Minimally Invasive Aesthetic Procedures: A Guide for Dermatologists and Plastic Surgeons 3319782649, 9783319782645

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Minimally Invasive Aesthetic Procedures A Guide for Dermatologists and Plastic Surgeons Adilson Da Costa  Editor

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Minimally Invasive Aesthetic Procedures

Adilson Da Costa Editor

Minimally Invasive Aesthetic Procedures A Guide for Dermatologists and Plastic Surgeons

Editor Adilson Da Costa Instituto de Assistência Médica ao Servidor Público Estadual (IAMSPE) Tenured International Professor and Mentor for PhD and MSc Programs São Paulo, SP, Brazil

ISBN 978-3-319-78264-5    ISBN 978-3-319-78265-2 (eBook) https://doi.org/10.1007/978-3-319-78265-2 © Springer Nature Switzerland AG 2020, corrected publication 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

To my parents, who taught that I only needed to work hard and ethically to achieve whatever I want in my career and private life. To my Professors and Teachers, who inspire me to share my knowledge without limits and with everyone. To my husband, Watson Possato, and my three kids, Asher, Spencer, and Kyle DaCosta-Possato, who make me refresh my wish for life, new projects, and a long life every minute of the day.

Foreword for Dermatoligist

In a constant search for beauty, increasingly more people devote their time and resources to obtain the aesthetic standards of their time. The rise in aesthetic procedures around the world, especially in the United States of America, reflects this trend accurately. Although sometimes seen as frivolous, aesthetic improvements can bring significant improvement to the quality of life and general well-being of individuals. I have devoted my career to the study and elaboration of innovative procedures in dermatologic surgery, mainly focused on the aesthetic field, where I developed the subcision technique to treat cellulite and microcanullas to inject dermal fillers. Given that, along the course of my career, I have had the opportunity to meet and work with extraordinary professionals, such as Dr. Adilson Da Costa, who has extensive knowledge and research experience in clinical and cosmetic dermatology. His expertise in the field and eagerness to share scientific knowledge with other professionals have prompted him to publish, once again, an important book in our specialty. I am glad to be part of Minimally Invasive Aesthetic Procedures: A Guide for Dermatologists and Plastic Surgeons, and to present this remarkable publication to our colleagues. This book addresses the needs of both dermatologists and plastic surgeons, providing the professionals with cutting-edge information and a practical step-by-step guide to the most broadly adopted, and possibly, most effective minimally invasive procedures. Dr. Adilson Da Costa, thank you for sharing this outstanding accomplishment with us!

Doris Hexsel, MD Porto Alegre, RS, Brazil

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Foreword for Plastic Surgeons

There is no doubt that minimally invasive aesthetic procedures have demonstrated explosive growth over the past two decades. This growth is not limited to the numbers, types, and categories of procedures and products available, but includes growth in the number of dermatologists and plastic surgeons offering these procedures and the patients who seek them out. Because of the wide scope of treatments now available, their many variations, and the continuous introduction of new options, it is imperative that both fundamental principles and therapeutic specifics are readily understood by the practitioner. For this reason, Minimally Invasive Aesthetic Procedures: A Guide for Dermatologists and Plastic Surgeons is a timely and critical resource. For plastic surgeons in particular, minimally invasive treatments represent a key sector of care that often must be integrated with surgical strategies. In some instances, a minimally invasive procedure, such as botulinum toxin or filler injections, may provide substantive patient benefits when surgery is not yet an indicated or optimal therapeutic option, as in the patient too young for a face-lift. In other instances, a minimally invasive procedure can become an important adjunct to a surgical procedure, exemplified by simultaneous autologous fat grafting or resurfacing. In still other circumstances, the minimally invasive procedure may be used to enhance or prolong the effects of treatment after a surgical procedure. To be most effective, plastic surgeons need to understand how to select the best procedure or set of procedures for the given patient and how to safely execute to optimize results. The technique-driven format of Minimally Invasive Aesthetic Procedures: A Guide for Dermatologists and Plastic Surgeons will serve as a valuable guide to the practicing plastic surgeon in selecting and performing minimally invasive procedures. Each chapter focuses on a specific product or technique and provides a rationale for its selection, concise clinical guidance, and delineation of side effects and complications. Tips contained within in each chapter provide a key reminder of important areas of focus and attention. A broad spectrum of minimally invasive aesthetic procedures is represented, from chemical peels to toxins to fillers to threads and beyond, including variations in approach due to material selection or anatomical location. The direct, focused, and brief nature of each chapter means that the text also serves as a quick pretreatment review of a planned procedure in addition to more longitudinal learning resource.

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Foreword for Plastic Surgeons

I think plastic surgeons will find Minimally Invasive Aesthetic Procedures: A Guide for Dermatologists and Plastic Surgeons a valuable resource in their care of the aesthetic patient.

Felmont F. Eaves III, MD, FACS Professor of Plastic Surgery, Emory University, Atlanta, GA, USA Director, Emory Aesthetic Center Medical Director, EAC Ambulatory Surgery Center Past President, American Society for Aesthetic Plastic Surgery

Preface

According to the 2017 Cosmetic Plastic Surgery Statistics Report, minimally invasive cosmetic procedures accounted for 89.77% of all 17,504,950 cosmetic procedures performed by plastic surgeons in the USA, per a survey conducted by the American Society of Plastic Surgeons. Moreover, in a similar survey conducted by the American Academy of Dermatology, procedures using laser, light, and energy-based devices, followed, respectively, by botulinum toxin, soft-tissue fillers, chemical peels, and body sculpting treatments were 2017s top cosmetic treatments among those specialists. This scenario makes it more than evident that minimally invasive aesthetic procedures dominate the practices of the majority of medical doctors that work in the cosmetic field, and it is undoubtedly a trend that will continue in upcoming decades. When I was first certified as a dermatologist, I began my practice at a time when minimally invasive aesthetic procedures were leaving the realm of disbelief and skepticism and entering the beginning stages of progression. Indeed, at that time, these procedures were first starting to follow scientific protocols in order to prove their real benefits and practical outcomes empirically. I feel honored to have been among those pioneering dermatologists that helped to move forward the science behind minimally invasive aesthetic procedures, thereby transforming the creativity and observations in practice into clinical and in vitro protocols and publishing outcomes in international medical journals and several chapters of books. This groundwork helped give me the courage to step onto the stage at a conference and actively advocate and teach the role of these procedures in daily clinical practice. I must say it was not an easy task. Many times, as happened to many of my colleagues that assumed that same role in their craft, this attitude attracted criticism from peers and former professors. However, I am delighted that I joined with so many of my colleagues around the world to make minimally invasive cosmetic procedures not only feasible, but now mainstream practice. I consider my work in having helped minimally invasive aesthetic procedures to be what they are today, aside from being one of the primary accomplishments of my career! This book, Minimally Invasive Aesthetic Procedures: A Guide for Dermatologists and Plastic Surgeons, is my new contribution to the world of aesthetic medicine. It is a 112-chapter, hard-copy book that compiles some of the most experienced authors and key procedural opinion leaders to share xi

Preface

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with readers their expertise and knowledge on how to get the best outcome in the most difficult procedures. More than simply an overview of the most common cosmetic procedures performed by both dermatologists and plastic surgeons, it constitutes a practical, useful guide to the specialists who practice in outpatient clinics. Further, this book’s aspiration is to assist practitioners preparing for each of these procedures in an easy, straight-to-the-point manner. I do hope you enjoy reading this book and making it your best friend in the world of minimally invasive aesthetic procedures.

Adilson Da Costa, MD, MSc, PhD São Paulo, SP, Brazil

Contents

Part I Peelings 1 Introduction: Classification of Peels��������������������������������������������   3 Carlos G. Wambier and Harold J. Brody 2 Pearl Chapter: Basis of Photoaging and the Use of Chemical Peelings����������������������������������������������������������������������  15 Suelen Montagner and Adilson Da Costa



3 Tip Chapter: Peels for Ethnic Skin����������������������������������������������  27 Renan Lage 4 Blepharopeel ����������������������������������������������������������������������������������  39 Laura Bariquelo Buratini and Sergio Talarico Filho 5 Cook Peel (70% Glycolic Acid + 70% Trichloroacetic Acid) for the Face ��������������������������������������������������������������������������  47 María del Pilar Del Río Navarrete Biot 6 Cook Peel (70% Glycolic Acid +40% Trichloroacetic Acid) for Extra-Facial Areas ��������������������������������������������������������  55 Carlos Gustavo Wambier 7 Fluor-Hydroxy Pulse Peel for Face����������������������������������������������  61 Erica Monteiro



8 Fluor-Hydroxy Pulse Peel for Extra-­Facial Areas����������������������  67 Maria Paulina Villarejo Kede and Bruna Sabatovich Villarejo Iosifovich 9 Genital Bleaching Peel ������������������������������������������������������������������  71 Adriana Awada 10 Glycolic Acid Peel for the Face ����������������������������������������������������  75 Jessica A. McCarrick and Valerie D. Callender 11 Glycolic Acid Peel for Extra-Facial Areas������������������������������������  81 Caroline Silva Pereira, Beatrice Martinez Zugaib Abdalla, and Adilson Da Costa 12 Jessner’s Peel for the Face������������������������������������������������������������  87 Vanesa Piquero, Daniela Moya, and Edgar E. La Rotta

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13 Jessner’s Peel for Extra-Facial Areas ������������������������������������������  95 Sarah Wilson, Howa Yeung, and Travis W. Blalock 14 Phenol-Croton Oil Peels����������������������������������������������������������������  99 Fernanda Ayres de Morais e Silva Cardoso, Carlos Gustavo Wambier, and Adilson Da Costa 15 Pyruvic Acid Peel for Face and Extra-Facial Areas�������������������� 107 Bogdana Victoria Kadunc, Renan Lage, and Renata Cristina Vasconcellos 16 Resorcin Peel for Face�������������������������������������������������������������������� 113 Andrezza Facci 17 Resorcin Peel for Extra-Facial Areas ������������������������������������������ 117 Erica Monteiro 18 Salicylic Acid for Face (Facial Salicylic Acid Peel)���������������������� 121 Mercedes Florez White 19 Salicylic Acid Peeling for Extra-­Facial Areas������������������������������ 127 Vanesa Piquero, Daniela Moya, and Edgar E. La Rotta 20 Tretinoin Peel for Face������������������������������������������������������������������ 135 Luciane Scattone 21 Tretinoin Peel for Extra-Facial Areas������������������������������������������ 141 Renata Indelicato Zac and Adilson Da Costa 22 Trichloroacetic Acid Peel for Facial and Extra-Facial Areas������������������������������������������������������������������ 145 Natacha Quezada Gaón and María Isabel Herane Herane 23 Thioglycolic Acid Peel for Dark Circles Under Eyes������������������ 159 Vanessa Lucília Silveira Medeiros 24 Thioglycolic Acid Peeling for Hemosiderin and Post-­inflammatory Hyperchromia���������������������������������������� 165 Rossana Cantanhede Farias de Vasconcelos Part II Botulinum Toxin 25 Introduction: What Is Botulinum Toxin?������������������������������������ 171 Doris Hexsel, Fernanda Camozzato, and Carolina Siega 26 Tip Chapter: Histology and Physiology of the Skin�������������������� 179 Renata Joffe, Jose A. Plaza, and Armineh Kajoian 27 Botulinum Toxin for Craniofacial Hyperhidrosis ���������������������� 193 Marcelo M. Bellini and Adriana de Cerqueira Leite 28 Botulinum Toxin for Superior Third of the Face������������������������ 197 Cristina Hachul Moreno, Aline Rodrigues Bragatto, and Caroline Moreira Albrecht 29 Botulinum Toxin for Middle Third of the Face �������������������������� 205 Loryart Marte Grullón and Javier Ruiz Ávila

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30 Botulinum Toxin for Inferior Third of the Face�������������������������� 209 Carlos Echevarria and Denise Durand 31 Botulinum Toxin for the Neck������������������������������������������������������ 217 Luciana R. Patricio Linhares and Adilson Da Costa 32 Botulinum Toxin for Axillary Hyperhidrosis������������������������������ 223 Clarissa Prati and Juliano Peruzzo 33 Botulinum Toxin for Palmar and Plantar Hyperhidrosis���������� 229 Ada Regina Trindade de Almeida and Elisa Raquel Martins da Costa Marques 34 Botulinum Toxin for Special Conditions: Chemical Rhinoplasty�������������������������������������������������������������������� 235 Francisco Marcos Perez Atamoros and Alberto Avila Lozano 35 Botulinum Toxin for Special Conditions: Facial Mesotherapy������������������������������������������������������������������������ 239 Eloisa Leis Ayres 36 Botulinum Toxin for Special Conditions: Gummy Smile – Advanced Points and Indications �������������������� 245 Rosemarie Mazzuco and Beatrice Martinez Zugaib Abdalla 37 Botulinum Toxin for Special Conditions: Masseter Hypertrophy������������������������������������������������������������������ 249 Caroline Romanelli T. A. Zelenika 38 Botulinum Toxin for Special Conditions: Myomodulation to Body Contour������������������������������������������������ 253 Roseli Andrade and Claudio Dias Part III Hyaluronic Acid Filler 39 Introduction: What Is Hyaluronic Acid Filler?�������������������������� 261 Nelise Hans and Thais Sakuma 40 Tip Chapter: Anatomy of the Face, Neck, Hands and Genital Areas�������������������������������������������������������������������������� 271 Mirna Duarte Barros, Antonio Cardoso Pinto, Bianca Maria Liquidato, and Wagner Ricardo Montor 41 Hyaluronic Acid for Dermic Hydration �������������������������������������� 293 Adriana de Cerqueira Leite and Marcelo M. Bellini 42 Hyaluronic Acid for Frontal and Glabella Areas������������������������ 299 Maritza L. Kummerfeldt 43 Filling Temporal and Eyebrow Areas������������������������������������������ 305 Karina Colossi Furlan 44 Hyaluronic Acid for Periocular Area ������������������������������������������ 313 Rodrigo Amaral de Lima and Adilson Da Costa

