Cosmetic Dermatology Lecture 14 PDF

Lecture 14 – Cosmetic Dermatology This lecture is intended to provide a basic understanding of the various procedures performed by cosmetic dermatologists. This understanding is necessary so that initial patient inquiries can be appropriately answered prior to referral to a dermatologist. The term...

Lecture 14 – Cosmetic Dermatology This lecture is intended to provide a basic understanding of the various procedures performed by cosmetic dermatologists. This understanding is necessary so that initial patient inquiries can be appropriately answered prior to referral to a dermatologist. The term “cosmetic” has several definitions, but for the purpose of this lecture, it is defined as: 1. Anything specifically done to make a person look younger. 2. Anything done to change the appearance of something that most people would consider normal in appearance. For example, most people would not consider papules, pustules, and cysts on the face to be normal; therefore, treating acne is not cosmetic. Most would consider a freckle on the face to be normal, so removing the freckle would be cosmetic. Facial procedures generally treat the following: wrinkles, roughness, and abnormal pigmentation. Recovery time refers to the amount of time needed until it is no longer apparent that the patient is healing from a procedure. It is important to note that the vast majority of aging of facial skin is due to chronic effects of UV light (photodamage/photoaging). If individuals used sunscreen every day from infancy, the skin of the face would show very little aging. This becomes evident by looking at the skin of the upper inner arm, which is naturally photoprotected and does not, therefore, undergo significant photoaging. The facial skin could have the same qualities (very few wrinkles, even texture, even pigment) if not for the chronic effects of ultraviolet light. “Wrinkle Creams” The search for a cream to make people look younger has been intense and lucrative. Most creams have antioxidants (vitamin C, vitamin E) that prevent further damage and allow existing damage to heal, co-enzymes (copper, co-Q) and precursors (amino acids, peptides), both of which accelerate natural production of favorable substances. Data supporting their use is not strong. Most patients who use any of the above will show an improvement in their appearance, because regular use of any moisturizer will improve the skin’s appearance through improved hydration. Several types of creams have been shown to cause the skin to appear younger: 1. Alpha-hydroxy acids. These agents mainly improve the texture of the skin surface, leading to smoother, softer skin that “glows” because it reflects light better. 2. Sunscreens. These agents improve the skin’s pigment distribution when used chronically. They also decrease the rate of photoaging by preventing further ultraviolet damage.  3. Retinoids. These are by far the most effective topical agents for improving the appearance of the skin. With chronic use, they improve the texture, pigmentation, and wrinkles of the skin, by promoting normal differentiation of epidermal keratinocytes and by stimulating dermal fibroblasts to produce collagen. The combination of a topical retinoid and sunscreen will have dramatic effects with chronic use. This combination will not improve the appearance of deep wrinkles, but will very significantly improve the appearance of fine wrinkles, abnormal pigmentation, and roughness. Side effects of topical retinoid use are mainly limited to erythema, scaling, and itching, and are most prominent for the first 6 weeks of use. They improve dramatically with continued use. Topical generic retinoid costs $30-75/month if applied to the entire face daily. A broad spectrum sunscreen should also be used every day, so new photoaging does not occur to replace the photoaging being repaired by the retinoid. Botulinum Toxin (Botox) Botox is effective for improving the appearance of dynamic wrinkles (i.e., wrinkles visible with facial expression but not visible when the face is at rest). It is most effective for forehead and periorbital wrinkles. Botox does not have any effect on static wrinkles (wrinkles visible when the face is at rest). It does not have any affect on roughness or abnormal pigmentation. The procedure involves multiple injections of very small amounts of toxin into the facial skin, which is moderately painful for an extremely brief period. The recovery time is less than 30 minutes. The effect is apparent in 1-2 weeks and lasts for 3-6 months. Botox works by blocking the release of acetylcholine from motor nerves. The cost of the procedure is generally between $400 and $800. Injectable Fillers Injectable fillers improve the appearance of static wrinkles, but are not effective for dynamic wrinkles, roughness, or abnormal pigmentation. They are most useful for wrinkles in the glabellar area, nasolabial folds, and perioral area. The procedure involves multiple injections of relatively large amounts of filler into the dermis. The filler actually fills in the wrinkles. It is very painful for a relatively brief period. Recovery time is often brief, but there can be bruising and swelling that takes several days to resolve. The effect is almost immediate, lasting varying amounts of time depending on the filler material used. The filler works by actually adding material to fill in depressions (wrinkles) in the skin. There are many types of fillers on the market, but the most common material is hyaluronic acid. The cost of the filler is generally between $500 and $1000. Chemical Peels Chemical peels are classified according to the depth of the peel: superficial (only the superficial epidermis), medium (the mid-epidermis), or deep (the entire epidermis and superficial dermis). Superficial peels are effective