| Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Facial Rejuvenation It does not matter what part of the planet you live on, looking nice, having beauty and looking very young is all universally desired. My grand rounds will focus mostly on non-surgical means—chemical peels, dermabrasion, laser resurfacing, etc, as a means of treating the aging face. Historically, the preoccupation with aesthetics, as I mentioned, is as old as man. You can go back as far in time as you want and if you can find a document that talks about human beings, you can probably find a document that talks about what our fears are in terms of aging and how we look and what ways we can treat it. The Egyptians in the Eber papyrus, which is one of the oldest known medical documents, actually have sections on facial beauty and facial scrubs. Their greatest fear was hair loss and wrinkles. In 2000 BC, facial makeup, hair dyes, facial ointments were all well described. Again, as we go through time you can pick any era almost and you can find literature that talks about how to rejuvenate the face with masks composed oils or rice or wax or paste. The Roman poet Ovid wrote a book called The Art of Beauty and in it he describes ways to keep the face appearing youthful. Cleopatra, whose beauty is universally well known, described a lactic acid pill which was used to rejuvenate the face. When Christianity rose after the birth of Christ, sickness and beauty were a matter of faith so there was a decline in the cosmetic aspect of medicine but with the Renaissance it came right back into popularity. Even when the Spanish came to the new world, the Mayans were using sugar cane as a facial mask in order to preserve their beauty, and then of course in Paris in the 17 th century, there were apple facial peels that were well described and so on and so on. In terms of the 20 th century, the creation of containers for compact makeup and aerosol cans made cosmetics acceptable for lay people, not just the rich and famous. In terms of the etiology of skin aging, it is twofold. You have intrinsic factors which you really cannot control such as hormonal changes, genetic mapping or genetic predisposition towards aging or aging at a particular age or not—and then you have extrinsic factors which we do think are controllable such as the amount of sun exposure that you have, smoking or not smoking, eating correctly, your physical activity. And it is important to note that once changes occur, few are reversible although there are techniques to help minimize the changes. So in terms of looking at each area just briefly, around the eyes we know about crow’s feet due to chronic contraction of the orbicularis muscle. Facial grimacing also contributes to the development of crow’s feet. When you look at the forehead you will start to see deep, vertical glabellar lines, you will start to see deeper forehead wrinkles, and the changes around the forehead and the eyes sort of correspond and interrelate. The nose, you start to lose cartilage support and this causes the nose to retract downward. It appears longer. The lower face, you begin to see deepening of the nasal labial fold because of loss of support and then the superficial muscular aponeurotic system also begins to lose its support and you get a mask of ptosis. The lips, you will start to see fine wrinkles as well as radial wrinkles. They also will lengthen and thin out and descend vertically and because as you age you lose fat, bone, and muscle as they begin to atrophy, these will exaggerate these changes. Here is a picture illustrating some of the changes you will see from a young man to an older gentleman. You start to see the deepening of the forehead wrinkles, the glabellar lines, and the nasal labial fold. The lips will start to thin out, you start seeing these radial wrinkles around the lips, sagging underneath the eye, etc. In terms of the skin itself, it is constantly exposed to stressors - heat, wind, ultraviolet radiation. There are numerous studies that show ultraviolet radiation is perhaps the most important and the effect is cumulative. Interestingly, most of the exposure we have is when we are children, so minimizing the exposure you have as a kid probably will go a long way towards minimizing the effects of aging as an adult; however it is kind of like “If I only knew then what I know now” sort of thing, but in terms of your own children try to keep that in mind. And with the epidermis, once it becomes sun damaged you start to see increased roughness; you will see mottled pigmentation and loss of elasticity, as well as wrinkling. Histologically, you will start to see thickening of the stratum corneum, the epidermis will become atrophic, and you will also see the cells become atypical. The melanin cells will start to disperse irregularly resulting in its mottled hyperpigmentation. You