lesional removal. A score of 5-9 would include all of the above plus repetitive superficial peeling programs. A score of 10-14 would include medium depth chemical peeling, and a score of 15 or above would include deep chemical peeling or laser resurfacing.

5. See question 4. Dermabrasion, medium and deep chemical peeling and laser resurfacing are the modalities used for Glogau III and IV. The Monheit-Fulton system, a score of 10-14 and above.

6. Dermabrasion is the treatment of choice for acne scars, traumatic scars and dermal contour changes. Best results are for the above. It also will remove epidermal growths and have an effect on wrinkles but this effect is not as long-lasting as deep chemical peeling or laser resurfacing. This may be because of the thermal heat effect in collagen contraction in laser resurfacing has a greater effect for deep wrinkles. There, though is less prolonged erythema than found in the resurfacing and less chance for pigmentary dyschromias. The degree of complexity is equal to that of laser resurfacing and more difficult than chemical peeling.

7. Drawbacks of dermabrasion include the necessity for general anesthesia or circumferential local anesthesia. Healing time ten days to two weeks with erythema lasting four to six weeks, risks of herpes simplex, milia formation and potential scarring. There is little indication for repeat treatments except of deeper scars where dermabrasion may be repeated after a year.

8. Dermabrasion is my primary treatment of choice for scars. It is my third treatment choice following chemical peeling and then laser resurfacing for epidermal growths, actinic keratoses and photodamaged skin. Rhytides and photodamage with dermal changes require either laser resurfacing or a second choice, dermabrasion.

9. Superficial chemical peeling is an exfoliation of the stratum corneum or the entire epidermis to encourage regrowth with less photodamage and a more youthful appearance. It usually takes repetitive peeling sessions to obtain maximal results. These agents have been broken down into very superficial chemical peels which will remove the stratum corneum only, and superficial chemical peels which will remove the stratum corneum and damaged epidermis also. It is to be noted that the effects of superficial peeling on photoaging skin are subtle and will not produced prolonged or very noticeable effect on dermal lesions such as wrinkles and furrows. Agents used include: trichloracetic acid 10-20%, Jessner’s solution, glycolic acid 40-70%, salicylic acid – beta hydroxy acid, and tretinoin. Each of these agents has its own characteristics and the physician must be thoroughly familiar with the chemicals, methods of application and the nature of healing. The usual time for healing is for one to four days, depending on the chemical and its strength.

10 /11. The advantages of superficial chemical peeling are the simplicity of the procedure, quick healing time, fewer complications and lack of need for anesthesia. The very superficial chemical peel has been called the “lunchtime peel” because it can be fit into a busy schedule with no downtime. One can though take into account what patient expectations and needs are because in many instances, this peel will not accomplish the results that an individual requires.

12. Medium depth chemical peeling is defined as controlled damage from a chemical agent to the papillary dermis resulting in specific changes that can be performed in a single setting. Agents currently used include combination products – Jessner’s solution, 70% glycolic acid, and solid carbon dioxide combined with 35% trichloracetic acid. The hallmark for this level peel was 50% trichloracetic acid. It has traditionally achieved acceptable results in ameliorating fine wrinkles, actinic changes and pre-neoplasia. However, since trichloracetic acid is an agent more likely to be fraught with complications, especially scarring in strengths of 50% or higher, it has fallen out of favor as a single agent chemical peel. It is for this reason that the combination products along with a 35% TCA formula have been found equally effective in producing this level of controlled damage without the risk of side effects.

13. The medium depth chemical peel has primary indications for the following conditions:

• Removal of diffuse actinic keratoses as an alternative to chemical exfoliation with topical 5-fluorouracil chemotherapy.
• Mild to moderate photoaging including pigmentary changes, lentigines, epidermal growths and rhytides.
• Melasma and dyschromia
• Used in combination with other modalities, i.e. dermabrasion and laser resurfacing – to blend areas of the face with mild to moderate photoaging changes.

14. This procedures requires mild pre-operative sedation and non-steroidal anti-inflammatory agents. The patient is told the peeling agent will sting and burn temporarily and aspirin is given before the peel and continued through the first twenty-four hours. I usually require sedation for my patients but when the peel is concluded, the discomfort has ended. The patient remains comfortable during healing.

On the downside, this is not a “lunchtime peel” and requires a week to ten days for healing. There is post-operative erythema, desquamation, drainage, and edema that may last seven to ten days. There are also risks for prolonged erythema, delay of healing, aggravation of herpes simplex, bacterial or fungal infection and even the possibility of scarring. In my fifteen years of using this procedure, I have yet to see true full thickness scars with medium depth combination peeling.

15. Level III-IV Glogau photodamage requires deep chemical peeling. This entails the use of either trichloracetic acid above 50% or Baker-Gordon phenol peel. Laser resurfacing can also be used to reliably reach this level of damage. Trichloracetic acid above 45% has been found to be unreliable with a high incidence of scarring and post-operative complications. For this reason, it is not included as standard treatment for deep chemical peeling. The Baker-Gordon phenol peel has been used successfully for over four years for deep chemical peeling and produces reliable results. It is a labor-intensive procedure that must be taken seriously as all major surgical procedures. The patient requires pre-operative sedation with an intravenous line and pre-operative IV hydration. Usually, a liter of fluid is given pre-operatively and in addition, a liter of fluid is given during the procedure. Phenol is both a cardiotoxin, hepatotoxin, and has nephrotoxicity. For this reason, one must be concerned with the serum concentration of phenol through cutaneous absorption. For that reason, all patients are given intravenous hydration prior to the procedure, patients are monitored for electrocardiographic abnormalities, and the procedure is spread out over a period of 1 ½ to 2 hours which decreases the amount of phenol absorbed at any one time, limiting serum phenol concentrations and, thus, toxicity. This is a tried and true technique for correction of deep rhytides and more severe photoaging changes. Crow’s feet, perioral rhytides and more severe facial changes respond dramatically to the phenol peel. It has been said that his peel is the most permanent procedure producing changes for photoaging skin. The immediate surgical drawbacks have already been discussed. Long-term side effects include hypopigmentation and textural changes. Deep chemical peels that are taped had given an alabaster or statuesque appearance to the skin. While this was acceptable twenty years ago, it is a trade-off for these changes in the skin, both the hypopigmentation and the alabaster skin is not acceptable today. The consumer today requires a natural look with less of a dramatic effect. This is a limiting factor for deep resurfacing, both peeling and laser, and the physician must take this into account.

16. The CO2 laser is a standard and the erbium:YAG laser also coming into use. The CO2 laser can selectively destroy thin layers of epidermis and dermis with little thermal effects to underlying tissue. Using the CO2 laser, the target chemical is water, the most common intracellular compound. The CO2 laser with a computer generated scanner (CPG) can efficiently accomplish deep resurfacing with three layers of the facial skin surface in the period time of one hour. Full face resurfacing, though, requires either general anesthesia or a full-face aesthetic blocks for local anesthesia. Post-operative side effects can be similar to those of deep chemical peeling including pre-operative erythema and even hypopigmentation with textural changes.

The Erbium:YAG laser now has been used for facial resurfacing but I feel it will never replace CO2 laser resurfacing as a primary agent for advanced photoaging problems. Erbium:YAG laser can be used for medium depth resurfacing but is not reliable as a primary agent for deep resurfacing. Recently, it has been combined along with CO2 resurfacing with combination laser therapy to promote faster healing with less prolonged erythema.

17. CO2 laser resurfacing is the primary treatment modality for advanced photoaging, especially of the eyelids and perioral area. It eliminates many of the risk factors found with phenol peeling and performed conservatively, it will give reliable results in eradicating dermal changes such as rhytides of the eyelids and lips. There is still a place for medium depth and superficial chemical peeling as well as dermabrasion today. The laser is the latest tool in our armamateria in resurfacing but these other tried and true techniques should not be abandoned in the proper indications.

18. Advanced photodamage, especially dermal changes of the eyelids and lips (see question 17).

19. The major advantages are the safety of this procedure for advanced photoaging skin over deep chemical peeling. Long-term side effects, though, can be similar with specific patients and one must carefully gauge the level of laser penetration to the skin type.

20. Laser technology is expensive and that cost must be reflective on the patient’s costs. The same procedure can be performed simpler at less of a cost with similar or less potential side effects and the physician should choose the simplest procedure. There are, though, procedures today that lasers alone can accomplish.

21. The typical patient requiring a combination procedure would be those with advanced photodamage around the eyes and mouth with only moderate photodamage on the rest of the face. Those who treat the eyelids and lips alone with a laser would deliver noticeable pigmentary and textural changes to those areas which the rest of the face would still have dyschromic and textural photodamage. Using a medium depth chemical peel for those other areas of skin, i.e. forehead, cheeks and chin, find that laser resurfacing around the eyes and mouth blend those areas to a uniform facial texture and color. It also reduces laser risks as the areas with greatest tendency to scar are the malar eminences, the forehead, and the hairline (often called “keloid alley”) by using the medium depth peel on these high risk areas. I even use a superficial chemical peel on the neck so that further blending will allow a gradual transition from the face down to the chest. The distinctive lines found when a face is resurfaced at the jawline is a deformity patients resent.

22. Dark-skinned patients have a greater incidence of post-inflammatory hypo and hyperpigmentation. One needs to be very careful in using either deep chemical peeling or laser resurfacing on dark skin. If these modalities are chosen, the patient must be prepared for the procedure with pre and post-operative bleaching, retinoic acid and sunscreen. The same is true for medium depth peeling without quite this risk.

23. I use all three modalities: 1) chemical peeling, 2) dermabrasion, 3) laser resurfacing. Having all of these tools available allows me to pick the appropriate technique for each of my individual patients. This is a far superior choice than relying on one modality for all patients. In that case, some are under-treated, some are over-treated and some are not treated correctly. Primarily speaking, I divide the following criteria in my choice:

• Dermabrasion – acne scars, contour defects
• Chemical Peeling – superficial and medium depth – Glogau I through III skin, dyschromias, actinic keratoses
• CO2 Laser Resurfacing – Glogau photoaging skin III and IV with distinctive dermal changes

24. Therapeutic resurfacing for a lesion of skin cancer is a covered expense when it is not being performed for cosmetic reasons alone. I have found this true for patients who have diffuse actinic keratoses and are not amenable to simpler procedures such as topical 5-fluorouracil and cryosurgery alone. It usually takes a precertification letter along with photographs to demonstrate the extent and degree of precancerous changes as well as their recalcitrant nature.

25. All patients will need a full sun block six weeks to three months after a resurfacing procedure. I also implore my patients having these procedures performed for photoaging skin to use a sunscreen regularly from this point on. Patients need to understand that the approach to photoaging skin is not a one-stage procedure but includes post-treatment therapy including long-term photo protection.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The pursuit of youth and beauty has become a hallmark of the baby-boomer generation, which has now advanced to mid life and beyond. The distinct increase in an older population due to newer advances and career development has brought a larger healthy population interested in cosmetic procedures. This mid-age population has remained active in the workforce and now demands “no down time” procedures for skin rejuvenation that will maintain their appearance for work and pleasure. This has encouraged the development of new lasers, new fillers, Botox, cosmoceuticals and many other innovations that have reduced the down time and increased the safety of our cosmetic facial rejuvenation procedures. All of us interested in providing facial cosmetic procedures and surgery need to become familiar with all the procedures now available.

Aging of the skin is the combined result of both intrinsic factors and extrinsic external influences from the environment. Intrinsic aging is the role genetics play in relationship to chronologic age. These include alteration of skeletal mass and proportion, atrophy and redistribution of subcutaneous fat, increased laxity of underlying fascia and musculature and skin changes characterized by thinning and atrophy. Most intrinsic factors cannot be prevented but rejuvenative changes can be made with cosmoceutical agents and resurfacing procedures.

Extrinsic factors are those preventable environmental influences leading to premature aging of the skin including ultraviolet exposure, smoking, chemicals and gravity. UV exposure is the primary environmental factor, preferentially affecting those with a lighter skin color. The mechanism includes the production of UV inducing oxygenated fine radiants that have been shown to invite a cascade of molecular events leading to the production of collagen degrading enzymes. This creates the characteristic features of photoaging, including rough texture, atrophy, fine and coarse wrinkles, sallow and leathery appearance with dyschromia.1

In the evaluation of the patient with photoaging, equal emphasis must be placed on prevention as well as treatment. Agents available range from cosmoceutical topical agents to filling agents that include resurfacing devices such as chemical peels, ablative resurfacing lasers and dermabrasion. An initial consultation is performed to determine which of these tools is best for the patient based on severity and diversity of the condition.

Methods to evaluate photoaging include the Glogau classification of wrinkles. It classifies patients into one of four groups based on degree of severity (Fig I). Category I is “no wrinkles” with young patients who have minimal photoaging and are best managed with cosmoceutical agents and superficial resurfacing procedures such as light chemical peels and Microdermabrasion. Category II are patients in their 30’s with early to moderate signs of photoaging and characterized by wrinkles in motion. Category III has moderate to advanced photoaging with static wrinkles requiring more significant ablative resurfacing techniques. Category IV are the older patients with more severe photoaging changes and wrinkles significant enough to justify deep resurfacing and other surgical techniques.2

Ablative resurfacing injures the skin in a controlled fashion to a specific depth encouraging the growth of new and improved skin. These methods include chemical peeling, dermabrasion and laser resurfacing. Skin resurfacing techniques are divided into superficial, medium depth and deep relating to the level of injury. The deeper procedures are restricted only to the face, as other body areas do not have the healing capacity to rejuvenate new skin after such an injury. Care must also be taken with the neck, which may scar with medium depth or deep injury.3

The following classification system is useful in categorizing skin resurfacing methods (Table 1). It is based on the objective data done by Stegman et al. correlating strengths of TCA by biopsy of depth of tissue destruction and then new collagen rejuvenation. Thus superficial, medium depth and deep resurfacing correlates modalities of peeling, dermabrasion and laser to common denominators; inflammation and injury.4

A useful method of assessing skin related photoaging is the Monheit-Fulton Index of Photoaging Skin (Table 2). This system categorizes the visual changes in photoaging skin and quantitates the amount to guide the physician with appropriate therapy. The system combines age related textural and lesional changes into a numeric system that will predict how aggressive a physician should be in using superficial, medium depth and deep resurfacing procedures.5

Medical Care of Photoaging Skin

The basis of all rejuvenative therapy involves using sunscreen protection and cosmoceutical preparation that will help reverse photoaging changes. These products include sunscreens, retinoids, hydroxy acids, antioxidants and bleaching agents as needed.

Ultraviolet damage is caused by both UVB (290-320 nm) and UVA (320-400 nm) ultraviolet damage. Both the burning rays of UVB and the more deeply penetrant UVA cause problems of photocarcinogenesis and photoaging of the dermis. Most sunscreens provide adequate protection against the burning effects of UVB but only deliver partial protection against UVA. Sunscreens are divided into chemical and physician blockers. The chemical screens include oxybenzene, para-aminobenzoic acid (PABA) and octyl methoxycinnamate. The physical blockers now are transparent micronized formulations of titanium dioxide and afford more complete UVA and B protection.6

Topical retinoids have a direct effect on epidermal cell proliferation and dermal collagen growth. It has demonstrated significant effects on photoaging skin including dyschromias, epidermal growths and fine wrinkle lines. The Federal Drug Administration has approved topical retinoids for the treatment of aging and photodamaged skin in the form of tretinoin cream (Renova 0.05% or 0.02%) and most recently tazarotene cream 0.1% (Avage). Use of a retinoid with a sunscreen is basic in skin care for photoaging skin problems. It is also used prior to resurfacing procedures to enhance the epidermal and dermal regenerative effect after resurfacing injury.7

Hydroxy acids have become a part of skin care programs for its effect on thinning the stratum corneum and decreasing epidermal cell cohesion. This has a regenerative effect on epidermal cell kinetics giving the skin texture a plumper rejuvenative appearance. There is little definitive evidence that topical alpha-hydroxy acids have an effect on dermal collagen per se.8

Topical antioxidants have shown an effect in retarding the reactive oxygen species (ROS) created by ultraviolet damage. Vitamin C or ascorbic acid has been shown to be a potent scavenger of free oxygen radials. Topical products have shown activity in the experimental mode but clinical efficacy is as of yet anecdotal. Vitamin E is a lipid soluble antioxidant, which has become popular in topical form but little true objective data is present to document its effect on photoaging skin.9

Chemical Peeling

Chemical peeling remains one of the most popular choices for both patient and physician. In comparison to some of the newer options available, chemical peels have a long-standing safety and efficacy record, are performed with ease, are low in cost, and have a relatively quick recovery time. Various acidic and basic compounds are used to produce a controlled skin injury and are classified as superficial, medium-depth, and deep peeling agents according to their level of penetration, destruction, and inflammation. (Table 1) In general, superficial peels cause epidermal injury and occasionally extend into the papillary dermis, medium-depth peels cause injury through the papillary dermis to the upper reticular dermis, and deep peels cause injury to the midreticular dermis.10

Prior to the application of peeling solutions, the surgeon must vigorously cleanse the skin surface to remove residual oils, debris, and excess stratum corneum. The face is initially scrubbed with 4” X 4” gauze pads containing 0.25% Irgasan (Septisol, Vestal Laboratories, St. Louis, Missouri), then rinsed with water and dried. Because of the defatting and degreasing properties of acetone, gauze pads moistened in an acetone preparation are then used to cleanse the skin even further. The importance of cleansing in the peeling procedure cannot be overemphasized. A thorough and evenly distributed cleansing and degreasing of the face assures uniform penetration of the peeling solution and leads to an even result without skip areas. (Illustration II-A and B) 11

The effect of a chemical peel is dependent upon the agent used, its concentration, and the techniques employed before and during its application. Each wounding agent used in peels has unique chemical properties and causes a specific pattern of injury to the skin.3 It is important for the physician using these solutions to be familiar with their cutaneous effects and proper methods of application to assure correct depth of injury. The marketplace has been flooded with numerous proprietary formulations of these peeling agents, with each product claiming unique advantages. These products are often expensive and have not been unequivocally shown to be safer or more effective than the conventional solutions. This article will therefore focus on the specific chemical agents that are actively responsible for producing the various patterns of injury.

Superficial Chemical Peeling

Superficial chemical peels are indicated in the management of acne and its post-inflammatory erythema, mild photoaging (Glogau I & II), epidermal growths such as lentigines and keratoses, as well as melasma and other pigmentary dyschromias. Multiple peels on a repeated basis are usually necessary to obtain optimal results. The frequency of peels and degree of exposure to the peeling agent may be increased gradually as necessary. Results are enhanced by medical or cosmoceutical therapy. All superficial chemical peels share the advantages of only mild stinging and burning during application as well as minimal time needed for recovery. They are a part of office-based procedures.13

Superficial chemical peels are divided into two varieties – very light and light. (Table 1) With very light peels, the injury is usually limited to the stratum corneum and only creates exfoliation, but the injury may extend into the stratum granulosum. The agents used for these peels include low potency formulations of glycolic acid, 10 – 20% trichloroacetic acid (TCA), Jessner’s solution (Table 3), tretinoin, and salicylic acid. Light peels injure the entire epidermis down to the basal layer, stimulating the regeneration of a fresh new epithelium. Agents used for light peels include 70% glycolic acid, 25 – 35% TCA, Jessner’s solution and solid carbon dioxide slush.14 During the application of superficial peeling agents, there may be mild stinging followed by a level I frosting, defined as the appearance of erythema and streaky whitening on the surface. (Fig I-A)

Alpha-hydroxy acids (AHA) peeling agents have been used widely in skin rejuvenation programs since the early 1990’s. The depth of injury is determined by the specific AHA used, its pH, the concentration of free acid, the volume applied to the skin, and the duration of contact or time the agent is left on the skin before neutralization.15 In low concentrations, 20-30% – AHA’s have been shown to decrease the cohesion of corneocytes at the junction of the stratum corneum and the stratum granulosum, while higher concentrations – 70% are associated with complete epidermolysis. Weekly or biweekly applications of 40 to 70% unbuffered glycolic acid with cotton swabs, a sable brush, or 2” X 2” gauze pads have been used most often for acne, mild photoaging, and melasma.15 The time of application is critical for glycolic acid, as it must be rinsed off with water or neutralized with 5% sodium bicarbonate after two to four minutes.

Application of 10 to 20% TCA with either a saturated 2” X 2” gauze pad or sable brush produces erythema and a very light frost within 15 to 45 seconds. The depth of penetration of the peeling solution is related to the number of coats applied, this deeper penetration and injury can occur with over coating. Ideally, a Level I frosting is obtained with superficial TCA peels. Protein precipitation results and leads to exfoliation without vesiculation. Concentrations of TCA up to 35% can also be used alone as a superficial peeling agent but may create an injury that extends partially into the upper dermis.16

Jessner’s solution is a combination of keratolytic ingredients that has been used for over one hundred years in the treatment of inflammatory and comedonal acne as well as hyperkeratotic skin disorders. (Table 3) Jessner’s solution has intense keratolytic activity, initially causing loss of corneocyte cohesion within the stratum corneum and subsequently creating intercellular and intracellular edema within the upper epidermis if application is continued.17 The mode of application for the Jessner’s peel is similar to that of the 10 to 20% TCA peel. The clinical endpoint of treatment is erythema and blotchy frosting. It is a good repetitive peel for photoaging skin because of its inflammatory effects. The peel can be repeated every two weeks.

Salicylic acid, a beta-hydroxy acid that is one of the ingredients in Jessner’s solution, can also be used alone in superficial chemical peeling.18 It is a preferred therapy for comedonal acne as it is lipophilic and concentrates in the pilosebaceous apparatus. It is quite effective as an adjunctive therapy for open and closed comedones and resolving post-acne erythema. (Fig II-A, B, C) It is also a peel of choice for melasma and pigmentary dyschromia because it has minimal inflammatory action. Used repeatedly, it has the least risk of post-inflammatory hyperpigmentation. Superficial peeling for abnormal pigmentation is combined with skin care and topical retinoids, a bleaching product (hydroquinone, including 4%-8%) and an adequate sunscreen.19

Prior to the initial treatment with a superficial peel, both patient and physician must understand the limitations, especially on photoaging, to avoid future disappointment. The effect of repetitive superficial chemical peels never approaches the beneficial effect obtained with a single medium-depth or deep peel, in that the improvements in photo aged skin following superficial peels are usually subtle because there is little to no effect on the dermis. Nevertheless, their ease of use and minimal down-time makes these “lunch time” peels rewarding for patients with realistic expectations and are a favorite among the busy baby-boomers.

Medium-depth chemical peeling

Medium-depth chemical peels consist of controlled damage through the epidermis and papillary dermis, with variable extension to the upper reticular dermis. During the next three months postoperatively, there is increased collagen production with expansion of the papillary dermis and the development of a mid-dermal band of thick, elastic-staining fibers.20 These changes correlate with continued clinical improvement during this time.

For many years, 40 – 50% TCA was the prototypical medium-depth peeling agent because of its ability to ameliorate fine wrinkles, actinic changes, and pre-neoplasia. TCA as a single agent for medium-depth peeling has fallen out of favor because of the high risk of complications, especially scarring and pigmentary alterations, when used in strengths approaching 50% and higher.21 Today, most medium-depth chemical peels are performed utilizing 35% TCA in combination with either Jessner’s solution, 70% glycolic acid, or solid carbon dioxide (CO2) as a ‘priming’ agent. (Table 4) These combination peels have been found as effective as 50% TCA alone but with fewer risks. The level of penetration is better controlled with these combination peels, thereby avoiding scarring seen with higher concentrations of TCA.

Brody developed the use of solid CO2 to freeze the skin prior to the application of 35% TCA. This causes complete epidermal necrosis and significant dermal edema, thereby allowing deeper penetration of the TCA in selected areas.11 Monheit then described a combination medium-depth peel in which Jessner’s solution is applied, followed by 35% TCA.23 Similarly, Coleman and Futrell have demonstrated the use of 70% glycolic acid prior to the application of 35% TCA for medium-depth peeling.24 The Jessner’s solution and glycolic acid both appear to effectively weaken the epidermal barrier and allow deeper, more uniform, and more controlled penetration of the 35% TCA.

Current indications for medium-depth chemical peeling include Glogau group II or moderate photoaging, epidermal lesions such as actinic keratoses, pigmentary dyschromias, mild acne scarring, as well as to blend the effects of deeper resurfacing procedures. The most popular of the medium-depth peels for facial rejuvenation is the Jessner’s – 35% TCA peel, with other combination peels being utilized less frequently. This peel has been widely accepted because of its broad range of uses, the large number of people in whom it is indicated, its ease of modification according to the situation, and its excellent safety profile. It though is not a “lunch time” treatment and should be considered a surgical procedure requiring preoperative consideration and preparation, operative sedation and aftercare for one week or more.

The Jessner’s – 35% TCA peel is particularly useful for the improvement of mild to moderate photoaging. (Fig III-A) It freshens sallow, atrophic skin and softens fine rhytids with minimal risk of textural or pigmentary complications. (Fig III-B) Collagen remodeling occurs for as long as three to four months postoperatively, during which there is continued improvement in texture and rhytides. When used in conjunction with a retinoid, bleaching agent, and sunscreens, a single Jessner’s – 35% TCA peel lessens pigmentary dyschromias and lentigines more effectively than repetitive superficial peels. (Fig IV-A, B) Epidermal growths such as actinic keratoses also respond well to this peel. In fact, the Jessner’s – 35% TCA peel has been found as effective as topical 5-fluorouracil chemotherapy in removing both grossly visible and clinically undetectable actinic keratoses but has the added advantages of lower morbidity and greater improvement in associated photoaging.25 (Fig V-A, B, C)

This peel is also useful to blend the effects of other resurfacing procedures with the surrounding skin. Patients who undergo laser resurfacing, deep chemical peeling, or dermabrasion to a localized area such as the periorbital or perioral region often develop a sharp line of demarcation between the treated and untreated skin. This is because the surrounding photoaging skin has significant dyschromia and textural aging. The treated skin may appear hypopigmented (also known as pseudohypopigmentation) in comparison to the untreated skin. A Jessner’s – 35% TCA peel performed on the adjacent untreated skin helps to blend the treated area into its surroundings. For example, a patient with advanced photoaging in the periorbital region and moderate photoaging on the remaining face may desire CO2 laser resurfacing only around her eyes. In this patient, medium-depth chemical peeling of the areas not treated with the laser would improve the photoaging in these regions and avoid a line of demarcation.26 It is important to note that when used in combination with other resurfacing procedures such as laser irradiation or dermabrasion, the peel should be performed first in order to avoid accidental application of the peeling agent onto previously abraded areas of skin. (Fig VI-A, B, C)

Using either cotton-tipped applicators or 2” x 2” gauze pads, a single, even coat of Jessner’s solution is applied first to the forehead, then the cheeks, nose and chin, and lastly, the eyelids. Proper application of Jessner’s solution causes minimal discomfort and creates a faint frost within a background of mild erythema (level I). After waiting one to two minutes for the Jessner’s solution to completely dry, 35% TCA is then applied evenly with one to four cotton-tipped applicators. (Fig VII-A, B, C) The effectiveness of this peel is directly dependent upon the depth of penetration of the peeling solutions, and this depth is a function of the adequacy of degreasing and the amount of both solutions applied. The use of cotton swabs, particularly for the application of TCA, is advantageous because is allows the surgeon to easily vary the amount of solution applied according to the patient’s specific needs. The amount of TCA delivered to the skin surface is determined by the number of applicators used, their degree of saturation, the amount of pressure applied to the skin surface, and the duration of their contact with the skin. Four moist cotton-tipped applicators are applied in broad strokes over the forehead and on the medial cheeks. Two mildly soaked cotton-tipped applicators can be used across the lips and chin, and one damp cotton-tipped applicator on the eyelids. The depth of penetration and completion of the peel reaction can be monitored by the level of frosting. A full combination Jessner’s – 35% TCA peel should obtain a level II to III frosting. One should never overcoat TCA on a level III frosting as the injury may be pushed to a level that can cause complications, i.e. pigmentation or scarring.

Anatomic areas of the face are peeled with TCA sequentially from the forehead to temple to cheeks and finally to the lips and eyelids. Careful feathering of the solution into the hairline and around the rim of the jaw and brow conceals the demarcation line between peeled and non-peeled skin. Areas of wrinkled skin are stretched taut with the help of an assistant to allow even application of the solution into the folds and troughs. This technique is particularly helpful on the skin of the upper and lower lips. For perioral rhytids, TCA is applied with the wood portion of a cotton-tipped applicator and extended onto the vermilion border. (Fig VII-D)

Eyelid skin must be treated delicately and carefully to avoid over-application and to prevent exposure of the eyes to TCA solution.27 The patient should be positioned with the head elevated at 30 degrees and excess peel solution on the cotton tip should be squeezed out so that the applicator is semidry. With the eyes closed, a single applicator is rolled gently from the periorbital skin onto the upper eyelid skin without going beyond the moveable lid. Another semidry applicator is then rolled onto the lower eyelid skin within two to three millimeters of the lid margin while the patient is looking superiorly. Excess peel solution should never be left on the lids because it can roll into the eyes and tears should be immediately dried with a cotton-tipped applicator because they may pull the solution into the eye by capillary action.

The white frost from the TCA application appears on the treated area within 30 seconds to two minutes.(Fig III-C) This response is representative of keratocoagulation and indicates that the TCA’s physiologic reaction is complete. TCA takes longer to frost than phenol preparations, but a shorter period of time than the superficial peeling agents. The desired endpoint in medium-depth peeling is level II to level III frosting. (Table 5) Level II frosting is defined as a white-coated frosting with a background of erythema. (Fig I-B)

Level III frosting, which is associated with penetration to the reticular dermis, is a solid white enamel frosting with no background of erythema. (Fig I-C) A deeper level III frosting should be restricted only to areas of thick skin and heavy actinic damage. Most medium-depth chemical peels achieve a level II frosting and this is especially important over the eyelids and areas of sensitive skin. Areas with a greater tendency to form scars, such as the zygomatic arch, the bony prominences of the jawline, and chin, should receive no greater than level II frosting.

Before retreating an area with inadequate frosting, the surgeon should wait at least three to four minutes after the application of TCA to ensure that frosting has reached its peak. Each cosmetic unit is then assessed, and areas of incomplete or uneven frosting are carefully retreated with a thin application of TCA. Additional applications of TCA increase the depth of penetration as well as the risk of complications, so one should apply more solution only to the under frosted areas.