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45 Hyaluronic Acid for Malar Area and Zygomatic Arch�������������� 321 Karina Colossi Furlan 46 Hyaluronic Acid for Pre-auricular Area�������������������������������������� 329 Liza R. Braun, Maxim Polansky, and Travis W. Blalock 47 Hyaluronic Acid for Ear Lobe������������������������������������������������������ 337 Adriana de Cerqueira Leite and Marcelo M. Bellini 48 Hyaluronic Acid for the Nose�������������������������������������������������������� 341 Carlos Echevarria and Denise Durand 49 Hyaluronic Acid for Nasolabial Folds������������������������������������������ 347 Aline Rodrigues Bragatto, Caroline Moreira Albrecht, and Cristina Hachul Moreno 50 Hyaluronic Acid for Lips and Perioral Fine Lines and Wrinkles������������������������������������������������������������������������ 353 Luca Piovano 51 Hyaluronic Acid Fillers for Treating Temporal Area Volume Loss�������������������������������������������������������������������������� 359 Francisco de Melo and Carmelo Crisafulli 52 Hyaluronic Acid for Chin�������������������������������������������������������������� 367 Nark-Kyoung Rho 53 Hyaluronic Acid for Neck Wrinkles �������������������������������������������� 375 Caroline Romanelli T. A. Zelenika and Adilson Da Costa 54 Hyaluronic Acid for Hands ���������������������������������������������������������� 379 Tatiana Basso Biasi and Ricardo Limongi Fernandes 55 Hyaluronic Acid for Genital Area������������������������������������������������ 385 Shirlei Schnaider Borelli, Mariana Isis Wanczinski, and Nátalie Schnaider Borelli Part IV Threads in Cosmetic Procedures 56 Introduction: Threads in Cosmetic Procedures�������������������������� 393 Thaísa Saddi Tannous Silvino, Ellem Tatiani de Souza Weimann, and Lissa Sabino de Matos 57 Tip Chapter: Anesthesia in Cosmetic Procedures���������������������� 403 Gaurav P. Patel 58 Eyebrow Thread Lifting���������������������������������������������������������������� 407 Iñigo de Felipe 59 Threads for the Middle Third of the Face ���������������������������������� 415 Tatiana Caloi 60 Threads for the Inferior Third of the Face���������������������������������� 421 Flávio Rezende and Aline Vieira 61 Threads for Chin Lifting �������������������������������������������������������������� 427 Claudio Dias and Roseli Andrade

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62 Threads for the Neck �������������������������������������������������������������������� 433 Paola Rosalba Russo and Gerhard Van Niekerk 63 Threads for Corporal Areas: Upper and Inferior Limbs���������� 445 Gabriel Aribi, Cidia Vasconcellos, and Monica Aribi 64 Threads for Abdomen�������������������������������������������������������������������� 455 Denise Rocha Luna Barcelos and Cyro Hirano 65 Threads for Special Conditions: Buttocks ���������������������������������� 461 Adriana Vilarinho, Raquel Cavalcante, and Renata Marques Sitler Part V Chemical Substances for Injectable Cosmetic Neocollagenesis 66 Introduction: Chemical Substances for Injectable Cosmetic Neocollagenesis�������������������������������������������������������������� 467 Elisangela Samartin Pegas, Felipe Borba Calixto dos Santos, and Beatrice Martinez Zugaib Abdalla 67 Tip Chapter: Improving Healing in Cosmetic Procedures�������� 475 Maria da Glória Martin Sasseron, Renan Lage, Larissa Mondadori Mercadante, and Luiza de Castro Fernandes 68 Calcium Hydroxyapatite for Face������������������������������������������������ 487 Eliandre Costa Palermo and Alessandra Anzai 69 Calcium Hydroxylapatite for Hands�������������������������������������������� 499 Tatiana Basso Biasi and Vinicius Pollo Pires 70 Calcium Hydroxyapatite For Unusual Body Areas�������������������� 505 Gabriela Casabona 71 Platelet-Enriched Plasma�������������������������������������������������������������� 513 Abraham Benzaquén-Barchillón and Eduardo de Frutos-Pachón 72 Poly-L-Lactic Acid for the Face���������������������������������������������������� 521 Carla Albuquerque, Kenia Calil, and Viviane Reis 73 Poly-L-Lactic Acid for the Neck �������������������������������������������������� 529 Renata Indelicato Zac and Adilson Da Costa 74 Poly-L-Lactic Acid for Arms �������������������������������������������������������� 533 Daniel Dal’Asta Coimbra and Betina Stefanello 75 Poly-L-Lactic Acid for Hands ������������������������������������������������������ 539 Francisco Marcos Perez Atamoros and Alberto Avila Lozano 76 Poly-L-Lactic Acid for the Gluteal Area�������������������������������������� 543 Maria Helena Lesqueves Sandoval 77 Polyacrylamide for the Face���������������������������������������������������������� 549 Natacha Quezada Gaón, Cristián Vera-Kellet, and Ximena Wortsman

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78 Polycaprolactone for the Face������������������������������������������������������ 555 Pierre Nicolau 79 Polycaprolactone for Extrafacial Areas �������������������������������������� 565 Natacha Quezada Gaón, Ximena Wortsman, and Patricia Apt 80 Polyethylene Glycol for the Hands and Face ������������������������������ 575 Samira Yarak and Luis Henrique Barbizan de Moura 81 Polymethylmethacrylate Microsphere Injections in the Face �������������������������������������������������������������������������������������� 581 Gottfried Lemperle 82 Polymethyl Methacrylate for the Body���������������������������������������� 589 Marcio Soares Serra Part VI Micro-aesthetic Surgery and Others 83 Introduction: Dressings to Improve Healing in Cosmetic Procedures ���������������������������������������������������������������� 595 Maria da Glória Martin Sasseron, Renan Lage, Larissa Mondadori Mercadante, and Luiza de Castro Fernandes 84 Tip Chapter: How Might Cosmeuticals Improve Skin Aesthetic Procedures Outcome?������������������������������������������ 605 Leslie Baumann and Erica Monteiro 85 Chemical Liposculpture of the Chin�������������������������������������������� 619 Valerie D. Callender and Jessica A. McCarrick 86 Microneedling for Neocollagenesis of the Face �������������������������� 625 Gabriella Fabbrocini, Caterina Mazzella, and Mirella D’Andrea 87 Acne Scar: Shaving and Electrosurgery�������������������������������������� 631 Joaquim José Teixeira de Mesquita Filho and Francine Papaiordanou 88 Acne Scars: 5-Fluorouracil (MMP® Technique) ������������������������ 637 Maria Teresa Pereira Soares, Dirlene Melo Palmeira Roth, and Samir Arbache 89 Acne Scars: Bleomycin Plus Triamcinolone Injection (MMP® Technique)������������������������������������������������������������������������ 643 Maria Teresa Pereira Soares, Dirlene Melo Palmeira Roth, and Samir Arbache 90 Acne Scar: CROSS (Chemical Reconstruction of Skin Scar) ���������������������������������������������������������������������������������� 649 Vito Abrusci and Valentina Benzecry 91 Acne Scar: Dermal Graft�������������������������������������������������������������� 659 Sergio Schrader Serpa

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92 Acne Scars: Dermabrasion������������������������������������������������������������ 667 Bogdana Victoria Kadunc 93 Acne Scar: Hyaluronic Acid Filler ���������������������������������������������� 673 Ada Regina Trindade de Almeida and Danielle Claudino de Oliveira Costa 94 Acne Scar: Microneedling ������������������������������������������������������������ 677 Flávio Barbosa Luz and Tadeu de Rezende Vergueiro 95 Acne Scar: Punch Elevation���������������������������������������������������������� 683 Caroline Silva Pereira, Beatrice Martinez Zugaib Abdalla, and Fábio Rebucci 96 Acne Scars: Subcision�������������������������������������������������������������������� 689 Jaime Piquero-Casals and Jaime Piquero-Martin 97 Aspiration Curettage for Axillary Hyperhidrosis ���������������������� 693 Rebeca Alvares Rodrigues Maffra de Rezende, Adilson Da Costa, and Flávio Barbosa Luz 98 Autologous Fat Grafting���������������������������������������������������������������� 699 Gabriele C. Miotto 99 Autologous Fibroblasts Injections in Face ���������������������������������� 705 Leticia de Chiara Moço, Fabio Antonio Abrantes Tuche, and Ricardo de Mendonça Filho 100 Cellulite: Subcision������������������������������������������������������������������������ 711 Camile L. Hexsel, Taciana Dal’Forno Dini, and Doris Hexsel 101 Chemical Lipolysis of the Infraorbital Fat Pads ������������������������ 719 Patricia Rittes 102 Electro-blepharoplasty������������������������������������������������������������������ 723 Daniel Dal’Asta Coimbra, Betina Stefanello, and Natalia Caballero Uribe 103 Submental Liposuction������������������������������������������������������������������ 727 Aline Rodrigues Bragatto and Cristina Hachul Moreno 104 Stretch Marks: Microdermabrasion and Superficial Localized Dermabrasion �������������������������������������������������������������� 733 Taciana Dal’Forno Dini and Camile L. Hexsel 105 Strech Marks: Transdermal Divulsion���������������������������������������� 741 Rogério Tércio Ranulfo, Marjorie Bezerra Porciúncula, and Lara Ranulfo de Mendonça 106 Upper Blepharoplasty�������������������������������������������������������������������� 745 Aline Rodrigues Bragatto and Cristina Hachul Moreno

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Part VII Aesthetic Approach of Scalp 107 Introduction: Clinical Emergency During Aesthetic Procedures�������������������������������������������������������������������������������������� 755 Merces Assumpcao-Morales and Javier Morales 108 Pearl Chapter: Methods and Tips for a Better Scar Quality �������������������������������������������������������������� 769 Luciana Takata Pontes, André Luiz Simião, and Arash Kimyai-Asadi 109 Tip Chapter: Low-Level Light Therapy and High-­Energy Lasers in Trichology���������������������������������������� 777 R. Minotto and L. Damiani 110 Low-Level Light Therapy (LLLT) in Alopecia���������������������������� 781 R. Minotto and L. Damiani 111 Scalp Mesotherapy������������������������������������������������������������������������ 785 Renan Minotto and Rodrigo Vettorato 112 Microneedling of the Scalp������������������������������������������������������������ 791 Renan Minotto and Liliam Dalla Corte 113 Tricopigmentation of the Scalp���������������������������������������������������� 795 Renan Minotto and Mariana Vale Scribel da Silva Correction to: Minimally Invasive Aesthetic Procedures�������������������  C1 Index���������������������������������������������������������������������������������������������������������� 801

Contents

About the Author

Adilson Da Costa, MD, MSc, PhD  Medical Doctor (1997) and Dermatology (2001) from the Santa Casa de São Paulo School of Medicine, Brazil. Dr. Da Costa obtained his Master of Science degree in Clinical and Surgical Dermatology from the Federal University of São Paulo (2006) and doctorate’s (PhD) in Dermatology from the University of São Paulo Medical School (2012), both in Brazil, and he did his Postdoctoral Research Fellowship in Dermatology at Emory University School of Medicine (2016). He is permanent professor and mentor of PhD and MSc at Instituto de Assistência Médica ao Servidor Estadual (IAMSPE), São Paulo, SP, Brazil. He is the author of two books on Dermatology (Dermatology and Pregnancy, Elsevier; International Textbook of Cosmeceuticals, Guanabara-­ Koogan), as well as author of several book chapters, scientific articles, and scientific conference’s posters in the field of aesthetic and clinical-surgical dermatology. He is a key opinion leader in dermatology, taking place as pharmaceutical and cosmetic companies’ advisory board member. Dr. Da Costa has given more than 200 lectures around world, aside of being principal investigator in about 200 clinical and in vitro trials.

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Contributors

Beatrice Martinez Zugaib Abdalla  ABC School of Medicine, Santo André, SP, Brazil 2nd Year Resident of Internal Medicine at FMABC, Santo André, SP, Brazil Vito Abrusci  Private Practice, Milan, Italy Caroline Moreira Albrecht  São Paulo, SP, Brazil Carla Albuquerque  Carla Albuquerque Clinic of Dermatology, São Paulo, SP, Brazil Roseli Andrade  Clinical and Aesthetic Dermatology, Clínica Dermatológica Dra Roseli Andrade, Santos, SP, Brazil Alessandra Anzai  Hospital das Clínicas of University of São Paulo Medical School, Dermatology, São Paulo, SP, Brazil Patricia Apt  Las condes Clinic, Santiago del Chile, Chile Samir Arbache  Deparment of Dermatology, University of Mogi das Cruzes, Mogi das Cruzes, SP, Brazil Gabriel Aribi  Department of Dermatology of Hospital Ipiranga, São Paulo, SP, Brazil Department of Dermatology of Centro Universitário Lusíada, Santos, SP, Brazil Monica Aribi  Department of Dermatology of Hospital Ipiranga, São Paulo, SP, Brazil Merces  Assumpcao-Morales Garden City Primary Care, Garden City, NY, USA NYU- Winthrop Hospital, Garden City, NY, USA Francisco  Marcos  Perez  Atamoros Centro Dermatologico Tennyson, Mexico City, DF, Mexico Javier Ruiz Ávila  Dermédica Clinic of Dermatology, Mexico City, DF, MX Adriana  Awada Adriana Awada Clinic of Dermatology, Santo André, SP, Brazil Brazilian Society of Dermatology, Rio de Janeiro, Brazil