lose aminoglycans, which starts to lose the smoothness of the skin and you also get abnormal appearing elastic fibers in the dermis as well. Here is a histogram illustrating those results. The young face, you see the nice, well-formed ridges and then as you get older you start to see flattening as well as thinning of the stratum corneum and you start to lose the nice fullness of the face as it becomes rougher and all the other changes start to occur. When you see your patient, there are several classifications you can use to describe the degree of aging or degree of photodamage that is seen. Fitzpatrick’s classification is one of the most famous and he has six types with Type I having very fair skin, almost always burns, and never tans. Then Type III fair skin will burn sometimes, tans about average, and of course, with Type VI you have very dark skin that almost never burns and is deeply pigmented. In terms of treating patients for aging with the elements I am going to describe, they say Types II and III or Types I, II, and III will respond best to the treatments available. This is another skin classification, Glogall. He has four types, Type I is mild, there are no wrinkles. Type IV is severe, only wrinkles. You see severe photoaging, yellow-gray skin color, may have prior skin malignancies, wrinkles throughout the face, etc. Here are some pictures illustrating some of the changes you can see with aging. This would be early change; you see very mild wrinkling if any at all. You do see some mottled hyperpigmentation, and then as you get more photodamage you start to see the fine wrinkles become more pronounced. You see more sun damage to the skin, and as you get further along in classification you see moderate wrinkles as well as sagging of the skin. So what can you do to treat these changes? Prevention is always worth a pound of cure. The most important step is sun avoidance and it has been shown that with time, with proper sun avoidance, you can actually reverse some of the histological effects. Clothing is also important, particularly wearing hats. We are talking about wide-brimmed hats, covering the entire head, and then sunscreens are also critically important. There are two types of sunscreens. One is a physical block and one is a chemical block. In terms of physical block, we have all seen pictures of lifeguards who have the zinc oxide painted on their faces and these are very effective physical barriers to ultraviolet radiation. Of course, the problem is they are not very cosmetic and so they are not used widely by average consumers. There are newer products that only leave a powdery film, but these still can cause discomfort and contact dermatitis, etc. So most people will use chemical sunscreens, and chemical sunscreens are essentially made up of benzene rings that have double bonds and the number of double bonds that exist will determine how well the chemical blocks ultraviolet radiation. There are two types of ultraviolet radiation, A and B. Earlier sunscreens mostly protected against B, but now we have newer wide spectrum sunscreens that protect against A and B. UV A, they think, may be more important than UV B but it is unclear. And as I said, it decreases the amount of radiation that penetrates the epidermis. In terms of older sunblocks, PABA was the most popular. It did cause some skin staining as well as contact dermatitis and it did not block UV A, so there are now a whole array of newer products on the market that block both UV A and UV B that are non-PABA based. You always hear about an SPF of 15, SPF of 16, etc. That just means it is the ratio between the dose of ultraviolet radiation required to produce erythema on a protected and unprotected skin. So you cover the skin with the sun protectant and then you treat it with ultraviolet radiation then you treat the same area that is unprotected and you get a ratio that will tell you how good the sunblock is. SPF 15 is considered ideal for most people. In terms of non-peel chemical techniques, we have talked about prevention. Now we can start talking about treating patients who have photodamage and aging effects. Retinoic acid is perhaps one of the most commonly used agents. It really jump started the chemical peel revolution because it made it acceptable for common people to start treating fine wrinkles and the effects of aging with medicines. There is considerable scientific evidence that it indeed improves aging as well as photodamage, and almost all users will see the benefit. It is available as a cream, gel, or liquid. Generally you prescribe it based upon the skin types. People with very dry skin will generally benefit from the creams. Alpha hydroxy acids can be used as a peel but they can also be used as a non-peel chemical technique in lower concentrations. In terms of retinoic acid just to give you a little bit more