Though there is an immediate burning sensation as the peel solution is applied, the discomfort begins to subside as frosting occurs and resolves fully by the time of discharge. This peel can be performed with light sedation such as:

• Diazepam 10 mg PO
• Meperidine 50 mg IM
• Hydroxyzine 25 mg IM

After cooling the skin with saline, the patient will remain comfortable throughout the post-operative period. Cool saline compresses offer symptomatic relief at the conclusion of the peel. Unlike the compresses in glycolic acid peels, the saline following a TCA peel simply provides relief and does not “neutralize” the acid.

Deep Chemical Peeling

Patients with more extreme photoaging skin may require deep chemical peeling, motorized dermabrasion, or laser resurfacing to improve their greater degree of skin damage. As discussed with medium-depth peels, deep chemical peeling leads to production of new collagen and ground substance down to a level in proportion with the depth of the peel. The peeling agent of choice is the Baker-Gordon phenol peel. The Baker-Gordon peel utilizes phenol in a formulation that permits deep penetration into the dermis, deeper than full-strength phenol.28 The Baker-Gordon formula consists of Septisol (Vestal Laboratories, St. Louis, Missouri), croton oil, and tap water added to a solution of phenol, reducing its concentration to 50 or 55%.(Table 6) The mixture of ingredients is freshly prepared and must be stirred vigorously prior to application due to its poor miscibility. The liquid soap, Septisol, is a surfactant that reduces skin tension, allowing a more even penetration. Croton oil is a vesicant epidermolytic agent that enhances phenol absorption. Recent investigations into the effects of this peel using varying concentrations of both phenol and croton oil have suggested that the procedure’s efficacy is more related to the amount of croton oil than phenol.29,30

There are two main variations in deep chemical peeling with the Baker-Gordon phenol formula – occluded and unoccluded. Occlusion of the peeling solution with tape is thought to increase its penetration and extend the injury into the mid-reticular dermis. This technique is particularly helpful for deeply lined, “weather-beaten” faces but should be utilized only by experienced surgeons because of the higher risk of complications.31 The unoccluded technique as modified by McCollough involves a more vigorous cleansing of the skin and the application of more peel solution.32 This may enhance the efficacy of the solution but without penetration as deeply as in an occluded peel. In the hands of a skilled and knowledgeable surgeon, both methods are safe and reliable in rejuvenating advanced to severe photo aged skin. Deep chemical peeling can significantly improve or even eliminate deep furrows as well as other textural and pigmentary irregularities associated with severe photoaging. (Fig VIII-A, B) A remarkable degree of improvement is the expected result of deep chemical peeling when performed properly on carefully selected patients.

The patient undergoing deep chemical peeling must understand and be willing to accept the significant risk of complications and the increased degree of morbidity. The most notable complications include scarring, textural changes such as “alabaster skin,” or “plastic skin” and pigmentary disturbances. It is not uncommon for patients to experience postoperative erythema that can take many months to resolve and may be followed by variable hypopigmentation. (Fig IX) Male patients and patients with darker complexions are less favorable candidates for deep chemical peeling since the hypopigmentation is less easily camouflaged. Since phenol is cardiotoxic , preoperative evaluation includes a complete blood count, liver function tests, serum urea nitrogen and creatinine and electrolyte determinations, and a baseline electrocardiogram. Any patient who has a history of cardiac arrhythmias or who is taking a medication known to precipitate arrhythmias should not undergo a full-face Baker-Gordon phenol peel. Patients with a history of hepatic or renal disease are also poor candidates.

Compared with medium-depth and superficial peeling, the Baker-Gordon phenol peel is a time-consuming procedure and it must be performed only in a properly equipped facility. The required waiting period after the treatment of each cosmetic unit limits the rate of cutaneous absorption, thereby preventing the serum levels of phenol from reaching a dangerous peak during the procedure. Intravenous hydration with a liter of lactated Ringer’s solution before the procedure and another liter during the peel also promotes phenol excretion and prevents toxicity. Continuous electrocardiography, pulse oximetry, and blood pressure monitoring are mandatory during the entire perioperative period. Any abnormalities, such as a premature ventricular contraction (PVC) or premature atrial contraction (PAC), necessitate abrupt stoppage of the procedure and careful evaluation for toxicity.33 Oxygen is supplemented throughout the procedure as some physicians feel that it has a protective effect against cardiac arrhythmias.

After thorough cleansing and degreasing of the skin, the chemical agent is applied sequentially to six aesthetic units: forehead, perioral region, right cheek, left cheek, nose, and periorbital region. There is a 15 minute time interval between the treatment of each cosmetic area, allowing 60 to 90 minutes for the entire procedure. Cotton-tipped applicators are used with a similar technique as discussed with the medium-depth Jessner’s – 35% TCA peel, though less solution is used because frosting occurs very rapidly. (Fig X) Occlusion of the peel can be accomplished with strips of waterproof zinc oxide tape (e.g., one-half inch Curity tape) to each cosmetic unit just after the phenol is applied. Care is exercised to extend the peel slightly beyond the mandibular rim to conceal the demarcation between treated and untreated skin. The last aesthetic unit, the periorbital skin, is treated cautiously and conservatively to avoid over penetration which can lead to ectropion or scarring. It is important to remember that diluting a phenol compound with water may increase its penetration, so mineral oil rather than water should be used to flush the eyes if contact occurs.

Application of the peeling agent creates an immediate burning sensation, which lasts for 15 to 20 seconds, subsides for 20 minutes, and then returns for the next six to eight hours. Ice packs may be applied as necessary for patient comfort. Narcotics are usually prescribed upon discharge for adequate pain control. Systemic steroids are also administered by some surgeons to lessen the inflammatory response. For untaped peels, petrolatum is applied and a biosynthetic dressing can be used for the first 24 hours.

Mechanical Resurfacing Procedures

During the last five decades, dermabrasion utilizing a rotating abrasive surface attached to a power-driven hand engine has been considered a premier skin resurfacing procedure for facial scars. It has generally been regarded as a deep resurfacing modality based on its depth of injury and its prolonged healing time. The original descriptions of modern dermabrasion involved the use of a wire brush which remains in use today.34,35 In 1957, the diamond fraise was introduced and became the preferred instrument for dermabrasion by some surgeons because it is less aggressive and more forgiving than the wire brush.36 Recently, there has been a resurgence of interest in manual dermasanding which allows for more deliberate and controlled skin planning and microdermabrasion.37,38

Microdermabrasion

Microdermabrasion is considered superficial because it removes the stratum corneum and outer epidermis. Whether it is classified as very light or light in comparison to the other superficial resurfacing procedures depends upon the techniques and aggressiveness of the operator. The microdermabrasion unit’s handpiece is a closed system, which propels aluminum oxide crystals at the skin at high speeds and simultaneously removes them with suction. These units were developed commercially in the mid-1990’s and are currently in widespread use in both physicians’ offices and non-medical aesthetic spas. Microdermabrasion may be indicated for acneiform conditions, pigmentary dyschromias, and as a “lunchtime” procedure for facial rejuvenation in all skin types.39,40 Both the patient and physician must understand that the degree of objective improvement with microdermabrasion may be limited. This is a repetitive procedure performed every 2 weeks along with appropriate cosmoceutical agents. Ideal candidates for microdermabrasion typically are young patients that desire limited facial rejuvenation without “downtime” and thus must have realistic expectations of the limited anticipated results. Patients often report that their skin has a smoother texture and that cosmetics are easier to apply and blend in with their skin more easily. (Fig XI) Although the role of microdermabrasion in facial rejuvenation has grown dramatically since these units were developed, the scientific data to justify their use has been lacking.

Manual Dermasanding

Manual dermasanding involves abrading the skin by hand using silicon carbide sandpaper or wallscreen commercially available at any hardware store. Its classification as a wounding agent is entirely dependent upon the type of paper used, the force applied by the surgeon, and the duration of contact with the skin. Although it can be used to produce a wound as deep as with wire brush dermabrasion or several passes with a pulsed CO2 laser, manual dermasanding is probably most commonly used as a medium-depth or “minimally deep” resurfacing modality. (Table 7)

Manual dermasanding is most often utilized for resurfacing localized regions to minimize the appearance of a scar or to blend or enhance the effects of a medium-depth chemical peel or a combination procedure.41 It can be used following CO2 laser resurfacing to feather the transition into hair-bearing areas that are inaccessible to the laser. Manual dermasanding of the eyebrows and hairline and gently abrading the upper neck at the inferior aspect of the laser-irradiated zone are all effective at minimizing lines of demarcation between treated and untreated skin. (Fig XII) It can also be useful immediately after laser resurfacing for stubborn rhytids, particularly in the perioral region. Manual dermasanding can improve the outcome by producing a slightly greater depth of injury in a controlled fashion where further thermal injury would be risky. It will also remove adherent necrotic debris and thermal damage, thus speeding up the healing process. Similarly, a medium-depth chemical peel can be immediately followed by manual dermasanding on the more troublesome areas to enhance the results and also along the borders of the peeled skin to blend the effects. Our clinical experience suggests that dermasanding after a Jessner’s – 35% TCA peel may yield impressive postoperative results that approach those seen with either motorized dermabrasion or CO2 laser resurfacing in patients with photoaging skin. (Fig XIII-A, B, C, D) This combination is particularly helpful in patients who may not tolerate the greater degree of sedation often necessary with CO2 laser resurfacing.

The necessary materials for manual dermasanding include silicon carbide sandpaper or wallscreen. Both may be purchased in a variety of grades: fine grade (#400), medium grade (#220-320), and coarse grade (#180). The sandpaper is easy to use because of its flexibility and is easily cut into smaller pieces, which can be steam autoclaved. A 1 1/2″ X 3″ piece of sterilized sandpaper is wrapped around either the barrel of a 3 cc syringe or a rolled up 2″ X 2″ gauze pad and moistened with saline or a soap-free cleanser (e.g., Cetaphil, Galderma Laboratories, Inc., Fort Worth, TX) for lubrication. A 1% solution of lidocaine with epinephrine may be used instead if additional anesthesia is necessary. Both back-and-forth and circular motions are used to gradually abrade the skin layer by layer until the hills and valleys are softened or adjacent areas are blended to the desired degree. Coarse grades may be used initially for “debulking” followed by finer grades later in the procedure. The fine grade is used to blend delicate areas of skin such as around the eyelids. At the completion of the procedure, the dark-colored silicon carbide particles remaining on the skin surface should be rinsed off because there is a theoretical risk of their becoming implanted.

Motorized Dermabrasion

Some of the units most commonly used today are the Bell hand engine (Bell International, Burlingame, CA), the AEV-12 hand engine (Ellis International, Madison, NJ), and the Osada surgical handpiece (Osada, Inc., Los Angeles, CA). A topical refrigerant spray (Frigiderm, Frigiderm Corp., Costa Mesa, CA) is used to produce anesthesia and to harden the skin as it is abraded. The spray immobilizes the topographic features so that there is no distortion by the pressure of the abrasive instrument.

The two abrasive instruments most often employed with these units are the wire brush and the diamond fraise. The wire brush has numerous, small-caliber stainless steel wires that project circumferentially from the curved side of a cylindrical hub. A diamond fraise consists of a stainless steel cylinder to which industrial-grade diamonds are bonded to create the abrasive surface. As compared with wire brush instruments, diamond fraises are manufactured with a greater variety in shape, width of abrasive surface, wheel diameter, and coarseness of grit. The wire brush is more aggressive and cuts more quickly and more deeply into the skin with each stroke, thereby posing a greater risk for injury and requiring more skill to operate. Though the diamond fraise is generally safer and more forgiving, it may not yield the degree of improvement possible with the wire brush, especially for more stubborn conditions such as deep acne scarring. (Fig XIV)

Because dermabrasion with either instrument is highly technique-dependent and its learning curve is steep, there may be considerable variability in the clinical results obtained by different operators. It is very important for beginning dermabraders to attain thorough hands-on instruction from an experienced operator in order to be adequately trained. The proper techniques for motorized dermabrasion have also been the subject of comprehensive reviews in the literature.42,43,44 Careful evaluation of the depth of injury throughout the procedure is critical to assure sufficient depth for optimal results without penetrating beyond the desired level and risk scarring. Because of the potential for aerosolization of infectious particles during dermabrasion, appropriate precautions are mandatory to protect the operating room staff. (Table 8)

Moderate to severe acne scarring is the most notable indication for dermabrasion as laser resurfacing has yielded variable results and chemical peeling is generally disappointing. Dermabrasion selectively planes off the “hilltops” that surround the atrophic “valleys” whereas chemical peeling and lasers produce an injury of equivalent depth in both areas. (Fig XV-A, B, C)

The use of CO2 lasers has revolutionized resurfacing techniques for photoaging skin. Because of the varying properties of lasers, the physician must be thoroughly familiar with the physics, the technology and operating geometry of the laser. Whether the laser is pulsed, continuous or computer scanned impacts the physiologic response. The level depth of destruction is different for each laser, thus the physician should be familiar with the laser of choice. For reliable vaporization of skin layers, a pulsed laser with a CPG (computer generated scanner) makes the procedure safer. Each pass destroys 75-100 microns of tissue with a zone of thermal damage below. Thus, two to three passes with an ultrapulse CO2 laser is maximal for rejuvenation of photo damaged skin; a deep resurfacing technique. The zone of thermal damage causes collagen shrinkage or contraction, which is a unique characteristic for CO2 laser resurfacing. This gives an added benefit to wrinkle treatment not found with either dermabrasion or chemical peeling. This is especially true with perioral and periorbital wrinkled skin.

Carbon dioxide laser resurfacing requires anesthesia; either general operative anesthesia or tumescent local anesthesia for the entire face. Laser safety precautions are needed to prevent laser fire or laser injury to the employees, the unprotected skin, the teeth or even the endotracheal tube for general anesthesia. These must be protected with appropriate laser resistant materials; eye shields, teeth guards and appropriate laser resistant endotracheal tube wrapping. Using the CPG, the operator must remember that the pulse overlap for a chosen pattern size and shape is set so that each pattern is made to touch yet not overlap. The density is an important parameter in determining laser beam intensity. One should not go above a density of 6 with facial resurfacing. Each pass should cover the face fully, vaporizing the tissue to ash and debris, which is wiped off between each pass. The visual endpoint is a mauve or slightly yellow discoloration indicating denaturization of dermal collagen. Further passes cause deeper dermal scarring. Special care must be taken over scar prone areas such as the bony prominences of the chin, jawline, malar ridge and forehead. The eyelid is treated more conservatively as collagen can precipitate an ectropion, with or without scar. The lips are treated with two to three passes but not over the vermilion line as this can flatten the lip in an unaesthetic manner. Bordered facial creases such as the jawline and neck should be blended with light chemical peeling and minimal dermasanding to soften the demarcations of treated and untreated photoaging neck skin.

As important as the operative technique is proper postoperative wound care. Partial thickness skin wounds heal fastest when kept at or near 100% humidity or occlusive or semi occlusive dressings. Non-stick pads and hydrogels such as Flexzan or Vigilon are changed daily to remove coagulation debris and necrotic tissue. This is important to prevent secondary wound infection with resultant scarring. My usual postoperative program is four to five days of biologic hydration changed daily followed by five days of ¼% acetic acid soaks (1 tsp. White vinegar in 1 pint warm water) four times a day followed by occlusive ointments such as petrolatum ointment or Eucerin cream. After ten days, the patient is usually ready for light cleansers and creams and a mild topical steroid cream for erythematous areas (Table 9).

Full makeup can be used with sunscreen after two weeks. Sunscreen with strong sun avoidance should be adhered to for two to three months to prevent post-laser hyperpigmentation.

Herpes simplex infection can occur during the healing period following medium depth or deep ablative injury. Antiviral prophylaxis should begin during the operative session and continue beyond reepithelialization, 10-14 days. If infection occurs, punctate vesicles occur with pain and full treatment therapy should begin to prevent scarring.

Delayed wound healing may be a sign of bacterial infection or resurfacing too deep to heal normally. It should be treated with biologic dressings, appropriate antibiotics and cortisones as indicated. The diligent physician must watch his patients carefully during the post-operative course to catch these complications early and prescribe appropriate treatment. This will prevent the permanent complications of pigmentation changes and scarring.

Conclusions

The general public has a renewed interest in skin rejuvenation. Although there are many techniques presently available, it is up to the cosmetic physician to match the appropriate tool with the patient’s needs to give proper benefit with the least risk. These tools need special training and experience and as one gains further knowledge and skill, these procedures generally occupy a rewarding part of ones practice.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The nasolabial fold represents the crease from the nose to the side of the oral commissure separating the cheek from the upper lip. Anatomically, the folds are the peripheral margin of the orbicularis oris muscle at the fusion of levator labii superioris medially and the zygomaticus major muscle laterally. The three branches of the levator labii superioris begin at the base of the nose, bottom edge of the orbit and zygomatic arch inserting into the skin of the upper lip. The zygomatic major originates on the zygomatic arch inserting on the lateral mouth corner.1 These muscles are known respectively as the sneering muscle and the smiling muscle.2 (Fig 1) The repetitive action of these muscles over time contribute to the delineated nasolabial fold. As the zygomatic major contracts and its mouth end rises to the cheekbone, a depression forms along the fold due to the bulging of the cheek.3 The nasolabial fold wrinkle gradually evolves from dynamic to static over time and always runs perpendicular to the direction of pull.2

In addition to the dynamic factor of the smiling and sneering muscles, other factors contribute to the evolution of the nasolabial wrinkle fold. This includes soft tissue atrophy and loss of skeletal muscle and fat, especially in the lower face with a redistribution of fat along the malar fat pad. Loss of suspension of the fat pad along with skin redundancy expands the fold to a deeper groove. In addition, the loss of elasticity and collagen support increases the development of photoaging wrinkles along the nasolabial area.4,5 Because the skin looses elasticity with age, gravity’s pull is most ardent along the lower face from the groove over marionette lines and jowls of the jawline.6 These are the major factors of the aging process – loss of soft tissue volume, repetitive muscle contraction, spasm, ptosis from loss of support and photoaging skin changes of elasticity.(Fig 2)

The prominence of the nasolabial fold is a major change revealing mid face aging. The fold has a dynamic stage in earlier life and a static appearance with aging. This is shown with the newborn face, which has no fold, as well as the paralyzed face in which the fold disappears.

Treatment efforts are directed to correct the following problems: volume, ptosis, muscle spasm and photoaging skin. The differences are individualized in each patient as to the degree of change within the fold and associated factors. In this chapter, we will concentrate on volume correction with injectable fillers as this is the most useful and common treatment correction. Other techniques will also be mentioned such as surgical corrections, resurfacing, and muscle relaxation with Botulinum toxin. They can contribute to correction as secondary factors.

The gradual evolution of the nasolabial fold wrinkle from absence in the 20’s, though mild and moderate grooves in the 30’s and 40’s to final severe grooves parallels the aging process through the decades. Quantitative scales of nasolabial fold prominence have been used to demonstrate the full evolution and guide the physician to proper therapy.7 The Fleming-Poff™ scale (Genzyme Corporation, Cambridge, MA) is an example of a measuring stick to determine groove level on a 0-5-severity level. (Fig 3) Early changes – 0 to 1 – are mainly dynamic as the fold is only exhibited with movement.(Fig 4) Moderate fold prominence exhibits malar fat pad depression at rest and is present because of early fat atrophy.(Fig 5) These individuals will get full correction with volume filling.(Fig 6) The more severe forms involve ptosis as well as volume loss and may not obtain the same degree of correction with injectable filling alone.(Fig 7) Delete Table 1 Citation

Patient Selection

When a patient seeks cosmetic treatment, it is important that they have realistic expectations and are educated on which treatment would be best for their particular concern and why. First of all, the physician needs to understand what the patient perceives as a problem area. After this is accomplished, the physician should begin educating the patient as to the etiology and available treatment philosophy. Changes in the skin due to inherent aging, actinic damage, and loss of subcutaneous tissue are variables different in each patient. This review is best done while a patient is looking into a mirror. Rhytids caused by recurrent movement verses changes in the skin caused by increased laxity and gravity need different treatment for each of these separate issues. When patients focus on prominent nasolabial folds, it is best to begin with simple procedures that have little risk or down time and then progress to more invasive procedures that require time needed for recovery. This then summarizes treatment options. The ideal patient for soft tissue augmentation of the nasolabial folds is a patient with moderate to moderately severe nasolabial folds who wants smoothing of the contour of the mid-face, who understands the risks and benefits of the procedure, and who has realistic expectations. If a patient wants improvement more than soft tissue augmentation can offer or has a prominent cheek overhanging the nasolabial fold, a better option may be a face-lift or a feather lift.(Fig 8) On the other hand, a patient who has fine line signs of skin aging and wants augmentation may better be treated with a good skin care regimen and possibly a noninvasive laser or microdermabrasion procedure.

Procedures for correction of the nasolabial groove concentrate on the four major causes. The dynamic phase of wrinkles in many areas is corrected with Botulinum toxin. This is used primarily on the glabella, forehead and crow’s feet.8,9,10 The use of Botulinum toxin in the perioral area has severe side effects by interfering with expression.11,12,13,14 Treatment creates an asymmetric paralytic appearance and thus should not be used around the zygomaticus, levator or orbicularis muscles laterally. It though can be used in the depressor labii superioris to elevate the lateral commissure as an adjunct to filling material in the lower nasolabial fold and marionette lines. Two to five units of Botox Cosmetic™ (Botulinum Toxin, Allergan) are injected into the section of the depressor muscle just above the mandible. This procedure will give minimal adjunctive help to fillers.(Fig 9)

Ptosis is the most difficult factor to correct and requires mainly surgical approaches. These include mid face lifting procedures such as subperiosteal mid face-lifts, endoscopic malar fat pad elevation and cable-suture fat pad elevations.15,16,17,18 The technique of Sulamanidze – Aptos Threads – offers a novel non-surgical approach to malar fat pad lifting to further correct severe nasolabial folds. It is most commonly used in combination with injectable fillers.19

Lasers can be used to correct photoaging skin along the nasolabial fold.20,21 CO2 or Erbium Laser Resurfacing are adjunctive techniques, which can be used in combination with volume filling. The resurfacing techniques include CO2 laser, Erbium laser, non-ablative lasers and most recently, the radio frequency devices that create collagen concentration with fold elevation.22,23,24,25,26,27,28,29 All of these procedures can be used to correct skin defects around the fold and may be used in combination with volume filling.

Volume is corrected with injectable and surgical filling material such as temporary or permanent injectables, solid implants or fat grafts. These procedures will be reviewed in detail for use in the nasolabial fold as volume replacement is the primary method of nasolabial fold correction.

The improvement achievable with soft tissue augmentation of the nasolabial folds depends on the amount of the implant used, the type of implant, the frequency of implantation, and the intrinsic qualities of the nasolabial fold. The benefits of filler substances include softening the nasolabial folds by filling the areas with the deficit of soft tissue thus decreasing the shadows created due to the aging face.(TABLE 1) A single implant or multiple implants can be used to attain the desired affect. If a patient presents with fine lines radiating from the nasolabial folds, the best treatment would be to utilize an injectable filler specific for fine lines plus filling the nasolabial folds with a deeper heavier volume filler for deeper furrows. This method works best when a few of the fine lines are treated with a fine line filler followed by deep filling of the folds, then returning to finish the filling of the fine lines.

Injectable soft tissue fillers are the primary choice for treatment of the nasolabial fold from minimal to severe frown. This chapter will briefly review the agents most commonly used and emphasize the techniques that work best in the nasolabial fold. Soft tissue augmentation is technique-sensitive so the individual procedure for each implant must be mastered.(TABLE 2)

Injectable implants can be as effective as the product packaging claims as long as the implant is injected as directed on the package insert. Variables in efficacy can be noted if the material is injected into the subcutaneous tissue causing much less augmentation compared to when it is injected correctly into the dermis. If the injectable implants are injected too superficially, beading or nodulation can occur. The beading will eventually decrease with time, decreasing fastest in areas with the most movement. When injecting into the dermis and inserting the needle in a forward fashion, the injectable material can be extruded into an area of the dermis that is not the ideal site. Firm massage of the injected sites can help to smooth the contour of the injectable filler and guide the filler to a more optimal location.

Injecting material into the nasolabial folds can cause considerable discomfort in some patients. Maximal discomfort occurs at the superior aspect of the nasolabial folds. Some injectables contain an anesthetic which helps with discomfort of the injection.(Table 3) Countermeasures to avoid pain include topical anesthetics, ice, infraorbital nerve block, or simultaneous stimulation with a massaging apparatus. While it may be tempting to inject an anesthetic into the area to be treated, this can distort normal contours and should be avoided. Topical anesthetics help to decrease the pain of the needle puncture, but help minimally with the injection itself or the forward motion of the needle through the dermis.30,31,32,33 Infraorbital nerve blocks or counter nerve stimulation have mixed results, but do help to lessen the pain.(Table 4 – changed from 3) (Fig 11)

Patient Interview

A thorough medical history, family history, and physical exam should be done with each patient. Any history of collagen vascular diseases (CVD) should be noted, as well as hypersensitivity to ingredients of the filler substance. Skin tests should be performed when indicated. Bleeding disorders or anticoagulation medications should be noted. Bruising occurs more frequently when an anticoagulant is used and the patient should be aware of this possibility. The patient should be asked to smile and sneer to evaluate dynamics and symmetry. Any asymmetries in the patient’s appearance should be noted and brought to the attention of the patient and documented in the chart.

The cosmetic patient is questioned as to what bothers them most about their appearance. They are asked to make a “wish list” including up to five aspects of their appearance they would like to have improved with the most important feature to be first on the list. The list is reviewed with the patient, having them demonstrate for us in the mirror exactly what is meant by each topic on their list, and adding suggestions as appropriate. Treatment options are then reviewed with the patient beginning with simple procedures and combined simple procedures with little down time and ending with more long lasting procedures requiring significant down time. If the patient has not had augmentation procedures before, we typically recommend beginning with a product that lasts the least amount of time so that the patient can decide if augmentation is right for them. Although permanent fillers have the advantage of fewer injection sessions to maintain a desired affect, there is less of a margin of error when injected and the products can shift over time and with muscular movement. As the face ages, the site first injected may not be the ideal site for injection five or ten years later in life leaving an unnatural appearance from the permanent implant to the area. The cost of each procedure is reviewed with the patient and written information is given to the patient. They can either proceed with treatment or can schedule a future appointment after considering their treatment options.

Treatment Technique

With every patient who is to be treated cosmetically, after the treatment plan has been made, it is reviewed with the patient and the risks, benefits, and alternatives to the procedure are discussed with the patient who must express understanding and sign an informed consent. Any last minute questions are answered at this time. The patient’s make-up is removed and the areas to be injected are cleansed with ethanol and allowed to air dry. Photographs both distant and close-up are taken at this time including a frontal view, a 45-degree angle view from the front, and a side view. It is important when comparing photographs that each picture is taken in a similar fashion under similar lighting. Make-up should be removed in all pictures and a similar background should be used.

Biodegradable Collagen

Zyderm/Zyplast

Bovine collagen is the first dermal filler approved for usage in the United States. It has a 20-year record of safety as a dermal filler and most commonly used on the nasolabial fold.34 Three types of bovine collagen are presently available – Zyderm I (ZI) is a 3.5% by weight bovine collagen (35 mg/ml). Zyderm II (ZII which is 6.5% mg/ml) and the third agent Zyplast. Zyplast 1.5 cross-linked bovine collagen which constitutes an injectable latticework of bovine collagen, more resistant to degradation with less immunogenicity (Inamed Aesthetics, Santa Barbara, CA). All of these products require skin tests to rule out allergy. Two intradermal injection tests should be performed at day 0, 2 weeks, and both evaluated in six weeks. The collagen is suspended in saline with 1% lidocaine.34 The products have different indications.

Zyderm I is primarily indicated for superficial defects while Zyderm II and Zyplast are used for deeper depressions and grooves.34 Zyderm I should be reserved for superficial defects and thus not as applicable as a primary treatment for the nasolabial fold which usually requires deep correction with greater volume change. It is placed in the papillary and upper reticular dermis. One hundred fifty to 200% over-correction is required and the endpoint of injection is a “peau d’orange” or blanching of the skin. Zyderm I is best used in combination with Zyplast or another heavier filler to correct the remaining fine wrinkles after the nasolabial groove is volume corrected.(Fig 12) This is a layering technique which will give a full correction to the dermal defect.(Fig 13)

Zyplast is a denser substance with greater longevity. It must be injected into the mid reticular to deep dermis and is especially useful for treatment of the nasolabial fold. Zyplast is placed at a mid dermal level with a 30-gauge needle at a 10-20 degree angle from the skin surface. The material is deposited serially in small volumes with a flow in the mid dermis.35

There are variable techniques developed for nasolabial fold injections which are also applicable to other injectable fillers.

The three injection techniques most commonly used in the nasolabial fold are: serial puncture, threading and fanning.(Fig 14) I find all three are useful for most injections. Serial puncture indicates the use of multiple injections into the mid dermis going up to the nasolabial fold, injected medial to the line/fold at a 30-degree angle. The injected implants are then massaged for even distribution. Threading technique uses a one-inch 30-gauge needle which is advanced at a 30-degree angle below the depth of the nasolabial fold. The filler is then injected as the needle is slowly drawn out. This fills the depth of the fold through the trough evenly. The fanning technique is used for diffuse volume filling and useful for the triangle at the superior aspect of the nasolabial fold as it approaches the alar lobule. Multiple 30 degree mid dermal pathways are formed out and from the groove to elevate the superior angle evenly. It is also useful for volume filling at the lateral lip commissure to elevate the corner of the nasolabial fold and marionette line. Zyplast injections should never be over-corrected and always within a mid dermal level, avoiding a peau d’orange.

Two or more implant sessions at intervals no less than two weeks apart may be needed for maximal correction. Touch up implants are performed at four to twelve-month intervals to maintain full correction.(Fig 15)

Best results are obtained by combining Zyplast with Zyderm I for correction of all levels of dermis within the fold. The two materials are layered with Zyplast injected first to 100% correction of the deeper groove. The author’s choice of techniques is to use the threading method first for volume filling and the deeper aspects of the groove. The serial puncture technique is then applied to areas of depression after full threading of the fold. Further volume filling is performed at the superior sulcus. It usually takes 1-2 cc. of Zyplast to correct most nasolabial fold volume deficiencies. Then, Zyderm I is placed above the Zyplast for the remaining wrinkle within the fold and any accessory wrinkles. Massage is necessary after each injection to avoid nodulation and assure a smooth, natural implant.

The variation in longevity is due to dynamic motion and mechanical stress along the nasolabial fold; continuous smiles break collagen down faster.

