1 A comprehensive skin care system prevents the effects of chronological and environmental age and therefore More and more patients seek cosmetic rejuvenation Treatments Retinoic and glycolic acid preparations chemical peels botulinum and collagen injections dermabrasion laser resurfacing

2 Tretinoin (Retinoic Acid) The most consistent and significant improvement within 4-10 months of therapy are: Skin texture Mottled hyperpigmentation Fine wrinkles The use of 0.05% and 0.1% tretinoin cream for 6 months leads to an increase in epidermal and granular layer thickness.

3 Complication The most important complication of retinoic acid is its tendency to cause skin dryness, therefore new emollient formulations have been produced. Clinical improvement of fine wrinklin Histologically After 24 weeks of use, reversal of stratum corneum compaction and epidermal and granular thickness is observed After 48 weeks of use melanin content decreases and epidermal mucin increases

4 Alpa Hydroxy Acids ( AHAS ) AHAs are linear organic carboxylic acids with an attached hydroxyl group and can be derived in natural foods; hence the common name, fruit acids. Glycolic acid ( in sugar cane) the simplest and most popular one is available in concentrations ranging from 5% to 15%. Higher concentrations of this acid are used in chemical peels. Other fruit acids are: Lactic acid from sour milk Citric acid from citric fruits Tartaric acid from grapes Malic acid from apple

5 The use of AHAs has been shown to reverse histologic sings of photoaging by: Increasing epidermal thickness Reversing basal cell atypia Dispersing melanin pigmentation and Normalising the rate pattern of the dermoepidermal junction The increased skin thickness is attributed to increased synthesis of: Glycosaminoglycans Collagen Elastic fibers

6 Chemical Peels The process of chemical peeling involves the application of a caustic agent on the skin to produce a controlled, partial-thickness inlury. Chemical peels are categorized into Superficial peels Medium depth peels Deep depth peels

7 Superficial Peels Superficial peels penetrate the epidermis down to the dermal- epidermal junction Some superficial peeling agents are: Jessner’s solution Glycolic acid at concentrations of 20% to 70% Trichloacetic acid at concentrations of 15% to 35% Obagi “blue peel”

8 Jessner’s solution Jessner’s solution is a combination of Resorcinol Salicylic acid Lactic acid In an alcohol solution Triple layer application produces stratum corneum separation with upper intraepithelial and intercellular edema.

9 Glycolic acid Glycolic acid at concentrations of 20% to 70%. The effect of the peel depends on the length of time it is left on the skin. Therefore it has to be neutralized either with water of sodium bicarbonate to prevent deeper dermal penetration Usually are performed in a series of 4 to 6 treatments at 1 to 6 week intervals in order to improve Skin shallowness Dyspigmentation Fine wrinkles Mild photodamage For the last two an initial application of 70% unbuffed glycolic solution is recommended for a duration of 4 to 8 min.

10 Trichloacetic Acid TCA CAUSES Necrosis Exfoliation of normal and actinically damaged cells Percipitation of epidermal proteins Therefore application of TCA causes: Transient frosting Erythema A great advantage of TCA is that it is nontoxic systematically and is neutralized by serum in superficial dermal blood vessels.

11 Obagi “blue peel” Obagi, “blue peel” contains a non ionic base with glycerin and saponine in order: To slow the rate of TCA action and To gauge the depth of peel A light blue endpoint signifies exfoliation to the stratum corneum while a dark blue endpoint denotes coagulation to the basal layer of the epidermis Superficial peels are desirable because: All skin types can be treated Have a minimal recovery time Minimize serious adverse sepuale

12 Medium Depth Peels Produce an injury depth down to the upper dermis and are best in use in: Actinic keratoses Dyschromia Mild wrinkling

13 TCA 40% to 60% can cause: Epidermal necrosis Edema Homogenization of the papilary dermis Sparse lympholytic infiltration in the midretieular dermis within 3 days after application TCA 60% to 75% Recommended only for spot treatment of localized keratoses 50% of TCA may be applied either: in a rapid fashion over the entire face without overcoating of In a slow controlled manner to each cosmetic unit Eyelids are peeled with 20% to 35% TCA

14 In an attempt to decrease the risk of complications ( hypochromia) a superficial agent is used initially. After decreasing the skin with acetone either dry ice or Jenssen’s solution can be applied to initiate an epidermal injury. This then enables the 35% TCA to penetrate more readily. These two deepest medium depth peels dry ice and TCA are not recommended for skin types V and VI due to the visit of hypopigmentation. A newer combination is the use of 70% unbuffered aqueous glycolic solution to soapclean skin without prior decreasing with acetone. Left on for 2 min this solution causes epidermolysis enabling deeper penetration of subsequent 35% TCA solution application.