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xxiv

Eloisa Leis Ayres  EZskin Dermatologia, Niterói, RJ, Brazil Fernanda Ayres de Morais e Silva  Cardoso Department of Medicine, Facid Wyden, Teresina, PI, Brazil Denise Rocha Luna Barcelos  Denise Barcelos Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Mirna Duarte Barros  Department of Morphology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil Leslie Baumann  Baumann Cosmetic Dermatology Clinic, Miami, FL, USA Marcelo M. Bellini  Marcelo Bellini Clinic of Dermatology, São Paulo, SP, Brazil Abraham Benzaquén-Barchillón  Clínica Benzaquén, Málaga, Spain Valentina Benzecry  Private Practice, Milan, Italy Tatiana Basso Biasi  Brazilian Society of Dermatology, Florianópolis, SC, Brazil Travis  W.  Blalock  Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA Nátalie Schnaider Borelli  Brazilian Society of Dermatology, Private Office in São Paulo, São Paulo, SP, Brazil Shirlei Schnaider Borelli  Brazilian Society of Dermatology, Private Office in São Paulo, São Paulo, SP, Brazil Aline  Rodrigues  Bragatto Aline Rodrigues Bragatto Clinic of Plastic Surgery, Valinhos, SP, Brazil Department of Dermatology, Santa Casa of São Paulo University Hospital, São Paulo, SP, Brazil Liza  R.  Braun Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA Harold J. Brody  Emory University School of Medicine, Atlanta, GA, USA Laura Bariquelo Buratini  Laura Bariquelo Buratini Clinic, Botucatu, SP, Brazil Natalia  Caballero  Uribe Department of Dermatology, ABC School of Medicine, Santo André, SP, Brazil Kenia Calil  Kenia Calil Clinic of Dermatology, Marília, SP, Brazil Valerie D. Callender  Callender Dermatology and Cosmetic Center, Glenn Dale, MD, USA Department of Dermatology, Howard University Hospital, Washington, DC, USA Tatiana Caloi  Tatiana Caloi Clinic of Plastic Surgery, São Paulo, SP, Brazil

Contributors

Contributors

xxv

Fernanda Camozzato  Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil Antonio  Cardoso  Pinto Department of Morphology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil Gabriela  Casabona Beauty Beyond Skin Clinic, Dermatology and Dermatologic Surgery, São Paulo, SP, Brazil Jaime  Piquero-Casals Dermik: Clinica Dermatologica Multidisciplinar, Barcelona, Spain Raquel Cavalcante  Clínica Adriana Vilarinho, São Paulo, SP, Brazil Liliam  Dalla  Corte  Preceptor of Nail and Hair Diseases and Coordinator (Head) of the Nail and Hair Diseases Unit, Dermatology Department, UFCSPA, Hospital Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil Carmelo Crisafulli  IMG Clinic, Dubai, UAE Adilson  Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil Elisa  Raquel  Martins  da Costa  Marques Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil Maria da Glória Martin Sasseron  Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil Mariana  Vale  Scribel  da Silva Department of Dermatology, Santa Casa Hospital, Porto Alegre, RS, Brazil Mirella D’Andrea  Dermatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy Daniel  Dal’Asta  Coimbra Daniel Coimbra Les Peaux Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Rubem David Azulay Institute of Dermatology, Santa Casa of Mercy of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Taciana Dal’Forno Dini  Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, RS, Brazil Ada Regina Trindade de Almeida  Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil Luiza  de Castro  Fernandes  Medical Resident in Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil Adriana  de Cerqueira  Leite Adriana Leite Clinic of Dermatology, São Paulo, SP, Brazil Leticia  de Chiara  Moço Cosmetic Dermatology Unit, Department of Dermatology, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

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Iñigo de Felipe  Clinica Dermatológica De Felipe, Barcelona, Spain Eduardo  de Frutos-Pachón  Clínica Kalos, Fundación Tejerina, Talavera, Spain Rodrigo  Amaral  de Lima Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil Lissa  Sabino  de Matos Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, São Paulo, SP, Brazil Francisco de Melo  ZO Skin Centre, Dubai, UAE Ricardo  de Mendonça  Filho Paulo de Goes Institute of Microbiology, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Lara  Ranulfo  de Mendonça Rogerio Ranulfo Clinic of Dermatology, Goiânia, GO, Brazil Joaquim  José  Teixeira  de Mesquita  Filho Dermatologi Surgery Unit, Ruben David Azulay Institute, Santa Casa of Mercy of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Luis  Henrique  Barbizan  de Moura Dermatology  – UNIFESP EPM, Hospital São Paulo, São Paulo, SP, Brazil Danielle Claudino de Oliveira Costa  Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil Tadeu  de Rezende  Vergueiro Department of Dermatology, University Hospital Pedro Ernesto, Federal Fluminense University, Niterói, RJ, Brazil Rebeca Alvares Rodrigues Maffra de Rezende  Rebeca Rezende Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil Ellem  Tatiani  de Souza  Weimann Universidade Federal de Roraima  – UFRR, Boa Vista, RR, Brazil Children’s Hospital Santo Antônio, San Antonio, RR, Brazil Rossana  Cantanhede  Farias  de Vasconcelos Dermatology Department, University of Santo Amaro, São Paulo, SP, Brazil María del Pilar Del Río Navarrete Biot  Clínica De Dermatológica Maria del Pilar Biot, Niterói, RJ, Brazil Claudio Dias  Clinical Aesthetic Medicine, Recife, PE, Brazil Felipe  Borba  Calixto  dos Santos Department of Dermatology at PUC Campinas, Campinas, SP, Brazil Denise Durand  Clinica San Pablo, Lima, Peru Carlos Echevarria  Private Practice, Dermanova Clinic, Lima, Peru Gabriella Fabbrocini  Dermatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy

Contributors

Contributors

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Andrezza  Facci Clínica Andrezza Facci de Dermatologia, Barueri, SP, Brazil Ricardo Limongi Fernandes  Brazilian Society of Dermatology, American Academy of Dermatology, São Paulo, SP, Brazil Sergio Talarico Filho  Talarico Clinic of Dermatology, São Paulo, SP, Brazil Mercedes  Florez  White Department of Dermatology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA Karina Colossi Furlan  Rush University Medical Center, Chicago, IL, USA Natacha  Quezada  Gaón  Department of Dermatology, Pontifical Catholic University of Chile, Santiago de Chile, Chile Loryart Marte Grullón  Department of Dermatology, Clinica Union Medica del Norte, Santiago de los Caballeros, Dominican Republic Nelise Hans  Private practice, Campo Grande, MS, Brazil María Isabel Herane Herane  University of Chile, Santiago, Chile Camile  L.  Hexsel Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil Madison Medical Affiliates, Mohs Surgery, Glendale and Waukesha, WI, USA Madison Medical Associates, Glendale, WI, USA Doris  Hexsel  Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil Hexsel Dermatologic Clinics, Porto Alegre/Rio de Janeiro, RS/RJ, Brazil Cyro  Hirano Cosmetic Dermatology Unit, Policlínica Geral do Rio de Janeiro, Rio de Janeiro, RJ, Brazil Bruna  Sabatovich  Villarejo  Iosifovich Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Renata Joffe  Inform Diagnostics, Irving, TX, USA Bogdana Victoria Kadunc  Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil Armineh Kajoian  Inform Diagnostics, Irving, TX, USA Maria Paulina Villarejo Kede  Private Clinic, Rio de Janeiro, RJ, Brazil Arash  Kimyai-Asadi  Department of Dermatology, Weill Cornell Medical College, Houston, TX, USA Maritza  L.  Kummerfeldt Clinic of Dermatology, Guatemala City, Guatemala Edgar  E.  La Rotta Centro Medico Buenaventura en Caracas, Guatire, Venezuela

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Hospital Clinic Barcelona, Barcelona, Spain Renan  Lage Cosmiatric Department, Department of Dermatology of the Pontifical Catholic University of Campinas - PUC Campinas, Campinas, SP, Brazil Gottfried Lemperle  Division of Plastic Surgery, University of California, San Diego, La Jolla, CA, USA Bianca  Maria  Liquidato  Department of Morphology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil Alberto Avila Lozano  Centro Dermatologico Tennyson, Mexico City, DF, Mexico Flávio Barbosa Luz  Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil Jaime Piquero-Martin  Hospital Vargas de Caracas, Caracas, Venezuela Caterina  Mazzella Dermatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy Rosemarie Mazzuco  Private Practice, Carazinho, RS, Brazil Jessica  A.  McCarrick Department of Dermatology, Howard University Hospital, Washington, DC, USA Vanessa  Lucília  Silveira  Medeiros Department of Tropical Medicine of Federal University of Pernambuco, Recife, PE, Brazil Instituto Davan Dermatologia, Recife, PE, Brazil Larissa  Mondadori  Mercadante Medical Resident in Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil Renan Minotto  Preceptor of Nail and Hair Diseases and Coordinator (Head) of the Nail and Hair Diseases Unit, Dermatology Department, UFCSPA, Hospital Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil Dermatology Department, UFCSPA, Hospital Santa Casa de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil Gabriele C. Miotto  Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA, USA Suelen Montagner  Private Clinic, Campinas, SP, Brazil Erica Monteiro  Department of Humanities and Medical Sciences, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil Wagner  Ricardo  Montor Department of Physiological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil Javier Morales  Advanced Internal Medicine Group, Greenvale, NY, USA Donald and Barbara Zucker School of Medicine at Hofstra / Northwell University, University, NY, USA

Contributors

Contributors

xxix

Cristina Hachul Moreno  Department of Dermatology, Santa Casa of São Paulo University Hospital, São Paulo, SP, Brazil Cristina Hachul Moreno Clinic of Plastic Surgery, São Paulo, SP, Brazil Daniela Moya  Hospital Universitario de Caracas, Caracas, Venezuela Hospital Intercultural Kallvu Llank Chile, Cañete, Región del Bío Bío, Chile Pierre Nicolau  Pierre Nicolau Clinic of Plastic Surgery, Figueras (Girona), Spain Eliandre  Costa  Palermo Faculty of Medicine of the ABC Foundation, Dermatology, São Paulo, SP, Brazil Francine  Papaiordanou Francine Papaiordanou Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Gaurav P. Patel  Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA Luciana  R.  Patricio  Linhares Sociedade Brasileira de Dermatologia (SBD), São Paulo, SP, Brazil Caroline Silva Pereira  Pontifical Catholic University, São Paulo, SP, Brazil ABC School of Medicine, Santo André, SP, Brazil Sírio Libanês Hospital, São Paulo, SP, Brazil Elisangela  Samartin  Pegas Leprosy, Phototerapy and Bullous Diseases Outpatient Clinic at PUC Campinas, Campinas, Brazil Juliano Peruzzo  Sociedade Brasileira de Dermatologia, Porto Alegre, RS, Brazil Luca Piovano  University of Camerino, Camerino, Italy Plastic Surgeon, Rome, Italy Vanesa Piquero  Clinica Leopoldo Aguerrevere Caracas, Caracas, Venezuela Clinica Dermik Barcelona, Barcelona, Spain Vinicius Pollo Pires  Brazilian Society of Dermatology, Florianópolis, SC, Brazil Jose A. Plaza  Inform Diagnostics, Irving, TX, USA Maxim  Polansky Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA Luciana Takata Pontes  Department of Dermatology/Surgical Dermatology, Hospital De Clínicas – Unicamp – State University of Campinas, Campinas, SP, Brazil Marjorie  Bezerra  Porciúncula Rogerio Ranulfo Clinic of Dermatology, Goiânia, GO, Brazil

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Clarissa  Prati Sociedade Brasileira de Dermatologia, Porto Alegre, RS, Brazil Rogério Tércio Ranulfo  Rogerio Ranulfo Clinic of Dermatology, Goiânia, GO, Brazil Fábio Rebucci  ABC School of Medicine, Santo André, SP, Brazil Viviane Reis  Viviane Reis Clinic of Dermatology, Bauru, SP, Brazil Flávio Rezende  Brazilian Society of Plastic Surgery (SBCP), International Society of Aesthetic Plastic Surgery (ISAPS), Rio de Janeiro, RJ, Brazil Nark-Kyoung  Rho  Leaders Aesthetic Laser & Cosmetic Surgery Center, Seoul, South Korea Patricia Rittes  Clinica Dermatológica Patricia Rittes, São Paulo, SP, Brazil Dirlene  Melo  Palmeira  Roth Deparment of Dermatology, University of Mogi das Cruzes, Mogi das Cruzes, SP, Brazil Paola Rosalba Russo  Modena, Italy Thais Sakuma  Private practice, Campo Grande, MS, Brazil Maria Helena Lesqueves Sandoval  Department of Dermatology, Aesthetic Dermatology Unit, Cassiano Antonio Moraes Hospital, Vitória, ES, Brazil Luciane Scattone  Clínica Dermatológica Dra Luciane Scattone, São Paulo, SP, Brazil Sergio Schrader Serpa  Clínica Dermatológica Sergio Serpa, Rio de Janeiro, RJ, Brazil Marcio Soares Serra  Marcio Serra Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Carolina Siega  Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil Thaísa  Saddi  Tannous  Silvino  Universidade Federal do Mato Grosso do Sul – UFMS, Campo Grande, MS, Brazil André Luiz  Simião  Department of Dermatology, Hospital E Maternidade Celso Pierro – Puccamp, Campinas, SP, Brazil Renata Marques Sitler  Clínica Adriana Vilarinho, São Paulo, SP, Brazil Maria  Teresa  Pereira  Soares Maria Teresa Pereira Soares Clinic of Dermatology, São Sebastião do Paraíso, MG, Brazil Betina  Stefanello Les Peaux Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Rubem David Azulay Institute of Dermatology, Santa Casa of Mercy of Rio de Janeiro, Rio de Janeiro, RJ, Brazil Fabio Antonio Abrantes Tuche  Pedro Ernesto Hospital, State University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

Contributors

Contributors

xxxi

Gerhard  Van Niekerk Medical Aesthetic Clinic, Somerset West, South Africa Cidia Vasconcellos  Department of Dermatology of Hospital Ipiranga, São Paulo, SP, Brazil Department of Dermatology of the University of São Paulo, São Paulo, SP, Brazil Renata  Cristina  Vasconcellos Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil Cristián  Vera-Kellet Department of Dermatology, Pontifical Catholic University of Chile, Santiago de Chile, Chile Rodrigo Vettorato  Department of Dermatology, Santa Casa Hospital, Porto Alegre, RS, Brazil Aline Vieira  Brazilian Society of Dermatology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil Adriana Vilarinho  Clínica Adriana Vilarinho, São Paulo, SP, Brazil Carlos G. Wambier  Yale University School of Medicine, New Haven, CT, USA Carlos  Gustavo  Wambier Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA Department of Medicine, State University of Ponta Grossa, Ponta Grossa, PR, Brazil Mariana Isis Wanczinski  Brazilian Society of Dermatology, Private Office in São Paulo, São Paulo, SP, Brazil Sarah  Wilson Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA Ximena  Wortsman Department of Dermatology at University of Chile, Santiago del Chile, Chile Samira  Yarak Dermatology  – UNIFESP EPM, Hospital São Paulo, São Paulo, SP, Brazil Howa  Yeung Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA Renata  Indelicato  Zac Dermatology Department, Minas Gerais Military Hospital, Belo Horizonte, MG, Brazil Caroline  Romanelli  T.  A.  Zelenika Pontifical Catholic University of Campinas, São Paulo, SP, Brazil

Part I Peelings

1

Introduction: Classification of Peels Carlos G. Wambier and Harold J. Brody

1.1

History/Background

Medical understanding and research followed the lay ancient and cultural formulas used to abrade or smooth the skin, such as sour milk, lemonade [6], vinegar, and even chemical formulas with phenol and croton oil [16]. Some peels are performed on an empirical basis, such as the retinoic acid peel, also known as tretinoin peel [10], which is performed throughout Brazil but lacks more studies of its benefits in acne, rejuvenation, and the field of cancerization [29]. The International Peeling Society tries to set open study points in chemical peels research each year at its pre-American Academy of Dermatology meeting event. Main scientific contributions are summarized in Table 1.1.