Though Zyderm/Zyplast is historically a reliable, forgiving product, disadvantages include the potential for allergy and need for skin tests prior to injection, the relative short duration and potential adverse events including nodulation, allergic potential, vascular infarction with deepest injection and the rare event of cystic formation.37,38,39,40,41,42

CosmoDerm/CosmoPlast® (Inamed Corporation) is a second-generation collagen wrinkle filler as a human bioengineered collagen product. It is derived from dermal fibroblast cells seeded and incubated in a bioreactor to produce a human collagen product. The type I collagen is isolated from the dermal tissue, purified and mixed with lidocaine and phosphate buffered saline. CosmoDerm I, II and CosmoPlast are used as injectable fillers in the nasolabial folds similar to the methods of Zyderm and Zyplast. No skin test though is required and the product is believed to last as long as Zyderm/Zyplast products, which is 4-6 months. It also can be used in combination with other products including hyaluronic acid fillers. It has an excellent record of safety and minimal adverse events. It produces little swelling or bruising with the least amount of down time of any filler presently available.(Fig 16)

Hyaluronic Acid

Restylane (Medicis Aesthetics), Hylaform (Inamed/Genzyme), Juvederm (Inamed)

The hyaluronic acid products are the most recently approved family of injectable fillers for contour defects.43 These are especially applicable for the nasolabial fold in which the unique viscoelastic properties and high water retention capacity fill the groove in a very natural manner. Hyaluronic acid is chemically, physically and biologically identical in the tissues of all species. It, thus is biocompatible with little or no allergenicity. The body rapidly clears the hyaluronic acid molecule in 24-48 hours so that it needs stabilization to be effective as a dermal implant. This occurs through the process of cross-linking which is slightly different for each product. Restylane® is a bacterial based product while Hylaform is derived from rooster coxcombs. Both products are purified and stabilized by cross-linking producing a hydroscope gel that is gradually eliminated by isovolemic degradation.44 Both Restylane and Hylaform have been approved by the FDA for intradermal injection to correct the nasolabial folds. This is especially applicable since the nasolabial fold was the area chosen for the paired double-blind studies used for efficacy and safety of the products.45 Both studies used Zyplast as a control but differed in intent. The Restylane study compared products on either side of the face in a double-blind paired comparison. It was to demonstrate efficacy and longevity. The Hylaform study was a “non-inferiority” study with outcomes for efficacy at four months. Both products were successful with the following outcomes:

• Both products achieved correction equal to or better than Zyplast at 4 months.
• Both products were declared safe with no need for skin test. The AE profile was safe.
• Both were declared safe and effective treatment for correction of the nasolabial folds.

Neither product has lidocaine; thus pretreatment topical anesthesia and/or local blocks are needed for patient comfort. I prefer using betacaine with an infraorbital nerve block. (TABLE 3)

The products are packaged as a gel within a syringe with 0.7 ml. product and a 30 gauge ½ inch needle. They should be injected into the mid dermis with only 100% correction, no over correction (Medicis Aesthetics, Scottsdale, AZ) (Inamed Aesthetics, Santa Barbara, CA)

Restylane and Hylaform can be injected into the nasolabial fold by all three defined techniques: serial puncture, threading and fanning. The viscoelastic properties of the gel make it malleable for massage in the fold resulting in a very natural correction.(Fig 17) The implant should not be placed superficially as it results in nodulation with a bluish discoloration to the skin.

The hyaluronic acids are relatively free of side effects with a very small risk of allergic or inflammatory reactions. Rare granulomas have been reported from both products in Europe.46,47,48,49 This filler, like all the biodegradable products are forgiving because they will resorb and side effects go away with time. (Fig 18)

Calcium Hydroxyalpatite (Radiance: Bioform)

Calcium Hydroxyalpatite (CaHA) is an inorganic substance that mimics the structure of bone. In the United States, it is marketed as Radiance. Radiance is currently FDA approved for use in oral maxillofacial defects and for soft tissue vocal fold augmentation and as a radiographic tissue marker (BioForm Medical, Franksville, WI). CaHA is currently widely used in Europe as a soft tissue filler. Radiance is not approved in the United States by the FDA for cosmetic applications and is an off-label use for soft tissue augmentation.50

In its soft tissue injectable form, CaHA microspheres are suspended in a carboxycellulose absorbable gel, and it is injected into the dermis or subcutaneous tissue. As the gel is absorbed, collagen deposition into and around the microspheres causes collagen formation and enhances augmentation. It is expected to last between two to five years with break down products of calcium and phosphorous.51

Radiance has been used effectively for correction of nasolabial fold defects by deep dermal injection. A local nerve block is needed for its comfortable usage. The gel is injected through a 25 or 27 gauge needle and the correction is usually 1:1. It is advisable to under correct the fold as lumpiness and medial over correction can produce a deformity. Conservative correction with follow up correction in two to four weeks is advisable. The pliability of the substances allows post injection massage minimizing irregularities or lumpiness which can occur. It is expected to last over two years.(Fig 19)

Poly-L-lactic acid: Sculptra (New-Fill): Dermik

Poly-L-lactic acid (PLLA) received conditional FDA approval for treatment of HIV-related lipoatrophy under the trade name Sculptra on March 2004.52,53,54,55 However, the FDA has not yet approved Sculptra for general cosmetic use in the United States. Studies of this product are currently underway to gain FDA approval. Poly-L-lactic acid has been marketed as New-Fill in Europe since November 1999.

PLLA is a synthetic polymer which is resorbable, biocompatible, and biodegradable. It has been used for several years in multiple medical devices and is a component of vicryl suture. PLLA can be injected into the deep dermal tissue or subcutaneous tissue. The area to be filled should be under corrected. After injection, gradual degradation takes place by hydrolysis while gradual deposition of collagen occurs.56,57

The initial volume correction, due to implantation of the PLLA decreases over the next few days as the diluent is resorbed. The area treated with PLLA will then slowly refill as the tissue reacts to the implant. A gradual increase in the volume will continue to occur over the next few months.58 Three treatment sessions are needed for full volume correction. The result though has been found to last up to three years.

The side effects of this material are similar to other injectables and include erythema, edema, and bruising at the injection site. Palpable but nonvisible subcutaneous nodules on the lip have been noted in some patients which can resolve spontaneously. These nodules may be due to over-correction. Massaging the treated area after injection may reduce the incidence of this side effect. Rare cases of sterile abscess, late granuloma formation and hypersensitivity reactions have been reported.59,60

Sculptra is injected with a different technique than the other wrinkle fillers. It is layered as a deep dermal and subcutaneous soft tissue filler that is used mainly to correct volume deficits rather than wrinkle correction alone. The technique of Vleggar demonstrates injection with a criss-cross pattern to lay down a uniform matrix for new collagen to be deposited in the deep dermis.(Fig 20) To correct nasolabial folds, the entire lower facial area should be blended to augment tissue and provide a volume enhancing effect. That not only corrects the furrow but also redefines the lost volume in surrounding skin and soft tissues.(Fig 21) A 27-gauge needle is used to implant the gel into deep dermis and subcutaneous tissue in a criss-cross pattern. No more than 1-2 ml is injected with under correction. The area is then massaged and iced to decrease inflammation. Two or three repeat procedures are performed for full correction. The product has been found to last two to four years.57

Non-biodegradable fillers include both injectables and solid products. (TABLE 5 – changed from 4) Over a period of time, our patients do request longer lasting fillers and discuss permanence. There are both advantages and disadvantages of these products. Most importantly, the physician must understand that errors and complications are not forgiving and in some cases, not correctable.

Silicone is the oldest filling material in the United States first used in 1930 and used for nasolabial fold augmentation since 1965 by Orentreich and Associates.61,62 The Dow Corning material had a viscosity of 360 centistokes, ideal for microdroplet deep dermal injection.63 The fine droplets are deposited as an under correction with only minimal change in the nasolabial fold.64 Collagen is laid down around the droplets and the process is repeated at six-month intervals until the desired correction is obtained. Optimal correction has been followed for over 30 years by Orentreich and Barnett with good cosmetic correction.65 The patient though must be alerted to the fact that aging changes facial contour and the silicone may “bead up” or change position as wrinkles and features fall. The most common complications seen are implant migration and nodulation.66,67,68,69 These are usually technique related.70,71 (Fig 22)

The Dow Corning silicone is not approved by the FDA. Other forms of silicone, though, are presently approved for ophthalmic usage. These are: Adato-Sil (5000 cs) and Silikon (1000 cs). They are presently being used as a dermal filler as an off-label usage.

Artecol is a permanent injectable filler used to correct the nasolabial fold since 1994.72 Polymethyl-methacrylate (PMMA) microspheres are suspended in bovine collagen for intradermal injection. The product is manufactured by Rofil Medical International but presently is not FDA approved. The product has had clinical trials in the United States under the name of Artefill. (Fig 23)

The suspension of bovine collagen and PMMA microspheres is injected into the deep dermis with 100% correction of the fold, yet not over correction (Artes Medical Inc., San Diego, CA). With three to four months, the collagen is degraded as new collagen is formed around the microspheres.51 The product is well indicated for deep nasolabial folds for long term correction.73,74

Artefill is designed for implantation into the deep reticular dermis. Implanting Artefill is more technique sensitive than injecting collagen due to its viscosity and permanence. The viscosity of Artefill is three times higher than that of Zyplast and therefore a greater and a constant pressure should be applied to the plunger of the syringe throughout the injection procedure. Also due to the increased viscosity, more pain occurs during injection compared to collagen. Before injecting, one should exert a firm and steady push on the plunger of the syringe to ensure that there is no blockage of the needle and that the material is moved to the tip of the needle and is ready for injection. The needle should be inserted into the deep reticular dermis tunneled just beneath the area to be filled while maintaining constant pressure on the plunger of the syringe. The material should only be injected while withdrawing the needle. Otherwise, it is as if you are injecting into a wall of tissue and the material injected can move in any directions away from the of the needle tip taking the path of least resistance. The areas should be slightly overcorrected. When injecting into the reticular dermis, a firm resistance is felt and a lifting of the skin is noticed. If the needle is in the subcutaneous tissue, the resistance will be much less and a much greater amount of product will be needed to achieve a lifting of the skin. If while injecting Artefill, a blanching occurs, the needle is placed too superficially. If this occurs, it is important to stop the injection immediately and massage the area with firm pressure helping to deepen the injected material. At the end of implantation, massage all areas gently. If lumpiness is noted, massage more firmly. Patients should limit movement of the injected site for the next three days as Artefill can be pushed deeper into the skin with pronounced movement during this time. The implant site can be taped for approximately three days serving more as a reminder to try to keep the area still than as a dressing. The patients are instructed that they may develop edema and erythema over the next few days.

The area should be allowed to settle for several weeks and the patient should then be reevaluated to see if any further augmentation is needed. If further augmentation is needed, Artefill should be injected in a layered fashion with care taken not to inject the material too superficially.

When correcting the nasolabial folds with Artefill, two to three strands are implanted in a parallel fashion 1-2 mm medial to the nasolabial fold. This is because the nasolabial folds are involved in many facial expressions. For the first three days after injection Artefill is more easily dislodged and due to muscular movement of this area can be moved laterally with facial expression during this time.74

Side Effects/Complications

The tolerability and acceptability of side effects due to Artefill is low due to the longevity of the implant and therefore the potential for nonresolving side effects. Although the PMMA microspheres are nonallergenic, allergic reaction can occur with Artefill as it can with any injectable collagen preparation. Even with a test-site, allergic reaction can occur.

True granuloma formation is a rare occurrence, occurring in less than 0.01% of patients and occurring 6-24 months after Artefill treatment. This side effect may not be reversible.74,75 In summary, Artefill is a permanent product with permanent results and permanent complications. Care must be taken to avoid the latter.(Fig 24)

As opposed to these injectable products, long-term correction can also be attained with fat injections. This is a more complicated surgical procedure involving fat harvesting, centrifuging and then injecting. There is down time with significant swelling, inflammation and bruising; thus it is not a procedure to be taken lightly. In fact, I like to try a simpler temporary filler first prior to fat injection procedures. This will show the patient the type of correction that can be obtained before this longer lasting procedure is performed. The following concepts have made fat injection a reliable and long lasting procedure:

• Fat is harvested atraumatically and handled in-vitro carefully to preserve the live fat cells
• Small alloquats of fat are injected in dispersed tissue – microlipoinjection
• Fat is injected deeply into muscle and deep subcutaneous tissue for best survival

The FAMI technique (Fat Autograft Muscle Injection) developed by Roger Amar, MD is a reliable method of deep fat injection to correct the lower face and nasolabial fold.76,77,78,79 It involves a careful analysis of muscle and fat loss around the nasolabial fold with correction of fat into those areas of loss. For example, deep nasolabial folds are corrected by microlipoinjection into the following muscles: levator labii, zygomatic major, orbicularis oris, depressor anguli oris and mentalis. This is performed through the use of a specially designed cannula through which the fat is injected longitudinally through the muscle mass and fat above.(Fig 25)

The thin patient with severe folds and skeletonized lower face responds to this operative procedure. The fat is injected through definitive incision sites for volume replacement of the lower face. Volume replacement will give longlasting (1-5 years) correction of folds and a new contouring of the lower face.80,81,82 (Fig 26)

Conclusion

This chapter has explored the available techniques to correct the nasolabial folds with emphasis on individualizing correction to meet each patient’s needs.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Rejuvenation of the aging face involves modalities that will:

• Refill
• Resurface
• Relax and
• Resuspend

As cosmetic rejuvenation procedures have become simpler and less-aggressive, the down-time has decreased as well as safety and morbidity. Most facial rejuvenation involves a combination of these procedures which can then be tailored to the needs of the patient. (Table I)

The aging face exhibits both intrinsic effects of volume loss and ptosis plus photoaging changes on the skin. Volume and ptosis first exhibits changes in the nasolabial fold which has a dynamic phase and then later a static phase.(Fig 1) It is interesting that the fold is absent in the newborn and disappears in the paralyzed face, revealing the importance of the dynamic phase. It is the result of both perioral and lower face volume loss with cheek skin ptosis. The volume loss involves atrophy of the lower facial fat muscle and bone in the perioral and cheek areas.(Fig 2) The nasolabial fold represents the peripheral margin of the orbicularis oris muscle at the infusion of the cheek levator muscles. It is, though, the overlying subcutaneous fat – the malar fat pad – that normally gives the youthful cheek a rounded convexity that merges smoothly with the nasolabial fold. The SMAS has the muscle-fat complex in place, giving it final definition and stability during movement of facial muscles. The fold deepens with age because of atrophy and ptosis of the malar fat pad, cheek-skin laxity and hypertonicity of the levator muscle on the lip margin.(Fig 3) Later, ptosis and atrophy of the malar fat pad characterizes the static phase of the deepening nasolabial fold.1 (Fig 4) Procedures for rejuvenation of the mid face include:

• Soft tissue augmentation
• Mid face lifting procedures
• Direct melolabial fold excision
• Adjunctive procedures
• CO2 laser
• Botulinum toxin
• Non-ablative laser and tissue tightening lasers

Skin fillers are only useful for early or mid to moderate nasolabial fold depressions. These include collagen products (Cosmoplast, Zyplast) and varying concentrations of hyaluronic acid fillers such as Hylaform, Restylane and Captique.(Fig 5) Longer lasting skin fillers must be injected deeper such as hydroxyapetite (Radiesse) and Silikon.2

For more severe volume loss problems, microlipoinjection of fat into subcutaneous tissue and muscle – FAMI – has been the treatment of choice. It will lost replace volume and accordingly produce some elevation as it pushes the cheek and malar fat pad back up. (Fig 6) Polylactic acid suspensions – Sculptra – produces volume filling by stimulating new collagen production in the subcutaneous tissue and deeper dermis. It also uses volume filling as well as some elevation of ptotic mid face structures.3 (Fig 7)

Though soft tissue implants can correct early problems of the aging face with volume loss and ptosis, more advanced facial aging conditions are problematic. This is because the implants are absorbable and temporary. They also do not address the ptotic malar fat pad and the nasolabial cheek bulge and do not change cheek contour. These conditions can only be addressed with lifting procedures. Procedures currently used include:

• Traditional rhytidectomy with SMAS lift
• Subperiosteal mid face lifts
• Deep plane lifts 4

During the last decade, the trend in lifting technique has become less invasive surgical techniques include endoscopic malar fat pad elevation and malar fat pad fixation with liposculpture.5 Minimally invasive lifting techniques have evolved such as percutaneous cable suture elevation as performed by Sasaki with vortex grafts anchored to temporal fascia.6

Both here in the United States and abroad, the most recent minimally-invasive lifting technique has been the barbed threads used for suspension. The Aptos subdermal suspension threads evolved from the concept of skin and fascia adhering to the barbed suture, creating elevation. This was developed by Marlen and George Sulamanidze in Russia.7 Concomitantly, the Contour Thread developed by Dr. Greg Ruff at Duke University and in the United States is now FDA approved and used as a similar barbed suspension thread.8 The suspension threads simplify the procedure of lifting by eliminating surgical incisions, undermining, plication SMAS, and suturing the various tissues back together. This simplified procedure reduces operative time, anesthesia, post-operative recovery and reduces the risk of face lift complications including hematoma, flap necrosis, infection, nerve damage and scarring. The barbed suture can be performed with local anesthesia through needle insertion in the subcutaneous tissue utilizing soft tissue vectors of upward suspension. Two devices have evolved simultaneously. The barbed Contour Thread by Greg Ruff, M.D. evolved in concept over the early 90’s and has recently become FDA approved in the U.S. for cheek, jowl and brow-lifting. The Aptos thread was developed by Marlen Sulamanidze in the 90’s. At present, it is not an approved device in the U.S.

Aptos is derived from the Greek “Anti” plus “Ptosis”. It is essentially a barbed thread which adheres to the dermis and acts as a gathering stitch or Velcro. The aptos thread is based on the concept that the skin can be lifted and held in a suspended position with barbs alone without affecting the underlying muscle or bone. The barbed adherence is performed without suturing or anchoring to fascia muscle or bone.

The thread itself is polypropylene, a nylon suture with barbed incisions in two directions. The bidirectional barbs thus hold tissue in both inferior and superior direction, giving greater adherence.(Fig 9) The aptos suture is introduced in an 18 or 20 gauge spinal needle in the subcutaneous tissue from the superior point of suspension to the lower limits of ptotic skin. For the nasolabial fold, the pathways traverse from the lateral malar cheek to the nasolabial fold and the lateral oral commissure.(Fig 10) As the spinal needle is removed and the cheek compressed upward, the barbs open up with pull on the suture. The barbs then grab skin and associated subcutaneous tissue, holding it in the new elevated position. The protruding suture is then cut at the skin surface and tucked into the subcutaneous tissue. The procedure is performed in the following stage:

• A map of vectors is drawn on the patient’s face in a seated position to determine the pathways of the threads and the number of threads needed to obtain the necessary elevation.(Fig 11)
• The patient’s face is cleansed and sterilized with an appropriate surgical scrub so that the procedure can be performed sterily.
• The procedure can be performed with local anesthesia alone; though I prefer using minimal anxiolytic sedation (diazepam 5-10 mg sublingually to supplement the local anesthesia alone). 1% lidocaine with 1:150,000 epinephrine with bicarbonate is used to infiltrate the skin and subcutaneous pathway. One can use a 1 ½ inch 30 gauge needle and 10 cc syringe producing first a bleb intradermally at the point of insertion, then a subcutaneous infiltration of the suture pathway. This usually produces enough anesthesia for painless placement of the suspension suture.
• A 20 gauge spinal needle – trochar in place – is introduced through the skin and advanced along the mapped pathway with a “serpiginous” pattern. This is to increase the tissue area of barbed contact and the changing of direction creates a stronger barbed attachment. The needle is advanced to its termination at the nasolabial fold and exited to the skin. The trochar is removed and the barbed suture introduced into the spinal needle from the termination point to the beginning. The inferior portion of protruding thread is clamped with a hemostat for security as the spinal needle is removed. At the same time, the cheek is compressed upward. After the needle is removed superiorly, the thread is pulled in both directions, opening the barb and holding the skin in its upward compressed position. The two sides are then compared for symmetry and even correction. At this time, change can be made to equal the elevation and create a natural lifting. The protruding sutures are then snipped with suture scissors and the suture tucked in to the subcutaneous tissue.(Fig 12, 13, 14, 15,)
• Antibiotic ointment is placed over the needle holes and steri-strips or micropore tape is placed over the cheeks for surface anti-tension suspension. (Fig 16)

Post-operatively, the patient is warned against excessive cheek or moderate mouth movement which – early on – can break the correction. Also, the patient is advised against massage or aggressively scraping the cheeks for the first few days which can also dislodge the barbs. My preference is to leave the tapes in place for the first five days; then advise the patient to re-tape at night, protecting the cheeks from sleep compression and immobilizing the tissues. In a majority of patients, the correction has been maintained for two to three years if early immobilization can be maintained. This has been reported by Sulamanidze and Lycka in two independent series.3,9

Basic questions have arisen as to the reason the barbs will maintain correction without anchorage to a mobile structure such as muscle or bone. Sulamanidze performed histopathologic studies on albino rats with inserted barbed threads in a control of non-notch prolene suture. The tissues were examined with special stains for collagen, fibroblasts and vascular response. A surprising difference was noted between the barbed suture and its control. The smooth prolene suture had no vascular, inflammatory, fibroblastic or collagen response with serial biopsies taken regularly up to six months. The barbed suture, though, demonstrated an early inflammatory response followed by a vascular proliferation and fibroblastic reaction, creating a collagen cuff around the barbs.11 (Fig 17) This, then, must account for the grip the barbs continue to hold on skin, giving it its longer-lasting response. It also explains the need to immobilize the skin in tissues early on until the collagen response is complete.

Further studies were performed by Lee WS et al to compare the tensile strength, skin compressibility and histology of barbed suture versus prolene suture. There studies demonstrated uniformly that the barbed sutures maintain greater tensile strength measured in pounds per square inch and greater skin compression than the plain suture. Histology in the rat model demonstrated myofibroblasts with a fibrotic cuff around the barbed suture and no fibroblastic response seen in the plain suture material, either monofilamentus or multifilamentus.12

This all adds scientific principle to the clinical results seen with the barbs. They are different in their results from plain suture material. The true test of the procedure, though, is in patient satisfaction.

Lycka et.al. followed 350 patients who had aptos threads placed for nasolabial fold, cheek and brow lifting. They found over 75% of the patients reported a favorable response with few side effects. The majority of them reported results lasting over one year. Fifty-two patients did, though, require a post-operative touch-up because of early destruction of results.13

Side-effects and complications seen include the following:

• Asymmetry
• Visible threads
• Suture spitting
• Post-operative pain
• Infection
• Correction destroyed by manipulation 14

Symmetry problems can be addressed at the conclusion of surgery and during early post-operative visits. Finger massage and manipulation can correct an overly-corrected cheek or side within the first week. It is, thus, important to see the patient during the first week to evaluate the results.

Threads may be visible early on, especially in the patient who has thin skin and little subcutaneous tissue. This usually improves with time. If it persists to the patient’s dissatisfaction after three or four weeks, the barbed suture can be removed.

Suture migration or spitting at the surface has been seen. The protruding suture can be easily snipped or a wandering suture removed.(Fig 18)

Infection is rare, especially with pre-operative antibiotics. Precautions of asepsis and sterility should prevent this.

The patient may complain of a pinching pain early on which is intermittent. I believe it is caused by the barb irritating a peripheral nerve. This usually occurs within the first week and subsides. The patient needs reassurance and this is usually all that is necessary; though, if it persists and creates a symptomatic problem, the suture may be removed.

The most important adverse sequelae is the destruction of correction by stretching the barb early on. Correct technique of insertion – using a serpentine pattern – along with proper post-operative protection can guard against this problem. Other areas of ptosis and dermatocholasis treated with aptos suspension threads include eyebrow and forehead lifting, cheek lifting, jowls and neck with platysmal suspension. The technique and procedure is essentially the same for each of these procedures; only the patterns and number of threads change as to the structure to be lifted. Forehead and brow give excellent results and can be combined with upper lid blepharoplasty. Cheeks and jowls can be more problematic with correction broken with cheek movement.

This is a technique in development with questions remaining as to longevity and the best areas for treatment.(Fig 19)

Contour Threads

Greg Ruff, M.D. has independently developed a different concept of barbed suture for facial suspension. Having used the model of the porcupine quill (erethizon dursaton) as a multi-barbed suture that maintains a hold or grasp on soft tissue through an even and spiral diffusion of barbs on each quill. Dr. Ruff began work on the “quill suture” in the early 90’s as a closure technique for surgical wounds. It was found to be self-anchoring with no knots, giving a faster and more efficient closure with tension broadly distributed. The “Contour Suture” was thus developed as a unidirectional barbed monofilament suture with a different pattern of insertion and anchored superiorly to a fixed structure. Data has been obtained as to tensile strength, tissue stretch and histologic studies of fibroblast migration and collagen development and this has shown to be a safe and reliable technique for facial suspension.16 In 2005, the FDA has approved it for suture suspension for cheeks, jowls and brow.(Fig 20)

The 25 cm. 2-0 prolene barbed suture is swedged onto a 7 inch straight needle with a tapered cutting tip and 26 mm. ½ circle tapered needle on the opposite end for suture fixation.(Fig 21) The sutures are used in pairs with the pathways ascending superiorly to a pointed V in the temporal scalp. At this superior point, the fixation needle is used to anchor the suture in the temporal fascia. The procedure is performed sterily as the aptos threads are employed with an initial incision made superiorly and the straight needle threaded through the subcutaneous tissue in a serpentine pattern.(Fig 22) Each pair of threads are tied in the superior temporal fascia. As the threads are pulled downward, the cheek then can be massaged upward into proper position.(Fig 23) It can be adjusted for symmetry and a natural appearance with the patient awake, in a seated position, checking for approval and satisfaction.(Fig 24, 25)

Whether this anchored thread will have the distinct advantages claimed over the free floating aptos thread, only time and clinical experience will tell us. Because it is FDA approved now, it will have a large following in the United States. It is, though, technique sensitive and does require proper training and experience.

Minimally invasive procedure correction of the aging face now includes the fourth R – Resuspension. This does open a new frontier for the dermatologic and cosmetic surgeon.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Introduction

Rejuvenation of the aging face involves modalities that will refill, resurface, relax and resuspend. As cosmetic rejuvenation procedures have become simpler and less aggressive, downtime has decreased and safety has increased. Most facial rejuvenation involves a combination of procedures that can be tailored to the needs of the patient. Suspension threadlifting provides a less invasive method for resuspending the aging face. Both here in the United States and abroad, the most recent minimally invasive lifting technique has been the barbed threads used for suspension. The Aptos subdermal suspension threads evolved from the concept of skin and fascia adhering to the barbed suture, creating elevation. This was developed by Marlen and George Sulamanidze in Russia. Concomitantly, the barbed suture or Contour Thread developed by Dr. Greg Ruff at Duke University and in the United States is now FDA approved and used as a similar unidirectional barbed suspension thread.

Mechanism of Action

Aptos is derived from the Greek “Anti” plus “Ptosis”. It is a barbed thread that adheres to the dermis and acts as a gathering stitch. The Aptos thread is based on the concept that the skin can be lifted and held in a suspended position with barbs alone without affecting the underlying muscle or bone. The barbed adherence is performed without suturing or anchoring to fascia muscle or bone. The thread itself is a polypropylene suture with barbed incisions in two directions. The bidirectional barbs hold tissue in both inferior and superior direction, giving greater adherence. Greg Ruff, M.D. has independently developed a different concept of barbed suture for facial suspension. Having used the model of the porcupine quill (erethizon dursaton) as a multi-barbed suture that maintains a hold or grasp on soft tissue through an even and spiral diffusion of barbs on each quill, Dr. Ruff began work on the “quill suture” in the early 90’s as a closure technique for surgical wounds. It was found to be self-anchoring with no knots, giving a faster and more efficient closure with tension broadly distributed. The “Contour Suture” was thus developed as a unidirectional barbed monofilament suture with a different pattern of insertion and anchored superiorly to a fixed structure. (Figure 1)

Safety and Efficacy

Marlen Sulamanidze developed the Aptos thread in the 90’s. At present, it is not an approved device in the US. Animal studies revealed the non-inflammatory status of the non-barbed praline suture while the barbed areas developed a fibrotic cuff over a period of 3 months. It is this fibrous sheath which theoretically holds the tissue in place. For Contour Threads, data has been obtained as to tensile strength, tissue stretch and histologic studies of fibroblast migration and collagen development. The studies demonstrated the thread to be a safe and reliable technique for facial suspension. In 2005, the FDA has approved it for suture suspension for cheeks, jowls and brow. The procedure itself is performed under local anesthesia as an outpatient with minimal trauma and thus little bruising and erythmosas with little resultant downtime. Potential complications, though, can include asymmetry, visible threads, suture spitting, post-operative pain, infection, and correction destroyed by manipulation.

Indications

The Aptos thread is not an approved device in the US. In 2005, the FDA approved Contour Threads for suture suspension of the cheeks, jowls and brow.

Proper Patient Selection

The patients who benefit most from threadlifting procedures are patients with some ptosis of the cheeks, jowls and brow, but not a lot of excess sagging skin. Also, heavyset patients are less likely to obtain optimal results due to destruction of correction by stretching and release of the barbs on the suture. The procedure can be combined well with other minimally invasive procedures such as skin and soft tissue filling agents and botulinim toxin.

Contraindications

The use of blood thinners increases risk of postoperative bruising but is not an absolute contraindication. Patients with active skin infection should be fully treated prior to thread placement. Also, patients with unrealistic expectations should be excluded. Patients should understand that this is not a face lift and thus more radical lifting and correction cannot be achieved.

Pre-Procedure Patient Education

Patients are educated on the risks and benefits of threadlifting. They are shown before, during, and after photographs of previously treated patients so that they can better understand the process involved in recovery after the lifting procedure. They are told that the threadlift procedure is not a substitute for a facelift, but rather a less invasive alternative that will provide some correction of ptosis but not to the degree of a facelift. The patient must understand that there is a period of “downtime” in which excessive pressure or movement may break the barb-hold on the elevated skin and destroy correction. There are also temporary folds, dimples and furrows where the skin is abnormally tight which will correct over 3 weeks as the threads commonly lose 20% of pulled correction. In addition, long-term expectations are discussed with the patient including the possibility that over time the correction will diminish. Patient questions should also be answered.