for very fine, superficial wrinkles, mild dyspigmentation, minimal roughness, and acne. Often multiple superficial peels are required to see significant benefit. Medium depth peels are effective for fine wrinkles, significant roughness, and significant dyspigmentation. A single peel is usually sufficient. Deep peels are effective for deep, significant wrinkles, severe roughness, and severe dyspigmentation. A single peel is sufficient. All peels involve application of acid to the skin. Superficial peels are minimally painful for a moderate amount of time. Recovery time is 1-2 days. Medium depth peels are extremely painful, and sometimes require conscious sedation in order to tolerate the procedure. Recovery time is 1-2 weeks. Deep peels require at least conscious sedation and sometimes full anesthesia to be tolerated. Recovery time is approximately 1 month. Chemical peels function by removing the relevant portion of the skin. Then the healing process generates a new skin surface that has a better appearance than the original skin. The depth of the peel indicates the depth of skin removed, and obviously, the greater depth removed, the longer the healing process takes. In superficial and medium peels, the epidermis is predominantly affected, although there may be some production of new collagen in the dermis. In a deep peel, the epidermis is totally regenerated and the superficial dermis is also significantly affected, with significant production of new collagen. The cost of a peel varies by depth. A superficial peel typically costs between $75-150. The cost of the peels increases with increasing depth. The entire procedure (anesthesia, follow-up visits, etc.) costs several thousand dollars for a deep peel. The cosmetic effect of a deep peel is quite dramatic, and it is a very effective procedure. Lasers The word laser is an acronym. Light Amplification by Stimulated Emission of Radiation While the actual process of generating laser light is not terribly important from a clinical standpoint, a basic sense of the process is useful. Energy, often in the form of pulses of electricity or visible light, is added to a solid, liquid or gas substance (“medium”). Most lasers are named after this substance. Electrons absorb this added energy, become excited, and jump to a higher energy state. When the electrons return to their original energy state, they emit a specific wavelength of light. Cumulatively, many electrons going through this process become an extremely powerful source of light of this specific wavelength. This monochromatic (single wavelength) light is generated continuously by some lasers and in pulses by others. If continuous, it can be pulsed using mirror systems. Different lasers differ in the wavelength and intensity of light generated, as well as whether it is generated continuously or in pulses. Lasers with different uses are created by changing these variables. In terms of determining the effect each laser will have on the body, the wavelength of light generated is the most important variable. The wavelength of the light determines what substance will absorb the light’s energy. The main target substances are water, melanin, hemoglobin, and tattoo pigments. Ideally, a given wavelength of light would be completely absorbed by one of these substances and not absorbed at all by the others, allowing the laser to have very specific effects on the tissue. Lasers specifically absorbed by hemoglobin are called vascular lasers and target blood vessels, and the light passes through tissue until it reaches a blood vessel. If the light does not encounter a blood vessel, it may travel up to 1 cm through tissue before it is completely dispersed by non- specific scattering. These lasers are used to treat port-wine-stains, telangiectasias, rosacea, and spider veins. The most commonly used, and one of the original lasers developed for clinical use, is the pulsed-dye laser (the laser medium is a dye, the laser light is pulsed). Vascular lasers heat the blood in the superficial blood vessels, thereby damaging the vessels and leading to their destruction. The destruction is not complete, so there is no concern about leading to ischemia. Vascular lasers often cause bruising that can take 1-2 weeks to resolve. The treatment is mildly to moderately painful. Several treatments are often required. Lasers specifically absorbed by melanin or tattoo pigments are called pigment lasers. Similar to a vascular laser, the light passes through tissue until it reaches a pigment that absorbs it. It will only travel for 1-2 mm through tissue before being dispersed by non-specific scattering. Lasers absorbed by melanin are used for treating freckles, lentigines, excess hair, and other causes of hyperpigmentation. They work best on patients with very pale complexions, as there is less “competing” melanin in the normal skin of these patients. For hair removal, they work best for dark hair in lightly pigmented skin. They do not work well for blond or other non-pigmented hair. Pigment lasers usually have no side effects. In rare cases there can be blistering, especially in patients with darker complexions. The cost of treatment completely depends on the size of the area needing treatment. Multiple treatments are often necessary. Lasers absorbed by tattoo pigments are used to remove tattoos. If a tattoo has multiple colors, multiple different lasers are likely necessary. The easiest tattoo colors to remove with laser are blue and black, the most difficult are yellow and white. Pigment lasers work by heating the pigment rapidly. This damages the pigment particles causing their removal by macrophages. Lasers specifically absorbed by water are used to destroy tissue, most commonly being the CO2 laser. Since most tissue is water, this laser’s energy is absorbed by the first