1.2

Histological Outcome

For superficial peels, such as Jessner’s solution (14% lactic acid, 14% salicylic acid, and 14% resorcinol in ethanol), also called a Combes’

C. G. Wambier (*) Yale University School of Medicine, New Haven, CT, USA H. J. Brody Emory University School of Medicine, Atlanta, GA, USA © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_1

Table 1.1  The seminal advances in medical literature, updated from [4] Authors and year Unna [30]

Main contribution Salicylic acid, resorcinol, phenol, and TCA descriptions Fox [13] Phenol for facial freckles Mackee and Karp [20] Phenol for scarring Eller and Wolff [12] Sulfur, resorcinol, salicylic acid, phenol lotions, CO2 slush Monash [21] Trichloroacetic acid peeling Urkov [31] Resorcinol, lactic acid, salicylic acid, phenol, cantharidin Max Jessner, 1950s Jessner’s solutions Combes et al. [9] Buffered phenol formulas Brown et al. [7] Phenol histology and buffered formulas Ayres [1] TCA for actinic damage Baker and Gordon [2] Phenol–croton oil formula Litton [19] Phenol–croton oil formula Resnik et al. [24] TCA peeling Stegman [27] Histologic comparison of wounding agents Van Scott and Yu [26] Alpha-hydroxy acids Brody and Hailey [5] Medium-depth peeling, CO2 slush, and 35% TCA Monheit [22] Medium-depth peeling variation, Jessner, and 35% TCA Griffin et al. [15] Pyruvic acid peel Coleman and Medium-depth peeling Futrell [8] variation, glycolic acid +35% TCA Hetter [17] Croton oil strength paradigm. Phenol–croton oil formulas Cucé et al. [10] Tretinoin peeling Dainichi et al. [11] Salicylic acid in polyethylene glycol Safoury et al. [25] Modified Jessner’s solution and TCA in melasma 3

C. G. Wambier and H. J. Brody

4

peel, there is only epidermal injury, with stratum corneum separation and upper epidermal intraepithelial edema and spongiosis. No dermal changes are present. The upper dermal injury is the main characteristic of medium-depth peels. When necrosis reaches mid-dermis, the peel is considered deep [4]. Samuel Stegman’s work on the histological depth of chemical wounding [27] was a hallmark for more scientific and controlled chemical peeling [23]. The experiment involved a comparison between dermabrasion, a mediumdepth peel, comprising 60% trichloroacetic acid (TCA) and liquid phenol (88%), and a deep peel: Baker’s phenol mixture. Peels were performed over the neck of a 55-year-old male, occluded for 24  h on the right side and unoccluded on the left side; the skin was biopsied at 3 days and 60 days after treatment. Histological outcomes were set: wound thickness (distance from basement membrane to the depth of the wound in the dermis), epidermal thickness, grenz zone (as a marker of sun damage: amorphous pale staining and elastosis), and distinct dermal scar formation. Dermabrasion produced more intense hypopigmentation clinically. Occluded peels on right side took longer to heal and apparently had slightly deeper wounding on the third day, and epidermis was thicker and still healing on the 60th day. At 120  days, peeled areas had normal ridge architecture, while dermabrasion produced an almost entirely flat epidermis. A dermal scar band from the middle to upper epidermis was formed at 60 days in all occluded specimens of sun-­damaged skin. This band was not formed in non-­sun-­damaged control skin and was not formed in unoccluded pure phenol and TCA peels, with phenol–croton oil peel producing, noticeably, more dense collagen fibers and increased glycosaminoglycan density both above and beneath this scar tissue [27]. Although this experiment was done in the neck skin, which differs from facial skin in penetration and healing, it was an excellent starting point in methodology and histological basis of croton oil action in phenol formulas. Since we know that drivers usually have their left side

more susceptible to sun damage [14], the discussion about tape occlusion effects remains open to debate.

1.3

Available Materials

• Degreasing agent: ethanol, acetone, or a mixture of both (preferred by the author) although some experts prefer more complex degreasing formulas, with ether, resorcinol, or glycolic acid, for increasing degreasing and penetration effects of the peeling agent, which could also be replaced by a sequential combination of chemical peels (preferred by the authors). See Fig. 1.1a. • Applicators: wooden or plastic, cotton-tipped applicators, cotton pads, or 4 × 4 gauzes. See Fig.  1.1b. Q-tips are better used for drying tears, because of the thin tube, which absorbs liquid by capillarity [34]. • Wounding agent: any chemical peel solution. See Table 1.1; Fig. 1.1c. • Priming: Skin priming with topical retinoids is indicated for faster postoperative healing and increased penetration [32]. Other priming agents may be used, such as glycolic acid and azelaic acid; however, they lack scientific evidence. • Post-peeling: Any moisturizer or ointment is safe enough not to cause further irritation or allergic reaction to the skin for superficial or medium-depth peels. Vaseline is very safe, from superficial to deep peels (Fig. 1.1d). For deep peels, there is still great debate on whether “tape occlusion” (originally, with Johnson & Johnson’s adhesive tape) dictates some extra strength or was just a costume derived from the first “phenolization” of war wounds during world war I. Although taping seems to increase the wound, it is still not clear if it is by occlusion and enhanced penetration of the wounding agents, irritation from solvents and components of the glue, or s­ imple debridement and maceration. Although baker and Gordon [28] have published an article stating that they had completely abandoned

1  Introduction: Classification of Peels

5

Fig. 1.1  Materials: acetone (a), multiple applicators (b), peeling agent disposed in a shot glass specific for that chemical, to avoid cross-contamination (c), Vaseline (d)

taping since 1986, using a thick layer of Vaseline instead, for cases of very deep wrinkles, they still used taping (Brody, personal communication, 2017). Some specialists, such as Peter Rullan and Marina landau, adopt taping for the first 24 h, with a different tape, Hy-­ tape®, which is secured by surgical net, followed by debridement and a powder mask that hardens over 24 h (thymol-iodine). During this regimen, the patients eat and drink only by pushing their fluids and milk shakes through three to four hair dye plastic bottles. They cannot chew or suck. If they talk it has to be by mumbling or by writing it out. They cannot wash their face for 7–8 days, which is the period when the mask falls off. Mouth hygiene is done by gargling their mouth with Periogard® (Rullan, personal communication, 2017). With Vaseline [3], patients are free to eat, drink, chew, and talk. Mouth hygiene is done as usual with toothbrush, dental floss, and gargle. And the main advantage to the surgeon is the direct observation of the skin during the first week of critical follow-up [28, 36]. One of the authors of this chapter, prof. Wambier, and Dr. Hetter agree that the croton oil concentration (cytotoxic fraction) is more important than post-peel regimens in determining rejuvenation [17, 18].

Fig. 1.2  Multiparameter monitor, showing left atrial flutter caused by high-concentration topical anesthetic before the beginning of a phenol–croton oil peel, which was aborted. Safety always comes first in case of a cosmetic procedure

• Multiparameter monitors: Electrocardiogram, pulse oximeter, blood pressure, along with necessary advanced cardiologic life-support drugs, intravenous access, and defibrillator, in case of phenol peels in more than one cosmetic unit, are advisable (Fig. 1.2; Table 1.2).

C. G. Wambier and H. J. Brody

6 Table 1.2  Examples of chemical agents, classified by depth of peeling Superficial chemical peels Salicylic acid 20–30% Retinoic acid 2–8% Glycolic acid 50–70% Jessner’s solution MJS Lactic acid 30–88% Pyruvic acid 40–50% Thioglycolic acid 10–35% Mandelic acid 30–40% Resorcinol TCA 10–35%

Medium-depth chemical peels Monheit’s Jessner + TCA 35% Coleman’s glycolic + TCA 35% Brody’s solid CO2 + TCA 35% MJS + TCA 35% Phenol 88% Pyruvic acid >50% TCA 40–60% (localized/CROSS) Phenol–castor oil

Deep chemical peels Phenol–croton oil TCA >80% (CROSS)a

TCA trichloroacetic acid; MJS Mmodified Jessner’s solution a TCA > 80% only indicated for rhinophyma or spot treatment of scars, xanthelasma, and actinic cheilitis

1.4

Methods and Techniques

• Degreasing: it is important to remove all makeup, sebum, beard, topical anesthetic, and sunscreen by cleansing with mild soap and warm water. Before the procedure, the patient can be instructed to firmly apply acetone or ethanol to the face, by scrubbing with a gauze pad or what is preferable for controlled degreasing; the physician may scrub the patient’s face with a semi-soaked gauze pad (Fig. 1.3). • Application of the chemical agent: each physician has a preference of applicator for each chemical peel. Depending on the area of the face/body to be peeled, the physician may change the applicator for a semi-dry or soaked application, or, for extra penetration of the chemical agent, the surgeon may use a rough applicator, scrubbed with pressure and speed, multiple times. The number of passes, saturation of the applicator, and concentration of the chemical agent have direct effect on the aggression of the chemical peel. It is important to face the indication of each chemical agent for each classification of peels. It is not wise to use a superficial peeling agent in multiple passes and with vigor to obtain a medium-­depth peel, for example, or to use a deep-peel formula lightly to obtain a medium-depth peel (Figs. 1.4, 1.5, and 1.6). • Washing or neutralization: in cases of excess superficial crystallization (pseudofrost) or when it is desired to stop the chemical reaction to the skin, the chemical agent may be

Fig. 1.3  Degreasing the face with acetone before phenol– croton oil peel

Fig. 1.4  Application of phenol–croton oil perioral peel with a cooler for patient comfort. The frosting is pronounced in a deep chemical peel

1  Introduction: Classification of Peels

Fig. 1.5 Chemical reconstruction of scars (CROSS), with punctual application of 90% trichloroacetic acid by drilling with a toothpick into the icepicks and boxcars (focal deep peel). The full face was previously treated with superficial 40% pyruvic acid

7

Fig. 1.7  Pseudofrosting of a modified Jessner solution peel (17% salicylic acid, 17% lactic acid, and 8% citric acid in ethanol). In superficial peeling, the end point is the background erythema. A hand-held ventilator was used for patient’s comfort. The pseudofrosting (crystals of salicylic acid) may be removed with a wet soft towel or rinsed in tap water

1.5

Fig. 1.6  Application of solid carbon dioxide slush before sequential treatment with 35% trichloroacetic acid (Brody’s peel); in this case, the perioral area was demarcated for combination treatment with deep chemical peels by using Hetter’s formula with 1.1% croton oil in 33% phenol. (Courtesy of Dr. Harold Brody)

removed with a humid soft towel with water or 10% sodium bicarbonate (which is only imperative for glycolic acid and pyruvic acid peels) (Fig. 1.7). • Post-peeling regimen: soon after the end of the desired effect of the chemical agent, the patient is started on a regimen to improve healing, by total avoidance of irritants, fragrances, allergens, and sun exposure. The first step is the application of a moisturizing cream or petrolatum in the office. The author does not recommend sunscreen in the first 24 h of superficial and medium-depth peels and in the first 7 days of deep peels to avoid allergen sensitization.

Clinical Outcome

• Superficial peels: there is thin scaling of the face. Some mild superficial peels such as salicylic acid in polyethylenoglycol (PEG) cause imperceptible scaling but may have excellent action in the follicles and open comedos. Some patients may present irritation with minimal exposure to water or dry environment; thus, it is advisable to keep regular use of a moisturizer during the first 7 days of follow-­up. Peels may be repeated every 7–14 days, depending on complete recovery. The desired clinical outcome depends on the intention of the surgeon. And it is of pivotal importance to the clinical results that superficial peels have their effects enhanced on each repeated sequential session, with more noticeable clinical end points, such as erythema and mild frosting [4], which reflect on increased scaling after some days. Since melasma is a full-thickness epidermal melanosis, very light superficial peels, although safe, are less effective than low-concentration TCA peels, and modified Jessner’s solution (MJS) may be used to improve TCA penetration and decrease risks of post-inflammatory hyperpigmentation (PIH), which is very common in peels that reach the basal layer [25] (Fig. 1.8). • Medium-depth peels: there is thick scaling of the face. Mild-to-moderate edema is to be expected,

8

Fig. 1.8  Superficial peel (modified Jessner’s solution) for rejuvenation and preparation for a medium-depth peel after 2 weeks. Uniform thin scales

C. G. Wambier and H. J. Brody

and the skin may be tender to touch for the first 48 h. The patient must be counseled regarding herpes activation and advised not to pull on scales, because this can lead to erosions and delayed healing. The author, Wambier, advises his patients to cut only the bothering hanging scales with small, clean, scissors and to rub the face with hair conditioner in the shower, after the fourth or fifth day of peel to assist with thick scale removal. Complete recovery is expected in 10 days. Peels may be repeated every 2 months if necessary. Regarding medium-depth peels’ modality, Brody’s peel is unique in a way that it combines a physical modality (CO2 slush) with 35% TCA, with increased efficacy for seborrheic keratoses, hypertrophic actinic keratoses, and superficial acne scars. Wambier prefers MJS over Jessner solution for sequential peel with 35% TCA for mild rejuvenation, because of fewer allergic reactions (resorcinol in Jessner’s); although there were no published biopsy data on the depth of peel, it seems to be as effective as Monheit’s peel for mild rejuvenation [34] (Figs. 1.9 and 1.10).