detail, what does it do? Histologically, it will thin the stratum corneum, it will thicken the epidermis, it will reverse keratinocyte atypia as well as disperse melanin. Remember these are all the things I talked about that happen with aging so retinoic acid reverses those changes or reduces them. The effects are smoother skin, tighter skin, improved pigmentation, and improved hue. But it is not all good. There are problems with retinoic acid. It is not the user-friendliest of medicines. There is retinoic dermatitis; patients do have increased photosensitivity. That is why the medicine is recommended to use at night, not during the day before you go outside. It can increase capillary aborization which may worsen in terms of erythema and telangiectasia, and probably the biggest problem is that it was over-hyped initially and, like a lot of things in this country, there is this big buildup: “Oh, you can cure your wrinkles in five days or less” and then when the expectations did not meet the hype there was a big backlash. But now that a lot of that is dying down, we are recognizing that retinoic acid is a very useful agent for treating aging effects. The alpha hydroxy acids are a group of organic acids. They are also called fruit acids. Even though they are derived from fruits like lactic acids, these are created in the labs so they are not organic even though you can buy some organic fruit-based facial scrubs in stores. The mechanism of action is unclear; however, they think it is different from retinoic acid so this can be combined with retinoic and there seem to be good effects. It has pretty much the same effect as retinoic acid. It will thin the stratum corneum, it will increase epidermal thickness, and again this all results in a more youthful appearing face. It is also well tolerated and, as I stated, can be combined with retinoics. You give the retinoic at night and you use the alpha-hydroxy acid during the day. This is a histogram of a patient who was started on combination therapy. The increased blueness is the glycosamino glycans, and you can see that there is a marked difference just after several weeks of therapy. So once you get past chemoprevention and using non-peel methods, you can start to use peel methods and which are all based on the same premise. You want to create a controlled wound that the body heals in a very predictable way, and hopefully as the body heals it will reorganize itself to eliminate the fine wrinkles, eliminate the hyperpigmentations, etc. Anyone undergoing a facial peel needs to have priming. In other words the skin needs to be prepped. Wound healing, understanding the concepts is very important. There are various methods that doctors use to accelerate it, and it is pretty much physician-dependent but in terms of dressing, ointment, antibiotics, pain control. It is also important to talk to your patients about recovery time. Light peels recover faster than deep peels and then there is the concept of regional peeling. You peel a certain area like the face, the neck will not be peeled, and there can be differences in terms of the shading and pigmentation so you have to have some effect or some aesthetic skill in terms of blending or camouflaging the lines of demarcation. And then in terms of repeeling, most patients will require several peels. Superficial peels can go as often as a week. Deeper peels, you may have to wait six months. This is an old classification but superficial peels would mostly deal with the epidermis and now some physicians will say there is a super, superficial peel that will just peel off a small layer of the epidermis and then as you go deeper you get down into the radicular dermis. And again, you are just creating a controlled wound and hoping that as the body heals it will eliminate some of the effects of aging. Priming is an important concept. It reduces healing time. It allows for a more uniform peel. It decreases the risk of post-inflammatory hyperpigmentation, and it also enforces to the patient that they need to have a maintenance regimen. They need to use retinoic acids daily, they need to use sunblock, etc. The agents that are commonly used are retinoic acid, the alpha hydroxy acids, hydroquinone, broad-spectrum sunscreens, and generally you want to treat for two to three weeks before you peel. Superficial to medium deep peels are Jessner’s solution, glycolic acid, trichloroacetic acid, and a combination of the three. In terms of Jessner’s, the peel is well described. Its usage is light peels and also can be used in combination with a medium to deep peel. The contents are listed here: lactic acid, salicylic acid, ethanol, or resorcinol. And generally peels are applied using a cotton tip, a cotton ball, and they also make synthetic fiber brushes that you can use. The end point depends on how the skin looks after you peel. Faint