15 Deep Peels Indication for their use include: Deep rhytides secondary to photodamage Severe or extensive actinic keratoses Baker’s formula Baker’s formula is the most common one. It is composed of mixture containing: 3ml 88% phenol US8 3 drops croton oil (augments phenol penetration causing epidermolysis) 8 drops Septisol (increases surface tension and slows the penetration of phenol) 2ml distilled reaction

16 Phenol The reaction following application of phenol is characterized by: Keratocoagulative necrosis of the epidermis extending into the papillary dermis A marked inflammatory reaction Epidermal regeneration begins within 48h and is completed within 1 week Dermal regeneration takes longer than the epidermal and is characterized by rigid, compact collagen in the upper dermis replacing the disorganized collagen seen in elastosis.

17 Cardiac arrythmias sometimes severe Deep phenol peeling may lead to irreversible hypopigmentation and therefore is advised not to be used on skin types V and VI.

18 Complications Of Chemical Peels Adverse sequelae following superficial and medium depth peels are usually minor and reversible including prolonged erythema and post inflammatory hyperpigmentation. Hypertrophic scarring can occur, rarely and can be managed by the use of anyone or a combination of therapies including topical or intracesional steroid, silicone gel sheeting and pulsed dye laser irradiation. 3t is a common practice to pretreat patients with tretinoin or/and hydroquinone for 4 to 6 weeks prior to a chemical peel. This regimen decreases the stratum corneum thickness ensuring a more uniform response following the application of the peeling solution.

19 Botulinum Toxin History Of Botox 1895 Van Ermengen de Gard discovers Clostridium botulinum 1946 Lamanna and Schantz crystallize the toxin 1950 Vernon Brooks suggests its possible use Publication of the first papers describing experiments in animals 1980 Alan Scott uses botulin in the treatment of strabismus Carruthers and wife apply it to the glabella 1988 MH Marion introduces it to France 1995 B Ascher, MH Marion demonstrate its potential for use in the frontoglabellar and peri-orbital area

20 Indications In Cosmetic Surgery Of The Face Horizontal forehead lines Glabellar frown lines Crow’s feet wrinkles (orbicularis oculi).

21 New Indications The platysmal muscle of the neck Platysmall bands 2-3 points, 0.05ml Horizontal creases of the neck, 20 to 30U Lower eyelid, 0.025ml, into subcutaneous tissue only. Adjuvant to fat transplants and fillings (Fagien 0.05ml >> 1.25 U) Décolletage Discarded Indications Horizontalisation of the labial commissure Peri-buscal lines Naso-labial furrows Marionette lines

22 Results Results are visible between Day 4 and Day 7 Effective for 4 to 6 months Subsequent return of tonus In some cases dose dependent, in others not Easing of headaches due to frontal hyperkinisis

23 Immunisation/ Resistance Predisposing factors for formation of antibodies. Short interval between 2 injections (a minimum 9 weeks should be observed High doses at a single session No production of antibodies in treatment of blepharospasm even though doses are 5 times those used in cosmetic therapy.

24 Contra-indications Absolute Myasthenia gravis Pregnancy, breast-feeding Lambert-Eaton Syndrome Relative Anticoagulants Combination with curares and aminoglycosides

25 Secondary effects/ Complications Eyebrow droop Prosis ‘Diabolic’ eyebrow Bags under the eyes, resolvent ( 2 cases at 15 days/ 1 case at 30 days) Palpebral edema Oculomotor paralysis Diplopia Hematoma

26 Conclusion Spectacular results Very reliable procedure, limited invasivity, low morbidity No immobilization, even on a temporary basis No anesthesia Adjuvant or preparatory therapy to accompany other medical/ surgical techniques No definitive complications Simple to use compared with fronto-orbital surgery, and an ideal solution in our hyperactive society with its requirement for increasingly short periods of social or professional indisposition.