tissue it encounters, rapidly heating the tissue and destroying it. In dermatology, it is used to remove portions of the skin. Based on the intensity of the light and the number of times it is repeated, any depth can be removed, from the superficial epidermis to the entire epidermis and significant portions of the dermis. These lasers never travel through tissue, since water is present in all tissue. The CO2 laser is used for the same purposes as medium to deep chemical peels. Epidermis and superficial dermis removal with self-healing dramatically improves wrinkles, pigmentation, and texture. CO2 laser resurfacing requires up to 6 weeks recovery time. It is extremely painful, and typically requires either conscious sedation or complete anesthesia. The recovery period is extremely difficult for patients to tolerate, and they require frequent office visits for dressing changes and reassurance. Sclerotherapy Sclerotherapy is used for treating spider veins of the legs. These are very common in women following pregnancy. They are small, blue-to-red, blood vessels visible on the skin surface. The procedure consists of injecting either hypertonic saline or chemical irritants into these vessels with a small needle, damaging the vessel and leading to its destruction. The procedure is not always successful, as the damage is not always severe enough to destroy the vessel. Side effects are uncommon. The most common is either a small ulcer or hyperpigmented spots developing at an injection site. In extremely rare cases there can be enough saline or irritant injected to damage the deeper veins, leading to deep venous thrombosis. Treatment is minimally painful. Recovery time is one to several days. It takes 6-8 weeks for the treated vessels to disappear. One treatment session is generally sufficient. Patients with large varicose veins, poor lower extremity circulation, or other lower extremity vascular problems should not be treated with this modality. They should be referred to a vascular surgeon. Scar Revision Scars can be treated in several ways depending on the type, size, and cause of the scar. Typically, significant trauma or burns scars and scars causing functional deficits are best treated surgically by a plastic surgeon. However, cosmetically-unappealing surgical scars are often best treated with more conservative modalities: 1. Elevated, pink, tender scar: intralesional steroid injections. 2. Elevated, pink scar: Pulsed-dye laser, intralesional steroid injections, or both. 3. Elevated scar: Dermabrasion (either using an abrasive head or a motorized, rotating brush). Essentially, the elevated scar is abraded until it is flat with the surrounding skin.  4. Depressed scar (usually from acne): Subscission, where a needle is inserted under the scar in order to create a wound under the scar. A scar forms in this wound raising the depressed scar. For severe acne scarring, the most effective treatment is CO2 laser treatment of the entire affected area, essentially bringing the surrounding skin down to the level of the depressed scar, then letting the entire area heal as a unit. Cost of treatment depends on the size of the scar and the modality used. A single scar usually costs up to several hundred dollars to treat, while CO2 laser treatment of the face may cost several thousand dollars. Liposuction Liposuction is not a useful modality for weight loss, but helps individuals who have effectively utilized diet and exercise to maximize their weight management, but still have specific problem areas where fat has persisted despite the patient’s best efforts. The safest liposuction technique uses a form of anesthesia called “Tumescent”, where large volumes of very dilute local anesthetic are infiltrated into the areas of fat that are to be treated. Thus, the procedure can be performed without general anesthesia, although conscious sedation is often utilized. After the anesthesia is infiltrated, the fat is removed via suction through a hollow metal cannula that is moved back and forth through the fat to be removed. Approximately 10 lbs of fat can be removed with a high degree of safety. If >10 lbs of fat are removed or if general anesthesia is used, the potential for complications increases significantly, mainly because of the amount of anesthetic needed and the potential for large fluid shifts to occur, leading to potential significant cardiovascular stress. Recovery time from liposuction is up to 6 weeks. Patients need to wear compression garments over the treated areas for at least several weeks after the procedure. The major serious potential complication is cardiovascular decompensation related to fluid shifts and anesthesia during the procedure. The common minor complications include post-operative bruising and swelling. Cost of the procedure is typically several thousand dollars. Facelift A facelift is useful for treating static wrinkles and lax skin. It does not improve pigmentary or textural abnormalities. Essentially, an incision is made just anterior to the ears along the hairline. Excess skin is then removed, and suspending permanent sutures are placed in the deeper fascia, because the fascia does not have potential to stretch, as the skin does. The incision lines are then hidden in the junction between the ear and face and in the hairline. The amount of skin removed and the amount of suspension accomplished by the fascial sutures determine how “big” the facelift is. Possible complications include visible scars, numbness around incision lines, and infection. Significant post-operative bruising almost always occurs. Recovery time is often several weeks. Small facelifts can be done under local anesthesia, but many are done under conscious sedation. Larger lifts are often done under general anesthesia. The procedure typically costs thousands of dollars.