erythema generally is a more superficial peel, and then as you get towards intense erythema with pinpoint frothing, that indicates a much deeper peel. The depth of the peel will be influenced by the number of coats you apply as well as the sensitivity of the patient’s skin. Here is an example of a patient with the Jessner’s peel. This is a deeper peel. She has some pinpoint light frothing as well as some erythema. Here is a patient who, after completion of the peel, has mottled hyperpigmentation and after the healing she has a much smoother appearing, much more uniform skin tone. Glycolic acid peels, again these are called the fruit acids because the acids are based on fruits. They are in a greater concentration than used with daily routine use. You can buy 10% and even less percent glycolic acid-based peels over the counter or through cosmetologists. If you go through a physician, generally they are using 30% or even greater concentrations. The pros are it is very well tolerated, it is efficacious, and there is generally no systemic toxicity. The cons are that is does need to be neutralized and it can penetrate unevenly. The endpoint, the depth of penetration, again a very light peel will show pink and as you go deeper you will start to get frothing. And it is important to remember to neutralize with alkaline solution. So the trichloroacetic acid peels are the gold standard peels. They are very well studied, versatile; they are stable, inexpensive, and non-toxic. The concentration of their acid is the most important factor in the depth of penetration. And as I mentioned, all peels are basically chemical cauterants; they coagulate the skin creating a white froth. With a superficial peel, you generally will not see froth and with a deeper peel you will see a solid white froth. This is an example of one physician's method of doing the peel itself in terms of his steps and progression. This is a woman who underwent a TCA peel and you can see before and after a much healthier hue, less irregularity with her pigmentation. This is the whole progression: The patient comes in, gets the peel, she has the whitely froth, and then as the peel starts to fade away in each step you get towards the end result. The phenol peel is the standard deep peel. It is a keratocoagulant. It is effective on some deep wrinkles. It is applied to spatial subunits and the adage is you want to take it slow. You have to allow time between treating the subunits because it is cardio-toxic and it is related to the surface area that you apply so you do not want to put a whole lot of phenol on someone and forget about it. The patient will develop a very deep white froth followed by erythema. The recovery period is pretty prolonged, so these patients need a lot of time away to recover. The complications of peels, really everything I am going to talk about from here on out, the complications are the same. You are creating a controlled wound so if the wound does not heal correctly that is when you will see the complications. You can see persistent erythema, you can see hypertrophic scarring, you can see the post-inflammatory hyperpigmentations. You can also get an infection or you can reactivate an old infection. This is a pseudomonas infection here, and this is a person who had an outbreak of latent herpes and potentially, as these heal, they can create more of the other complications we see, post-inflammatory hyperpigmentation, etc. Dermabrasion is another technique that you can use. We have sort of moved past peels. You remove tissue down to the level of the dermis. It will create more organized collagen as it heals and again, hopefully, you will get a smoother appearance and they also say it is great for scar treatments. You use a wire brush or a diamond frise, and this is a picture of the equipment and some of the brushes here. Some people use this refrigerant to coat the skin in order to glide the burr or the frise over the skin smoothly. This is an up close picture of the wire brush and a diagram illustrating the technique as you go down to deeper and deeper levels of the dermis. And again here is another picture showing the technique for doing dermabrasion. And I just said, some people use a refrigerant to help guide it over the skin or you can use local anesthesia and you want to do this until you see pinpoint bleeding. If you start seeing yellow globules you have gone too deep. Universal precautions, there are blood products that become aerosolized so there is a risk to the doctor so you want to use universal precautions. Side effects are the same as dermabrasion but scarring is particularly problematic. Here is a picture of a patient who had some scarring here and after dermabrasion the skin is much smoother. Microdermabrasion is less invasive and uses a compressor aspirator. Aluminum oxide crystals are one type of