Procedure Protocol

Tray Set-Up

The tray used for insertion of threads for both Aptos Threads and Contour Threads is a standard excision tray with a needle holder, forceps, scalpel (with a number 11 or 15 blade), suture scissors, Gradle scissors (or similar) for undermining, gauze, a small bowl of saline, and the appropriate threads. For Aptos Threads, a 20 gauge spinal needle is also needed. For Contour Threads, an undermining needle may be used. (Table 1)

Procedure

• A map of vectors is drawn on the patient’s face in a seated position to determine the pathways of the threads and the number of threads needed to obtain the necessary elevation. For Aptos threads the pathways are drawn along the appropriate vectors and do not need to connect in the scalp (Figure 2). Unlike the Aptos threads, Contour Threads are used in pairs with the pathways ascending superiorly to a pointed V in the temporal scalp (Figure 3).
• The patient’s face is cleansed and sterilized with an appropriate surgical scrub so that the procedure can be performed sterily.
• Although the procedure can be performed with local anesthesia alone, minimal anxiolytic sedation (diazepam 5-10 mg sublingually to supplement the local anesthesia alone) is often advisable. 1% lidocaine with 1:150,000 epinephrine with bicarbonate is used to infiltrate the skin and subcutaneous pathway. One can use a 1 ½ inch 30 gauge needle and 10 cc syringe producing first a bleb intradermally at the point of insertion, then a subcutaneous infiltration of the suture pathway. This can easily be performed with a 20 gauge spiral needle. This usually produces enough anesthesia for painless placement of the suspension suture.
• For Aptos Threads: A 20 gauge spinal needle – trochar in place – is introduced through the skin and advanced along the mapped pathway with a “serpiginous” pattern. This is to increase the tissue area of barbed contact and the changing of direction creates a stronger barbed attachment. The needle is advanced to its termination at the nasolabial fold and exited to the skin. The trochar is removed and the barbed suture introduced into the spinal needle from the termination point to the beginning. The inferior portion of protruding thread is clamped with a hemostat for security as the spinal needle is removed. At the same time, the cheek is compressed upward. After the needle is removed superiorly, the thread is pulled in both directions, opening the barb and holding the skin in its upward compressed position. The two sides are then compared for symmetry and even correction. At this time, change can be made to equal the elevation and create a natural lifting. The protruding sutures are then snipped with suture scissors and the suture tucked in to the subcutaneous tissue.
• For Contour Threads: There are 2 suture types available for use. The CT-200 I is a 25 cm. 2-0 polypropylene barbed suture which is swagged onto a 7 inch straight needle with a tapered cutting tip and 26 mm. ½ circle tapered needle on the opposite end for suture fixation. At the superior point in the temporal scalp, the fixation needle is used to anchor the suture in the temporal fascia. The CT-200 is the first suture developed and commonly used now for neck lifting. The CT 400 suture has paired barbed sutures with 2 straight taper-cut needles attached together with non-barbed portion of 3-0 proline suture. The paired insertion thus does not require suturing the 2 barbed sections together but does require passage to deep fascia superiorly for fixation. Like the Aptos threads, an initial incision is made superiorly and the straight needle threaded through the subcutaneous tissue in a serpentine pattern (Figure 4). Each pair of threads is sutured into the superior temporal fascia. In some patients an additional incision can be made in between the threads and also on either side near the insertion point in the temporalis fascia. A small undermining needle can then be inserted and used to free the surrounding tissue to allow for a more plate-like lift. As the threads are pulled downward, the cheek then can be massaged upward into proper position. The lift can be adjusted for symmetry and a natural appearance with the patient awake, in a seated position, checking for approval and satisfaction. The protruding sutures are then snipped with suture scissors and the suture tucked in to the subcutaneous tissue.

Antibiotic ointment is placed over the needle holes and steri-strips or micropore tape is placed over the cheeks for surface anti-tension suspension (Figure 5).

Post Procedure Instructions

Post-operatively, the patient is warned against excessive cheek or moderate mouth movement that, early on, can break the correction. Also, the patient is advised against massage or aggressively scraping the cheeks for the first few days which can also dislodge the barbs. The tape is left in place for the first few days and patients are also advised to sleep propped up and stabilized to prevent rolling over and dislodging the barbs from sleep compression. In a majority of patients, the correction is well maintained if the early postoperative care is followed. 0.25% Acetic acid soaks are used everyday and polysporin is applied to suture insertion points.

Recommendations for Follow-Up

Patients return 3 to 7 days post-procedure for minor corrections of dimpling and asymmetry. Care must be taken to not undo too much of the correction because 25-35% of the correction will relax with time and most dimples will resolve with tincture of time. It is important to reassure patients in the early stages of recovery because their appearance is often quite pulled.

Complications

As discussed in the safety and efficacy section, complications seen include asymmetry, visible threads, suture spitting, post-operative pain, infection, and correction destroyed by manipulation. Pre and postoperative photographs are important with threadlifting procedures. Often patients have degrees of natural facial asymmetry that were not apparent to them preoperatively. In the early postoperative period it is easy to release some of the barbs and decrease the amount of lift to improve symmetry.

Threads may be visible early on, especially in the patient who has thin skin and little subcutaneous tissue. This usually improves with time. If it persists to the patient’s dissatisfaction after three or four weeks, the barbed suture can be removed. In addition, if threads are placed too superficially they often remain visible. Care must be taken intraoperatively to insure the threads are placed in the appropriate subcutaneous plane. Suture migration or spitting at the surface has been seen. The protruding suture can be easily snipped or a wandering suture removed. One of the most common complaints is a firm papule at the insertion point of a Contour Thread. Occasionally the tail end of the thread needs to be trimmed closure to the knot to avoid this complication.

Infection is rare, especially with pre-operative antibiotics. Precautions of asepsis and sterility should prevent this. The patient may complain of a pinching pain. This may be due to a barb irritating a peripheral nerve. This usually occurs within the first week and subsides. The patient needs reassurance and this is usually all that is necessary; though, if it persists and creates a symptomatic problem, the suture may be removed. True neurasthenia or prolonged motor nerve injury is rare but theoretically can occur, especially in the temporal and mandibular area where the facial nerve is most superficial.

The most common important adverse sequelae is the destruction of correction by releasing the barbs. Correct technique of insertion – using a serpentine pattern – along with proper post-operative protection can guard against this problem. Patients need to be aware that manipulation of the face in the early postoperative period can completely undo their lift. Manipulation includes the use of makeup, vigorous massage or face washing or rolling over in their sleep. If the lift is undone, additional threads will have to be placed.

Pearls

Patient selection and preoperative education make a huge difference in outcomes. Patients need to understand that the procedure does involve some postoperative downtime and that the true result is not apparent immediately. For physicians, this means resisting the urge to release every dimple and pull on the skin as the end lift will be significantly decreased. Also, patients who need facelifts are not good candidates for threadlifting.

Pitfalls

Failing to insert the suture in a serpiginous pattern will lessen the likelihood of a long-term lift. Failing to obtain preoperative photographs will make it difficult to assess postoperative lift and symmetry.

Table 1. CONTOUR THREADS TRAY SET-UP SUPPLY

• Contour Threads
• Mohs’ Pack (includes sterile towels, 2x2s, 4x4s, cotton tipped applicators)
• Mohs’ Instruments (includes scalpel handle, needle holder, Iris scissors, Gradle scissors, Bishop-Harmon or Castroviejo forceps, skin hooks, and Brown-Adson forceps)
• Purple marking pen
• Sterile Saline in large cup
• Number #15 Blade x2
• x1 25 gauge Spinal Needle
• Ultradex Scrub Brush to prep patient’s face and hairline
• Appropriate size sterile gloves

LOCAL ANESTHESIA

• x4 or more 3cc Syringes of Lidocaine with SB (8.4% Sodium Bicarbonate)
• x4 or more 5cc Syringes with Lidocaine with Epinephrine
• 30 gauge ½ inch needle

MEDICATIONS

• Take or Written Verbal Orders from Physician

Table 2. Procedure Checklist

• Preoperative photographs including a frontal view of the entire face, side views taken at 90? and 45? from each side
• Informed Consent
• Mapping of thread pathways while patient is sitting upright
• Injection of thread tracts with local anesthesia (generally 1% lidocaine with epinephrine)
• Confirmation of the number of threads needed
• Insertion of the threads and contouring
• Post-operative instructions and follow-up appointment given
• Procedure note documented in chart

Table 3. Sample Procedure Note

The patient received a fully informed consultation and consent prior to surgery and photographs were taken. The patient approved of an outline of ___________ threads on either side to elevate ________________________. DESCRIPTION OF THE PROCEDURE: The pathways for the cogged threads were outlined with a gentian violet marking pen and the entire face was prepped with ________________ and draped sterily. _____________ cc’s of ____________________ was injected along the pathway on ___________________. The needle thread was inserted into the temporal subcutaneous tissue and advanced serpiginously to the exit point along the nasolabial fold, the oral commissure and the lower cheeks. The cogged thread was inserted and advanced fully. The needle was then extracted with cheek elevation. ______________ threads were placed on each _________________ and a similar pattern was used along the retroauricular neck and the medial neck area bilaterally. The tips of the suture were then clipped and the suture end was pushed back in the subcutaneous tissue.

The patient tolerated the procedure well and left the operating room in stable condition and will be discharged home.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The cosmetic surgical patient is usually found at a dermatology office seeking help with skin care and, in many instances, wishing to proceed further with cosmetic surgical procedures. The dermatology practice is fertile ground for discovering patients wishing cosmetic surgical correction of their skin and facial rejuvenation. The two practices can feed each other and easily can run side by side. There, though, are significant differences in the approach to the patient requesting cosmetic surgery and the patient seeking medical help for a skin disease or problem. The approach of the office to this patient will determine how successful the physician is in integrating his cosmetic surgical practice with a general dermatology practice. Certain aspects are as incompatible as oil in water and must be separated, either structurally or temporally.

The first aspect is the physician’s understanding of the needs, desires and general psychology of the cosmetic surgical patient. This patient will window-shop in your office and many other offices, inspecting materials about procedures such as skin resurfacing for wrinkles, chemical peeling, liposuction, blepharoplasty, etc. He/She will have examined brochures and booklets from many practices prior to developing the courage to call for an appointment. Many of these patients are literally afraid of the phone call and might dial your number two or three times and hang up prior to finally connecting with an office staff to make the appointment. The office staff must be encouraging to make this appointment and have time available for this patient to respond promptly. Too many busy signals, a hurried and abrupt telephone operator, an appointment weeks away may discourse this reticent shopper from making the initial contact needed for the consultation. This is your office staff’s first outreach to this patient and it must be done courteously, promptly and receptive to their needs. A “smiling voice” is the tone that will be embraced by this patient while the hurried, abrupt operator who gives the sneering impression that cosmetic surgery is not as important as the medical part of the practice will turn many cosmetic patients away.

The same pampering is needed from the personnel in the waiting room, the front desk, the consultation room, and thus throughout all aspects of pre-operative evaluation, operative session, post-operative care and follow up care. To accomplish this, many of the normal procedures, policies and relationship between staff and patients must be changed to meet the needs of the cosmetic patient.

There are unique requirements of the cosmetic surgical office and practice which can be broken down into the following categories:

• Office structure
• Operating room structure
• Management of the telephone
• Personnel
• Marketing

The fast past of a general dermatology practice does not coincide with the time needed to satisfy questions, responses and pampering for the patient seeking cosmetic surgery. A waiting room packed with patients with skin diseases, bandages from cancer surgery, ulcers, etc., are not the setting for patients seeking beauty. One must either schedule these patients at different times or structurally separate a different waiting area for the patients seeking cosmetic surgery. In that case, a smaller waiting room with less turn-over and the physical ambiance emphasizing composition, form, beauty, precision and competence should be displayed. This should include artwork, soft creative music, pamphlets concerning cosmetic procedures, reading material, and even pre and post-operative photographs. Coffee table books of artwork should be available as well as a reception secretary with a smile on her face, knowledgeable of the procedures and encouraging questions. The hectic pace of a general dermatology practice with telephones ringing, charts flying and little eye contact between staff and clients are not the ambiance of a cosmetic surgical practice.

A separate room should be set aside for consultations that is different from a typical treatment room. It should have more comfortable seating for the patient and special tools needed to display the patient’s needs. This could include a three-way mirror, a projector for slides, an easel to draw and sketch profiles as well as illustrate procedures for a full understanding of the procedure. The physician should be seated on an equal level with the client of patient, encouraging a frank discussion that would include the patient’s wishes and desires from the procedure, the nature of the procedure and the ability of the surgery to fulfill the patient’s requests. The consultation should be uninterrupted to cement a firm relationship between physician and patient.

The operating room facility must have the appearance of excellence. It is best to have a pre-operative area, a fully equipped AAAHC approved operating facility, and a separate recovery area. It should be spotless in appearance with new, fully functional equipment and a staff ready and eager to carry out the necessary procedures with a smile. Little details such as a dirty 4 x 4 on the floor, instruments left on the floor, surgical staff not fully gloved and gowned, can be used as an excuse by the perceptive patient on why a procedure did not meet his or her needs or a reason for a side effect or complication. None of these reasons should be available in the physical facility itself.

Once the patient has made an appointment for a consultation and arrives at the office, a prompt response is made by the entire staff. The patient is brought back to the consultation room by nursing personnel who are thoroughly familiar with the consultation procedure. A “patient advocate” can be used to initiate the consultation and give the patient an opportunity to express her needs. Beginning the session with statements such as “what brought you in to see us?” or “if you could have anything in particular changed, what would it be?” Then, the advocate must be a good listener and allow the patient to express herself fully concerning what the changes are he/she wants, what those changes would mean to him/her, what his/her appearance means now, and the effect he/she feels it would have on him/her later. A sensitive listener can readily assess a level-headed, realistic patient who would be easy to work with during surgery or those with particular pathologic problems in which a red flag should alert one to the individual who should not have surgery; those who are unrealistic in their needs and demands and would not be a good candidate for surgery. As the patient advocate answers questions, these must be consistent with the physician’s response. Initially, these can be “scriptive” but as the interviewer spends more time with the physician during his consultations, the consultation nurse will sound like the physician over a period of time and carry out the same messages. This, then, is the ideal person to have for interviews.

Three conditions for the physician to continue a productive consultation would include:

• The patient’s wish list is surgically possible and realistic.
• A medical evaluation and emotional screening evaluation are within normal limits and consistent with the surgery proposed.
• The financial obligations for the patient are realistic and accepted.

Only if these needs are met should the physician proceed on with a full interview. As the physician begins, he, again, should give the patient a chance to tell what he or she desires with a question “what brought you in to see us?” Moving into particular details, the physician should then hold a mirror in front of the patient and ask particularly what the patient would like changed. The patient, then, can show you areas that bother him/her. For example, in acne scars, there may be one or two particular lesions that bother the patient most and those lesions, in fact, may be too deep for resurfacing or dermabrasion and need surgical correction or soft tissue augmentation. The physician should be sure to understand what particular items bother the patient and not spend the consultation evaluating the perfect face or form and showing the patient how to achieve this. The patient may not be interested in any of these things at all, but in one particular item she wishes corrected.

In the final analysis, the physician and patient should meet a common goal by understanding his or her needs and plugging this into the corrective procedure or procedures to fulfill those needs. Only then should the physician feel that the deal is closed and the procedure can be scheduled. At that point, the physician should turn the consultation over to the patient advocate or scheduling nurse for the final arrangements, which would include:

• Financial arrangements
• Medical evaluation and bloodwork
• Consents for surgery, reviewed and signed
• Pre-operative photography
• Scheduling
• Pre and post-operative instructions and prepared kits for post-operative care

Marketing the cosmetic practice involves both an external outreach, letting the general public know of the cosmetic practice, and an internal marketing approach, educating patients of the cosmetic portion of the practice. Both of these can be accomplished in a professional demeanor consistent with the medical practice. One must always remember that a cosmetic surgeon is not selling a product as the lady in the white coat at the cosmetic counter in your local department store, but rather making the practice and the community aware of the professional cosmetic services you offer. The difference between gaudy advertising and professional education can have a major impact on the perception of your practice in the general community. One should never compromise on professionalism in accepting advertisements, writing articles and speaking. Look, not only at the content, but the style, the graphics and where the ad is being placed. Many times, associated ads can influence acceptance of your practice’s announcement or ad in cosmetic surgery.

Marketing a practice with a long shopping list of procedures is an impossibility. The goal should be to take one procedure at a time as a campaign and repeatedly show the marketing audience your practice’s association with that procedure over and over again for acceptance. This form of campaign works well over a period of time. It can be done externally through public form lectures on a particular subject with newspaper announcements, press releases concerning new procedures to both newspapers, magazines, radio and television, advertisements tactfully placed in newspapers, local journals, radio and even television, and the physicians presence on talk shows, local news announcements and lecturing to civic groups and professional societies.

Internally, the judicious placement of pamphlets concerning procedures with before and after pictures in waiting rooms, treatment rooms, and even on racks in hallways can educate patients on cosmetic procedures available. In many instances, a busy dermatology practice can be the very best marketable environment for the physician. The best advertisement still remains the satisfied patient who will tell friends and colleagues of how pleased they were concerning their surgical procedure. A letter to these patients thanking them for their referral and trust in you as a cosmetic surgeon will continue to bring you many more referrals from those satisfied patients.

Thus, the needs of a cosmetic practice are different from those of a general dermatology practice. The physician must make the decision on how much investment he wishes to place of time, office structure, and personnel into a cosmetic practice to fulfill his goals.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The explosion of interest in chemical peeling and laser resurfacing on the part of dermatologist has paralleled the general public’s interest in acquiring a youthful appearance by rehabilitating photoaged skin. The public’s interest has been further heightened by advertising for cosmetic agents, over the counter chemicals and treatment programs that have entered the general market of products meant to rejuvenate skin and erase the marks of sun damage and age. Most of these over the counter home do-it-yourself programs have been tried by patients and by the time they consult their plastic surgeon, cosmetic surgeon, or dermatologist, they are ready for a more definitive procedure performed with either chemical peeling or laser resurfacing. It is the obligation of the physician to analyze the patient’s skin type, degree of photoaging skin, and thus prescribe the correct facial rejuvenation procedure that will give the greatest benefit for the least risk factors and morbidity. The cosmetic surgeon should have available for his consumer the options of medical or cosmoceutical topical therapy, dermabrasion, chemical peeling, and lasers available for selective skin destruction and resurfacing. Each of these techniques maintains a place in the armamenteria of the cosmetic surgeon to provide the appropriate treatment for each individual patient and his specific problem.

The approach to photoaging skin has expanded beyond a one-stage procedure to now include preparatory medical therapy and post-treatment cosmoceutical topical therapy to maintain results and prevent further photodamage. Thus, the dermatologist’s office has become not only a surgical treatment session, but also an educational setting for skin protection and care and a marketplace for the patient to obtain the necessary topicals for skin protection. It is up to the dermatologist, cosmetic surgeon, plastic surgeon to fully understand the nature of skin and sun damage, protective techniques available, and active agents that work as cosmoceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right procedure to restore and rehabilitate their skin.

Chemical peeling involves the application of a chemical exfoliant to wound the epidermis and dermis for the removal of superficial lesions and improve the texture of skin. Various acidic and basic chemical agents are used to produce the varying effects of light to medium to deep chemical peels through differences in their ability to destroy skin. The level of penetration, destruction and inflammation determines the level of peeling. The stimulation of epidermal growth through the removal of the stratum corneum without necrosis consists of light superficial peel. Through exfoliation, it thickens the epidermis with qualitative regenerative changes. Destruction of the epidermis defines a full superficial chemical peel inducing the regeneration of the epidermis. Further destruction of the epidermis and induction of inflammation within the papillary dermis constitutes a medium depth peel.1 Then, further inflammatory response in the deep reticular dermis induces new collagen production and ground substances which constitutes a deep chemical peel. These have now been well classified and usage has been categorized for various degenerative conditions associated with photoaging skin based on levels of penetration. The physician, thus, has tools capable of solving problems that may be mild, moderate or severe with agents that are very superficial, superficial, medium depth, and deep peeling chemicals. The physician must choose the right agent for each patient and condition.

Indications and Patient Selection

Analyzing the patient with photoaging skin must take into account skin color and skin type as well as degree of photoaging. Various classification systems have been available and I would like to present a combination of three systems that would simplify and help the physician define the right program or therapeutic procedure for his patient. The Fitzpatrick skin type system classifies degrees of pigmentation and ability to tan using a graded I through VI. It prognosticates sun sensitivity, susceptibility to photodamage, and ability for facultative melanogenesis (one’s intrinsic ability to tan).2 In addition, this system classifies skin as to its risk factors for complications during chemical peeling. Fitzpatrick divides skin types I through VI, taking into account both color and reaction to the sun. Skin type I and II are pale white and freckled with a high degree of potential to burn with sun exposure. Three and four can burn but usually is an olive to brown coloration. Five and six are dark brown to black skin that rarely ever burns and usually does not need sunscreen protection (Table I). The patient with type I or II skin with significant photodamage needs regular sunscreen protection prior to and after the procedure. He, though, has little risk for hypopigmentation or reactive hyperpigmentation after a chemical peeling procedure. The patient, though, with type III through VI skin has a greater risk for pigmentary dyschromia – hyper or hypopigmentation, after a chemical peel and may need pre and post-treatment with both sunscreen and bleaching to prevent these complications.3 Pigmentary risks are generally not a great problem with very superficial and superficial chemical peeling, but may become a significant problem with medium and deep chemical peeling.

The Glogau system classifies severity of photodamage, taking into account the degree of epidermal and dermal degenerative effects.4 The categorization is I through IV, ranging from mild, moderate, advanced and severe photodamaged skin. These categories are devised for therapeutic intervention. Category I in young individuals or minimal degree photodamage should be treated with light chemical peeling and medial treatment. Category II and III would entail medium depth chemical peeling while category IV would need those modalities listed plus cosmetic surgical intervention for gravitational changes (see Table II).

Monheit and Fulton have devised a system of quantitating photodamage and have developed numerical scores that would fit into corresponding rejuvenation programs.5 In analyzing photodamage, the major categories include epidermal color with skin lesions and dermal with textural changes. Dermal changes include wrinkles, crosshatched lines, sallow color, leathery appearance, crinkly thin parchment skin, and the pebblish white nodules of milia. Each of these is classified, giving the patient a point score, 1 through 4. In addition, the number and extent of lesions are categorized from freckles, lentigenes, telangiectasias, actinic and seborrheic keratoses, skin cancers, and senile comedones. These also are added in a classification system 1 through 4 and the final score results are tabulated. A total score of 1 through 4 would indicate very mild damage and the patient would adequately respond to a five-step skin care program including sunscreen protection, retinoic acid, glycolic acid peels and selective lesional removal. A score of 5 through 9 would include all of the above plus repetitive superficial peeling agents program such as glycolic acid, Jessner’s solution, or lactic acid peels. A score of 10-14 would include medium depth chemical peeling, and a score of 15 or above would include deep chemical peeling or laser resurfacing. The patient thus could understand during the consultation his degree of photodamage and the necessity for an individual peeling program. (See Table III)

The chief indications for chemical peeling are associated with the reversal of actinic changes such as photodamage, rhytides, actinic growths, pigmentary dyschromias, and acne scars.8 The physician thus can use his classification systems to quantitate and qualitate the level of photodamage and prescribe the appropriate chemical peeling combination.

Superficial Chemical Peeling

Superficial chemical peeling is truly an exfoliation of the stratum corneum or the entire epidermis to encourage regrowth with less photodamage and a more youthful appearance. It usually takes repetitive peeling sessions to obtain maximal results. These agents have been broken down into very superficial chemical peels, which will remove the stratum corneum only, and superficial chemical peels that will remove stratum corneum and damaged the epidermis also. It is to be noted that the effects of superficial peeling on photoaging skin is subtle and will not produce a prolonged or very noticeable effect on dermal lesions such as wrinkles and furrows. Agents used include: trichloroacetic acid 10 – 25 %, Jessner’s solution, glycolic acid 40 – 70 %, and salicylic acid-betahydroxy acid.9 (Table IV) Each of these agents has its own characteristics and methodology and a physician must be thoroughly familiar with the chemicals, methods of application, and the nature of healing. The usual time for healing is from one to four days depending on the chemical and its strength.

Very light peeling agents include low concentrations of glycolic acid, 10% trichloroacetic acid, and 20% salicylic acid, a betahydroxy acid. Glycolic acid is an alpha hydroxy acid derived from organic products and pH dependent to produce a superficial chemical peel through Keratolysis. Its intensity is dependent on concentration ranging from 10%-70%.

Salicylic acid, called a beta hydroxy acid molecule, is a salicylate derivative in ethanol solution used in concentrations 20%-40%. Jessner’s solution is a combination of these chemicals – resorcinol, salicylic acid and lactic acid. It is used as a superficial chemical peel for photoaging skin. Lactic acid is an alpha hydroxy acid useful in this combination.

TCA is the most versatile of all peeling agents as its concentration correlates directly with the depth of penetration and thus the degree of destruction within the skin. The concentration is usually compounded in a weight per volume measurement. It is important to distinguish this from the volume per volume formulation as the concentrations do not correlate. Most of the medical literature concerning TCA peeling uses a weight per volume measurement. TCA is usually standardized as an aqueous solution though it has been formulated as cream or paste. The author feels there is no distinct advantage to these formulations.

TCA destroys epidermis and partial dermis through keratocoagulation and protein precipitation, producing a white coating referred to as frosting. The degree of whitening or frosting can be correlated to penetration of the TCA within the epidermis and related to the depth of the peel. Level I frosting has the appearance of erythema with a streaky white frosting, which indicates superficial penetration. Level II frosting is a white enamel color with no erythema. Level III indicates the deepest penetration and is usually found with full medium depth peels through the epidermis with superficial dermal destruction.9

It is important to note that TCA applications are cumulative increasing penetration and peel depth with more quantity applied, even in low concentrations. Overcoating will always produce a deeper peel so that once the desired level of frosting is obtained, no further acid should be applied. Ten to twenty percent trichloroacetic acid will produce a light whitening or frosting effect on the skin with a result of sloughing of the upper one-third of the epidermis. Before this peel, the skin is prepared by washing the face thoroughly and using acetone, which removes surface oils and excessive stratum corneum. The trichloroacetic acid is applied evenly with either saturated 2 x 2 gauze, or a sable brush and it usually takes fifteen to forty-five seconds for the frosting to become evident. This would be categorized as a level I frosting with the appearance of erythema and streaky whitening on the surface. Level II and III frosting is seen in medium-depth and deeper peels. (Fig I) The patient experiences stinging and some burning during the procedure, but very rapidly this subsides and the patient then can resume normal activities. There is erythema and resulting desquamation which can last anywhere from one to three days. Sunscreens and light moisturizers are permitted and care is minimal in this superficial chemical peel.

Repetitive superficial TCA peels are useful for treatment of dyschromias and superficial skin lesions such as lentigines, ephelids, and thin seborrheic keratoses as well as fine surface texture. TCA as a superficial peel is best used in aqueous form with a concentration of 15%-25%. The peel should be repeated in 2-4 weeks and accompanied by home skin care products such as glycolic acid emollients, ascorbic acid to peel preparations and retinoids.

My favorite peel for photoaging is the Jessner’s solution peel. It is an inflammatory peel causing keratinocytes of the epidermis as well as inflammation. It causes mild erythema and peel for 2-4 days and should be repeated monthly. Jessner’s solution is a combination acid – escharotic which has been used for over one hundred years in the treatment of hyperkeratotic skin disorders. (Table V) It has been used as part of acne treatment for the removal of comedones and inflammatory acne activity. Its use as a superficial peeling agent performs as an intense keratolytic agent. The application is similar to superficial TCA application with wet gauze, sponges, or a sable brush, producing an erythema with blotchy frosting. Tentative applications are done on an every-other-week basis and the levels of Jessner’s solution coatings can be increased with repetitive applications. The visual endpoint produces a predictable outcome with epidermal exfoliation and regrowth. The superficial Jessner’s peel is a relatively inflammatory peel and thus useful for mild photoaging textural changes. It, though, can produce post inflammatory hyperpigmentation, which limits its usefulness for melasma and dyschromias. This usually occurs within two to four days and is treated with mild cleansers, moisturizing lotion, and sunscreen protection.

Alphahydroxy Acids

Alphahydroxy acids, specifically glycolic acid, have become the wonder drug of the early 90’s with promises of skin rejuvenation with home use and topical therapy. Hydroxy acids are found in foods such as glycolic acid as naturally present in sugar cane, lactic acid in sour milk, malic acid in apples, citric acid in fruits, and tartaric acid in grapes. Lactic acid and glycolic acid are widely available and can be purchased for physician use. Glycolic acid is found in unbuffered concentrations of twenty to seventy percent for use as a superficial chemical peel. Weekly or biweekly applications of twenty to seventy percent unbuffered glycolic acid treatments have been used for wrinkles by applying the solution to the face with a cotton swab, a sable brush, or saturated 2 x 2 gauze. The time of application is critical for glycolic acid, as it must be rinsed off with water or neutralized with 5% sodium bicarbonate after two to four minutes. Mild erythema may occur for an hour with slight stinging and minimal result in scaling. Superficial wrinkle reduction and removal of benign keratoses have been reported from repeated applications of these peeling solutions.10

Many proprietary forms of glycolic acid have emerged on the marketplace with novel approaches to limit the burning and stinging such as buffering the acid and altering the pH and pKa. Though many of these prepackaged treatments are elegant and simple to use, the physician should be concerned over the efficacy as the peel is pH dependent. The strength of the product is dependent on available free acid, which is limited with buffers and higher pHs. I find it most practical to use concentration as the parameter for patient comfort and begin with 20% glycolic acid peels and gradually work up to the more potent concentrations of 50 and 70% as the patient tolerates the procedure. Using the generic product makes the peel reproducible and comparable with the percentage glycolic acid refined in the medical literature. Using proprietary peels that are buffered or esterified, the pH is greatly changed and though the patient may be more comfortable, the product may not have the same results as similar generic concentrations. As a pH dependent peel, I find the generic forms more reliable. If there is a question about efficacy, always ask what the pH is for equivalent results.

The peel is uneven in that there is no visible endpoint. It is a time-dependent peel which must be neutralized to stop the reaction.

Salicylic acid peeling or as commonly called, the ß-Hydroxy Acid peel, is unique in that it is a lipophilic agent formulated in ethanol. It is a non-inflammatory superficial peeling agent creating Keratolysis of the epidermal cells and sebaceous glands. Used as a 20-30% solution, it produces a white color, which is not a true frosting but rather a precipitation of salicylic acid crystals.

This peel is especially useful in the treatment of active acne, comedones and pores. Its lipophilic character targets sebaceous glands, pores and comedones with active crystals penetrating the skin surface. (Fig II) The peel will produce mild desquamation with little erythema and healing within 1 to 3 days. The effect in pores may continue for 5-7 days as penetrant crystals remain active with the pilosebaceous units. This superficial peel is the least inflammatory and thus can be used safely on those patients with darker skin. It is also an effective adjunct agent used for melasma because there is little risk of post inflammatory hyperpigmentation. It is also a very effective peel for acne, comedones and pores because of its lipophilic constitution. The peel produces a frosting which is the result of crystal precipitation. This splotchy frosting is the endpoint. It does not require neutralization though cool water soaks will add to patient comfort. It can be purchased from a chemical supply house in generic form such as Dermatologica Lab Supply, Council Bluffs, Iowa, or as a proprietary peel package called The Beta Lift.