Fig. 1.9  Medium-­depth peel. Sequence of modified Jessner’s solution followed by 35% trichloroacetic acid for rejuvenation, sixth postoperative day

1  Introduction: Classification of Peels

Fig. 1.10  Medium-depth peel. Solid carbon dioxide followed by 35% trichloroacetic acid (Brody’s peel) for treatment of moderate acne scars, third postoperative day

• Deep chemical peels: there is intense edema, which usually lasts 72 h. Vesicles, blisters, and oozing occur in the first 48  h. Pustules and purulent exudate occur after 48–72 h. Crusts and eschars fall off by the 8th day. Careful debriding and crust removal are advised if there is liquid collection or localized pain. The patient may be started on systemic and topical combination antibiotic therapy if any sign of

9

Fig. 1.11  Deep chemical peel. Phenol 35%, croton oil 1.6%, and Septisol 5% for perioral area (one of Hetter’s formulas). The rest of the face was first peeled with Monheit’s medium-depth peel. Yellow crusts and exudate on the fourth postoperative day. Dry crusts illustrate this patient was not using Vaseline as instructed, which may result in fissures. Feathering was done to prevent demarcation marks between peels and to the neck

i­nfection is observed, such as odor, pus, increase in erythema, edema, or pain. Interestingly, a split-face study was performed with occluded Baker’s peel (50% phenol, 2.1% croton oil) and Hetter’s medium-heavy peel (33% phenol, 0.7% croton oil), without clinically relevant differences at a short follow-up [33]. This split-face experiment was criticized for short follow-up to observe chronic pigmentation changes and lack of side randomization [35] (Fig. 1.11).

C. G. Wambier and H. J. Brody

10

1.6

Before and After (Figs. 1.12, 1.13, and 1.14)

Fig. 1.12  Before and after two sessions of superficial chemical peels (modified Jessner’s solution) for treatment of melasma and facial melanosis

Fig. 1.13  Before and after medium-depth peel with modified Jessner’s solution followed by 35% trichloroacetic acid. Left to right: 0, 3, 5, 14 days

Fig. 1.14  Before and after deep chemical peels with 35% phenol and 1.6% croton oil (Hetter’s heavy formula). Left to right: 0, 3, 5, 7 days

1  Introduction: Classification of Peels

1.7

 ide Effects, Complications, S and Their Management

• Allergic reactions: They are most common with resorcinol and Jessner’s solution; thus, the author prefers modified Jessner’s solution, which is exempt of resorcinol. Acute

Fig. 1.15  Allergic contact dermatitis following superficial retinoic acid (5%) peel blended with skin-tone makeup (top left) and blended with Curcuma longa, melatonin, and golden colorant. Intense pruritus occurred after 24 h. This patient, Dr. Wambier’s secretary, was managed

11

urticarial reactions may occur with salicylic acid, so it is always advisable to have one shot glass for each solution, and disposable applicators, to avoid cross-contamination. The office must be equipped with emergency crash medications (corticosteroids, anti-histamines, epinephrine). Figure  1.15 illustrates

with topical and systemic corticosteroids. Spot tests may be indicated in patients with known allergic contact dermatitis or atopic dermatitis. Retinoic acid peels may exacerbate seborrheic dermatitis and rosacea

C. G. Wambier and H. J. Brody

12

an allergic contact dermatitis to retinoic acid peel formulas. • PIH: This is the most common side effect of chemical peels in general. Predisposing factors are melasma, phototype, sun exposure. To minimize risks, skin preparation for 1 month and post-peel regimen with hydroquinone and corticosteroids may be indicated in some cases. Treatment is performed with low-­ fluency Q-switched Nd-YAG 1064  nm, Kligman’s formula, superpotent steroids, and very mild superficial peels, such as MJS, 10% TCA, or 20–30% salicylic acid. • Convulsions: The odor of the chemicals, anxiety, ventilators with flashing LEDs might predispose the patient with epilepsy to convulsions. It is advisable to have proper emergency medications (benzodiazepines, oxygen) and adequate environment when treating these patients. • Eye irritation: It can occur from volatile chemicals and accidental splash or tearing. To maximize eye safety, it is always advisable to have saline bottles in the room, advise the patient to keep their eyes closed until the end of the procedure, keep eyelids dry with Q-tips during the procedure, and avoid general anesthesia or sedation. It is a general rule not to hold any applicator or chemical bottle directly above the patient’s eyes for accidents do happen. After deep peels, it is advisable to check the conjunctiva of the patient for any signs of erythema or chemosis and manage it properly with moisturizing gels, lubricating eye drops, and eyelash hygiene.

Tip Box

• Undisputed cost effectiveness. • Hands-on training and supervision are mandatory for acquiring the correct technique. • Dedication and chemical quality are vital for successful outcomes.

References 1. Ayres S.  Dermal changes following application of chemical cauterants to aging skin. Arch Dermatol. 1960;82:578. 2. Baker T, Gordon H. The ablation of rhytides by chemical means: a preliminary report. J Fla Med Assoc. 1961;48:541. 3. Beeson WH, McCollough EG.  Chemical face peeling without taping. J Dermatol Surg Oncol. 1985;11(10):985–90. 4. Brody HJ.  Chemical peeling and resurfacing [Internet]. 3rd ed. Atlanta: Emory University Digital Library Publications; 2009. p. 1–267. Available from: https://pid.emory.edu/ark:/25593/s2xpg 5. Brody HJ, Hailey CW.  Medium-depth chemical peeling of the skin: a variation of superficial chemosurgery. J Dermatol Surg Oncol. 1986;12(12): 1268–75. 6. Brody HJ, Monheit GD, Resnik SS, Alt TH.  A history of chemical peeling. Dermatol Surg. 2000;26(5):405–9. 7. Brown AM, Kaplan LM, Brown ME. Phenol induced histological skin changes: hazards, techniques, and uses. Br J Plast Surg. 1960;13:158. 8. Coleman WP, Futrell JM.  The glycolic acid trichloroacetic acid peel. J Dermatol Surg Oncol. 1994;20(1):76–80. 9. Combes FC, Sperber PA, Reisch M. Dermal defects: treatment by a chemical agent. NY Physician Am Med. 1960;56:36. 10. Cucé LC, Bertino MCM, Scattone L, Birkenhauer MC.  Tretinoin peeling. Dermatol Surg. 2001;27(1):12–4. 11. Dainichi T, Ueda S, Imayama S, Furue M, Ainichi TED, Eda ÃSEU, et  al. Excellent clinical results with a new preparation for chemical peeling in acne: 30% salicylic acid in polyethylene glycol vehicle. Dermatol Surg. 2008;34(7):891–9; discussion 899. 12. Eller J, Wolff S. Skin peeling and scarification. JAMA J Am Med Assoc. 1941;116:934–8. 13. Fox G. Photographic atlas of the diseases of the skin, vol. 2. Philadelphia: Lippincott; 1905. 14. Gordon JRS, Brieva JC. Unilateral dermatoheliosis. N Engl J Med. 2012;366(16):e25. 15. Griffin T, Van Scott E, Maddin S.  The use of pyruvic acid as a chemical peeling agent. J Dermatol Surg Oncol. 1989;15:1316. 16. Hetter GP.  An examination of the phenol-croton oil peel: part II.  The lay peelers and their croton oil formulas. Plast Reconstr Surg. 2000a;105(1): 240–8-51. 17. Hetter GP.  An examination of the phenol-croton oil peel: part IV. Face peel results with different concentrations of phenol and croton oil. Plast Reconstr Surg. 2000b;105(3):1061–83; discussion 1084-7.

1  Introduction: Classification of Peels 18. Larson DL, Karmo F, Hetter GP.  Phenol-croton oil peel: establishing an animal model for scientific investigation. Aesthet Surg J. 2009;29(1):47–53. 19. Litton C. Chemical face lifting. Plast Reconstr Surg. 1962;29:371. 20. Mackee G, Karp F. The treatment of post acne scars with phenol. Br J Dermatol. 1952;64:456–9. 21. Monash S. The uses of diluted trichloroacetic acid in dermatology. Urol Cutan Rev. 1945;49:119. 22. Monheit GD.  The Jessner’s + TCA peel: a medium depth chemical peel. Dermatol Surg Oncol. 1989;15:945–50. 23. Orekoya O, Oremule B, Hanna T. Historical abstracts. Br J Dermatol. 2016;175:191–8. 24. Resnik SS, Lewis LA, Cohen BH.  Trichloroacetic acid peeling. Cutis. 1976;17(1):127–9. 25. Safoury OS, Zaki NM, El Nabarawy EA, Farag EA. A study comparing chemical peeling using modified Jessner’s solution and 15% trichloroacetic acid versus 15% trichloroacetic acid in the treatment of melasma. Indian J Dermatol India. 2009;54(1):41–5. 26. Van Scott EJ, Yu RJ.  Hyperkeratinization, corneocyte cohesion, and alpha hydroxy acids. J Am Acad Dermatol. 1984;11(5):867–79. 27. Stegman SJ.  A comparative histologic study of the effects of three peeling agents and dermabrasion on normal and sundamaged skin. Aesthet Plast Surg. 1982;6(3):123–35. 28. Stuzin JM, Baker TJ, Gordon HL.  Chemical peel: a change in the routine. Ann Plast Surg. 1989;23(2):166–9.

13 29. Sumita JM, Leonardi GR, Bagatin E. Tretinoin peel: a critical view. An Bras Dermatol Sociedade Brasileira de Dermatologia. 2017;92(3):363–6. 30. Unna P. Therapeutiques generales des maladies de la peau. 1882. 31. Urkov J.  Surface defects of skin: treatment by controlled exfoliation. Ill Med J. 1946;89:75. 32. Vagotis FL, Brundage SR. Histologic study of dermabrasion and chemical peel in an animal model after pretreatment with Retin-A.  Aesthet Plast Surg. 1995;19(3):243–6. 33. Vasconcelos B, Figueira G, Fonseca J, Mendonça L, Fonseca C.  A splitface comparative study between two phenolbased peelings (BakerGordon and Hetter formulas) in the treatment of facial rhytids. Surg Cosmet Dermatol. 2013;5:40–4. 34. Wambier CG.  My personal experience with peel ings. In: Issa MCA, Tamura B, editors. Chemical and physical procedures. Cham: Springer International Publishing; 2017. p. 1–9. 35. Wambier CG, Brody HJ, Hetter GP.  Comments: Hemiface comparative study of two phenol peels (Baker-Gordon and Hetter formulas) for the correction of facial rhytids. Surg Cosmet Dermatol. 2017;9(2):190–1. 36. Wambier CG, de Freitas FP.  Combining phenol-­ croton oil peel. In: Issa MCA, Tamura B, editors. Chemical and physical procedures. Cham: Springer International Publishing; 2017. p. 1–13.

2

Pearl Chapter: Basis of Photoaging and the Use of Chemical Peelings Suelen Montagner and Adilson Da Costa

2.1

Intrinsic Aging

Intrinsic aging is the process of senescence that affects all body organs, and the skin clearly shows the action of time and is transformed by it [1]. In 1990, there were more than 300 theories of aging. Today, the situation is even more complicated [2]. Intrinsic skin aging or chronologic aging is characterized by physiological changes genetically determined and includes structural, biochemical, and functional alterations [3, 4]. These changes are complex, and there are many theories of skin pathophysiology, like shortening of telomeres, reduction of cellular DNA repair capacity [5], cellular senescence, and decreased proliferative ability [6] mutations of extranuclear mitochondrial DNA [7]. Some of them are highlighted.

2.1.1 Shortening of Telomeres Telomeres are sequences of repeating nucleopeptides present at the end of chromosomes (Fig. 2.1) [8]. Because DNA polymerase cannot transcribe the final sequence of bases present in the DNA ribbon during replication, the telomeric size is reduced at each mitotic cycle [9]. This telomere reduction is associated with cellular aging [10–13]. This mechanism contributes to the regulation of growth arrest in senescent human cell cultures the same way as stress or aberrant signaling-­induced senescence (STASIS) [14]. Telomeres themselves are regarded as possible biomarkers of biological aging and cellular senescence. Other possible biomarkers are the free radicals [15].

S. Montagner (*) Private Clinic, Campinas, SP, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_2

Fig. 2.1  Representation of a telomere, highlighted

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S. Montagner and A. Da Costa

16

2.1.2 Free Radicals and Antioxidizing Ability In 1956, Denham Harman proposed a theory that free radicals are also involved in this aging process: they would cause cellular damage, which would accumulate over the course of life and result in acceleration of dysfunctions [16]. Later, Yu and Yang described that not only the overexpressed production of reactive oxygen species (ROS) but also other oxidants, such as the reactive nitrogen species and reactive lipid species, cause oxidative damage [17]. In other studies, the degradation of oxidized products was unraveled. The body can neutralize ROS through the production of antioxidant enzymes, such as superoxide dismutase, catalase, and glutathione peroxidase, by an innate antioxidant defense system [18, 19]. This function is exerted by proteasome (multicatalyctic protease), whose activity seems to diminish over the course of life. With this, an incomplete degradation of oxidized proteins, increased protein aggregates, and the acceleration of cell dysfunction are observed, which, ultimately, lead to cellular aging [16, 20].

2.1.3 Cellular Senescence The theory of cellular senescence has been demonstrated in keratinocytes, fibroblasts, and melanocytes [21]. There is a reduction in the proliferative potential of cells after a certain amount of division [22–24]. Senescent cells can also produce several cytokines, chemokines, growth factors, proteases, and matrix ­ metalloproteases, a phenomenon described as senescence-­associated secretory phenotype (SASP) [25]. A hallmark of skin aging is the degradation of collagen and other extracellular matrix components in the dermal connective tissue and can be induced through chronic MMPs secretion by senescent cells [26].