microdermabrasion, and it is felt it is a really good alternative to peels and dermabrasion because you get a much more superficial peel and less chance of complications. The laser has also found its application in facial plastics. Einstein, as we all know, theorized light amplification by stimulated emission of radiation, but it was brought into practice by Dr. Goldman in 1963 and the laser energy again creates a controlled wound. It is photochemical, photomechanical, and thermal damage and hopefully when the wound heals you will get a much better aesthetic result. The type of laser will dictate the depth and the target tissue. Ablative lasers such as the CO 2 lasers are the most versatile lasers we use. You can treat it for tattooing, fine rhytids, scar revision. There are other types of ablative lasers. All the ablative lasers are characterized by serous discharge, crusting as well as burning during the recovery period. Here is a patient who underwent CO 2 laser resurfacing and you can see fine rhytids, a little deepening of the nasal labial fold and, as you see there, the rhytids have been pretty effectively removed. Here is another patient, you can see the after. And a third patient, again you can see the wrinkle and then afterwards much smoother appearing skin. And here is another patient with much smoother appearing skin. There are other lasers that are non-ablative. For resurfacing the epidermis will remain intact. There are the continuous wave lasers such as KTP argon. These are great for pigmented lesions, and then there are pulse lasers where the energy is delivered in pulses and can selectively target pigments, and again these are mostly used for pigmented type lesions. And this is not the best picture but this woman has a lot of telangiectasias and after non-ablative laser treatment the pigmentations become smoother. This is a patient who has had a progression of treatments for vascular hyperpigmentation here on the cheek and you can see she has a very good result. And a patient with “aging spots” treated and again a very excellent result. Botulinum toxin is the newest thing we have in our armamentarium. We know that it selectively blocks acetylcholine release at the nerve terminals, it provides temporary paralysis and the effect can last up to three months, and it has shown tremendous usage in the area of the aging face. You can treat facial crows feet, lip wrinkles, thinker’s wrinkles, and nasal labial fold; there are just a lot of different treatments. These are some of the places that you would try to target. For example, crow’s feet or fine wrinkles around the lips or forehead wrinkles. And as we know, with botulinum toxin there is no standard dose. You start off small and you work your way up to give the patient the best result possible. This is a woman who had her glabellar lines treated and as you can see, it looks very good. And these are examples of crow’s feet before and after. The side effects are really minimal. You can have local pain at the injection site, feeling of numbness. If you over inject, you can have lid ptosis or brow ptosis, but all the effects pretty much are reversible. The one problem with repeated Botox injections is that some patients do develop immunity and, of course, you can then switch from Type B Botox to Type A Botox and, hopefully, you can overcome that immunity. It is unclear exactly how these patients develop it. As we know, aging is inevitable. Prevention will always remain the best means of limiting the effects of age. There are numerous options available for early changes. Case Presentation: Physical exam show a well developed female in no apparent distress. Her face shows fine periorbital rhytids. The rest of the head and neck exam is unremarkable. Multiple treatment and preventative strategies were discussed. She elected to use a wide spectrum sun block and OTC hydroxy acid based facial scrubs. Her follow-up is pending. Bibliography: Ariagno RP, Briggs DR. Chemexfoliation as an adjunct to facial rejuvenation. Trans Am Acad Ophthalmol Otolaryngol 1975;80:536-9. Ayhan S, Baram CM,. Yavuzer R, Latifoglu O, Cenetoglu S, Baran NK. Combined chemical peeling and dermabrasion for deep acne and posttraumatic scars as well as aging face. Plast Reconstr Surg 1998;102:1238-46. Badin AZ, Casagrande C, Roberts T 3 rd, Saltz R, Moraes LM, Santiago M, Chiaratti MG. Minimally invasive facial rejuvenation endolaser mid-face lift. Aesthetic Plast Surg2001;25:447-53. Becker DG, Kim S, Kallman JE. Aesthetic implications of surgical anatomy in blepharoplasty. 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Effect of botulinum toxin pretreatment on laser resurfacing results: a prospective, randomized, blinded trial. Arch Facial Plast Surg 2001;3:165-9. BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2005
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