Preparation for the peel includes the daily use of retinoic acid up to six weeks prior to the peeling event.11 There are available various strengths of retinoic acid on the market, and one must use a weaker formulation for sensitive skin and a stronger formulation for significant photodamaged skin. The preparation Renova has been approved by the FDA for the treatment of photoaging skin and wrinkles. It is more adept for usage with aging skin as the retinoid is suspended in a moisturizing vehicle. It is available in 2 concentrations: .02% and .05%. The more irritating Retin A acne preparations should be avoided because of irritation. Other OTC “retinol” products are in cosmetics and moisturizers but of less clinical value than the prescription drug.

A retinoid dermatitis may ensue a week or two weeks after initiation of the agent. One should not perform a peeling procedure with retinoid dermatitis present as the inflamed skin may develop problems with healing or even post operative complications. The dermatitis should subside by decreasing treatment so that the skin does not appear inflamed when the chemical peel is performed.12 The use of tretinoin prior to a chemical peel will enhance peel solution absorption and promote an even and uniform peel.13

Superficial chemical peels can be used for comedonal acne and post inflammatory erythema or pigmentation from acne, treatment for mild photoaging skin – Glogau I & II, and the treatment of melasma.

To treat melasma effectively, the skin must be pretreated and post treated with sunscreen, hydroquinone 4 to 8 %, and retinoic acid. Hydroquinone is a pharmacologic agent that blocks the enzyme tyrosinase from developing melanin precursors for the production of new pigment. Its use essentially blocks new pigment as the new epidermis is healing after a chemical peel. It is thus necessary to use when peeling for the treatment of pigmentary dyschromias and also when using chemical peels in type III – VI Fitzpatrick’s skin, the skin type most prone to developing pigmentary problems.14

When using superficial chemical peels, the physician must understand that repetitive peeling will not summate into medium depth or deep peels. A peel that does not effect the dermis will have very little effect on textural changes that originate from dermal damage. The patient must understand this preoperatively so that he will not be disappointed with his results. On the other hand, repetitive peeling procedures are necessary for maximal benefits to be obtained with superficial chemical peeling. These are timed weekly or every other week for a period of six to eight chemical peels and enhanced by the appropriate cosmoceutical agents. The ease of the procedure with little down-time makes these “lunch time” chemical peels a favorite with the baby-boomers who will not take time off.

Superficial chemical peels are used in concert with other non-invasive procedures to produce safe and effective results with little or no downtime. These complementary procedures include:

• Cosmoceutical agents – retinoids, glycolic acid lotions, bleaching agents and home care exfoliants will enhance the results from a solitary peel and maintain the results. An appropriate sunscreen is very important. There are many other materials that have various claims of rejuvenating photoaging skin such as ascorbic acid, vitamin E, copper peptides and other antioxidants. The jury is still out on whether these are truly efficacious.
• Skin fillers will augment deeper rhytids and atrophic tissue so that peels can then refine the surface. Using collagen, cosmoplast or hyaluronic acid products will smooth deeply wrinkled skin which peels cannot change.
• Botox is used for the relaxation of dynamic wrinkles, especially in the glabella, forehead and crow’s feet. Injected prior to medium or deep peeling procedures will enhance the final results. Immobilizing the dynamic wrinkle will further lighten the dermal collagen remodeling in these areas producing a better peeling result.

Peeling will not correct granulation changes or problems with excessive skin. If a patient has a need for rhytidectomy or blepharoplasty, these procedures should precede the peel procedure.

Other alternative resurfacing procedures are currently available for rejuvenating photoaging skin. Non-ablative laser subsurfacing is a conservative method for regenerating dermal collagen without destroying the epidermis. It will thus control damage to the dermis, spare epidermal damage and create thermal contracture and collagen remodeling without epidermal destruction. These lasers either target water with wavelengths from 1300 to 1450 or are flash lamp vascular lasers at 585 nm. wavelength. The 1320 Nd:YAG laser has had more objective studies to document positive results. These are conservative results on photoaging skin that require multiple treatments and maintenance therapy. It is most successful in treating fine lines on eyelids and crow’s feet. These lunchtime procedures will produce very conservative results and not very helpful for more advanced photoaging skin. Fine lines and crêpe eyelid skin can be improved with a 1320 Nd:YAG non-ablative laser. The products are numerous but fall into the following categories:

Each of these systems is different in technology and application and thus requires training and instruction. The tissue lightening effect of these procedures may produce results on eyelids with early blepharochalasis those patients not yet ready for blepharoplasty. They may also be used as a skin adjunctive procedure after blepharoplasty.

Intense pulsed light is a non-laser light source with a broadband of absorption producing conservative yet safe treatment for vascular and pigmentary sequellae of photoaging. Fewer than six treatments at three week intervals will destroy lentigenes and ephelides, clear rosacea flushing and photoaging, telangiectasias and have a mild effect on fine lines and pores. Its effect is noted on mottled coloration such as seen with poikiloderma and weathered skin. This procedure also depends on repetitive treatments and needs maintenance follow up treatments for lasting results.

Microdermabrasion is a specific treatment for correcting the rough texture of photoaging skin. Aluminum oxide crystals are blown onto the skin surfaced in a closed system with suction. This exfoliates the stratum corneum and upper epidermis. It produces a similar injury pattern as a very superficial chemical peel but creates the damage with mechanical rather than a chemical burn. There is less inflammation but also less visible results. The patient finds the tactile texture of the skin is greatly improved with a smoothness superficial lasers and/or peels do not fully achieve. This procedure is a repetitive lunchtime treatment which must be repeated and is used in combination with other resurfacing procedures.

Superficial chemical peeling thus is one of the available cosmetic procedures used in concert to produce results that are greater than it can produce alone. It is best to present a package of treatment modalities that are a treatment plan for changing skin surface. These include:

• Cosmoceutical agents and sunscreens
• Superficial chemical peeling
• Lasers – vascular and non-ablative
• Intense pulsed light
• Microdermabrasion
• Botox
• Dermal filling agents – collagen or hyaluronic acid products

With patients demanding no downtime treatments with results that will reverse photoaging skin, it is the physician’s obligation to have available appropriate treatment. Though chemical peeling is the cornerstone for all cosmetic skin resurfacing, the other treatment modalities should be available. It is the responsibility of the treating physician to have a thorough knowledge of all of these tools to give each patient the correct treatment his condition warrants.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Over the past thirty years, the methods available for the removal or improvement of acne and contour scars on the face increased exponentially with the advent of new skin filler substances, improved techniques for elevating existing scars and technology for abrading and resurfacing facial contours. It seems that every month, a new and improved filling agent or laser is available that will be the best of all available methods. In the midst of these technological breakthroughs, the basic mechanisms still remain the same. There are three categories of techniques presently available to improve acne scars: 1) scar removal and revision; 2) filling depressed scars; 3) contouring the surface of scars.

Thirty years ago, one would either excise a scar or dermabrade the surface. Combinations of these two methods were beginning along with punch grafts and the use of autodermal grafts. The basic work-up and evaluation of these scars essentially remains the same because these same choices are available for types of scars the clinician will evaluate for improvement. This review will discuss skin filling agents available for scar correction.

Distensible cutaneous scars are best elevated with filling material. A distensible scar is defined as one which will rise to the surface when tension is placed on either side. This simple test will tell the clinician if scars respond to filling material. Those fibrotic ice pick and bound down scars cannot be elevated because the scar tissue extends through to the subcutaneous tissue plane. Placing filling material in the dermis will only elevate the surrounding skin, producing a donut effect and making the scar appear worse.

The ideal skin filling agent is safe, physiologic, simple and permanent. At this point, there is no known substance that meets all these criteria. Each of the available substances have side effects that detract from these properties but all of them strived to perfect their qualities to fulfill these requirements. The list of injectable filling materials increases each month with both synthetic and natural substances. Other implant materials are surgically placed. The excisional procedures place the synthetic implant materials within or below the scar for elevation. A current list of implant material available for acne scars is listed in Table I.

Injectable Filling Material

Zyderm and Zyplast Collagen

The first injectable filling material to be approved by the FDA is Zyderm collagen. This porcine collagen implant has been used for approximately ten years and the injection technique has been standardized. Each is delivered in 1 cc. syringes packaged with lidocaine and a 30 gauge needle. There are three variations available for this collagen implant. Zyderm I collagen is a 25% suspension of purified porcine dermis in saline with a 0.3% lidocaine. The saline carrier is absorbed and the remaining implant persists for six to ten months. Zyderm I is used most successfully to treat shallow distensible scars and fine scars. Zyderm II has double the concentration and is a more viscid substance. The longevity of scar correction is increased and it can be used for larger filling defects. Zyplast is a cross-linked derivative of porcine collagen which is a heavier filling material and has greater longevity. Zyplast can be used for larger scars that require a greater and deeper filling of volume and will last longer. It is placed deeper in the dermis and gives 100% correction at the time of implantation rather than 150% used for Zyderm I. Zyderm I has a longevity of six weeks to three months; Zyderm II, four to five months, while Zyplast may last nine months to one year, especially in a relatively immobile scar.

These two filling agents are the most commonly used in implants in the United States today with a low abuse potential. They are user friendly, relatively easy to inject, and can be integrated into a simple office visit for the patient requesting dermal augmentation. Frequent maintenance, though, is necessary and the question always arises whether it is cost-effective. The filling agent is technique dependent for longer lasting results, proportional to the clinician’s ability to place the collagen correctly. Adverse reactions have been noted including allergic reactions, hypersensitivity reactions with Zyderm I and II and vascular necrosis occurring with Zyplast, particularly in the glabella and on the nose. Though these complications are rare, they have been reported and proper allergy testing must be done for each patient.

Fibrel

Fibrel has been an effective method of elevating scars utilizing three agents – gelatin, amino caproic acid and plasma that are injected within or under a scar to stimulate collagenosis. This has subsequently been refined and simplified so that the plasma is not a necessary component in the mixture. This “new Fibrel” is composed of a gelatin powder, amino caproic acid mixed with saline and 1% lidocaine. The mixture is placed within distensible scars and gives correction for over one year. In selective cases, scar elevation has persisted for up to five years. Side effects have included a prolonged inflammatory reaction in selective cases, probably related to an idiosyncratic sensitivity response to the products. It has been used extensively in Zyderm allergic patients and has been a reliable filling agent for acne scars. Recent problems with production and availability presently make this product hard to find for clinical use.

Artecoll

Artecoll is a synthetic mixture of polymethyl methacrolate microspheres (PMMA) suspended in collagen, saline and 0.3% lidocaine. The mixture is injected deeply in the dermis and subcutaneous tissue and following injection, the collagen is gradually degraded with the permanent deposition of the PMMA spheres. Artecoll should be injected subdermally and overcorrection avoided with no blanching of the dermis. Broad experience in Europe has found this product reliable and long-lasting and its use in acne scars is well documented. It presently is not available in the United States but soon to be approved by the FDA for widespread usage.

Hylaform Gel

Hylaform Gel is a hylauronic acid derivative of a mammalian polysaccharide. It is a cross-linked derivative of natural hylauronan polymer with little immunologic activity and no species specificity. It is an intradermal injection used to augment scars. No skin test is required but the procedure requires a series of injections rather than a single treatment session. After two or three injections, the initial clinical trials have resulted in 80% of patients satisfied with their correction at twelve weeks. Longevity, though, is nine months to one year and reinjection then is necessary. Adverse reactions have been minimal including erythema, ecchymosis and acneiform dermatitis with no reported allergic reactions. This product is available in Europe and under investigation in the United States.

Resoplast

Resoplast is a monomolecular bovine collage product suspended in solution at 3.5 and 6.5% concentration. It is very similar to Zyderm I and II and its indications and techniques of implantation are the same. A skin test is necessary with similar risks of allergenicity. If one is allergic to Zyderm collagen, it also applies to Resoplast as the products have similar antigenicity.

Autologen

Autologen is an injectable dermal implant harvested from autologous collagen. It provides two theoretical advantages on an implant material:

• It is autologous: allergic and tissue reactions should not occur
• It contains intact dermal collagen fibers which may exhibit greater resistance to enzymatic degradation. The skin material is provided from skin specimens obtained from plastic and reconstructive surgery procedures in which skin is removed and discarded. The removed skin is processed into collagen dispension concentrations from 25 mg/ml to 100 mg/ml and injected through a 27 gauge to 30 gauge syringe.

Results from controlled evaluations in thirty patients show that three layered Autologen treatments provided greater than 75% correction for more than one year.

Isolagen

Isolagen is also a method of harvesting autologous collagen, purifying the material and packaging it in a suspension for intradermal injection. Results are promising but objective data is presently not available.

Methods include harvesting the skin from patients prior to the procedure which they are sent to home laboratory for processing. From this model, autologous collagen is produced, repackaged and sent back to the clinician. Because the product is autologous, there is little risk of allergic response and the collagen functions as an autoimplant. Once harvested and processed, a long term supply of collagen is then available for the patient as secondary procedures are required to maintain scar correction. These are currently under investigation and may soon be available for selected patients.

Fat

Fat injections have been available and performed over one-hundred years as live, free fat grafts. Liposuction has made the harvesting of fat a simpler procedure and for grafting, this is done with a syringe in an atraumatic manner. The best donor sites include the thighs, buttocks, knees and abdomen and the resultant fat is then gently centrifuged to separate the intact fat cells from supernatant serum free lipid. Fat cells are then injected into a subcutaneous plane under larger scars with a 16 to 18 gauge needle. Fat is used as a subcutaneous filling substance and is not indicated in dermal augmentation. Thus, it is reserved for those large, atrophic defects that include skin and fat. Larger acne scars and lipodystrophies are best for fat correction. Recent techniques have resulted in fat survival for over one year and 50% or greater of patients treated. These results are technique sensitive requiring many different methods to purify, wash, separate, centrifuge or prepare the fat. Each investigator seems to have a different method to justify results. Unified techniques are needed to standardize the technique.

Surgical Methods

Other procedures include surgical methods of replacing or implanting material into dermis for scar elevation.

• Dermal grafting is not a new technique but recently has been perfected by Swinehart. Dermis is surgically harvested and de-epithelialized. According to Swinehart’s method, the area for surgical excision is first dermabraded to remove the epidermis. An excision of collagen is then performed and the defect closed. A prime location is the retroauricular sulcus and neck. The dermis is defatted, placed in saline, and then divided into sections to fit the size defect needed. A simple stab incision is made to create a pocket within and under the scar in which the dermal implants are placed. Because this represents a graft rather than just substance, there is little absorption and the results appear to be long term. It is truly a skin transplant of both cellular fibroblasts and collagen that maintain long-term correction. It is, though, a surgical procedure more complex than a simple injection and is quite technique sensitive.
• Similarly, synthetic grafts such as Gore-Tex and SoftForm can be used to fill scars also. These are synthetic products that are placed surgically within and under the dermis for augmentation. Gore-Tex is a polytetrafluorethylene product that has been used extensively in cardiovascular, urologic and reconstructive surgery. Its placement for skin augmentation must be done in the superficial subcutaneous tissue below the skin and anchored in a subdermal pocket. It is a technique sensitive operation with adverse reactions that include infection, foreign body extrusion, and movement of the implant from the site of placement. The product is best for atrophic scars and full thickness skin defects and subcutaneous defects and requires significant augmentation. The implant, though, is permanent and movement or extrusion needs replacement and will require surgical revision.

The use of either injectable or surgically placed implants for the correction of acne scars is dependent upon the surgeon and the patient’s desires. Many patients are satisfied with the simple but repeatable procedure of Zyderm collagen while others insist upon a single procedure. Both of these choices are available with the advent of new injectable and implantable skin filling substances.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Jacques Michael Casparian, M.D.
Assistant Professor of Medicine (Dermatology), Pathology, and Otorhinolaryngology
Kansas University Medical Center
4023 Wescoe, Division of Dermatology
3901 Rainbow Boulevard
Kansas City, Kansas 66160

Erin Jane Rodewald, Medical Student
University of Missouri-Kansas City
2411 Holmes
Kansas City, Missouri 64108

Abstract

Background: Methods described to achieve intraoperative tissue expansion have drawbacks.

Objective: We report an intraoperative tissue expansion technique using standard suture material and hemostats to create a “modified” which stitch.

Methods: A continuous running suture is placed with both ends left free. A “fixed” hemostat is placed above the skin at one end. After pulling at the other end with a second hemostat, a third hemostat is placed proximal to this hemostat just above the skin, which is left in place to produce stretching. The second and third hemostats are then used in an alternating pulling and holding fashion.

Results: This suture produces significant tissue expansion. If the desired degree of approximation is achieved, the ends of the suture can be tied together, as in the previously described winch stitch.

Conclusion: The modified winch stitch is a simple and inexpensive means to facilitate closure of wounds under a significant amount of tension.

Intraoperative tissue expansion is often used in closing wounds under significant tension. Some methods in the literature utilize devices such as balloons and the Sure-Closure. These techniques have drawbacks including expense and the need for specialized equipment which is not typically available to a dermatologic surgeon. Other methods using readily accessible equipment include towel clamps, which produce significant trauma to surrounding skin, as well as skin hooks, where the entire mechanical load is dependent on operator effort.

Recently, Casparian and Monheit described a simple, easily available means of intraorperative tissue expansion utilizing a continuous running suture called the “winch stitch.” The winch stitch that we described is a temporary multiple pulley suture which can be left in place for up to about an hour. Moreover, if desired, this temporary stitch can be pulled to achieve a greater stretching force compared with that attained at the time of initial placement.6

This report describes another temporary, multiple pulley suture that is a modification of the winch stitch. This “modified” winch stitch only requires standard suture material, such as 3-0 polypropylene, a needle holder, and three hemostats. As with the other methods outlined above, the modified winch stitch utilizes mechanical creep to achieve approximation of wound edges that are initially under excessive tension. This modified stitch has a number of advantages in producing tissue expansion, in comparison with the previously described techniques, which will be discussed.

The usefulness of permanent two loop pulley sutures to close wounds under tension has been reported in the literature for various types of closures. Snow et al, and others have described the value of two loop pulley sutures in superficial wound closures. Variations of the two-loop pulley stitch have also been reported for dermal and subgaleal closures. While the temporary and modified winch stitches also employ pulleys, the number of loops is greater, typically in the range of three to five, resulting in a greater mechanical advantage.

The previously described, original winch stitch6 is a “holding stitch” that achieves tissue expansion by using multiple pulleys to generate a load on the wound edges. This temporary stitch is performed as a continuous running suture that has the ends tied together at the time of initial placement. If desired, this temporary stitch can be pulled after its initial placement to help achieve further wound edge approximation. The slack on the suture created by tissue expansion limits the usefulness of this suture for more than a short period of time. Typically the temporary winch stitch is removed once other sutures are secured, thereby relegating its role to being a holding suture.

Like the original which stitch, the modified winch stitch is another temporary holding stitch performed using a similar technique. However, while the two ends of the temporary winch stitch are tied together at its initial placement, prior to achieving mechanical creep, this step is not required in performing the modified winch stitch. However, if the surgeon does choose to tie the two ends together, this may be performed as an optional, final step in achieving tissue expansion.

As with the other methods of tissue expansion already discussed, standard procedures to relieve tension such as undermining may be performed prior to placing the modified winch stitch. The stitch is a type of running suture, where the initial free end is not tied off. Instead, this free end is clamped above the skin surface with the first hemostat (the “fixed” hemostat). The suture is then run as a continuous running simple suture. Upon completing the desired number of throws, the suture at the end closest to the needle is then grasped with a second hemostat (the “pulling” hemostat) (Figure 1). At this time, the surgeon uses this second hemostat to pull one end of the suture away from the skin surface. This results in the wound edges being brought closer together. By employing multiple pulleys, less force is needed by virtue of the reciprocal relationship between force and distance; the greater the number of throws, the larger the mechanical advantage.

While taking care to avoid an excessive amount of tension on the wound edges, the surgeon places the third hemostat (the “holding hemostat”) just above the skin surface proximal to the pulling hemostat, and the pulling hemostat is removed (Figure 2). This “holding” hemostat is left in place for several minutes to achieve mechanical creep. After allowing the skin to be stretched, this third hemostat is lifted from the skin surface, thereby becoming the new “pulling” hemostat. The action of the second and third hemostats is then alternated analogous to the way a tug of war participant alternates his hands in a “pulling” and “holding” fashion (Figure 3).

During the period of time a holding hemostat is left in place, the tension on the wound edges diminishes because of additional mechanical creep, created by the multiple loops of the suture. The process of pulling and repositioning the hemostats can be repeated numerous times; using the second and third hemostats in a reciprocal fashion produces further closure of the wound. Similarly, one can alternate hemostats at the initial end of the wound as well, involving the first “fixed” hemostat along with another “pulling” hemostat, to achieve more uniform wound edge approximation. It is imperative to avoid the use of excessive force which may result in strangulation, as may occur with any pulley or running stitch. For this reason, this suture is typically employed selectively on wounds located on the scalp, and rarely at other sites such as the trunk and proximal limbs.

The gradual advancement of tissue also allows the surgeon to place buried sutures at each side of the winch, towards the tips of the wound. If desired, the actual securing of these sutures may be delayed until the wound edges are further approximated by virtue of additional mechanical creep. Additionally, staples or superficial sutures can be secured between the throws of the winch stitch to enhance approximation. These additional closure methods serve to further relieve the tension experienced by the winch stitch, thereby facilitating wound closure. An optional final step is to bring the two ends of the suture together across the loops of the running stitch, where they are tied together (Figure 4). In this way, the modified winch stitch can be converted to the original winch stitch once tissue expansion is at or near maximal. However, this final step has the drawback of making it more difficult to place sutures or staples between the throws of the suture, because of the diagonal component.

We do not recommend that the modified winch stitch be made left in placer longer than as a temporary “holding” suture under most circumstances, however. There may be ischemic complications associated with this multiple loop suture. Moreover, If this suture were to remain in place for days, the cosmetic result may be impaired as a result of the diagonal component contributing to suture track marks.

There are numerous advantages of the modified winch stitch compared with the original form. Because the suture need not be tied together until the end of the stretching procedure, the surgeon is able to place one or more additional throws to create more pulleys, if they are needed to facilitate wound approximation. The hemostats permit a more controlled mechanical load to be placed on the tissue. Furthermore, the fixed and holding hemostats create a passive load on the skin, without requiring active pulling to achieve stretching. Consequently, the surgeon can leave the field for a few minutes, pull on one end of the suture, and place a holding hemostat, thereby achieving greater control and efficiency in the tissue expansion process.

In summary, the modified winch stitch is a simple, inexpensive, efficient, easily assessable and readily controllable means of achieving intraoperative tissue expansion.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Abstract

Background: Botulinum toxin is used to treat glabellar lines, but the optimal dose of Reloxin™ (Dysport®) for this indication remains to be established.

Objectives: Evaluation of three doses of Reloxin to determine the efficacy and safety in treating glabellar lines.

Methods: Participants were given 20, 50, or 75-units Reloxin, or placebo, injected across the glabella. Follow-up was on Days 7, 30, 60, 90, and 120. Adverse events were also elicited by telephone on Day 3.

Results: From investigators’ and participants’ assessments at Day 30, there were significantly more responders in each Reloxin-treated group than placebo (p?0.001). The 50 unit dose was as effective as the 75 unit dose, with a similar duration. The most common adverse events were mild headache and nasopharyngitis, occurring similarly in all groups.

Conclusions: Reloxin (Dysport) treatment resulted in a significant improvement in glabellar lines, and the 50 unit dose was identified as optimal. All doses were well tolerated.

The growth of the aging population, especially over the last decade, has led to an increasing demand for procedures to reverse the appearance of aging, particularly around the face. This has resulted in the development of minimally invasive cosmetic procedures such as ablative and non-ablative resurfacing lasers, chemical peels and the use of chemodenervation and filling agents. Because none of these is risk-free, continuing research is necessary to provide the safest and most effective methods for treating the aging face.

The interplay of five factors is considered to produce “the aging face”(1), but it is primarily the interaction of two that produces the more significant lines: the skin and the underlying muscles. The skin factors are treated with many therapies, among them ablative and non-ablative resurfacing and injections for soft tissue augmentation. One treatment directed at the muscles underlying the hyperkinetic lines, is botulinum toxin type A (BoNT-A). This agent temporarily paralyzes specific muscle groups and has been shown to ameliorate lines and folds (2-14). Both clinical observation and objective measurement of glabellar folds, have shown that low doses of BoNT-A suppress the muscular activity of the glabellar area by temporarily paralyzing the procerus and corrugator supercilii muscles. Many studies regarding the cosmetic use of this agent have now been published (15).

Reports on the use of Dysport (Reloxin) in cosmetic treatments suggest that it is effective in reducing the severity of glabellar lines (15-23). The doses used in these studies ranged from approximately 40 to 100 units.

The aim of this study was to evaluate three doses of Reloxin, by comparison with placebo, to determine the optimal dose in reducing the severity of hyperfunctional glabellar lines, with a view to using this dose in subsequent studies. We also assessed the safety of Reloxin at the doses tested.

Methods

Study Design

This was a multi-center, double-blind, placebo-controlled study.

Written informed consent was obtained from 373 adult male or female participants, who had moderate or severe vertical glabellar lines at maximum frown and who fulfilled the other entry criteria.

Women of childbearing age were required to take appropriate contraceptive measures throughout the study period.

Participants were treated on Day 0 with Reloxin (Ipsen Biopharm Ltd., Wrexham, UK) (20, 50, or 75 units), or placebo, injected at five sites (0.05 mL per injection site) across the procerus, corrugator, and orbicularis muscles. Both participants and investigators were blinded to the treatment. Following injection, participants remained under observation for 30 minutes and were contacted three days later, by telephone, to check for adverse events and concomitant medications. Follow-up visits were made on Days 7, 30, 60, 90, and 120.

A blood sample was taken on Screening and on Day 120 for testing to establish whether neutralizing antibodies to BoNT-A were present.

Primary outcome measures

Co-primary efficacy endpoints were selected: the investigators’ live assessment of glabellar lines at maximum frown at Day 30 and the participant’s self-assessment of change in severity of glabellar lines at Day 30. All other assessments were either secondary or exploratory and are described below.

Investigators’ Assessments

On Days 30, 60, 90, and 120 after treatment, investigators evaluated the participants by comparing their appearance to validated scales of glabellar lines, at maximum frown and at rest. Each scale was comprised of four photographs graded 0 to 3: Grade 0 (none), Grade 1 (mild), Grade 2 (moderate), or Grade 3 (severe). The scales were established in conjunction with several clinical experts, Parexel International and Canfield Scientific Inc., who provided the reference photographs and assisted with the scale validation process and the analyses.

“Live” assessments of the participants were made and compared to the validated photographic scales. Live assessment was considered to have a number of advantages over photographic comparisons, in that the assessor was able to evaluate the level of effort being made by the participant in attempting to frown and the dynamic nature of frowning was taken into consideration. In addition, factors which could vary across the different centres, such as lighting and camera angle, could be discounted by the investigator when focusing on the frown lines. The nature of photographs tends to flatten the facial image of the face, including the lines, confounding the accuracy of assessments. Live assessment is most commonly used by physicians treating wrinkles and this is the method of choice for assessment.

A “responder” was defined as a participant who had a rating of none (0) or mild (1) glabellar lines at maximum frown at Day 30.

At each visit (except Screening) a photograph was taken of each participant. These were used to support the validity of study assessments, but not to assess the outcome per se. The Day 7 photograph was taken by an individual independent of the study assessments, in order that the study blinding was not broken. On completion of the study (Day 120) this photograph was assessed by the investigator for efficacy, using the validated 4-Point Photographic Scale.

Participants’ Assessments

Participants were asked to assign a score that best described their overall assessment of the change in severity of their glabellar lines on Days 30, 60, 90, and 120, compared to pretreatment

.They were asked: “How would you rate the change in the appearance of your glabellar lines compared with immediately before the injection?” using the following nine point scale.

+4 (complete improvement, about 100%)
+3 (marked improvement, about 75%)
+2 (moderate improvement, about 50%)
+1 (minimal improvement, about 25%)
0 same
-1 (slight worsening, about 25%)
-2 (moderate worsening, about 50%)
-3 (marked worsening, about 75%)
-4 (very marked worsening, about 100%)

A “responder” was defined as having a grade change of at least +2 (moderate improvement, about 50%) at Day 30.

Participants were also asked to assess the status of their glabellar lines using a 10 cm visual analogue scale (VAS). On this scale zero represented ‘no glabellar lines’ and ten represented ‘severe glabellar lines’.

Statistical Analyses

Continuous data were summarized by treatment group using descriptive statistics (number, mean, median, standard deviation, minimum, and maximum). Categorical data were summarized by treatment group using frequency tables (frequencies and percents). Ninety-five percent confidence intervals were constructed for proportions of successes.

Comparability of the investigators’ assessment of glabellar lines at baseline, across treatment groups, was confirmed using a Chi-squared test. Similarly, comparability among treatment groups for participants’ assessment at baseline using a VAS was confirmed with analysis of variance using an F-test.

A Mantel-Haenszel Chi-Square test, adjusting for age group (?50 years, >50 years) was performed to compare the proportion of responders between each Reloxin group and placebo, at each visit, for the investigators’ assessment and for the participants’ assessment.

Bonferroni’s adjustment was used for multiple comparisons and p ? = 0.0167 (0.05/4) was taken as the significance level.

Population samples

The intent-to-treat (ITT) data set included all participants randomized and treated with study medication. This data set was used for the analysis of primary and secondary endpoints.

A modified ITT (MITT) data set was used for all exploratory analyses. This data set excluded 13 participants from the ITT population, due to protocol violation.

Exploratory Efficacy Endpoints

• Day 7 Efficacy Measurements
• Participant’s Global Assessment of Appearance of Glabellar Lines using VAS
• Duration of Response Measured by Investigator’s Assessment at Maximum Frown
• Duration of Response Measured by Participant’s Assessment using the nine-point scale
• Subgroup Analyses
• Correlation Between Participant’s Assessment of change in appearance of glabellar lines and change in Investigator’s Assessment at Maximum Frown
• Correlation Between Participant’s Assessment Using 9-point Scale and Using VAS

Results

Demographic characteristics

The demographic data relating to the ITT population is shown in Table 1. The majority of participants were female, under 50 years of age, and Caucasian. The non-Caucasian participants were predominantly Hispanic.