27 Collagen Injections Aim: to elevate skin contour depression. There are three formulations of injectable exogenous collagen: Zyderm I (contains 35mg/cc and 0.3% lidocaine) Zyderm II(contains 65mg/cc and 0.3% lidocaine) Zyplast (which consists of highly purified bovine collagen with 0.3 lidocaine and % glutaraldehyde. Cross links in the collagen molecule are produced with the addition of glutaraldehyde to make the collagen more resistant to degradation by proteolytic enzymes and less immunogenic.

28 Collagen Injections Zyderm I is the most versatile and is used to correct superficial dermal defects. It is very good for upper lip and “crow’s feet” lines. Zyplast is used for deeper dermal defects such as the nasolabial folds and is best placed in the mid-dermis. To optimize clinical correction after Zyplast injection there can be immediately implantation over the mid-dermal Zyplast injection of Zyderm I.

29 Complications of collagen injections Common: Erythema Temporary overcorrection Wheal formation Edema Brusing

30 Complications of collagen injections Occasionally: Skin lumpiness Hypersensitivity reactions ( despite negative skin testing) Reactivation of herpes simplex infection

31 Complications of collagen injections Rarely: Adverse sequelae ( include recurrent intermittent swelling at the treatment site) Local necrosis Abscess formation Loss of vision ( due to collagen embolus to the ophthalmic artery)

32 Microdermabrasion Microdermabrasion (MDA) is a new procedure used for the treatment of cosmetic problems and especially to combat: Dyschromia Fine wrinkles Mild scarring Freedman MB. Ryeda-Petraza E, Waddell SP in a study of 10 subjects, aged from 31 to 62 years, underwent a series of six aluminumoxide MDA facial treatments with 7 to 10 days intervals. Biopsies were obtained prior to the study, after three and after the last treatment.

33 They observed the following histologic changes: Thickening of the epidermis and dermis Flattering of the rete pegs Vascular ectasia and perivascular inflammation Hyalinization of the papillary dermis with newly deposited collagen and elastic fibers.

34 Shim et al in another study of 14 patients who underwent MDA treatments over 12 to 14 weeks, with intervals one week, by patient assessment they observed that there was statistically significant improvement in: Roughness Mottled pigmentation Of skin appearance but not in deer rhytids Acne scarring sometimes improved, but required deeper ablation.

35 Nonablative Rejuvenation The epidermis and superficial dermis can be selectively damaged by two basic mechanisms: By targeting discrete chromophores in the dermis or at the dermal-epidermal junction or By using midinfrared (IR) lasers in the range of 1.3 to 1.55 μm, wavelengths at which absorption by water is weak enough that relatively deep beam penetration is allowed ( only 50% beam attenuation at depths of mm )

36 Lasers That Target Discrete Chromophores Pulsed Dye Laser (PDL) PDL emit yellow light, which selectively targets hemoglobin and melanin. This wavelength allows for 50% dermal penetration to a depth of approximately 400μm. Pulse duration typically spans 0.35msec to 1.5msec but a more recently introduced version can deliver pulse trains of up to 40msec.

37 Lasers That Target Discrete Chromophores and Tissue Water 1064 nm Q-switched Neodymium: Yttrium-aluminum-garnet Laser The chromophores for 1064 radiation are, in decreasing order Melanin ( absorption coefficient of 55 cm­1 for a single melanosome) Hemoglobin ( about 4 cm-1 for blood with 45% hematocrit) Water ( 0.1 cm-1)

38 The Q-switched Nd:YAG laser was the first laser used as a nonablative tool for skin rejuvenation. Goldberg and Whitworth treated 11 patients with perioral or periorbital rhytids, all of them were skin types I and II; all had class I or II rhytids laser at fluence of 5.5 J/cm2 with a 3mm spot size and an endpoint of pinpoint bleeding. Newman et al treated 12 patients with q-switched Nd:YAG laser in conjuction with a carbon- suspension lotion. Two patients were selected for study from each skin type category (I-VI). 4 treatments were delivered at 7 to 10 day intervals and treatment parameters included a fluence of 2.5 J/cm2, a repetition rate of 10Hz and a 6 to 7mm spot.