2.2

Intrinsic Factors

2.2.1 Genetic Characteristics Many studies correlated genomes with the aging process [27, 28]. According to one of them, of all

genes studied, 39 were regulated overlappingly in both sexes. They could serve as gender-­ independent biomarkers of endogenous skin aging. On the other hand, Wnt signaling pathway showed to be significantly downregulated in aged skin with decreased gene and protein expression for males and females [29]. Genic expression studies from aged sun-­ protected skins showed differential expression, possibly responsible for dysregulation of the insulin and STAT3 signaling pathway, the extracellular matrix (PI3, S100A2, A7, A9, SPRR2B), and the cell cycle (CDKs, GOS2). There was also evidence of a high regulation of proapoptotic genes, in part by a dysregulation of FOXO1. An under-expression of the JUN and FOS family members and cytoskeleton genes (KRT2A, KRT6A, and KRT16A) is also affected by intrinsic aging [30]. Another alteration observed in skin aging is the reduced expression of type I collagen due to downregulation of the transcription growth factor (TGF) β-1 and the connective tissue growth factor (CTGF). This reduced collagen expression is even associated with increased nuclear factor-κB (NF-κB) activity and increased expression of matrix metalloproteinase (MMP)-1 [31, 32]. An interesting discovery is that DNA methylation measures the cumulative effect of an epigenetic maintenance system, like a “clock of aging,” and can determine the individual age with an error of less than 3.6 years. This additional information can be used to address a host of questions in developmental biology, cancer, and aging research [33].

2.2.2 Sexual Hormones With aging, the functional reserves of the endocrine system are reduced. As a result, the levels of sexual hormones decline. In females, hormonal changes are well documented. Women have a rapid decline of estrogen during menopause [34]. Estrogen is related to the stimulus of keratinocyte proliferation, which leads to the thickening of the epidermis, avoiding its atrophy [35]. In the dermis, the stimulus is of blood vessels and fibroblast production, thereby preserving collagen, elastic fibers, and glycosaminoglycans [36, 37]. With the

2  Pearl Chapter: Basis of Photoaging and the Use of Chemical Peelings

reduction of this hormone, the maintenance of these processes would be compromised. The characterization of hormonal changes in males is a challenge, as there is not a remarkable hormonal decrease when compared with females. During the aging process, most men show a gradual reduction of circulating testosterone—something around 1% a year after 30  years of age. However, this number substantially varies among men [38]. Testosterone reduction is related to intrinsic aging because it broadly interacts with the skin, the whole body, and the male behavior itself [39].

2.3

Extrinsic Aging

Extrinsic aging results from the exposure to environmental factors—critical for the final result of the process [35]. Sun exposure intensifies skin aging due to ultraviolet radiation, a process referred to as photoaging [40]. Factors such as smoking and pollution may also lead to aging [41]. All these factors can lead to ROS generation, reducing collagen synthesis and increasing its degradation, contributing to premature skin aging (Fig. 2.2).

Generation of ROS

ing

rad

Deg

sis

the

Syn

Collagen

Premature Skin Aging

Fig. 2.2  Air pollution, smoking, and sun exposure leading to ROS generation, reducing collagen synthesis and increasing its degradation, contributing to premature aging

2.4

17

Extrinsic Factors

2.4.1 Air Pollution The World Health Organization defines air pollution as contamination of the indoor or outdoor environment by any chemical, physical, or biological agent that modifies the natural characteristics of the atmosphere [42]. The skin acts as a physical, chemical, and immunological barrier against the environmental factors. This barrier can fail when the exposure to stressors is prolonged and repetitive, leading to the development of various skin diseases [43]. Major air pollutants which affect the skin are solar ultraviolet radiation, polycyclic aromatic hydrocarbons, volatile organic compounds, nitrogen oxides, particulate matter, cigarette smoke, heavy metals, and arsenic [44]. Air pollutants damage the skin by inducing oxidative stress and can lead to aging of the skin [41, 44]. Some pollutants stand out, such as ozone, particulate matter (PM), and polycyclic aromatic hydrocarbons. Ozone can affect the integrity of the skin on murine cutaneous tissue, can act as a strong oxidative agent, and can induce the expression of MMP-9, indicating a role in matrix remodeling [45, 46]. Oxidation of epidermal lipids and disturbed activity of matrix metalloproteinases contribute to wrinkling and extrinsic skin aging [47]. Particulate matter in the air consists of complex and varying mixtures of different sizes and composition. After penetrating the skin either through hair follicles or transdermally, PM exerts its detrimental effects through the generation of oxidative stress, contributing to extrinsic skin aging, characterized particularly by pigment spots on the face and nasolabial folds and less so by coarse wrinkles, solar elastosis, and telangiectasia [48–50]. Furthermore, particles can serve as carriers for organic chemicals and metals that are capable of localizing in mitochondria and generating ROS directly in mitochondria [51], leading to skin aging by mitochondrial damage [41]. Polycyclic aromatic hydrocarbons (PAHs) are adsorbed on the surface of suspended PM in the air of urban areas [52] and are converted into quinines, redox-cycling chemicals that produce reactive oxygen species [53]. They are associated with extrinsic skin aging, pigmentation, cancers, and acneiform eruption [52].

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2.4.2 Smoking In 1969 it was recognized that smokers look older than non-smokers [54]. Later, smoking was found to be an independent risk factor for premature facial wrinkling even after controlling for sun exposure, age, sex, and skin pigmentation [55]. A dose–response relationship between wrinkling and smoking has been identified, with smoking being a greater contributor to facial wrinkling than sun exposure [56]. Reactive oxidants and free radicals from cigarette smoke cause oxidative stress or secondary oxidative events and inhibition of antioxidant mechanisms [57–59]. Components of cigarette smoke increase transepidermal water loss, degeneration of connective tissue in the skin, and upregulation of matrix metalloproteinases-1 and -3 which degrade collagen and elastic fibers, which causes skin to become less elastic [43, 60, 61].

2.4.3 Ultraviolet Radiation and Photoaging Photoaging is a cumulative process that is dependent on sun exposure degree and skin pigmentation level. Clinical presentation of sun-aged

skin includes dryness of the skin; yellowish, wrinkled, atrophic, irregular pigmentation; telangiectasias; and pre-malignant lesions [62, 63]. Histologically there is thinning of the stratum spinosum, increased thickness of granular cell layer, flattening of the dermoepidermal junction, and an increased number of hypertrophic dopapositive melanocytes [62, 64]. In aging process it is observed that keratinocytes become resistant to apoptosis and susceptible to DNA mutations. The number of melanocytes is also reduced, and the melanocytic density is altered. Langerhans cells also decrease in number with aging, resulting in loss of antigenic ability [62]. The immediate effect of sun exposure on the skin is cutaneous hyperpigmentation with delay in the formation of new melanin, which is reversible. The prolonged, recurrent sun exposure implies definitive changes in the quantity and distribution of melanin in the skin. The deposition of amorphous material in the papillary dermis, in place of conjunctive tissue, is the main element in differentiating chronologic aging and photoaging [62]. The morphological changes resulting from photoaging are, essentially, different from those observed in intrinsic aging. A parallel between such changes is shown in Table 2.1 [62, 40, 64, 65].

Table 2.1  Skin changes caused by intrinsic and extrinsic aging

Wrinkles Stratum corneum Dysplastic cells Collagen fibers

Intrinsic aging (chronologic) Thin Unchanged Few Slight change in size and organization Reorganized ↓ number and thinning Normal ↓ number

Elastic fibers Capillary follicle Melanocytes Sebaceous and sweat glands Dermoepidermal junction Slight flattening Microvasculature Reduced area Benign changes Pre-malignant changes Malignant changes

Seborrheic keratosis _ _

Reprinted with permission from Montagner and Costa [65]

Extrinsic aging (environmental factors) Deep Tapered Many Great change in size and organization ↓ production and ↑ degeneration ↓ number and structure: hair loss ↓ number and melanin ↓ number: dry skin Major flattening Telangiectasias, ecchymoses, inflammatory perivascular infiltrate. Seborrheic keratosis Actinic keratosis Basal cell carcinoma Spindle cell carcinoma

2  Pearl Chapter: Basis of Photoaging and the Use of Chemical Peelings Table 2.2  Main mechanisms involved in aging Intrinsic aging  Shortening of telomeres  Reduction of cellular DNA repair capacity  Cellular senescence and decreased proliferative ability  Mutations of extranuclear mitochondrial DNA Extrinsic aging  Receptor-initiated signaling  Mitochondrial damage  Protein oxidation  DNA damage  Arylhydrocarbon receptor signaling

The ultraviolet (UV) B (290–320 nm) and A (320–400 nm) fractions [66] as well as the infrared (IR) A (770–1400 nm) fraction [67–69] can induce the extrinsic skin aging process [41]. Ultraviolet radiation penetrates the skin, and in accordance with the wavelength, it interacts with the different cells located in the different strata. Shortwave radiation (UVB) is more absorbed in the epidermis and predominantly affects keratinocytes but is also able to cross this layer and reach the papillary dermis [70]. Longer waves (UVA) penetrate more deeply and hit ­epidermal keratinocytes and dermal fibroblasts [71, 72]. IRA is able to penetrate through all three layers of the skin: the epidermis, dermis, and subcutis [41]. The UV-induced skin aging process is complex and can occur by various pathways including receptor-initiated signaling, mitochondrial damage, protein oxidation, DNA damage, and arylhydrocarbon receptor (AhR) signaling [41]. Table  2.2 compares the main mechanisms of intrinsic and extrinsic aging.

2.4.4 Receptor-Initiated Signaling Pathway The reactive oxygen species produced by ultraviolet radiation activate cell surface receptors of cytokines and growth factors in keratinocytes and fibroblasts, which activate kinases, that induce expression and transcription factors such as nuclear κB transcription factor (NF-κB) and protein 1 (AP-1) [41, 63].

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The activated NFkB stimulates the transcription of inflammatory cytokines (IL1, IL6, TNFa), attracting neutrophils and collagenases, associated in collagen degrading [73]. Increased AP-1, in turn, decreases the gene expression of dermal collagens I and III in fibroblasts, reducing collagen synthesis. Besides that, AP-1 stimulates the transcription of genes of matrix-disintegrating enzymes, such as metalloproteins (MMP-1, MMP-3, MMP-9), degrading mature dermal collagen [74, 75]. The radiation is not only related to collagen degradation but also contributes to reducing its synthesis. UVA ray exposure triggers two factors related to photoaging: induction of matrix metalloproteinases (MMPs) and mitochondrial mutation [72, 76, 77].

2.4.5 Mitochondrial Damage Actually, mitochondrial DNA damages are likely to be mediated through ROS.  Mitochondria ­contain multiple DNA copies and generate ROS during energy production (adenosine triphosphate—ATP), by consuming oxygen via the respiratory chain. ROS can easily damage lipids, proteins, and even the mtDNA itself [78, 79]. The mitochondrial DNA shows a high mutation rate due to its histone deficiency, limited capacity of base excision repair, and proximity to ROS [79, 80]. UVA exposure can further increase ROS generation and induce mutations at the mitochondrial DNA [72, 81], like deletion of 4977  bp (base pair), the most often found mutation in aged tissues [63, 82–87]. While this genic change can be detected in tissues that are non-susceptible to solar rays [83], mtDNA mutations can be tenfold more frequent in photoaged skin in comparison to sun-protected skin [64, 78, 79, 88–92].

2.4.6 DNA Damage Sunlight-induced DNA damage is considered the main cause for the genetic changes leading to skin lesions and carcinogenesis including malignant melanoma [93]. DNA, the main intracellular

S. Montagner and A. Da Costa

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chromophore for UVB [70], absorbs photons from UVB. This interaction increases ROS production and creates dimeric photoproducts, such as pyrimidines, which may be related to pre-­ malignant skin lesions [94, 95]. The DNA photoproducts that are induced by UVA are potentially more mutagenic than those induced by UVB, although UVB induces more cyclobutane pyrimidine dimers than UVA [96]. Ultraviolet radiation also alters RNA and implies the formation of dysfunction-causing proteins. A blockade in RNA transcription by a DNA photoproduct allows p53 activation, thereby inducing the apoptosis of irradiated keratinocytes [94]. These events activate multiple important signaling pathways related to cell growth, differentiation, senescence, DNA damage repair, connective tissue degradation, and inflammation [97]. This is followed by an irreversible blocking of cell cycle progression to prevent further DNA damage and increase the expression of senescence-associated genes [97, 98].

2.4.7 Arylhydrocarbon Receptor Signaling It is known that UVB also generates ROS species [99] initiating DNA damage, in the nucleus, once DNA is chromophore of UVB [100]. But, in the recent years, arylhydrocarbon receptor (AhR) was demonstrated to integrate part of the UVB stress response associated with photoaging. This DNA damage-independent pathway is initiated outside the nucleus by the cluster ring and the internalization of cell membrane-bound growth factor receptors, such as the epidermal growth factor receptor (EGFR) [101]. AhR is activated in human epidermal keratinocytes upon exposure to UVB radiation, producing a series of photoproducts from tryptophan, which is free in the cytoplasm. These photoproducts are ligands of the AhR and activate it. This process leads to regulation of inflammation-associated genes, such as cyclooxygenase2 (COX2), that increase the expression of matrix metalloproteinases such as MMP-1 and MMP-3, among other proteases

[102–105], melanocyte proliferation, and melanin synthesis [58, 106]. In this scenario, the molecular response to solar aggression is evident. These mechanisms are briefly illustrated in Fig. 2.3.