Baseline assessments

At baseline, there were no significant differences between the investigators’ grading of the glabellar lines at maximum frown or at rest, across the treatment groups (Table 2).

Effects of treatment – Investigators’ assessments

The investigators’ assessment of glabellar lines at maximum frown found that a there was a statistically significantly larger proportion of responders in each Reloxin treatment group compared with placebo at all time points (p < 0.001 for all comparisons) with the exception of 20 units at Days 90 (p = 0.004) and Day 120 (p = 0.071) (Figure 1).

At the time points beyond Day 30, the number of participants exhibiting a response declined slowly. By Day 120 after treatment, a significant proportion of participants (26% and 27%) continued to show a response in the groups treated with Reloxin 50 or 75 units, respectively. In the groups treated with placebo or Reloxin 20 units, the numbers of participants exhibiting a response was not significant.

In some responders, there was no decline in benefit by Day 120 after injection. None of these individuals was seen in the placebo-treated group. In the Reloxin-treated groups three individuals who received 20 units, eight who received 50 units and seven who received 75 units were considered to have had a sustained improvement at Day 120.

The investigators’ assessment of glabellar lines at rest also found that there was a statistically significantly larger proportion of responders in each Reloxin treatment group compared with placebo (p ? 0.001 to 0.01 for all comparisons). (Figure 2).

Effect of treatment – participants’ assessments

The participants’ assessments of change in severity of glabellar lines showed that there was a statistically significantly larger proportion of responders in each Reloxin treatment group compared with placebo at all time points (p?0.001 for all comparisons) with the exception of 20 units at Day 120 (p = 0.005) (Figure 3).

At the time points beyond 30 days, the number of participants exhibiting a response declined slowly. By Day 120 after treatment, a significant proportion of participants (20%, 42% and 51%) continued to show a response in the groups treated with Reloxin 20, 50 or 75 units respectively.

Some responders, estimated that there was no decline of benefit by Day 120 after injection. Two individuals in the placebo-treated group, made this observation. In the Reloxin-treated groups two individuals who received 20 units, seven who received 50 units and twelve who received 75 units considered that they had a sustained improvement at Day 120.

Similarly, the participants’ assessment of glabellar lines using a visual analogue scale, found that there was a statistically significantly greater reduction in the severity of these lines in the Reloxin treatment groups compared with placebo at all time points with the exception of 20 units and 50 units at Day 120, Figure 4.

Subgroup analyses

Data on different subgroups were available by the end of the study, but due to the small numbers of participants in these groups, no formal analyses were possible. In general, greater benefit was seen in younger participants (< 50 years) compared with older (> 50 years), females compared with males, and Caucasians compared with non-Caucasians.

Correlation Between Participant and Investigators’ Assessments

It is clear from the assessments of benefit, that there was good agreement between the investigators’ ratings and those of the participants. That is there was good agreement between the assessment made by the investigators comparing appearance with a battery of reference photographs (static scaling) and the assessment of the participant relying on memory of their appearance at the start of the study (dynamic scaling).

The level of this agreement between the value on the participants’ 9-point scale and the investigators’ assessment at Day 30 was calculated. The correlation coefficient (rho) was 0.645, (p<0.001, n = 355, Spearman’s correlation). A similar correlation was found for the assessments of all participants at all visits (rho = 0.645, p<0.001, n = 1417).

Adverse Events

During the course of this study a number of participants reported at least one adverse event. The most common adverse events were headache and nasopharyngitis. The incidence of events, occurring in more than 5% of the participant population in any treatment group, is shown in Table 3 below.

Following treatment, mild ptosis was reported in three participants (0.8 %) at Day 7. One participant (1 event) was in the group that received 50 units Reloxin and 2 participants (3 events) received 75 units. There was no evidence of any ptosis in any of the participants in the groups treated with placebo or 20 units Reloxin.

Four serious adverse events were reported, all of which were assessed as being unrelated to treatment. In the group who received 20 units Reloxin, one participant developed diverticulitis and one reported an unintended pregnancy. In the group receiving 50 units Reloxin, one participant reported an unintended pregnancy. Among the participants receiving 75 units Reloxin, one participant developed dehydration. No deaths were reported and no adverse event led to withdrawal of a participant from the study.

The overall incidence of adverse experiences for all Reloxin treatment groups was similar to that in the placebo-treated group.

There was no evidence of neutralizing antibodies in any participant at baseline or at follow-up.

Discussion

Glabellar wrinkles may arise as a result of overactivity of the underlying corrugator supercilii, procerus and orbicularis oculi muscles. Their appearance is often unwelcome, especially in younger adults, but also in older subjects where they can create an impression of greater age, or the unintentional appearance of anger or worry.

A number of treatments are available to reduce the severity of these wrinkles (e.g. injections of collagen, silicone oil, or autologous fat; browlifts; surgical ligation; resurfacing). However, none of these treatments addresses the underlying problem of muscle overactivity.

Botulinum neurotoxin toxin type-A (BoNT-A) acts by chemodenervation of the underlying muscles and has been used to treat the severity of wrinkles since 1992 (24).

Many of the early studies were performed using the American botulinum toxin type-A (Botox®) (11; 25-27), but there have also been publications reporting the use of the UK product Dysport (Reloxin)(17; 22; 23; 28). In these studies the doses varied between 40 and 100 units Dysport. Data from the published studies also show that Dysport (Reloxin) is effective in reducing the appearance of wrinkles, although none of these investigations was placebo-controlled. The number of injection points also varied in these investigations, from two (17) to seven (22).

The aim of this prospective study was to determine the optimal dose of Reloxin in reducing the severity of glabellar lines, with a view to using this dose in subsequent Phase 3 trials.

In this study, all doses of Reloxin resulted in a statistically significantly better response in the appearance of glabellar frown lines compared with placebo. This effect was reported by both the investigators and the participants when evaluating glabellar lines at maximum frown or at rest.

The response was first observed at Day 7 and persisted throughout the study. This difference from placebo treatment was observed at all time points for the participants receiving Reloxin at 50 or 75 units, but in those receiving Reloxin at 20 units, the effect remained apparent at Day 90 but not at Day 120. In terms of the number of participants responding to treatment, 50 units Reloxin was found to be as effective as 75 units Reloxin, and a similar duration was observed in these two treatment groups.

The duration of benefit in this study was not formally captured between assessments. At 90 days after treatment, a large number of participants continued to show a response (47% at the highest dose, based on investigators’ assessments and 72% based on participants’ assessments). In a number of participants, this response continued to be observed at Day 120 (27% and 51%; investigators’ and participants’ assessments respectively) . This finding is similar to that reported in other publications. Ascher et al. (23) found that the mean duration of effect was 3.4 months after the injection of 40 units Dysport (Reloxin) into the glabellar region. Le Louarn (17; 29) also reported retreatment every 3 – 4 months, although this was extended to 7 – 10 months with later treatments, to avoid visible muscle atrophy.

In our study, we observed greater benefit in women than in men, which has also been reported by Pribitkin et al. (14). However, unlike our findings, these authors found no difference in the benefit in people of different ages.

The majority of subjects enrolled in our study were of Caucasian origin, with the second largest group being Hispanic. There was some evidence of greater perceived benefit in the Caucasian participants, although botulinum toxin treatment is also clearly effective in people of Hispanic origin (30). There are some suggestions that there may be differences in skin thickness between people of Asian origin compared with Caucasians (31), although there may also be a difference in the perception of the youthfulness in the Asian face (32). The small numbers of participants of non-Caucasian origin in our study mean that sub-group analyses could not be performed.

All doses of Reloxin were well tolerated in this study, although ptosis was observed in three participants (0.8 %). Ptosis has been reported by other investigators using botulinum toxin in the treatment of facial wrinkles, but Reloxin (Dysport) was not the product used in these studies. They found an incidence ranging from below 0.5% (33), to 3% (34). Feller et al. reported no ptosis in their study involving Dysport (Reloxin), at doses up to 70 units (22) and Ascher et al. found no ptosis when using Dysport (Reloxin) at doses up to 75 units (35)

The most commonly reported adverse event was headache, which occurred with a similar frequency in all treatment groups, including placebo. This was also observed by Feller et al. (22) who commented that this effect probably resulted from the injected volume exerting a greater pressure in the glabellar region.

From the data obtained in our study, the 50 unit dose was identified as the optimal dose with respect to efficacy, duration and safety profile. It is planned that this dose will be used for rigorous testing in Phase 3 trials.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Needs Assessment

Chronic exposure to ultraviolet radiation results in histological damage to the skin that can produce undesirable visible alterations, such as rhytides, telangiectasias and dyschromia, as well as precancerous lesions. A wide variety of non-invasive treatments, including cosmoceutical topicals such as retinoids, hydroxy acids and bleaching agents, nonablative light therapies, and ablative procedures such as chemical peels, laser resurfacing, and dermabrasion, are available. Topicals are often a starting point for the treatment of milder cases of photodamage, and can also be used before, during, and after office-based procedures to augment outcomes for patients with more extensive damage. A review of current treatment options, including the application of combination therapy regimens, can assist clinicians in the development of individualized treatment plans for patients with photodamaged skin.

Learning Objectives

Upon completion of this continuing education activity, participants should be better able to:

• Describe the categories of change that occur in photodamaged skin.
• Discuss the available treatments for the signs of photoaging.
• Discuss the role of topical agents in the treatment of photodamaged skin.
• Discuss the advantages of using both topical and procedure-based treatments as part of a combination therapy regimen.

Introduction

Chronic exposure to solar ultraviolet (UV) radiation results in premature skin aging. The clinical manifestations of photoaged skin include wrinkling, mottled pigmentation, roughness, sallow color, and loss of elasticity. Underlying these visible signs of photoaging are various histological and cytological changes induced by chronic UV exposure. The loss of collagen fibers, which normally provide structural stability, and the degradation of elastin fibers, which gives skin its natural elasticity, result in a general breakdown of the skin’s fibrous matrix. This creates an inelastic, thin, dull-appearing skin. In addition to the structural damage to the dermal extracellular matrix, chronic exposure to the sun’s UV rays causes a generalized dysplasia of a variety of epidermal cell types, including keratinocytes and melanocytes. This type of cellular damage contributes to the mottled and/or hyperpigmented appearance of photoaged skin.

Photoaging (extrinsic aging) differs histologically from intrinsic aging, the changes that occur normally over time. The histological signs of intrinsic aging include epidermal atrophy, resulting in thin, translucent skin with hypocellular changes of the dermis, and increased crosslinking of the collagen matrix. Extrinsic aging, on the other hand, produces changes such as thickening rigidity and scaling of the epidermis with a concomitant destruction of collagen and elastin and the deposition of colloid material with hypercellularity of the dermis. Susceptibility to photodamage is largely determined by an individual’s Fitzpatrick skin type. Lighter skin tones—Fitzpatrick types I through III—are more susceptible to extrinsic photoaging than darker skin tones—Fitzpatrick types IV through VI. The intrinsic photoprotection present in darker skin makes it less prone to damage from actinic exposure.

Photodamage can be classified into three categories of change. Color changes include the redness of inflammation, irritation, and telangeictases, and areas of brown coloration in the form of lentigines and postinflammatory hyperpigmentation. Dermal changes, in the form of the irregular destruction of collagen and elastin, are the cause of wrinkling, surface irregularities, and skin sagginess/loss of elasticity. Finally, epidermal dysplasia, hyperkeratosis with actinic keratoses fall into the category of pre-pre or precancerous changes; these are atypical proliferations on the skin that stem from deeper cellular damage and that may evolve into cancerous lesions.

Recognizing the specific types of changes that have occurred in a patient’s skin and quantifying the extent of the damage are crucial first steps in designing an effective treatment plan. In 1996, Glogau published a system for classifying patient photoaging types (the “Glogau wrinkle scale”; Table 1), with the aim of facilitating discussion and rational comparison of therapies and their outcomes. The Glogau wrinkle scale may be a valuable tool for determining which treatment modalities may be of the most benefit for patients.

Table 2. Glogau Wrinkle Scale

Many treatment options, including both topical agents and office-based procedures, are available for treating photodamage, and different treatment modalities can target different features of photoaged skin. For this reason, combination therapy plans that incorporate more than one treatment modality may help patients achieve the greatest benefit.

In a recent roundtable discussion, experts in the treatment of photoaging skin discussed the available treatments, and the benefits of a combination therapy approach to the treatment of sun damage and related conditions.

Available Options for the Treatment of Photodamage

Dr. Alster: In addition to all the options that will be discussed, it is very important to emphasize to our patients that every single aspect of photoaging starts and ends with photoprotection. We have to make it very clear to our patients when we’re attempting to treat them that we want to prevent further photoaging as much as possible, and photoprotection is a big part of that.

Dr Nestor: Peels have been used for the longest time for photodamage. Peels help treat some of color changes that occur with photodamage—specifically the brown type of coloration. In my experience, peels are only minimally effective for the telangiectatic changes. They are certainly beneficial for the sun damage aspect of hyperkeratotic, precancerous changes, and, depending on the depth of the peel, they can help improve rhytides and related dermal changes.

Recently, a lot of peels have been supplanted by ablative laser treatments. The CO2 and erbium laser are still being used, and they have the same general type of effect as peels. In some hands they can be specifically targeted to be deeper or more superficial, depending upon the laser and how it’s used.

For nonablative treatments, the classic treatment for me is photorejuvenation, with intense pulsed light (IPL). IPL can treat two aspects of photoaging: coloration, both red (telangiectases) and brown (lentigines), and dermal remodeling, though perhaps not as dramatically as with the ablative lasers.

The newest treatment on the block is photodynamic therapy, the topical application of aminolevulinic acid, followed by exposure to blue light. Photodynamic therapy, when combined with IPL or other devices, can improve all three aspects of photoaging: color changes, dermal remodeling, and precancerous changes.

There are a variety of laser devices that can affect change in one or more of the processes of photoaging. From the standpoint of the telangiectatic red changes, certainly lasers such as the pulsed dye 532 nm laser, as well as other lasers in that general category, can affect change in the blood vessels, in addition to having an impact on dermal remodeling. The Q-switched ruby, Q-switched YAG, and Alexandrite lasers can affect changes in pigmentary states. Lasers in the 1320 nm to 1450 nm range can be used to target changes related to dermal remodeling.

I look at the topical treatments as either a step-up process or an augmentation process to the procedural treatments. Certainly retinoids, such as Renova and Retin-A, to me are a very, very good adjunctive treatment, and a starting point for people who are not ready for more significant laser or other physical treatments. A variety of different topical agents, such as cosmeceutical agents containing glycolic acid, other over-the-counter topical agents, and a variety of other categories, from amino acid filagrin-based antioxidants (AFAs) to azelaic acid, can be used adjunctively as part of a combination treatment plan to target several different histological aspects of photodamage. DR. NESTOR—PLEASE ELABORATE ON HOW YOU CHOOSE A TOPICAL AGENT

Dr. Alster: We next turn to Gary Monheit for background on fillers, dermabrasions, Botox, and peels.

Dr. Monheit: My first approach is always to ask “where is the problem, what are we looking at, and what is the best way that we can solve the problem?” I developed an index of photoaging skin that I use with my patients. It categorizes the problems of photoaging skin into textural changes and lesional changes, quantifies the level of damage, and gives it a score. It is a good tool for identifying where the problem is, and it allows the clinician to individualize the treatment plan.

[DR. MONHEIT—PLEASE PROVIDE YOUR INDEX to be inserted here]

The aging face must be considered in addition to aging skin, when we target our treatments. In order to target problems of volume loss, both in the skin and below the skin, fillers can be used. Muscle spasms are responsible for the development of dynamic wrinkles and furrows, and for this we use botulinum toxin, a relaxing agent to ease muscle spasms that have caused crow’s feet, forehead wrinkles, and glabellar lines.

Before resurfacing techniques are used, we have to determine where the damage lies in the skin: is it superficial, medium depth, or is it deep? Superficial damage, involving just the epidermis, can be targeted by a superficial agent that exfoliates the stratum corneum in the uppermost epidermis. Light chemical peels, including glycolic acid, Jessner’s solution, salicylic acid, or some of the other combination peels, can be used. The very superficial peels are designed to to remove the stratum corneum,stimulate epidermal proliferation and encourage the growth of a plumper, fresher epidermis. Microdermabrasion, a mechanical abrasive method, can also be used to remove the stratus corneum and stimulate epidermal growth. Lasers aren’t used for superficial exfoliation at all.

Medium depth techniques destroy the epidermis, and either inflame or destroy a portion of the papillary dermis. For medium depth chemical peeling, my favorite is the combination Jessner’s solution and 35% trichloracetic acid, a very safe, effective, peeling formula. It completely destroys the epidermis, and also inflames the papillary dermis, causing enough destruction to get regeneration of a new epidermis that does not have the pigmentation, hyperkeratosis, or atrophy that the patient had before. The creation of a newly rejuvenated epidermis also addresses the fine line changes we find in the papillary dermis. A medium depth peel will not have an effect on blood vessels, so there will not be a change in telangiectases or reddening. For medium depth dermabrasion, I mainly use manual dermasanding. This technique uses silicon carbide sandpaper on water to sand off epidermis until we get to petechial bleeding. I like to use this in combination with superficial or medium depth peeling as a background, and we can sand into lesions all the way into the mid-papillary dermis. Erbium lasers can also be used for medium depth resurfacing. [DR. MONHEIT: PLEASE DISCUSS HOW YOU CHOOSE A MODALITY FOR AN INDIVIDUAL PATIENT- See below]

For deep levels of resurfacing, we can use a deep chemical peel. Deep chemical peels destroy the epidermis, the papillary dermis, and portions of the reticular dermis or the mid-reticular dermal area. The Baker’s (phenol) peel is the major peel used. It has major side effects and is a major surgical procedure that is not used as much as it used to be, but it still has a place. [FACULTY PLEASE PROVIDE ADDITIONAL INPUT] A mechanical dermabrasion procedure can bring the destruction and removal down to the mid-reticular dermis. Finally, CO2 laser resurfacing can be used, which can reach the reticular dermis in order to achieve regeneration of new collagen and a completely new epidermis. For example, this patient has significant rhytids in the periorbital and perioral areas. They require deep resurfacing. The remaining face has medium depth damage of epidermal growths, dyschromias and fine rhytids. I have chosen a combination procedure utilizing C02 laser resurfacing – perioral and periorbital medium depth chemical peel (Jessner’s + 35% TCA) – remaining face with light chemical peeling on the neck. This will blend the cosmetic units giving a natural appearing skin rejuvenation.

See Figures 1, 2, 3, 4 and 5

Dr. Alster: Dr. Lask, how are lasers used in your practice, versus other types of surgeries you perform? I think it’s important to note that some people still do some mainstay surgical procedures in addition to some of these other cosmetic enhancement procedures.

Dr. Lask: Like phenol peels, I think deeper laser resurfacing has gone out of fashion. I think that now, more nonablative techniques are used for photoaging, primarily vascular and pigmented lasers for removing erythema, telangiectases, and dyschromia. The ones we like best are intense pulsed light, pulsed dye lasers, and Q-switched lasers, which all seem to work very well. Because downtime with most of these devices is quite minimal, and the improvement is fairly significant, these are very popular in our practice.

Topical Agents and Combination Therapy

Dr?-can someone identify the speaker?Dr. Monheit: Combination therapy has two major benefits: number one, enhancing the ultimate effect of the treatment, and number two, prolonging the effect for the longest period of time and preventing problems from occurring. With any type of treatment, we want to get the best effect with the least amount of problems or side effects and the least amount of treatment for the patient. The ultimate treatment would give superior results without any side effects or downtime. Combination therapy using retinoids and other topicals, along with the other treatments we’ve been talking about, gets us much closer towards this best-case scenario.

Dr-identify speaker Dr. Monheit: Topicals add a pharmacologic aspect to the destructive procedures we are using. Everything mentioned—whether it is nonablative, selective thermolysis, peeling, or dermabrasion—is destructive in the sense that we are destroying one cell or one structure or generally destroying a layer of epidermis or dermis. We are stimulating a regeneration of skin. Topicals can allow us to tailor the regeneration process to fit the result we’re seeking.

Hydroquinone blocks the enzyme tyrosine, thus preventing the production of new melanin and stopping pigment production. This pharmacologic effect is combined with light chemical peels to lighten dyschromic skin.

Dr. Alster: Another reason we use topicals is really as a primer for some of the other procedures we do. There Is a certain amount of improvement we can get by using a combination of topicals alone, and they “prepare the canvas” for the other destructive methods that we use in our office, and enable us to use either fewer, or less intense, treatments.

Dr. ?identify speaker:Dr. Monheit: I think an important point is that we are all talking about long-term care of people with an ongoing problem: photoaging skin. What we suggest at the beginning of treatment may be different from what the patient will have a year from now, or two years, or five years, but what we are doing is incorporating these patients into a program where we are going to be the primary physicians for their skin. Many times the topical treatment is the glue that holds the treatment plan together temporally—we start with some of the less aggressive treatments, such as IPL, and then as the patient gets older and the photodamage increases, we can move on to other things like fillers, or some of the more aggressive ablative treatments. But, that’s down the road, and they will continue to look to us for continued improvement, and to protect the skin from further photodamage.

Dr. Alster: That’s a very good point, not only in terms of moving patients up to other, more aggressive forms of treatment, but also in terms of using some of these topicals as maintenance. The topicals are like steps to the bridge. We use them as primers, throughout the treatments, and then as maintenance down the line.

There’s been a trend towards using a combination of lighter therapies, as opposed to the more invasive treatments like ablative lasers or even dermabrasion, because when you can do this with topicals, and with some of these other nonablative treatments that we have been talking about, you can get very much the same results without as much downtime or as many side effects.

[FACULTY—PLEASE PROVIDE A SIMPLE LIST/TABLE BRIEFLY COMPARING THE TOPICAL AGENTS FOR PHOTODAMAGE YOU USE MOST FREQUENTLY IN YOUR PRACTICES (EG SUNSCREEN, TAZAROTENE, AHAs, HYDROQUINONE, AZELAIC ACID, ETC ). FOR EACH, PLEASE PROVIDE GENERIC NAME, PURPOSE, AND TYPICAL PROTOCOL FOR USE – Below]

Topical Agents Most Commonly Used to Correct Photoaging Skin

• Sunscreens
• Retinoids: Retinoic acid
• Tazarotene
• Glycolic Acid
• Hydroquinone
• Ascorbic Acid

Tretinoin in the Treatment of Photodamage

Tretinoin (all-trans-retinoic acid), a compound derived from retinol (Vitamin A), is the only topical pharmaceutical agent proven to repair photodamaged skin. While the exact mechanisms of action are not fully understood, treatment of photodamaged skin with topical tretinoin is known to result in the regeneration of the dermal collagen matrix, epidermal thickening, compaction of the stratum corneum, and promotion of epidermal hyperplasia and angiogenesis. Studies have demonstrated that retinoids are able to induce collagen synthesis in cultured human dermal fibroblasts, and that retinoic acid applied topically to the skin prevents UV induction of the matrix metalloproteinases (MMPs) that play a role in the destruction of the extracellular matrix. The histological alterations induced by tretinoin treatment have been correlated with clinical improvements, including smoothening of the skin, lightening of hyperpigmented lesions, disappearance or significant improvement of fine wrinkles, and, to a lesser extent, of coarse wrinkles. Tretinoin has also been shown to protect skin against photodamage induced by repeated UV exposure, making it an ideal agent for maintenance therapy.

Tretinoin is available in several formulations and concentrations, the choice of which is usually determined by the patient’s tolerance. Tolerance of topical retinoids by patients may vary with age, race, skin type, extent of photodamage, and local climate. Treatment should be combined with photoprotection in order to prevent further photodamage. Clinical effects may be noted as early as the first month of treatment.

Summary of the cytological, histological and vascular effects of topical tretinoin on photodamaged human skin:

• Epidermal thickness
• Compaction of the stratum corneum
• Stratum granulosum thickness
• Melanin content and ? melanocytotic hypertrophy/hyperplasia
• Reduced epidermal atrophy and promotion of epidermal hyperplasia
• Epidermal atypia and dysplasia
• Synthesis of collagen
• Number of collagen-containing anchoring fibrils in the cutaneous basement membrane zone
• Skin elasticity at high test loads
• Exfoliation of retained keratinous horn in follicles
• New blood vessel formation and blood flow
• Symbols: indicates significantly increased; ? indicates significantly decreased.

Table adapted from Noble & Wagstaff, 1995.

The first step in treating a patient with photodamaged skin is the assessment of the type and extent of damage. Our faculty experts discussed possible combination therapies for several hypothetical patients.

Case Study #1: A patient with dyschromia (redness or brown mottling of the skin, with very little loss of elasticity).

Dr. Lask: If a person comes in with dyschromia, I almost always start them on some bleaching agents first. The biggest problem with bleaching agents we have is local irritation. In people that irritate, obviously we have to stop, but we still find improvement without irritation, even using it once every second or third day. For dyschromia, we almost always also put patients on retinoids. They diminish pigmentation, which has been proven in many different clinical studies, and improve skin texture and quality. [DR. LASK, PLEASE EXPAND ON PROTOCOL FOR USE (DOSE, TIMING, ETC)]

For the next step with dyschromia, we primarily use the Q-switched lasers. We also use intense pulsed light (IPL) for dyschromia, but I think the Q-switched lasers like the YAG or the Alexandrite give you a quicker response. There is a little bit of downtime, five or seven days, but the response is much quicker.

And for the erythema or vascular component of photoaging, we primarily use the V Beam or pulsed dye laser, as well as IPL. I do think the V Beam is a little better for erythema, and it is certainly safer to use and a little more user friendly than IPL, but both work fine. They both require multiple treatments.

Dr. Monheit: I think you have to separate the younger patient with dyschromia, who really doesn’t have a lot of atrophy, poikiloderma of the skin, or telangiectasia, but who mainly has more of a melasmic discoloration and sun dyschromia as the major problem. Like Dr. Lask, I would begin with topical therapy. I would include a bleaching agent such as a hydroquinone: depending on the severity of the dyschromia, I would either go from 2% or even up to 8%. As you increase the concentration of hydroquinone you get more irritation, so you must be careful with it.

I like to combine that with a topical retinoid, because I think that with our bleaching agent, we essentially stop or inhibit the transformation of dopa to tyrosine through tyrosinase by blocking it, so we’re mechanically stopping the production of new pigment. At the same time we want to speed up epidermal proliferation to push out old pigment, and that’s what we’re doing with the topical retinoid. In addition, the use of sunscreen is essential to protect the skin from further sun damage.

So, those three topicals (a bleaching agent, a retinoid, and sunscreen) are the real baseline we want to have the patient using readily before we add on office procedures. For this particular kind of patient I would start with a light chemical peel. I like salicylic acid peels better than the others because they are less inflammatory with less of a chance of postinflammatory hyperpigmentation occurring. They remove the stratum corneum, stimulate more epidermal proliferation, and pull out more pigmentation. I would do this as a repetitive peel every three to four weeks, along with topical treatment, and follow them along on this regimen first.

If the response is not significant, I would then go on to a medium depth chemical peel, which would obliterate the entire epidermis but then have to be followed carefully with both bleaching agents and anti-inflammatories, such as topical steroids, to prevent postinflammatory hyperpigmentation. After that, I would use some selective lasers such as the Q-switched YAG, or if more extensive damage is present, even intense pulsed light (we use the Quantum laser). That is my basic regimen for treating pigmentation as a major sign of photoaging.

Dr. Nestor: I like to look at it more from the aspect of what patients can and will tolerate. In my patient population, more and more of them really want as much benefit as possible without the downtime. I rarely see a lot of dyschromia in and of itself without other changes. Certainly, it occurs, but I would really categorize this as spot dyschromia versus generalized photoaging. I look at photoaging much less as spot dyschromia, which would be lentigines here or there, or something that would occur separately from the photodamage type of dyschromia, which is more generalized. Certainly lentigines are a part of it, but it is much more of an overwhelming presentation than individual lentigines or brown areas. I would agree with Dr. Monheit that the melasma picture is something different, and I think that’s really not necessarily associated as much with photoaging as it is with a genetic predisposition and hormonal changes. I look at photoaging in a different category.

For the majority of my patients I tend to use and start with photorejuventation or IPL because of the benefit of having no downtime for many of them, and because this is not just pure hyperpigmentation. We generally see some degree of redness and telangiectases, as well as some degree of dermal change. I believe IPL does a nice job of helping all of these at the same time.

I generally use a Q-switched laser as a secondary treatment for this category, but for the category I mentioned earlier—the individual lentigines or areas—I tend to use it much sooner, because those patients tend to have a lesser degree of photoaging, and the individual lesions are very easy to remove with the Q-switched laser.

For patients that can tolerate downtime, in the past I’ve started with an erbium laser or in some cases a CO2 laser, but recently I have been using more photodynamic therapy, because it really augments the photorejuvenation process significantly. It does have at least two or three days of downtime, possibly more depending upon how you use it.

When it comes to topicals along with these treatments, I look at them as adjuncts in this case. For the hyperpigmentation aspects I use a combination agent containing fluocinolone acetonide 0.01%, hydroquinone 4%, and tretinoin 0.05%, which can, I believe, significantly augment the problem of repigmentation, and can also help with the overall improvement. I also use retinoids in this category. [DR. NESTOR, PLEASE EXPAND ON THIS—HOW AND WHY ARE THEY USED]

Again, I want to stress the issue of photoprotection. For a lot of these patients, I use a broad spectrum physical block with titanium dioxide or zinc oxcide. I think that we tend to make many of our patients significantly better, and they tend to go down the tubes pretty quickly by just creating more sun damage so I think that’s a big factor.

[FACULTY—PLEASE PROVIDE before & after pictures of patient(s) treated for dyschromia]

Dr. Alster: To summarize the various treatment regimens for dyschromia, everyone uses some sort of adjunctive topical. Most people use it preliminarily to prime the skin, and keep their patients on this therapy while they pursue other treatments, most notably in the case of Dr. Lask—pulsed dye laser and intense pulsed light for the erythema, and then Q-switched pigment-specific lasers with IPL for the pigment. In the case of Dr. Monheit, he starts with topicals, goes through light peels and medium peels, depending on the amount of dyschromia, and then finishes up with laser or light sources for any residual erythema. Dr. Nestor uses the adjunctive topicals and quite a bit of photodynamic therapy for the more generalized dyschromia, versus Q-switched pigment-specific lasers for spot dyschromia. Photoprotection is also very important.

Case Study #2: A patient with periorbital and perioral rhytides.

Dr. Alster: How do you mix and match treatments for a patient with rhytides around the eyes and mouth?

Dr. Lask: Well, now if anybody comes in with periorbital rhytides, usually the first thing I will suggest is botulinum toxin, because most people do get significant improvement. Again, I put almost everybody on a topical retinoid as well in order to enhance the outcome and improve skin texture.