39 They observed that: Erythema persisted longer in patients with skin types III and IV Rhypid improvement was scored at 25% for all skin types Pigmentary improvement was greater 35% in skin types IV through VI than in types through I through III (20%).

nm Diode Laser Hemoglobin, melanin and water are all targeted at this wave length. Mucine et al used a 980nm diode laser in vitro and invivo in a study treating solar elastosis. The treatment parameters included: pulse duration of 400msec and power range of 6 to 24w

41 The authors observed that at 8w 16% tissue shrinkage was obtained which compared favorably with three passes with a CO2 laser 15%. Two patients were also treated as a part of wound healing studies, and biopsies were performed 6 and 21 days after treatment.

42 The biopsies revealed : Almost complete digestion of denatured collagen on day 6 and A modest amount of unorganized new collagen deposition. By day 21: The band of collagen bundles was thicker than before treatment and New elastin fibers were observed throughout the dermis These histologic changes persisted for at least 1 year following treatment

43 Intense Pulsed Light (IPL) IPL is a nonlaser light source that emits a broad, continuous spectrum of electromagnetic radiation ranging from 500 to 1200 nm. With cutoff filters shorter wavelength portions of the spectrum can be blocked. The transmitted spectrum targets hemoglobin melanin and water in varying degrees depending on the filter the doctor is using.

44 The effect on dermal collagen is presumably caused by: heat diffusion from the vasculature and the secretion of inflammatory mediators induced by direct vessel heating. Tissue water is also directly heated to a smaller degree.

45 Goldberg and Samady treated 15 patients in a comparison study of the IPL and 1064nm lasers. Cosmetic units were divided into one control and three treatment quadrants and the number of treatment sessions ranged from three to five performed at 2-week intervals.

46 The three treatment types consisted of: the IPL with 590nm filter the IPL with 755nm filter and the 1064nm Nd:YAG laser.

47 The Nd:YAG laser pulses were comprised of : the three 3-to-8 msec pulses in a train with a 2-to 30msec interpulse delay total fluence of 100 to 130 J/cm² were applied with a 6mm spot-size handpiece.

48 24 weeks after treatment, wrinkle improvement was similarly modest for all three treatment types. Overall the Nd:Yag laser was better tolerated by the patients than the IPL.

49 Combining Short And Long Wavelength Lasers Some physicians combine the two lasers to target discrete chromophores and tissue water in the same session. One of these techniques has been used in a clinical trial (personal communication Min-Wei Christine Lee, MD, MPH, Director, The East Bay Laser and Skin Care Center, Walnut Creek, CA, 2001). Dr. Lee evaluated a long pulsed KTP laser (Aura Laserscope, San Jose, CA) and a long pulsed Nd:YAG laser (Lyra, Laserscope, San Jose CA both separately combined for noninvasive rejuvenation.

patients with skin prototypes I through IV were treated 3 and 6 times at 4 to 6 week intervals and were observed for 3 to 6 months following the last treatment. The patients were divided into 3 groups: 50 patients were treated with the 532nm Nd:YAG laser alone. 50 with the 1064nm Nd:YAG laser alone 50 patients were treated with both lasers at the same visit first with the 532nm laser followed by the 1064nm laser.

51 Patients with skin prototypes I through IV were enrolled for the first and third group and patients with skin prototypes I through V were enrolled in the second group. The number of treatments was based on the level of patients’ satisfaction. The physician, another independent observer and the patient also evaluated redness, pigmentation, rhytids, skin tone tightness and texture using a severity scale before the first treatment session and after the final treatment.

52 The Group treated with 532nm Nd:YAG laser alone after 3 to 6 treatments showed: 70% to 80% improvement in redness and pigmentation 20% to 40% improvement in skin tone and tightening 30% to 40% improvement in skin texture and 20% to 30% improvement in rhytids. In general fluences and pulse widths ranged from 6 to 10 J/cm and 10 to 30msec depending on the epidermal hyperpigmentation the areas had. For telangectasias fluences ranged from 6 to 24 J/cm² depending on spot size and vessel characteristics.

53 The group treated with the 1064 nm Nd:YAG laser alone after 3 to 6 treatments showed: 10% to 20% improvement in redness 0% to 10% improvement in pigmentation 10% to 30% improvement in skin tone and tightening 20% to 30% improvement in skin texture and 10% to 30% improvement in rhytids. Fluences ranged from 22 to 26 J/cm² with a 30 msec pulse duration and the 10mm cooling handpiece.