2.4.8 Infrared Radiation IRA irradiation is mainly absorbed by mitochondria, where copper could serve as a chromophore [107], and increases intra-mitochondrial production of ROS [108, 109]. ROS can increase intra-­ cytoplasmic calcium levels, activate the MAP kinases signaling pathway, and lead to elevated MMP-1 expression. Approximately 600 genes are IRA responsive [110], and thus IRA radiation might further induce the extrinsic skin aging process through various other pathways. Important functions of the human skin which are characteristic for photoaging, such as angiogenesis [111] and production of mast cells [54], can be induced by IRA. Though IR does not induce tumorigenesis in the skin to the same extent as UVB, it is associated with a more aggressive tumor growth [112].

2.5

Conclusion

Ultimately, simply put, aging results from the modulation imbalance of collagen (with higher degradation and reduction of its synthesis) caused by excessive free radicals. Exposure to certain environmental factors, such as ultraviolet radiation, smoking, and air pollution, induces or enhances this process, thereby leading to premature or exogenous aging. Even with all biomolecular advances, prevention is still the best way to fight aging and its consequences, by avoiding the exposure to well-known exogenous factors. Endogenous and exogenous aging are objects of many research studies involving diet components in order to avoid or minimize the signs of time; however, there is still a lot to be proven. The advance in the knowledge of its pathogenesis is expected to corroborate with new therapeutic findings.

2  Pearl Chapter: Basis of Photoaging and the Use of Chemical Peelings

EGFR

UVB

21

UVA Cell Membrane Cytoplasm

AhR

TGF-β type II receptor

ROS

Activate kinases

Deletion of mitochondrial 4,977bp Nucleus

AP-1 Dimeric photoproducts

p53 activation

NF-kB

MMP1,3,9 MMP

MMP1 MMP8 MMP9

Collagen degrading

Pre-malignant skin lesions

Cancer Cells

Fig. 2.3  Cellular effects of ultraviolet radiation. AhR signaling pathway. UVB forming photoproducts that lead to pre-malignant lesions. UVA/UVB action on p53, producing cancer cells. Deletion of mitochondrial 4977 bp and

Collagen synthesis

Photoaging

ROS production by UVA radiation, ultimately, resulting in photoaging. (Adapted with permission from Montagner and Costa [65])

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2  Pearl Chapter: Basis of Photoaging and the Use of Chemical Peelings nexus of aging. Front Genet. 2016;7:13. https://doi. org/10.3389/fgene.2016.00013. 99. Stege H, Roza L, Vink AA, Grewe M, Ruzicka T, Grether-Beck S, et  al. Enzyme plus light therapy to repair DNA damage in ultraviolet-B-­ irradiated human skin. Proc Natl Acad Sci U S A. 2000;97:1790–5. 100. Bender K, Blattner C, Knebel A, Iordanov M, Herrlich P, Rahmsdorf HJ. UV-induced signal transduction. J Photochem Photobiol B. 1997;37:1–2):1–17. 101. Fritsche E, Schafer C, Calles C, Bernsmann T, Bernshausen T, Wurm M, Hubenthal U, Cline JE, Hajimiragha H, Schroeder P, Klotz LO, Rannug A, Furst P, Hanenberg H, Abel J, Krutmann J. Lightening up the UV response by identification of the arylhydrocarbon receptor as a cytoplasmatic target for ultraviolet B radiation. Proc Natl Acad Sci U S A. 2007;104(21):8851–6. 102. Herrmann G, Wlaschek M, Lange TS, Prenzel K, Goerz G, Scharffetter-Kochanek K.  UVA irradiation stimulates the synthesis of various matrix-­ metalloproteinases (MMPs) in cultured human fibroblasts. Exp Dermatol. 1993;2(2):92–7. 103. Brenneisen P, Oh J, Wlaschek M, Wenk J, Briviba K, Hommel C, Herrmann G, Sies H, Scharffetter-­Kochanek K. Ultraviolet B wavelength dependence for the regulation of two major matrix-­ metalloproteinases and their inhibitor TIMP-1  in human dermal fibroblasts. Photochem Photobiol. 1996;64(5):877–85. 104. Brenneisen P, Sies H, Scharffetter-Kochanek K. Ultraviolet-B irradiation and matrix metalloprotein-

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ases: from induction via signaling to initial events. Ann N Y Acad Sci. 2002;973:31–43. 105. Krutmann J, Morita A, Chung JH.  Sun exposure: what molecular photodermatology tells us about its good and bad sides. J Invest Dermatol. 2012;132:976–84. 106. Jux B, Kadow S, Luecke S, Rannug A, Krutmann J, Esser C.  The aryl hydrocarbon receptor mediates UVB radiation-induced skin tanning. J Invest Dermatol. 2011;131(1):203–10. 107. Karu TI.  Mitochondrial signaling in mammalian cells activated by red and near-IR radiation. Photochem Photobiol. 2008;84(5):1091–9. 108. Schroeder P, Pohl C, Calles C, Marks C, Wild S, Krutmann J. Cellular response to infrared radiation involves retrograde mitochondrial signaling. Free Radic Biol Med. 2007;43:128–35. 109. Darvin ME, Haag S, Meinke M, Zastrow L, Sterry W, Lademann J.  Radical production by infrared A irradiation in human tissue. Skin Pharmacol Physiol. 2010;23:40–6. 110. Krutmann J, Schroeder P.  Role of mitochondria in photoaging of human skin: the defective powerhouse model. J Investig Dermatol Symp Proc. 2009;14(1):44–9. 111. Chung JH, Eun HC. Angiogenesis in skin aging and photoaging. J Dermatol. 2007;34:593–600. 112. Jantschitsch C, Weichenthal M, Maeda A, Proksch E, Schwarz T, Schwarz A. Infrared radiation does not enhance the frequency of ultraviolet radiation induced skin tumors, but their growth behaviour in mice. Exp Dermatol. 2011;20(4):346–50.

3

Tip Chapter: Peels for Ethnic Skin Renan Lage

Created in 1976, the Fitzpatrick scale (FST) classified the skin into six types (I–VI). The classification is based on each individual’s skin response to sun exposure and the susceptibility to tanning or burning when exposed to ultraviolet radiation (UVR) [1] (Table  3.1). Types IV, V, and VI are known as “skin of color” or ethnic skin, contemplating individuals who tan easily and usually do not burn [1, 3]. It is well established that there are no differences in the number of melanocytes in the skin, considering the different phototypes. Ethnic skin presents differences in the size, number, and aggregate of melanosomes, thus resulting in differences in the epidermal distribution of melanin. That way, the greater the amount of melanin, the more pigmented the skin will be [1, 3, 4]. Structural differences in the epidermis and dermis are also observed. There is greater cohesion between the epidermal layer cells, these being more compact and with an increase of the lipid layer. Fibroblasts are larger, multinucleated, and in greater quantity in the dermis. The bundles of collagen fibers are strongly attached, smaller,

R. Lage (*) Cosmiatric Department, Department of Dermatology of the Pontifical Catholic University of Campinas PUC Campinas, Campinas, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_3

Table 3.1  Fitzpatrick phototypes [2] Fitzpatrick phototype I II III IV V VI

UVR response Always burns and never tans Always burns and tans with difficulty Sometimes mild burn, gradually tans Rarely burns and tans with ease Very rarely burns and tans easily Never burns

and parallel to the epidermis [1]. Skin with a higher phototype presents greater protection to the effects of the UVR as a result of melanin function and melanosome distribution, which reflects in signs of photoaging, presenting less expressive wrinkles, actinic keratoses, and photo-­ damaged skin. Pigmentation is another aspect to be considered on ethnic skin. It can consequently present pigmentary disorders like post-­ inflammatory hyperpigmentation (occurring commonly as a response to injuries) and melasma. A greater tendency to form keloid scars should also be considered [3, 5]. It is important to highlight existing ethnic differences within the group of patients with higher skin phototypes. While Asian patients are more sensitive to chemical stimuli, probably due to a thinner stratum and higher density of the sweat glands, African descendant skin presents lower irritability, probably associated with a more 27

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cohesive stratum corneum. Other differences in African descendant skin that must be emphasized are the greater amounts of apocrine glands, larger glandular pores, sebaceous secretion, and bacterial flora [4]. Considering that the world population is mostly composed of people of higher skin phototypes (Asian, African, and Afro-descendant) and that noninvasive procedures, such as chemical peels, have become popular in recent years, it is important to study these procedures in this particular group of patients [6].

3.1

History/Background

The use of caustic substances for the preparation of chemical peels was first described in Ancient Egypt, in the Ebers Papyrus in 1550  BC [7]. Egyptians used animal oils, salt, and sour milk, whose active agent was lactic acid, to improve skin appearance [8]. In 1874  in Vienna, Dermatologist Ferdinand von Hebra, using a combination of exfoliative agents, performed the treatment of patients with melasma, Addison’s disease, and ephelides, and in 1882, Paul G.  Unna described the action of salicylic acid, resorcinol, trichloroacetic acid (TCA), and phenol on the skin. His work was followed by many others [8]. Mackee in 1903 used phenol peel in acne scars, but it was only in 1952 that he, together with Florentine Karp, published the results [9]. During this period, in the 1940s in the United States, Eller and Wolff made the first systematic description on the use of phenol, salicylic acid, resorcinol, and cryotherapy spray for scar treatment [8, 10]. The modern era of peeling began in the 1960s when Baker and Gordon developed the modified phenol formula (adding croton oil, Septisol, and water) and performed a histological evaluation of results, comparing effects between phenol and TCA [11]. In the 1970s and early 1980s, the scientific basis for TCA peelings was expanded by comparing the histological effects between three concentrations of the product. In parallel,

alpha-hydroxy acids (AHA) were developed by Van Scott and Yu for more superficial peels, being indicated for the treatment of hyperkeratosis. Subsequently, peeling with glycolic acid was developed [11]. The combination of two substances for surface peels (Jessner’s solution and 35% TCA) to reach medium depth was described in 1986 by Brody and Hailey and then by Monheit, providing a great deal of progress in the use of peels and reflecting on their current use [11].

3.2

Genesis

The action of chemical peeling is based on the application of a caustic substance causing skin layer destruction. The epidermis and the dermis react to the stimulus with repair mechanisms, culminating, respectively, in regeneration and remodeling, with consequent improvement of skin uniformity [6, 11]. The indication of chemical peeling considers some criteria such as age, phototype, area to be treated, degree of photoaging, desired goals, medical practitioner’s habilitation, and inherent factors of each patient [12]. The benefits of the procedure vary according to phototypes, presenting differences in both indications and possible complications [6]. Unlike the pale skin in which the peels are mostly used to treat photoaging changes, in ethnic skin, the major indications are dyschromias, acne vulgaris, postinflammatory hyperpigmentation (PIH), melasma, and pseudofolliculitis barbae [5, 6].

3.3

Classification/Types

Peelings are classified according to the depth they reach the skin from superficial, medium, to deep. The first reaches the epidermis (preserving the basal membrane), the second to the papillary dermis, and the third to the reticular dermis. Superficial peels can still be subdivided into light, being able to reach to the spinosum, and deeper, when it reaches the entire epidermis. The depth is influenced by several factors: the type

3  Tip Chapter: Peels for Ethnic Skin

and concentration of the substance used, the pH of the solution, and exposure time to the substance [6, 11]. Superficial peelings can be used in all phototypes, including IV, V, and VI.  Medium-depth peels may be indicated in some cases with ethnic skin; however, the deeper peels should be used very carefully in these patients considering the high risk of adverse effects like pigmentary disorders and scars [6]. The substances used for superficial peelings are glycolic acid, salicylic acid, Jessner’s solution, and trichloroacetic acid (TCA) concentrated to 10–30%. TCA at concentrations of 35–50% and phenol at 88% comprise the substances used for medium depth. For deep peelings, the Baker-­ Gordon formula (88% phenol combination, tap water, liquid soap, and croton oil) is used [5, 11].

3.4

Available Materials

To indicate peeling, one should evaluate the patient’s profile, phototype, their professional activity, availability to be absent from work, and expectations. It is very important to explain, through educational material, the procedure that will be performed, as well as the previous preparation of the skin, period of desquamation, and the cosmetic results to be achieved. It is important to carry out a detailed medical history, assessing the degree of sun exposure, personal history of herpes simplex, tendency for dyschromia such as post-inflammatory hyperpigmentation, predisposition to keloid development, active smoking, inflammatory diseases, and isotretinoin use in the last 6 months and evaluating medications in use [5, 6]. The pre-peeling preparation starts 2–4 weeks earlier and is suspended within 3 days prior to the procedure. Formulations containing retinoic acid (0.025–0.1%) and/or glycolic acid (5–10%), associated or not with depigmenting agents, such as hydroquinone (2.5–5%), kojic acid (1–2%), or phytic acid in appropriate vehicles for each skin type, are used [13]. A study by Nanda et al. compared the use of hydroquinone versus topical isotretinoin as an adjunct agent to peeling therapy

29

in patients with melasma. Although both substances improve the skin within 12 weeks, after a 6-month follow-up, hydroquinone showed a superior improvement [14]. Patients should be advised to the possibility of skin irritation, dryness, and erythema with the use of these products. Adequate photoprotection and pre-peeling preparation are extremely important, reducing the risk of post-inflammatory pigmentation [6, 13]. Patients with a personal history of herpes simplex must receive prophylactic therapy with antivirals. Aciclovir (1000  mg/day) or valaciclovir (1000 mg/day) is commonly used for a period of 5 days. This preparation is unnecessary for superficial peels [13]. Post-peeling care involves the use of photoprotectors and mild emollients in all phototypes and the reintroduction of bleaching agents after 1 week, especially in the higher skin phototypes [6, 11]. When applying a chemical peeling agent, some general observations are relevant for safety: avoid application to irritated, inflamed, or erythematous skin; always have neutralizing substances available when necessary; assess the patient’s pain using a sensitive scale of 1–10; and be attentive to frosting, as it helps to identify the degree of penetration and depth of the substance on the skin [11].