I do not use peeling much anymore. I used to use some laser peeling for the eye area, but I’ve found it not to be dramatically rewarding for eyelid wrinkles. The skin is very thin, so if you peeled to a certain depth you either got pigment loss or some texture change on the lower eyelids. I do think it helps texture, but not really wrinkling. The only thing I believe helps with significant wrinkling of the lower eyelids is phenol peeling, but I do think it often results in some long-term or permanent pigment loss.

As far as the upper lip rhytides, I think they’re the hardest, I find, to treat in my office. The simplest approach may be a topical retinoid; I’ve seen some studies showing that retinoids actually enhance even upper lip wrinkling to some degree, though in very small amounts, so I think using retinoids on the upper lip is a worthwhile endeavor. Some people will try botulinum toxin injections for the upper lip, and I do think it helps. The problem is that botulinum toxin does alter the upper lip a little bit, making it a little bit flatter, and it can also cause the patient to have a strange sensation in their mouth. A lot of people don’t like that, so I don’t do it a lot. It does help wrinkling for some patients.

The fillers such as Hylaform, Restylane, and the human and bovine collagens can be useful as well. Patients who are relatively young and whose lip lines are small may benefit from CosmoDerm, CosmoPlast, Zyderm or Zyplast, but these only provide short-term improvement, so the patient has to be willing to come back quite often. Hylaform, which I’ve only been using for a short time now, seems to last at least a few months, so it seems to have a longer duration than Zyderm, Zyplast, CosmoDerm, and CosmoPlast. These products may have a bigger role in upper lip treatments than the collagen products.

The ablative processes (laser abrasion, chemical peeling, dermabrasion) all can improve upper lip rhytides, but in a fair amount of patients they do result in some long-term pigment loss. Some patients, especially younger patients, do not want to deal with that. So I think that unless you’re willing to face that potential complication, it is a hard road to go down.

Dr. Monheit: The first thing I do is quantify the problem: how much damage is there, and how much do we have to correct? Most of the “lunchtime procedures” work very well for people who have either Glogau I or II levels of rhytides and damage. The other factor we have to consider, as Dr. Nestor mentioned earlier, is how much downtime a patient is willing to put up with. My initial approach is to be conservative and to explain and make suggestions about what we can offer to the patient as far as the lunchtime procedures. All of my patients get a topical program to begin with, and that includes a retinoid, some form of exfoliating agent, such as glycolic acid or mechanical exfoliation, and sunscreen protection. [DR. MONHEIT, PLEASE EXPAND ON HOW THESE AGENTS ARE USED—DURATION? DOSE?]

The patients are treated for two to six weeks prior to other resurfacing procedures. Topical home therapy is the cornerstone of all other procedural therapy to be performed in the dermatologist’s office.

First I address wrinkles around the eyes and the periorbital area. Using botulinum toxin, we can relax frown lines and glabellar lines, and a unit or two of botulinum toxin directly below the tarsal plate may relax a hypertrophic orbicularis muscle and actually smooth some of the larger wrinkles under the eye. The next step is resurfacing, and for nonablative procedures we use the Cool Touch laser for periorbital areas; we also use IPL around parts of the forehead. Again, these are conservative—minimal to moderate—changes we will see. As I get into the ablative procedures, I still use CO2 laser resurfacing around the eyes but I do not use phenol peeling. When I use CO2 laser resurfacing, I like to do at least a medium depth chemical peel on the rest of the face to blend it so that if there is a pigmentary change, it won’t be apparent.

As we move down to the lower aspects of the face, volume changes are very important, especially in the perioral area. I find that rhytides need a combination of both volume filling and some nonablative or ablative resurfacing to get results. I like to combine filling agents together for these patients, for example using a hyaluronic acid like Hylaform or Restylane and then combining it with CosmoDerm, first to take care of the deeper filling in the dermis, and then the very superficial fine lines with a lighter filling agent. I also believe when combining hyaluronic acid along with a collagen, we are in essence adding back the substances that are being lost in the skin: the collagen fibers, the elastic fibers, and the hyaluronic acid. When we put them back together again, we’re adding back the bricks and mortar of the dermis, filling it back up. After we accomplish the filling, then we look at what we can do with nonablative resurfacing.

For the population of people with more severe photodamage, I use blepharoplasty. I will do transconjunctival blepharoplasty for removal of fat and relocation of fat to resurface the area. We will do fat filling for sad pockets underneath the eye and to augment the tear trough, and we’ll take skin out from the upper lid. For around the mouth, I’m now using the Feather Lift to bring up some of the skin on the perioral area to raise the nasolabial fold, as well as filling. For more permanent filling, we’re using fat injections and fat autograft muscle injections (FAMI) as filling material, and we combine that with resurfacing techniques for patients with more severe forms of aging (Glogau III and IV).

So we really have a step-wise program we go through, based on the patient’s needs and desires. While many patients prefer lunchtime procedures with no downtime, I often say “go for the gold”: give up some downtime, have more permanent procedures and address more severe problems with the more aggressive procedures we use.

Dr. Nestor: Around the eyes, I also use a step-wise process and approach it from the patient’s needs. One thing we have not covered is the issue of either dyschromia or dark circles under the eyes, which can accompany superficial or deep rhytides. I tend to use a fair amount of erbium laser resurfacing for these patients to combine the improvement in both the pigmentation and the fine lines. [DR. NESTOR—HOW MANY TREATMENTS?]

In patients who are not significantly affected around the eyes, I do see some benefit with nonablative laser, either the Cool Touch, Smooth Beam, or even pulsed dye laser. The nonablative laser seems to be less effective around the mouth. Certainly I have found that, for more superficial damage, combining the deeper tightening agents such as Thermage or ThermaCool with photodynamic therapy can result in some degree of significant improvement. Certainly this can be augmented with the use of fillers.

Since the advent of Restylane, we’ve seen wonderful improvement in treating perioral rhytides in those patients that really don’t want to have the downtime of the deeper laser procedures. For the lips, I often use a combination of CosmoPlast and Restylane, and I’ve found that this works well for improving the perioral area, as well as the areas of the mesiolabial fold. We can inject Botox into some areas, including the musculature that pulls down the angle of the mouth, to improve any sagging.

I do use topicals as adjunctive treatments, including Renova and Retin-A. With my population of patients here in this warm climate, I tend to use a lot more .025% Retin-A; studies have compared the lower to the higher concentrations of Retin-A, and found little difference except for the degree of side effects and irritation. I do think that the combination therapy gives us a dramatic degree of improvement.

[FACULTY—PLEASE PROVIDE before & after pictures of patient(s) treated for perioral/periorbital rhytides See figures 6 and 7]

Dr. Alster: So, for dyschromia, and perioral and periorbital rhytides, we all incorporate some sort of topical, typically a retinoid product, to get the process started. Very rarely will we see enough change in our patients to not go at least an extra step, particularly around the mouth. Sometimes people can improve enough with the topical retinoid around the eyes, but if there is any movement association there, which I think the majority of our patients have, Botox comes into play. Fillers are useful around the mouth, and of course, as was pointed out, ablative or nonablative lasers and peels also play a role in treating some of the deeper rhytides. If downtime is not an issue, they can go through some of these more intensive procedures. In terms of the dark circles under the eyes, in addition to the erbium laser, you can still use a CO2 laser at a lower energy in order to get the same peeling effect; peels also work very nicely in that area.

Case Study #3: Patients with photoaging and acne and/or rosacea.

Dr. Alster: In our aging population, we see a lot of people who have acne and rosacea; many of the procedures we’ve been talking about also apply to these conditions. [FACULTY—IS IT ACCURATE TO SAY YOU SEE A LOT OF PATIENTS WITH PHOTODAMAGE AND ACNE OR ROSACEA?]

Dr. Nestor: Acne and rosacea are physiologically different conditions, although there certainly is some crossover. In the photoaging population, we’re probably dealing more with rosacea than with acne in general. My regimen for acne has changed dramatically over the past year or so because of the advent of both the blue light therapy (420 nm) and photodynamic therapy. For rosacea, I tend to use a lot of intense pulsed light; I think this works great. Certainly pulsed dye laser also works in this case, and I’ve combined that more and more with photodynamic therapy, mainly because of the effects it has on sebaceous glands and the augmentation that occurs in the other aspects of rosacea. For acne, this has also proven to be a tremendous advancement because of the effect on the sebaceous unit, and we tend to get very, very significant effects, especially in the older populations. In my hands, we get more of a long-term clearing in the older patients than the younger patients, for whatever reasons. The blue light has also helped us as an augmentation. Again, I tend to see even better results in the older population of patients than I do with the younger patients, and for all of these patients, I almost always augment with a retinoid. I tend to use a lot of adapalene, just because for many of my patients there’s less of an issue of irritation, but I certainly use a lot of Retin-A Micro in these patients. I tend not to use Renova because the emollient formulation tends to aggravate the acne. For my patients with rosacea, I will add a metronidazole cream or another topical to help augment the treatment.

[FACULTY: HOW DO YOU COMBINE TREATMENTS FOR PHOTODAMAGE WITH TREATMENTS FOR ACNE/ROSACEA? IS ONE TREATED FIRST, THEN THE OTHER, OR IS TREATMENT CONCURRENT? PLEASE REVISE THIS SECTION ACCORDINGLY]

It is best to control the active rosacea first with topical and systemic antibiotic therapy before the vessels and dyschromia are treated with specific lasers. Rosacea exhibits vasomotor flushing which can be triggered by facial trauma; i.e. chemical peels, Microdermabrasion or lasers. Thus, the inflammatory condition must be controlled first.

Dr. Monheit: I think it’s important to separate the adult acne population and the photodamaged patient who has true acne from the rosacea population, mainly because of the vasomotor phenomena that occurs in rosacea, which some of our acne therapies can actually make worse. I usually start with a topical regimen, then I suggest to them physical modalities that will augment it. I want them on a topical treatment program that they can adapt to for long periods of time, and to know that the lasers, or the peels I’m going to use, are not going to cure the situation, and they’re not going to maintain it. They will augment what the patient’s basic home care is going to do for this condition, which is a long-term condition.

Starting with patients with adult acne, if I need to I put them on antibiotics, and on topical therapy a retinoid is very important. I like Retin-A Microgel. If the patient has sensitive skin we use the 0.04%; we use the stronger one (0.1%) if the patient has an oily complexion and can tolerate it. This is a daily regimen. Along with that, I add an azelaic acid and/or a benzoyl peroxide to be used at night, depending on their skin tolerance.

We use a blue light laser, and I think that a series of four to six treatments can really put a lot of lesions to rest and cut down on the frequency of topical therapy. One other treatment that I think is invaluable is salicyclic acid peels for acne. They are lipid soluble; the crystals will penetrate into the comedones and break up the blockage, and this can really be a nice adjunct to help make the retinoid work much better, and more quickly.

In contrast, when we treat rosacea, I really do not use a lot of inflammatory peels, or even microdermabrasion, because of the flushing response these patients get. Metronidazole and sulfacetamide are important for basic maintenance therapy. In addition, I use IPL and pulsed dye lasers. I tend to use IPL more for the flushing and the telangeictases. I tell my patients that we need to control the acne component of the rosacea first, and once we see that this has resolved with either antibiotics or topicals, I’ll then put them on an IPL program to deal with the flushing and the telangiectases.

Dr. Lask: Two different lasers have been used a lot more recently for acne, the Smooth Beam and the Cool Touch, both of which have FDA clearance for acne treatments. As mentioned earlier, a lot of these devices are used for three to six treatments. I don’t think there’s any set numbers of how many times you treat these patients, but I do see quite a variety of responses. Some do very well, and some don’t respond at all, but there are nice new innovations for acne besides the topical medications.

For the rosacea, besides the effect on the erythema, flushing, and heat response that the B Beam and the intense pulsed light can give, I think there’s some correlation diminishing the breakouts in these patients as well, so these make very nice adjunctive therapies.

[FACULTY—PLEASE PROVIDE before & after pictures of patient(s) treated for photodamage and acne and/or rosacea See figures 8 and 9]

Case Study #4: Treatment of darker-skinned patients.

Dr. Alster: In general, do you modify your treatments for different ethnicities? I know in my practice I will tend to use less aggressive forms of treatment in my patients with darker skin types, and incorporate more of the topical and lighter peels, compared to somebody with lighter skin tones.

Dr. Lask: People with darker skin types tend to come to me because of dyschromias, not generally the classic photoaging problems, and in this population I use primarily the bleaching agents, and the retinoids. I do sometimes use less aggressive treatments, i.e. lower concentration of hydroquinone or fewer applications, or how often they apply it, because if they irritate, as we all know, they will discolor more than a fair-skinned patient, so I have to be more careful.

Dr. Alster: Dr. Nestor, how do you treat these individuals, especially in terms of the intense pulsed light and PDT combination? Do you scale back what you use, in terms of energies, or do you tend to use other forms of treatment?

Dr. Nestor: I think these patients of different Fitzpatrick skin types come in with different aspects of photoaging. I think that the classical triad of hyperpigmentation, redness, and actinic-type changes, with actinic keratoses, are much more geared toward type I, II, and maybe some type III. We see more rhytides, though certainly not to the same extent as in types I, II, or III, and dyschromia with types IV or V, and the type VI patients tend to have more acneform eruption, much less rosacea, and certainly much less of the other classical signs of sun damage, though there could be some dyschromia.

I tend to individualize my treatment plan based on the presentations of the patients. In darker-skinned individuals, we tend to use more nonablative procedures if we’re targeting rhytides and those types of changes, as we’ll certainly use botulinum toxin and fillers, because those are not necessarily sensitive to Fitzpatrick skin types. In this population there is much less of a need for the more aggressive, more ablative, procedures.

I find that the other nonablative procedures that we’ve talked about (Cool Touch, Smooth Beam, and others), are equally tolerated by darker-skinned and lighter-skinned individuals, although with the pulsed dye laser and IPL, you have to be much more careful with the darker skin types—using less energy, and possibly using different filters for the IPL. With regard to topicals, the only thing I would stress is that with the darker skin types, when there is a lot of irritation associated with topical treatments, you may see some hyperpigmentation, so you have to be a lot more careful with a postinflammatory change. This is just something to keep in the back of the mind. [DR. NESTOR—CAN YOU PROVIDE AN GENERAL TREATMENT PROTOCOL?]

[FACULTY—PLEASE PROVIDE before & after pictures demonstrating treatments for darker-skinned patients]

Conclusion

Chronic sun exposure results in deleterious effects on the skin, a process known as photoaging. Characteristics of photoaged skin include fine and coarse wrinkles, roughness, laxity, mottled pigmentation, actinic lentigines and keratoses, coarseness, sallowness, and telangiectasia. Depending on the extent of photodamage and the desires of the individual patient, there are many available options for treatment, including both topical agents and office procedures such as lasers, dermabrasion, peels, and fillers. The use of multiple treatment modalities as part of a combination therapy plan may provide the most benefit to patients, as this approach allows for concurrent treatment of multiple symptoms. Topical retinoids are recommended for priming the skin prior to office procedures, and as maintenance therapy to maintain treatment results and to prevent further sun damage. Photoprotection should be an essential part of any photoaging treatment regimen.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The purpose of suturing is wound closure. Ideally, suturing should approximate the wound edges so that the tissues can reestablish closure with a final scar that is functional and aesthetic. The method and techniques of suturing as well as materials used are determinants in the final outcome. The surgeon must also have a full understanding of wound healing, tensile strength, and wound closure to perform skin approximation. Ideally, the wound should be approximated with little tension and the skin edges handled gently. It is the fine attention the surgeon gives to handling skin edges and the techniques of approximation that create the optimal aesthetic scar line. This chapter will review the techniques and materials available for suturing wound closure.

The history of dermatologic surgery begins in the ancient world where evidence of surgical wound closure is found in the Edwin-Smith Papyrus relating methods of suturing and dressings. The document relates a deep facial wound which was closed with silk sutures and covered with linen dressings and ointments.1

Wound closure was also noted in ancient Indian sanskrit texts describing suture material made of animal sinews, bark, leather straps and even ant pincers.

The importance of cosmesis in wound closure was noted by the Greeks and Romans with the first description of layered closures, local flaps and pedicles. Galen referred to the usage of catgut and silk suture material for closures and as vessel ligature. The principles of antiseptics by Lister later enabled sterile wound closures to progress to the modern era for fine cosmetic dermatologic surgery.

The Materials

Needle and Suture

All surgical needles have three basic components; the point, the body, and the swage.2 Most all sutures used in dermatologic surgery are directly attached to a surgical needle rather than threaded through a hole. The swage is the tail of the needle connecting the suture. The suture is inserted into the hollow end of the needle and is mechanically crimped to hold the suture securely in place. The swage is the broadest point of the suture. The tip of the needle is the fine delicate point which pierces the skin. The remaining portion where the needle is grasped with instruments is the body. The needle body can be round, triangular, or oval and may have ribs for grasping. Most needle bodies have an arc of either 135 (3/8 circle), or 180 degrees (1/2 circle).3 Either of these configurations can be helpful for various suture techniques. For deep closure in which both fascia and subcutaneous tissue must be grasped to close dead space, the 180 degree needle is helpful. It is also helpful when suturing in cavities in which the arc of closure needs to be smaller to bring deeper tissue together. The 3/8 circle, though, seems easier to handle for basic skin closure on an open surface. The needle point is a triangle with three cutting surfaces. A conventional cutting needle has the third cutting edge of the triangle on the inside surface of the needle arc. This places the apex of the triangle facing the wound. The reverse cutting needle has the triangular tip pointing away from the wound edge or on the outside of the arc. This creates less cutting with tension on the suture line.4 For fine plastic closures, reverse cutting is advantageous. Needles also differ as to material and needle sharpness, and are coated by the major companies as for usage and durability. F.S. (for-skin) is least expensive and for non-cosmetic skin closures. The P, PS and PC refer to plastic, plastic skin, and precision cosmetic needles which are made of higher quality steel and honed to a sharper point. The dermatologic surgeon can choose which of these materials best suits his needs in areas of wound closure. For example, a PS or PC needle should be used for fine facial skin closure while an FS needle is sufficient for suture closure on a covered area of the body.5

Suture Material

Suture material is generally divided into two types, absorbable and non-absorbable. Each has a distinctive role when used properly for wound closure techniques. Ideally, wounds are closed under minimal or no tension so that skin edges can be directly approximated and sutures placed for five to seven days. Absorbable suture will be digested by enzymes or hydrolysis and, thus, do not need to be removed from the closed wound. These are placed normally in fascia, subcutaneous tissue, and deep dermis to close defects and take skin tension off the skin surface edges. After skin tension is fully removed, permanent sutures are used to approximate the skin surface for precise coaptation of the epidermis. Permanent surface skin sutures should be removed within five days to reduce the incidence of tunneling or skin tracts which occur as the epidermis grows around the suture tracts. Prompt removal of these permanent sutures, though, can only be done if the tension is alleviated by buried absorbable suture which will maintain the strength of the wound edge until collagen synthesis has been completed and the scar line is stable.6 It is, thus, the surgeon’s knowledge of suture material and wound healing to give the best combinations for wound closures in various parts of the body.

• Absorbable suture material is used in the deep dermis and subcutaneous tissue to reduce skin tension. The ideal absorbable suture material will retain tensile strength until collagen replacement is complete and will remain non-reactive until fully absorbed. None of the materials used are fully non-reactive and the tensile strength diminishes with time. Absorption time also is not consistent with loss of tensile strength and some material remains reactive for months after tensile strength has disappeared. Other factors the surgeon must consider are tieing ability, drag in the tissue, and stability of knots in deeper tissue.
  • Catgut Plain gut or chromatized catgut is an organic substance derived from the serosal layer of cattle intestine or submucosal layer of sheep intestine. The material is treated to become purified collagen which will be totally digested in sixty to ninety days. Because gut is derived from an organic material, chemical composition is uneven and, thus, its tensile strength and ability for breakage varies through the suture. In many instances, there are weak spots, uneven absorption and suture breakage which must be taken into account. It induces an intense inflammatory response destroying most of its tensile strength in seven to ten days and virtually has no strength within two weeks. It is absorbed by inflammation and phagocytosis as a foreign body. It should not be placed in contaminated wounds as it forms a nidus for bacterial infection to spread, creating suture abscess and tunnels. The advantage, basically, of this suture is that it is inexpensive, it ties easily and is readily available.7 Chromatized gut has been process with a chromic salt to retard absorption. This seems to reduce the inflammatory response but does not prolong the tensile strength of gut suture to any significant degree.
  • Polyglycolic Acid (Dexon) This is a synthetic polymerized material of glycolic acid which is braided into a polyfilamentous suture material. It appears less reactive than catgut, retaining greater tensile strength during healing. Fifty percent of its tensile strength is present in two weeks and twenty percent still remains present in three weeks. It is absorbed by hydrolysis rather than an inflammatory reaction which occurs in thirty to sixty days. In this process of hydrolytic degradation, there is less inflammation but a foreign body reaction and “spitting” through the epidermis can still occur. The suture material ties easily but the braided suture can catch tissue as it passes through skin and subcutaneous tissue. This tissue drag can be cumbersome with buried knots and limit the surgeon’s ability to place the suture accurately in the depth of the skin. Because of its polyfilamentous character, it also can trap bacterial and be a nidus for infection.8
  • Polyglycan – 910 (vicryl) is a coated polyfilamentous synthetic polymer of glycolic and lactic acid. It is similar in basic structure and function to polyglycolic acid suture but is coated for easier passage in tissue and more accurate knot tieing. It has a similar tensile strength and absorption time and is degraded by hydrolysis with less inflammation than catgut suture. Its tensile strength seems to be reliable maintaining sixty percent in two weeks and thirty percent in three weeks. It also is polyfilamentous and has some tissue drag, though its outer coating makes it easier to use than polyglycolic acid suture. It, though, also has the risk of spreading infection inherent in braided suture.9
  • Polydioxinone and maxene glycolic acid suture is a monofilament absorbable suture with long retained tensile strength and slow absorption. It appears to be less reactive than polyglycan suture with a two week tensile strength of seventy percent. Being a monofilament, it slides more easily through tissue and it is easier for deep tissue knot tieing.10 The choice of the appropriate absorbable suture depends on location, skin type, the nature of surgical defect, and stress on the wound edges. Each of these factors plays an important role in determining the absorbable suture most useful to reduce skin tension for a particular wound closure.
• Non-absorbable suture is used to close skin defects through the surface with little or no skin tension. The puncture of the epidermis and dermis with the suture material will produce a tunnel or tract that if left in place for a period of time longer than epidermal regeneration, will create skin tracking or permanent spots along the scar line. On the other hand, removal of a permanent suture where tensile strength is not great enough to preserve the wound closure will create a stretch scar or even worse, a dehiscence. The appropriate choice of non-absorbable suture and time for suture removal is important in surgical planning.
  • Silk suture has been important in skin closures for many years and set apart as the standard for skin closure. This braided suture is easy to handle and tie but does have a significant amount of tissue drag. Though it is classified as a permanent suture, it is eventually degraded by inflammation if left for long periods of time. It is, though, best removed within seven days as it produces a significant inflammatory reaction. Because the suture is braided, it is comfortable to use in creases of the body, mucosal surfaces, and around cutaneous orifices in which monofilament suture has an uncomfortable feeling during wound healing.11 It cannot be used in infected wounds because its polyfilamentous nature traps bacteria.
  • Nylon Suture is a non-absorbable monofilament which has low tissue reactivity and high tensile strength. It appears as either a single monofilament or multiple braided filaments,both of which tend to pass through tissue easily. It, though, has a tendency to return to its original state, a feature called memory which may cause the suture to coil and the knots to unwind and come loose during healing. Extra ties must be passed with this suture for the security of interrupted suture ties.12
  • Polypropylene (prolene suture) is a synthetic non-absorbable compound created as a monofilament suture with a tensile strength equivalent of nylon and less reactivity. It is easier to handle than nylon because of an intrinsic stretching ability as it passes through tissue easily and ties well. It, though, also has memory which can create slippage and knots to untie.12
  • Polyester sutures are made from tightly braided multifilamental fibers which have been shown to last indefinitely in the body surface. They have come under the brand name of Mercylene, Ethybond, and Novafil, a polybutester. These sutures are easy to handle with good knot tieing ability and little problems with recoil or memory. There is some tissue drag because of its braided nature and this is by far the most expensive suture on the market.4
  • Surgical Staples afford a convenient and easy method for wound closure in covered areas of skin such as the scalp and selective areas of the trunk. It can grab a large bite of skin and tissue and evert the skin edges facilitating wound closure. It, though, produces staple marks as permanent scars and should not be used in cosmetically important areas of skin such as facial closures. Staples can be uncomfortable in body areas of pressure such as buttocks or groin.

Surgical Instruments for Wound Closure

The standard instruments used for wound closure include a needle holder or driver, tissue forceps, skin hooks, needle forceps, and suture scissors. These tools vary in size, material and shape depending on their usage for wound closure. Matching the appropriate instruments with the needle size and suture material as well as the defect to be closed is essential for good surgical work. For example, a 6 mm. eyelid defect should be closed with 6-0 prolene suture, a delicate Castroviejo needle holder, and .5 Adson needle holder. The use of these delicate instruments with larger suture and needles may bend instruments and damage them. Thus, the surgical instrument must be correlated to needle and suture size.

The standard needle holder has a ratchet locking mechanism that stabilizes the needle securely in its jaws. The needle holder should be locked on the first ratchet and not beyond as this indents the needle and damages the holder. The needle should be grabbed 3/4 distance along its body for accurate stabilizing. For most facial skin closures the delicate ratchet locking Webster needle holder made of stainless steel with a carbon bite aids the surgeon in accurate suture placement. Larger needle holders conventionally used in general surgery are awkward, cumbersome, and inhibit good cosmetic work. Tissue forceps should delicately grasp skin edges with little or no trauma to the wound surface. Flat forceps compress and squash skin edges creating ragged scar lines. The Adson tissue forcep creates less trauma but still pinches the skin edge with pinpoint trauma. The most delicate of tissue forceps is the Brown-Adson with its fine tooth-like projections which can delicately move the skin edges with little compression or tissue necrosis.

The most delicate instrument, though, is the skin hook which can both pull and push tissue with little or no trauma. One needs dexterity and experience to use this instrument carefully and the danger of skin puncture to the surgeon is present if one is not careful. It behooves the good dermatologic surgeon to learn the techniques to use this instrument properly for good cosmetic closure.

Suture scissors can either be of the iris type or hooked variety. What is necessary is that the scissors should be able to cut the suture cleanly near its tip. This should work as effectively for buried suture in subcutaneous tissue and skin sutures. Undermining tissue scissors should not be used to cut suture. Monofilament suture and the synthetic nylons will dull tissue scissors and make them ineffective instruments for undermining. thus, the basic instruments on a typical repair tray should include:

• Webster needle holder
• Single or double pronged sharp skin hook
• Brown-Adson tissue forceps
• Needle forceps
• Metzenbaum curved undermining scissors
• Suture scissors
• Bard-Parker handle with #15 and #11 blades

Suture Technique

Proper use of sutures to close surgical wounds takes planning prior to the surgical session to elevate the levels of closure. What will the depth of the wound and the resultant tension on the skin edge do to the final scar line? A simple closure is the use of direct interrupted non-absorbable skin sutures to close the wound with interrupted sutures. A layered closure entails buried absorbable sutures and interrupted permanent skin sutures. A complex closure involves the essentials of layered closures along with methods to reduce skin tension such as undermining and tissue transfer.13 The surgeon must evaluate his excision and then his defect as to the anatomic site and the nature of skin tensions for the appropriate closure. Each of these will be reviewed in the general concepts of wound closure. Interrupted suture closure is the simplest and easiest method to close uncomplicated wound defects. To use interrupted suture as the primary mechanism of closure, the defect must be:

• A skin defect extending to subcutaneous tissue but without dead space or a deep tissue defect.
• Little or no skin tension on the wound edges.

An interrupted suture is placed through opposite wound edges, full thickness through the skin, to bring the wound edges together. The technique is accomplished as follows:

• The needle is grasped with the needle holder 3/4 length along the body of the needle and the needle tip is then pointed perpendicular to the skin surface. It is usually placed 1-2 mm. from the wound edge and the point pierces through epidermis and dermis. This is accomplished with a rotational thrust beginning perpendicular and extending in an arc outward to subcutaneous tissue. At this point, the surgeon feels a pop of the needle through the dermis as it advances into subcutaneous tissue.
• The arc of the half circle is continued through subcutaneous tissue below the deepest point of the defect and then advances to the dermis of the opposite side perpendicular to the plane of the skin surface and emerges the same distance from the skin edge as the entrance point, 1 to 2 mm. As the surgeon sees the needle tip emerging through the skin surface, it can be grasped with needle forceps by an assistant and pulled through the surface. It is important that the needle be pulled through either by an assistant or the surgeon with its opposite hand so that it will not fall back into subcutaneous tissue when tension is released.
• The surgeon then pulls the needle through all the way advancing the suture through the wound so that 1 to 2 cm. of suture remain on the opposite side. Grasping the end of the suture with a pair of forceps and the opposite side with a needle holder, the surgeon can test the closure tension along the skin edge. Ideal closure tension should advance the skin margins together but not crush tissue within the suture. The point of pressure is tested prior to tieing the surgeon’s knot.
• The surgeon’s knot is accomplished as a double square knot. The square knot is the fundamental knot used and when placed properly, it will lie flat on the skin surface and maintain its position without slipping. To tie the knot, the surgeon pulls the long end across the skin edge and the needle holder is brought across the wound edge and the long end is looped twice along the end of the needle holder. The needle holder grasps the end and the two loops are brought into approximation. A single loop is then placed over the double loop tie and this is placed securely over the double loop. An additional single loop in the opposite direction is placed over the second single loop, making a square knot. As the last loop is tightened, the knot is then approximated and further pressure will not put any further tension on the wound edge.14

The advantages of interrupted sutures for simple closures is the ease and simplicity of the procedure. The risks are small and it provides stability for the wound edges during healing. Disadvantages include inversion of the suture line if the suture is placed too superficial. That is, if the tension pull across the suture line is too superficial, it will pull the scar line downward creating a trough. The other disadvantage is the railroad tracking or scar tunnels left by the suture if kept in for the five to seven days necessary for wound healing.