54 The group treated with the combined laser approach after 3 to 6 sessions showed: 70% to 80% improvement in redness and pigmentation 40% to 60% improvement in skin tone and tightening 40% to 60% improvement in skin texture 30% to 40% improvement in rhytids.

55 Lasers That Exclusively Target Tissue Water Midinfrared lasers with deeply penetrating wavelengths can be coupled with surface cooling to stimulate new collagen production by gentle dermal heating. These are 3 lasers that target water and penetrate to a depth of 0.4 to 2.0mm: 1.54 μm Enbium Glass Laser 1.32 μm Neodymium: Yttrium aluminum-garnet Laser 1.45 μm Diode Laser The respective tissue absorption coefficients are approximately 3cm-¹, 8cm-¹ and 20cm-¹ for 1.32-μm, 1.54-μm, and 1.45-μm respectively.

nm Neodymium: Yttrium-aluminum-garnet Laser The 1320 Nd:YAG laser was the first commercially available system designed exclusively for selective dermal heating and several studies have been conducted using the laser coupled with a cryogen-spray cooling system. Several recent studies have demonstrated the effectiveness of this laser system for treating mild periorbital and perioral rhytids and atrophic scars.

57 Goldberg studied 10 female subjects aged 40 to 64 years with class I to III facial rhytids and Fitzpatric skin types I-II. Patients were excluded if they had used oral retinoids within one year prior to the study, or had a history of photosensitivity or inflammatory skin disease. All patients were treated 4 times over a 16-week period with a 1320 Nd:YAG laser. Fluences varied between J/cm2. Energy was delivered with approximately 30% overlap and a 5mm spot size. Dynamic cryogen cooling was applied for 30 ms with a delay time of 40 ms before each laser pulse. Peak measured therapeutic temperatures from 40 C to 48C were obtained. Endpoints of reactive erythema were sougth. To achieve this some subjects required one pass of laser treatment and some two passes. All of the patients were evaluated six months after the last treatment and for immediate and delayed complications. Improvement was evaluated in 4 categories.

58 Six months after the final treatment the following were observed: GradeResponseNumber (n=10) 1No improvement2 2Some improvement6 3Substantial improvement2 4Total improvement0 All patients showed histologic evidence of new collagen deposition and 6 showed that deposition after 4 months of the last treatment. Also no erythema, pigmentary changes or scaring was noted in any of the subjects

Diode laser The midinfrared 1.45μm diode laser targets tissue water and penetrates skin to a depth of approximately 500μm. Although this system is similar in several respects to the 1320 Nd:YAG laser system, there are a few important differences. The diode laser is a low-power system. With peak powers in the range of 10 to 15W, relatively long exposures are required to achieve sufficient fluences for selective dermal heating.

60 Typical diode laser exposures are 150 to 250ms versus an approximately 20ms macropulse (train of three 300ms pulses) for the 1320 Nd:YAG system. These longer pulse durations require cooling to be delivered in a sequence of sprays before, during and after the pulse. The total fluence (roughly J/cm2) is about ½ that used to achieve similar immediate responses (edematous papules) with the 1320 Nd:YAG laser (1600μm penetration depth). This higher treatment fluence is required because of the deeper beam penetration: the 1320 Nd:YAG laser beam must fill a larger tissue volume to achieve the same temerature effect.

61 We studied 50 subjects, skin types I through III age range years. All subjects were treated three times with a 1450nm diode laser over a period of weeks. Half of subjects were simultaneously submitted to 7 mictodermabrasion facial treatments at 15 days intervals. Clinical and photographic assessments were recorded monthly. Self rated questionnaires were given in order to evaluate patient satisfaction score. All subjects were evaluated one month after the last treatment. To our disappointment, the analysis did nit indicate any statistically significant macroscopic wrinkle improvement in the majority of the subjects that have been treated with single nonalative laser therapy. In this group the patients satisfaction score was low. Only 10% were satisfied with the overall results.

62 On the second group with the combined protocol, although the rates of clinical wrinkle improvement were similar to the first group, the patient satisfaction score was considerably higher. By patient assessment, there was an overall improvement of skin appearance. We suggest that despite the reports of histologic evidence of new collagen formation our study failed to prove any noticeable macroscopic wrinkle improvement.