Vertical Mattress Sutures

The vertical mattress suture is used to accentuate eversion when there is significant skin tension and to close dead space in deeper tissue defects. Vertical mattress sutures can be placed in conjunction with interrupted sutures to ensure significant wound closure tension and evert the skin edges. Between these, interrupted sutures are placed. The vertical mattress suture is begun 0.5 to 1 cm. from the wound edge with the needle pointed vertically to the depth of the wound, then under the wound and back out along opposing sides equidistant from the wound edge. The needle is then reversed, the skin is penetrated again on the same side but closer to the wound edge and at this point, passes more superficially through dermis to the opposite side exiting the same distance from the wound margin, 1 to 3 mm. from the wound edge. The sutures are then pulled together bringing the wound edges together and at the same time, obliterating dead space and everting the wound edge. Care must be taken to place the right amount of tension on the suture edge so as to close the defect without crushing tissue and skin caught within the suture. Excessive pressure at the depth of the wound can cause ischemic necrosis and strangulation so, thus, it is important to minimize wound tension prior to tieing the knots. This is a strangulating suture with significant tension on the scar line. Thus, the vertical mattress suture is rarely used on the face because it does produce scarring. Other methods of reducing tension such as buried suture with fine approximating sutures are reserved for facial closures.

Horizontal Mattress Suture

Horizontal mattress sutures are used for minimizing wound tension, closing dead space, and further exaggerating wound edge eversion. Areas with significant wound tension such as the back, the chest, and the scalp may need a horizontal mattress suture to ensure that tension is reduced during healing. On wound closure, one or two horizontal mattress sutures may be used in conjunction with interrupted sutures to approximate a wound edge properly. With a horizontal mattress suture, the needle penetrates the skin 1/2 to 1 cm. from the wound edge and passes vertically to the depth of the defect across the depth of the defect then back out along the opposing side the same distance from the wound edge. It re-enters at the same distance from the wound edge and passes vertically to the depth of the wound and back out along an equidistant space on the opposing side. The double square knot is then used to tie this off, being careful that tension will approximate the skin edges and is not too great. This is a strangulating suture as the vertical mattress suture, and can crush the tissue with tension. A bolster may be used with the horizontal suture.

Layered Closure

A layered closure is the use of buried absorbable sutures in fascia, subcutaneous tissue, deep dermis, combined with the use of buried absorbable suture in deeper skin and tissue removes the tension from the skin edge and provides stable reduction of closure tension during healing. To perform this correctly, the wound must be prepared. This includes undermining the skin a minimum of 2 mm. and, at times, up to 1 cm. beyond the wound edge to reduce skin tension and for the accurate placement of the buried absorbable suture. Meticulous hemostasis has been accomplished prior to suture placement. The type of buried suture used depends on the thickness of the defect, the tension on the wound, and the amount of dead space.

The buried subcutaneous suture or the dermal subdermal stitch is begun first to the deep side of one of the undermined edges of the defect. This is accomplished by lifting the wound edge with a skin hook and advancing the needle tip 1 or 2 mm. from the wound edge on the undersurface of the skin. This allows the suture pathway to proceed upward through subcutaneous tissue entering into mid dermis. It will then pass through the wound margin at mid dermis and reenter the opposite wound side through mid dermis proceeding in an arc downward to the opposing subcutaneous tissue and exiting 2 or 3 mm. from the wound edge. The suture lines are then tied with the knot pulled along the long axis of the defect. This allows the knot to slide to the base of the defect in the subcutaneous tissue, burying the knot. Pulling the suture line perpendicular to the scar line will trap the suture upward creating an inadequate closure and a knot placed too high. Multiple buried subcutaneous sutures are placed along the defect reducing tension along the skin edge at critical points. This will then allow the placement of single interrupted sutures with no tension on the skin edge, minimizing scarring. It also stabilizes wound closure so that the interrupted suture may be removed in under seven days, producing a better cosmetic result. It also lessens the risk of surgical dehiscence when the interrupted sutures are removed. The buried absorbable suture will maintain closure tension during healing. Layered closure using buried sutures is a useful technique for skin closures and this author feels it can be used in most areas of the skin surface. Dangers with buried sutures include foreign body reaction, strangulation of deep tissue with necrosis, local infection, and prolonged inflammation.14

Chromic suture has the highest potential for inflammation and possibilities of secondary infection. This becomes increased if the suture is placed high on the surface or the knot is wide enough to strangulate deep tissue causing necrosis. If the knot is placed superficial with a significant amount of inflammation, a persistent nodule can occur which may last for months. It may cause suppuration with superficial necrosis and the suture extravasating or spitting through the surface.15 Rarely, it can induce scar tissue that will make a persistent nodule. Techniques to prevent these complications include:

• Choosing the appropriate suture material – both size and type.
• Avoiding absorbable buried suture in wound closure that has the potential for infection or already has bacterial contamination.
• Placing the knot deep enough in the subcutaneous tissue to avoid persistent nodules.
• Keeping the tie small and sliding it to the base, avoiding strangulation or necrosis.

After buried suture has been placed correctly, tension has been eliminated from the skin margin. At this point, the skin surface can be draped together and approximated with interrupted sutures. These can be removed in four to six days because there is no tension on the skin margin. It will, thus, be possible to avoid stitch marks along the scar line by removing the sutures early.

Complex Closures

Complex closures usually involve more extensive undermining and local skin movement. Both of these preliminary closure techniques involve a combination of suture techniques in the deeper dermis as well as on the skin surface. Each of these closure techniques will be reviewed in context to the clinical situation where it is most likely to be used. The basis of these techniques depends upon reducing skin tension with buried suture below the skin surface. This must be performed with fascial sutures, buried subcutaneous sutures, and interrupted dermal sutures to take the tension off the skin edge. It is only then that the variety of running suture, running locking suture, tip stitch, and running subcuticular sutures can be used for skin margin approximation.

Tip Stitch

The tip stitch is a modification of the horizontal mattress suture in which half the suture is buried. It is used to secure and close acute angles of closure with tips of skin that would be damaged by interrupted suture. In this way, the suture travels through the dermis of the tip and advances the tip with interrupted sutures on either sides. It, thus, is used to secure the tip of skin flaps without compressing the epidermal tissue and avoiding ischemic necrosis. Mechanically, the needle is passed through the skin on one side of the V, exiting mid dermis and penetrating the tip mid dermis and back out along the opposite side mid dermis. It then will go through the opposite side of the V at a mid dermal level and exit through the skin. As the suture is pulled, the tip will advance into the V with enough pressure for good closure. It then is tied with a double square knot. The tip stitch is useful in the closure of M-Plasties, angles along transposition flaps, geometric broken line closures, and Z-Plasties.16

Running Suture

The running suture can be used to close skin edges in wounds in which tension has been reduced fully. It is an approximating suture which can simply and easily close a long scar line. Using permanent suture, it is useful on body surface areas such as the retroauricular sulcus, upper eyelids, and supraclavicular neck where skin grafts are harvested. It can also be used for closures of body skin in which tension has been reduced with interrupted subcutaneous sutures. In facial closures, a running suture of 6-0 mild chromatized gut is used in conjunction with buried subcutaneous sutures to reduce tension. The mild chromatized gut suture, when placed under steristrips, will be absorbed in four to six days. When the steristrips are removed, the suture is absorbed. This will prevent suture marks or cross hatch scars and alleviates the need for suture removal.

The running suture is initiated by placing a simple interrupted suture at one end of the wound that is tied but not cut. Simple suture passes are then placed down the length of the wound as a “baseball suture” until the end of the suture line is reached. At this point, it is simply tied off with a simple knot created by the last loop of suture. Running suture shares tension along the closure line creating an even scar line. It is an easy and rapid method of closing wounds and when used correctly, it will create a cosmetically superior scar line. Performed incorrectly, though, it can cause thicker tissue to bunch and pucker and if placed too deeply, may create uneven edges. It can strangulate the epidermal edge if pulled too tight and create an uneven, cross-hatched scar.

Running Locked Suture

Locking the running suture as it is closed is a modification that will counteract some degree of tension on the skin edge. It can be performed as a locked suture for each pass or individualizing locked when needed for areas of tension along the scar line. Additionally, it may help prevent inversion of the wound edge which can account for an uneven thickness in skin types. This suture technique is best performed with an assistant who can grab the needle with each pass and place it back in the surgeon’s needle holder. It, thus, can be used efficiently for both running and running locked suture lines. The major disadvantage of this technique is that it may strangulate the skin edges creating excessive scarring. This is overcome by taking small bites and keeping tension on the suture line to what is minimally needed.

Running Subcuticular Suture

The running subcuticular suture uses a permanent monofilament suture placed as a horizontal running intradermal suture. The successful use of this suture is dependent upon reduction of tension below the skin surface with buried subcutaneous sutures. With skin tension removed, the two skin edges then can be draped together and approximated with a running subcuticular suture. The running subcuticular suture is begun by placing the needle through one wound edge and enters into the defect. The opposite edge is held firmly with a skin hook as the needle is passed in a horizontal pattern through the mid dermis. It exits with a 1/2 cm. pass and then is brought in approximation to the opposite wound side and enters the mid dermis. This is repeated on alternate sides of the wound as the suture is advanced down the wound edge. It is then terminated at the skin surface and then the surgeon can pull the monofilament back and forth to adjust the tension correctly. Because the suture is entirely below the skin surface, permanent monofilament suture may be left in place for two or even three weeks without risk of skin marks.17 At that time, the suture can be removed promptly by pulling out along the long axis of the scar line. Braided or silk suture should not be used as a subcuticular stitch as this cannot be removed after two weeks. The subcuticular suture is used primarily to enhance the cosmetic results with defects in which tension has been fully reduced and the skin edges are of relatively equal thickness.

Combined Closure Techniques

A preferential approach to facial defects in which maximal cosmetic results are necessary is to use as a complex closure the use of both buried absorbable suture and permanent suture. Closure is performed in a layered fashion with buried dissolvable suture in fascial layers of subcutaneous tissue and buried dissolvable suture place in the skin. Chromic suture or vicryl suture of 4-0 or 5-0 can be used depending on the thickness of the skin and the location of the excision. Tension should be fully removed from the skin with buried sutures so that the permanent skin sutures placed for final approximation will not have any tension or pull. This will reduce the incidence of suture lines and cross hatches or stretching on the scar line. For further approximation of an elliptical closure, 5-0 prolene suture may be used where tension still exists on the skin edge. Dog-ears or skin redundancy at the tips should be repaired at the time of closure and geometric points closed with appropriate tip stitches. A final skin layer of 6-0 mild dissolvable chromic suture is placed in the facial skin to further coapt the skin edges together and level the sides equally. A running baseball suture can be placed with no tension and ties at the ends. This mild chromic suture or fast dissolving suture is occluded with steristrips. Since this suture dissolves within five days, there will be no epithelial channels on the skin to create cross hatches or suture marks when the dressing is removed in seven to ten days. Being able to leave the wound dressing for this longer period of time will enhance the stability of the scar and lessen the incidence of dehiscence. Anti-tension tape stripping is important for both occlusion and to take tension off skin edges. These strips which are covered with narrow 1/2 inch flesh colored paper tape will create a stable wound bandage that may be left in place for the entire week. This will also cover the wound for protection and for cosmetic reasons during healing.

Techniques of suture and wound closure, thus, are essential for good dermatologic surgery. Though many of the techniques appear basic, a thorough understanding of these techniques is essential for the dermatologic surgeon to close wounds correctly.

Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

Laser resurfacing produces a partial thickness wound that will heal by second intention. The principles of healing the laser wound is very similar to that of those created by medium depth or deep chemical peeling or dermabrasion. Both chemical peeling and laser ablation creates a zone of necrosis – one thermal and one chemical, which will separate under the healing coagulation tissue. In this respect, there is a difference with dermabrasion in which there is very little necrotic tissue in the wound and healing can begin more promptly. Careful and meticulous wound care is necessary to prevent the coagulum from interfering with healing and become a nidus for infection, foreign body reaction and delayed healing.

Prior to the resurfacing procedure, pre-operative treatment of the skin with cosmoceutical agents can influence the post-operative course, quality of the final result, and the rapidity of healing. Treatment with these agents should be instituted as early as six weeks prior to the procedure. The following pre-operative preparation is frequently used prior to laser resurfacing procedures (1):

• Institution of sunscreen protection daily, and sun avoidance
• Exfoliation
• Tretinoin – retinoic acid
• “Bleach” formulation for specific skin types.

Preparation for laser skin resurfacing is discussed further in this chapter.

The most common usage of resurfacing procedures is for the reversal of photoaging skin. This includes the degenerative solar effects including lentigenes, dysplastic epidermal growths, collagen and elastic tissue damage, and other degenerative dermal defects. All of these result from the chronic effects of actinic damage and for this reason, it is advisable to institute a daily program of sunscreen protection and sun avoidance prior to the resurfacing procedure. The use of an SPF of 15 or greater with both UVA and UVB protection will place the skin at rest and allow its reparative processes to act in concert with the resurfacing procedure. The benefit of a full block encourage many physicians to recommend sunscreen which contains titanium dioxide or other mechanical block. Dysplasia and actinic proliferative dysgenesis has been found to improve with sunscreen protection alone.

Exfoliation is the use of either mechanical or chemical processes to remove the thickened stratum corneum and, thus, accelerate the process of epidermal proliferation. Stripping the stratum corneum will produce a thinner and more even outer epidermal layer. Some surgeons believe that this will make the first laser pass more uniform and, thus, the final result more even across the face. Other surgeons do not believe that this pretreatment is beneficial. Additionally, the more rapid epidermal growth rate will help skin healing and the quality of the final result.

Mechanical methods include mechanical exfoliation with buffing grains, mineral blocks, and exfoliant devices such as Buff Puffs and loofa pads. These can be used on a nightly or every other night basis for the purpose of thinning the stratum corneum. Over treatment, though, may inflame or irritate the skin and have a negative impact on healing. If the skin is inflamed or irritated, resurfacing should be deferred until this resolves.

Hydroxy acid preparations such as topical glycolic acid, lactic acid, and salicylic acid have a similar effect of chemically dissolving the stratum corneum and, thus, creating a proliferative epidermis with a thin and uniform stratum corneum. This also can be instituted on a daily or every other day basis but care must be taken not to inflame the skin. This is especially true for those patients who may have a sensitive skin problem such as atopic dermatitis, seborrheic dermatitis, or contact irritant sensitivities. The physician should warn the patient prior to the institution of exfoliation that if the skin becomes inflamed, the patient should discontinue the process and report this to the physician prior to the procedure. A negative rather than a positive impact from these agents can cause delayed wound healing and persistent erythema (2). The problems associated with negative impact have caused some physicians to eliminate pretreatment other than sunscreen and/or sun avoidance.

Tretinoin is the first pharmaceutical agent proven to have a positive reparative impact on photo aging skin. The effects have been demonstrated both in the epidermis and the dermis. Using a topical tretinoin preparation of 0.05% to .1% has shown histologically to reverse epidermal dysplasia, remove the thickened basket-weave stratum corneum, and accelerate epidermal proliferation. In relation to the surgical procedure, this effect has been shown to speed up wound healing after the procedure as well as have a positive qualitative effect on the final resurfacing result (3). Tretinoin is, thus, instituted four to six weeks prior to procedure on a daily basis. A retinoid dermatitis can occur in the first two weeks of its usage and care must be taken to curtail this inflammatory process prior to the resurfacing procedure. In normal skin, they will subside after two weeks, but in those with sensitive skin or susceptible to irritant dermatitis, one must decrease the dosage to every other day or even every third day until the retinoid dermatitis has subsided. There is a danger of performing this procedure when the dermatitis is active, as it will prolong wound healing and the syndrome of persistent erythema. Tretinoin can be used in the form of a cream retinoic acid (Renova) begun on a daily basis. The medication should be stopped five days prior to the procedure, but can be re-instituted again three to four weeks after the procedure to continue the positive effect.

As part of the pre-operative consultation, skin color must be taken into consideration for correct pre or post-operative treatment. Fitzpatrick’s skin type III through VI should be treated pre-operatively with a bleaching topical medication to prevent the complication of post-operative hyperpigmentation.(4) Treatment for this skin type as well as those patients with melasma or already existing mottled hyperpigmentation require the use of the following agents:

• Sunscreen protection
• Pre-operative tretinoin 0.05% to 0.1%
• Bleaching agent – hydroquinone 2% to 8%

Hydroquinone will prevent re-pigmentation by interfering with the production of new melanin. It acts as a tyrosinase inhibitor, preventing the reaction of tyrosine to dopa. Without the necessary precursors, the substraights are not available for renewed pigmentation.(5) The effects of hydroquinone are reversible and limited to the site of application. With hydroquinone applied six weeks prior to a chemical peel, the mechanism for reactive pigmentation is blocked. This agent is used in a concentration of 2% to 8% depending on the degree of pigmentary problems, applied in a b.i.d. dosage and continued until the day of the chemical peel. Side effects, though, can include irritation and allergic contact dermatitis which is more prevalent in the higher concentrations. The usual concentration for most mild to moderate pigmentary dyschromias or skin type III or IV is 2-4% hydroquinone. The use of concentrations of 6-8% though is helpful in helpful with more difficult pigmentary problems and skin types IV to VI. In these problems, necessitating 6 weeks of 8% hydroquinone pre-operative is helpful in enhancing the long term effect of preventing post-operative hyperpigmentation.(6)

Priming the skin with these cosmoceutical agents has been found to be effective in insuring the quality of the resurfacing procedure, enhancing the rate of healing, and preventing post-operative complications. Each of the agents listed must be evaluated independently as to the nature of skin type to be treated so that each patient received the appropriate pre-operative therapy. Trial pre-operatively will ensure that the patient is not having a side effect from the agent or contact irritant dermatitis which may contribute to a delatarious effect to the resurfacing procedure. Used correctly, priming the skin is equivalent to training an athlete to respond at his or her maximum for the final event. In this case, the event is the resurfacing procedure where the epidermis is prepared and trained to respond to its maximum.

The use of antiviral agents, antibiotics, antifungal agents, anti-inflammatories, and non-steroidal anti-inflammatories can all be instituted either pre-operatively or at the conclusion of the resurfacing procedure. These all have valuable effects for particular situations which will be reviewed during the wound healing segment of this chapter.

At the conclusion of the laser procedure, cool saline soaks or other dressings are placed over the wounded skin as the stage of inflammation and coagulation begins. The stages of wound healing are:

• Inflammation and coagulation
• Reepithelialization
• Granulation tissue formation
• Angiogenesis
• Collagen remottling (7)

Each of these stages has a definitive time table and must proceed in a step-wise fashion for final results of normal healing. The inflammatory phase has begun at the conclusion of the procedure with a brawny, dusky erythema that continues to progress during the first six hours post-operatively. Concurrently, coagulation begins with serum exudation characterizing the activation of kinins and complement as inflammatory mediators for neutrophils, macrophages and lymphocytes are released. The chemotactic factors elaborated attract neutrophils and monocytes to the injury site which remain over the first three to five days. This is the coagulation phase which clinically demonstrates serum exudation, edema, and accumulation of coagulum and fibrin, creating exudation and crust. From day three to ten, macrophages are present and subsequently direct the granulation tissue phase. This later attracts fibroblasts which direct the dermal reconstruction with collagen and elastic fiber remottling (8).

The process of reepithelialization begins after twenty-four hours with the initial migration of undamaged keratinocytes from hair follicles and wound margin to the surface of the injured skin. Inflammatory induced mediators such as fibronectin, laminin, and platelet derived growth factors stimulate keratinocyte cell movement over the granulation tissue bed. The matrix on which the migrating keratinocytes travel is fibronectin, a product of granulation tissue consisting of fibrin and collagen. The process of epiboly – the migration of epidermal cells horizontally across the denuded wound bed – continues until epidermal cells grow together. At this point, the undifferentiated keratinocytes begin a vertical differentiation migrating upward to recreate a normal epidermis (9).

Occlusion – either by salves, ointments, or biosynthetic membranes – conserve water content in the wounded tissue and, thus, accelerate the process of reepithelialization. Maibach and others have shown that occluded wounds reepithelialize faster than dry, desiccated wounds (10). A dry wound has a hard crust – scale on its surface, blocking the epiboly process and prolonging reepithelialization. Laser resurfacing wounds thus should not be allowed to dry and form a hard crust. It is during this phase that it is important to use debrident soaks and compresses as well as occlusive salves. These will soften and remove crusts and scale and prevent serum exudate from hardening.

Dilute acetic acid solution is a reliable soaking solution which is debrident, antiseptic and hydrating. One quarter percent acetic acid soaks can be prepared by adding one teaspoon white vinegar to one pint of water. This solution is antibacterial, especially against pseudomonas and gram negatives. In addition, the mildly acidic nature of the solution is physiologic for the healing granulation tissue and mildly debrident, as it will dissolve and cleanse the necrotic material and serum. Alternatively, saline soaks or water can be used . Daily post resurfacing wound care is recommended to facilitate healing and diminish the chance of infection. This would care can be performed with either ¼% acetic acid solution, saline or water. Cleansing agents should nto be used as they can cause irritation or dermatitis. Occlusive dressings including bland emollients, salves and biosynthetic membranes further hold in moisture and accelerate the granulation tissue phase and reepithelialization.

Two methods of wet or occlusive healing are available:

• Open occlusive healing with soaks, salves and ointments
• Closed occlusive healing with biosynthetic membranes

Both have merits and strengths and are used with equal success by various cosmetic surgeons. The open technique involves the use of repetitive compresses and soaks followed by the use of bland emollient ointments. Antibiotic ointments should not be used as these can cause dermatitis. Bland emollients or ointments include: petroleum jelly, or other long chain aliphatic hydrocarbons such as Eucerin (Biersdorf), Theraplex emollient (Medicis Corporation), Aquaphor, or other similar hydrocarbon emollients. Potential contact allergic or irritant sensitizers should not be used during this phase, as the newly healing skin is highly susceptible to irritant and allergic injury patterns. Topical antibiotic ointments with Neomycin or Bacitracin can become allergic sensitizers as well as moisturizers with perfumes, alcoholic preservatives, or stabilizers (11). Silvadene cream and aloe vera are also significant sensitizers that may create a secondary inflammatory reaction delaying wound healing. For this reason, bland emollients such as petrolatum or Aquaphor should be used rather than those with a higher risk of contact irritant or allergic sensitivity. The occlusive soak-salve healing method can be a successful technique of post-operative care. It permits close observation of the healing wound so that the patient and physician can recognize problems in healing early on. The patient, though, must be involved in wound care and be able to soak three to four times a day and apply ointments regularly. The patient can remain comfortable with occlusive salves in place but must understand methods of application and be able to perform these tasks regularly. Some patients, though, are not able to or do not wish to be so intimately involved in their wound care and for these, it may be easier to use biosynthetic membranes.(10)

The newer biosynthetic occlusive dressings create the necessary occlusive environment for faster wound healing and seems to decrease pain after laser resurfacing. It is thought that the occlusive dressings not only provide a moist environment for healing, but may retain growth factors at the surface of the wound that can shorten the inflammatory phase and accelerate the appearance of fibroblast and blood vessels during wound healing (12). Although, many membranes allow exudation to occur, it has been found that normal bacteria flora and pathogenic organisms can increase in some of these occlusive wounds. For this reason, it is recommended that occlusive dressings should be changed every twenty-four to fourty-eight hours.(13)

The biosynthetic occlusive dressings fall into three categories: 1) hydrogel; 2) polyurethane membrane; 3) silicone membrane (14). The hydrogel membrane prototype is a layer of hydrogel between two pieces of polyethylene oxide. This type of dressing (Vigilon – Hermal Labs, Delmar, New York, Second Skin) absorbs exudative material and is occlusive to water while still transmitting oxygen. It is used extensively by cosmetic surgeons with successful wound healing but must be changed daily with daily soaks to debride the exudative material and remove precipitated portions of the hydrogel.

The second variety is the polyurethane membrane which has less absorbent potential than the hydrogels. Flexzan is the polyurethane foam dressing most useful in laser resurfacing. Its conformability along with ease of application and comfort, make it a desirable dressing for resurfacing procedures. The third variety is silicone membrane dressings such as Sylon TSR (Biomed, Inc., Bethlehem, PA). This is a semi-permeable membrane coated on one surface with collagen peptides which has the capacity to decrease water loss from the wound (15). This particular dressing is easy to apply and can remain in place twenty-four to forty-eight hours.

Although some laser surgeons prefer to leave the biosynthetic membranes in place longer than two days at a time and continue their usage through healing, the risk of infection increases if the dressing is left on over 48 hours. I prefer to switch to the open occlusive technique of soaks and salves after 48 hours. It is at this time the patient should be involved in wound care and open technique seems to prevent secondary staph, gram negative bacterial infection or yeast infection reported with occlusive membranes.(16)

The granulation tissue phase in wound healing is directed by the fibroblast. It produces matrix, collagen and elastin, GAG’s and proteases that stimulate dermal remottling (17). At the same time, angiogenesis begins with endothelial cells migrating directly into the wound during the granulation tissue phase. The neo-vascularization is necessary for collagen remottling and the final phase of fibroplasia. Collagen and elastic tissue remottling begins at the conclusion of granulation tissue phase after reepithelialization occurs and is responsible for the manufacturing of new dermal collagen and the changes in texture of the skin. It, thus, begins at the second week post-operatively and may continue as long as four to six months. Persistence of fibroplasia with neoangiogenesis can account clinically for the prolonged erythema and prolonged improvement in texture over this period of time.

The laser surgeon should follow his patients during the post-operative period regularly to monitor healing and thus prevent complications. Biosynthetic membranes should be changed every two or three days and at that time, the surgeon has the opportunity to inspect the healing wound and monitor the stages of healing. The complications seen in laser resurfacing can be recognized early during healing stages. The laser surgeon should be well acquainted with the normal appearance of a healing wound in its time frame for depth of resurfacing. The elongation of the granulation tissue phase beyond ten days may indicate delayed wound healing. This could be the result of viral, bacterial or fungal infection, contact irritants interfering with wound healing, or other systemic factors. A red flag should alert the physician that careful investigation and prompt treatment should be instituted to forestall potential, irreparable damage that may result in scarring. Thus, it is vitally important to understand the stages of wound healing in reference to laser resurfacing so that the cosmetic surgeon may avoid, recognize and treat any and all complications early on.

Herpes simplex virus infection can be a major complication of laser resurfacing. The wounding effect of the laser can be an activating factor, stimulating recurrence of herpes virus. It, then can spread over the entire denuded facial surface and potentially create scars. It is important for the virus to be suppressed by an anti-viral drug. Acyclovir (Zovirax) and its other new agents (Famvir, Valtrex) inhibit viral replication in the intact epidermal cell. The drug does not prevent the migration of the virus down its neurotrophic pathway, but will stop viral growths and reproduction once it is transmitted to the epidermis (18). The practical implication is that the drug can be instituted prior to the procedure but must be continued until the epidermis is fully formed. In most resurfacing procedures, this means the anti-viral agent should be continued until ten to fourteen days. It is judicious to treat all patients prophylactically with anti-viral agents as an accurate history of herpes virus infection cannot be obtained as part of a pre-operative evaluation (19).

Generally speaking, if biosynthetic membranes are used, systemic antibiotics are necessary. The most common bacterial infection is staphylococcus and these are a problem with occlusive dressings that do not permit exudation where necrotic material and serum can serve as culture media for pathogenic bacteria.(20) For open occlusive salves with frequent soaks, prophylactic antibiotics may not be necessary. I personally do not use antibiotics post-operatively because the frequent and meticulous soaks and ointments seem to prevent the accumulation of debris preventing bacterial infection. If, though, occlusive membranes are used, anti-staph antibiotics such as dicloxicillin, methicillin, or cephalexin should be instituted in non-allergic patients.

Rarely, a gram negative bacteria may be a problem, especially in a patient who had been on anti-staph antibiotics or even long courses of tetracycline. In this case, the possibility of pseudomonas, klebsiella or e-coli infection should necessitate the antibiotic use for gram negative coverage. Antibiotics of choice include cephalexin or ciprofloxacin. It has been reported in patients using occlusive membranes and those on antibiotics that secondary candida infection can be a problem. The physician must be alerted to this complication and at the first clinical signs of candida or yeast infection, ketaconazole or itraconazole should be instituted.(21)

Some surgeons use anti-inflammatories in all patients with laser resurfacing. Forty mg. of Triamcinolone and Celestone is given intramuscularly at the conclusion of surgery and in most cases, this is sufficient to suppress the prolonged inflammatory reaction. Some patients, though, may need a second dose on day three to five, but this should be an individual decision as to the degree of inflammation and the rate of wound healing. The single dosage is recommended above a prolonged course of oral corticosteroids.

Mild to moderate pain medications such as acetaminophen, propoxyphene or oxycodone are usually sufficient to control discomfort in the first twenty-four to forty-eight hours. Any patient who complains of severe pain should be evaluated, as to the cause of the pain. Severe pain post-resurfacing is uncommon and may be the first sign of a complication. After that, analgesic medication is not necessary. Non-steroidal anti-inflammatories have been used as a post-operative medication and may help suppress the mediators of inflammation during the early phases of wound healing.

Frequent post-operative visits are essential to monitor the healing and direct the patient in wound care. It is during this time the patient needs guidance, motivation and support. A knowledgeable and supportive nursing staff can make this phase more tolerable to the patient who is homebound and restricted from normal activities. I would encourage frequent office visits, daily phone calls, and emotional support for the patient to care for the healing wound correctly. It also allows the physician to monitor closely any abnormal aberration in healing and respond with early intervention minimizing complications.

After epithelialization is complete – usually ten days to two weeks – soaks, occlusive dressings and ointments are discontinued. The patient should first be placed on a mild cleanser (Cetaphil, Neutrogena, Aveeno) and mild moisturizer (Eucerin, Theraplex, Neutrogena Facial). If there are areas of intense erythema or contact irritant dermatitis, these now could be treated with a topical steroids such as triamcinolone ointment or hydrocortisone 2.5% ointment for up to two weeks. A sunscreen with UVA and UVB block is necessary for the patient to resume normal activities but this should be one with little irritancy potential and an SPF of at least 15. Sunscreens that provide a mechanical block are preferred. All lotions with acetyl alcohol should be avoided, as the patient is more susceptible to contact irritant and allergic dermatitis at this stage of healing.

Cosmetics and make-up can be resumed but the patient should be warned that they may be more susceptible to irritation. For this reason, they should be used cautiously, conservatively, and if irritancy occurs, a non-sensitizing cosmetic should be used. For prolonged erythema, a green tint underbase can camouflage this. It is at this point that the physician should encourage the patient to resume as much normal activity as possible but monitoring weekly still should continue through the first month.

The phase of wound healing after laser resurfacing is as important in patient management as the operative procedure itself. It is here that the physician utilizes his/her knowledge of skin and wound healing, and his/her ability as a practitioner to recognize normal healing and manage pathology. Managing patients post-resurfacing has an associated learning curve. Until the physician learns to recognize and manage the potential problems and complications, consultations should be obtained as needed.