3.4.1 Glycolic Acid Glycolic acid belongs to the alpha-hydroxy acid (AHA) family. Its mechanism of action is by epidermolysis, followed by scaling and dispersion of epidermal melanin. Epidermolysis usually occurs after a few minutes from application and is therefore applied for 3–5 min. It has commercial concentrations ranging from 10% to 70%, needs to be neutralized with saline or sodium bicarbonate, and can be performed at intervals of 2–3 weeks. It is possible to associate with 35% trichloroacetic acid when the goal is to perform a medium peel [5, 6, 15]. Its indications include acne, melasma, and post-inflammatory pigmentation [6, 16, 17]. In

30

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acne, glycolic acid presents bactericidal and 3.4.2 Lactic Acid anti-­ ­ inflammatory actions and also corrects abnormal keratinization [6, 18, 19]. For melasma, Lactic acid is also a member of the alpha-hydroxy a melanized keratinocyte is eliminated and a acid family, which has similar activity to glycolic stimulus for skin renewal occurs. Treatment acid. It is used in the concentration of 85% and should be considered only for epidermal and can be used in the treatment of melasma and acne mixed variants, since there may be an important scars [6, 13]. increase in complication risks for the treatment Sachdeva [23] conducted a study with seven of deeper forms [6, 20]. Indian patients (phototypes IV and V) with acne Wang et  al. [16] performed a study with a scars; four peeling sessions were performed selection of 40 Asian patients with moderate to every 2  weeks using lactic acid. At the end of severe acne. Patients were divided into two 3 months, there was an important improvement in groups and treated with four glycolic acid peel- texture, pigmentation, and appearance of the ing sessions of 30 and 50%, associated with daily scars [23]. topical 15% glycolic acid. The authors observed Sharquie et  al. [24] conducted a study of 20 a significant decrease in the number of comedo- Iraqi, phototype IV, patients with melasma. Six nes, papules, pustules, and pore size, as well as peeling sessions were performed with pure lactic improvement in the texture of the skin, giving a acid every 3  weeks. Twelve patients completed more rejuvenated appearance to the patients. the study and a significant improvement (as meaGlycolic acid peeling was considered an effective sured by Melasma Area and Severity Index therapy with minimal side effects [16]. (MASI)) was observed, with no reported adverse Burns et al. [17] studied 19 patients with IV to effects [24]. Another study, with the same authors VI phototypes, with post-inflammatory hyperpig- [25], compared lactic acid with Jessner’s solution mentation, randomly divided into two groups. every 3 weeks in 30 patients with melasma (phoBoth groups received topical treatment with totype IV), each substance being applied to one hydroquinone 2% associated with 10% glycolic half of the face. Twenty-four patients completed acid, twice daily, with 0.05% isotretinoin at night. the study demonstrating that both treatments In one of the groups, six sessions of glycolic acid were statistically significant, with no reported peeling (maximum concentration of 68%) were adverse response [25]. associated with a greater and faster improvement Further studies with a greater number of of pigmentation, with skin clearing [17]. patients are needed to evaluate the effectiveness Grover and Reddu [21] performed a study of lactic acid in the treatment of melasma specifiwith 41 Indian patients (phototypes III–V) using cally in patients with ethnic skin. 10–30% glycolic acid to treat acne, melasma, post-inflammatory hyperpigmentation, and scarring. Peeling has proven effective especially in 3.4.3 Salicylic Acid the treatment of superficial scars and melasma, being moderately effective in acne and ineffec- Salicylic acid (SA), another surface peeling tive in dermal pigmentation. Adverse effects agent, considered an ortho-hydroxybenzoic acid, were irritation, post-inflammatory hyperpigmen- belonging to the beta-hydroxy acid family, can be tation, cold sores, and hypopigmentation [21]. handled in a hydroalcoholic solution in concenGlycolic acid peels are usually well tolerated trations of 20–30%. At concentrations of 3–5%, on ethnic skin and have few side effects, espe- it presents keratolytic function. It can be used in cially when applied in gradually titrated concen- 6–8 sessions per week. It is lipophilic and protrations (from the lowest to the highest) [5, 6]. duces desquamation of the superficial layers of The most common side effect is post-­ the stratum corneum [5, 6]. inflammatory pigmentation, also erythema and It is useful in acne, post-inflammatory hyperdesquamation [15, 22]. pigmentation, melasma, pseudofolliculitis

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b­ arbae, and improvement of oily skin [5, 26]. In peeling agent or in combination with other agents acne, it also has a comedolytic effect, with an such as TCA for medium peeling [5, 6]. improvement in inflammatory and non-­ The penetration varies according to the numinflammatory lesions [5]. A gradual bleaching ber of layers applied. The use of one layer reflects effect with the use of salicylic acid peeling seri- level I that forms slight erythema and whitish ally has been observed [27]. It is considered safe flocculation on the surface as an easily removable for use in patients with higher phototypes, pre- powder. If applied from two to three layers, a senting a lower risk of post-inflammatory pig- more lively erythema will form, as well as frostmentation when used in increasing titers and ing, accompanied by a burning sensation. Level when associated with hydroquinone 4% [6, 28]. III can be achieved with three to four layers and Lee and Kim [29] conducted a study about SA causes significant erythema, with areas of frostpeeling in acne vulgaris in Asian patients to dem- ing and mild burning. It is important to take into onstrate its safety and efficacy. Thirty-five account the level to be achieved, being able to Koreans with facial acne were selected and achieve up to medium depth [13]. underwent the biweekly application of SA at This solution is indicated as an adjuvant treat30% for 12  weeks. In these patients, there was ment for acne, pigmentary disorders, improvereduction of inflammatory and non-inflammatory ment of oiliness and texture of the skin, fine lesions [29]. wrinkles, and pseudofolliculitis barbae [5]. Other studies have found similar results, such Some authors have shown that although as that conducted by Ahn and Kim [27], in which Jessner’s peeling can be used individually, it is they demonstrated a skin clearing for Asian more effective when associated with other peels patients who underwent 30% SA peeling for [31–33]. 3 months [27].

3.4.4 Tretinoin It is a trans-retinoic acid and synthetic analogue of vitamin A.  It acts on collagen synthesis, increase in neovascularization, reversal of epidermal atypias, and dispersion of melanin. It can be used in concentrations of 5–12% for improvement of acne, melasma, and post-inflammatory hyperpigmentation [6, 13]. Khunger et  al. [30] compared 70% glycolic acid peeling with 1% tretinoin in patients of Asian ethnicity, phototypes III to V, demonstrating similar results in both groups [30].

3.4.5 Jessner’s Solution The solution contains three keratolytic compounds with synergistic action: salicylic acid (14 g), lactic acid (85%, 14 mL), and resorcinol (14 g) diluted in 100 ml of 95% ethanol. It also has a bleaching effect provided by the last component. It can be used individually as a surface

3.4.6 Trichloroacetic Acid (TCA) Trichloroacetic acid is an inorganic compound and acts to cause protein denaturation with consequent cell death by coagulative necrosis. It does not need to be neutralized, and it can be used in the concentrations of 10–65%, being applied in an isolated form in lower concentrations as a superficial peeling agent (up to 35%) [6]. The depth achieved is associated with TCA concentration and exposure time to the product [11]. At the end of its application, the degree of depth reached can be divided into three levels. Level I is represented by erythema associated with light and irregular frost, level II by white coating and erythema, and level III by a solid white frost with little or no background erythema [34]. White frost (levels II and III) is not a desired effect for ethnic skin, since it increases the risk of complications such as scars and pigmentary disorders. For this reason, although commonly used for lighter skin, it should be used more cautiously in patients with higher phototypes [15, 26].

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It is useful for the treatment of acne scars and for rejuvenation, generating more uniformity of skin color [26]. It can also be used focally for benign lesions such as seborrheic keratosis and solar lentigo [35]. Kalla et al. [36] performed a study with 100 patients comparing trichloroacetic acid with glycolic acid in melasma treatment. The patients were divided into a group treated with glycolic acid peeling at 55–70% and the other with trichloroacetic acid at 10–15%. The applications were carried out fortnightly. The authors of this study concluded that trichloroacetic acid is more effective compared to glycolic acid, but it has more adverse effects (burning sensation and hyperpigmentation), which must be considered when working with ethnic skin [36].

3.4.7 Other Agents 3.4.7.1 Thioglycolic Acid It is an organic acid, is easily oxidizable, and has sulfur in its composition. It has iron affinity and the ability to chelate hemosiderin iron. It is used in concentrations from 5 to 10%. It can be used as a peeling agent in ochre dermatitis of the lower limbs and in constitutional periocular hyperpigmentation [13]. It presents as main side effects discreet erythema and transient desquamation and is considered a safe and effective agent. In a study by Costa et al. [37], when using 10% gel-­ containing thioglycolic acid, phototype IV patients presented improvement in constitutional periocular hyperpigmentation [37]. 3.4.7.2 Resorcin It is a caustic chemical peeling agent commonly used in association with other substances, its main combination being the Jessner’s solution. The concentrations range from 10 to 70%, and their indications include acne, dyschromias, fine wrinkles, and post-inflammatory hyperpigmentation. Its advantages are low cost and stability, and potential side effects are intoxication and allergic reactions. Its use in ethnic patients and tendency to hyperpigmentation make it a viable option [13].

3.4.7.3 Mandelic Acid It belongs to the alpha-hydroxy acid family, with a slow and safe penetration as a superficial peeling agent. It can be used in acne for the treatment of active lesions and scars, especially when associated with salicylic acid [38]. 3.4.7.4 Pyruvic Acid Pyruvic acid is an alfa-ketoacid, with keratolytic, antimicrobial, and antiseborrheic function and with capacity to stimulate the formation of neocollagen and elastic fibers. Its mechanism of action consists of epidermolysis, penetrating the skin in 1–2 min. Its penetration can be unpredictable and if too rapid can lead to the formation of scars. The main indications include acne, superficial scars, photoaging, and dyschromias in patients with low phototype. Additional studies in high-phototype patients are needed to indicate their efficacy and safety [6, 13, 15].

3.4.8 Salicylic-Mandelic Acid Combination It consists of 20% salicylic acid and 10% mandelic acid. It is a useful combination in the highest phototype skins, since mandelic acid has a slow penetration, being ideal for sensitive skin, and salicylic acid penetrates quickly, with the added benefit of preventing post-inflammatory pigmentation. Although still less widespread, it can be used in acne (active and scarring) and dyschromias [13, 15]. Sarkar et al. [39] demonstrated similar efficacy to glycolic acid for the treatment of melasma in patients with phototypes IV and V, with the benefit of better tolerance [39]. Some new compounds have been studied as chemical peeling agents such as beta-­lipohydroxy acid and “amino fruit acids,” with good results. However, additional studies focusing on ethnic skin are still necessary [6].

3.4.9 Medium Peelings Combination peels may be useful, the main example being the average peel performed with

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33

the combination of Jessner’s solution and TCA, indicated for moderate to severe photo-damaged skin. Another widely used option is the use of 70% glycolic acid with 35% TCA, with the advantage of an important improvement of dyschromias and post-inflammatory hyperpigmentation from the use of glycolic acid [40]. An improvement in melasma is also reported with the use of Jessner’s solution and 15% TCA combination [6, 15].

water), 2 ml common/distilled water, 8 drops of 0.025% soap (liquid hexachlorophene), and 3 drops of croton oil are used. When diluted in this solution, phenol becomes capable of generating keratolysis and keratocoagulation, reaching deeper layers [13]. Its correct use requires anamnesis, physical examination, and laboratory tests. Phenol can be absorbed systemically, with potential cardiotoxicity, nephrotoxicity, hepatotoxicity, and central nervous system depression. It should be performed in a hospital environment due to the 3.4.10 Fluor-hydroxy Pulse Peel obligatory monitoring of the patient’s heart. Tachycardia, ventricular extrasystoles, atrial Fluor-hydroxy pulse peel is a combination of fibrillation, and ventricular fibrillation may be 5-fluorouracil and 70% glycolic acid, used in the observed as adverse effects. Therefore, its use is treatment of actinic keratoses. It has good cos- avoided in cases of heart, kidney, or liver disease, metic results; however, to date, there are no stud- herpes simplex, recent isotretinoin use, psychoies applied to patients with higher phototypes logical instability, keloid predisposition, and con[41, 42]. tinuous exposure to UV rays and in patients with phototypes IV to VI [40]. It is a very painful peeling due to the action of 3.4.11 Deep Peelings phenol in the intermediate reticular dermis, requiring sedation and analgesics. It is necessary Deep peels reach the reticular dermis and act to maintain good hydration before and during the through the coagulation of proteins, leading to a procedure. Burning pain for up to 8 h and marked restoration of dermis architecture [11]. swelling may occur. In the postoperative period, They are considered aggressive because they it is recommended to use anxiolytics, analgesics, provoke the formation of many thick crusts, antibiotics, and ice packs. Epidermal regenerabeing necessary the use of post-peeling dressings tion begins in 48  h and completes in around and presenting a more delayed recovery that lasts 10 days [13, 40]. for months. However, a very significant cosmetic Pruritus is common during the healing process result is observed, with important skin renewal and can improve by applying low-potency cortiand reduction of deep wrinkles. The agents used costeroids and ice packs. Erythema and crusts are phenol and Baker’s solution. They should be may remain for up to 14 days, and milia formaavoided in higher phototypes by the risk of post-­ tion is also possible [13, 40]. inflammatory hyperpigmentation and scar formaIt can be said that phenol peel when well indition [13]. cated is considered extremely effective but should be avoided in patients with higher phototypes due to the high risk of complications [13].

3.5

Phenol Peeling

Phenol when used at a concentration of 88% can penetrate to the depth of the upper reticular dermis. By coagulating keratin, it prevents its permeability to deeper levels. The best-known deep peeling formulation is Baker-Gordon. For this formulation, 3  ml phenol (88% phenol  +  12%

3.5.1 Blepharopeeling Parada et  al. [43] conducted a pilot study on blepharopeeling in the upper eyelid using the Baker-Gordon formula. For this, they applied the solution only in the region with excess skin. Eight

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34 Table 3.2  Main indications for ethnic skin Pathology Acne Post-inflammatory hyperpigmentation

Melasma (epidermal or mixed) Acne scar Pseudofolliculitis barbae

Main agents indicated Salicylic acid 20–30% Glycolic acid 30–50% Full face:  Salicylic acid 20–30%  Glycolic acid 30–50% Spot peel:  TCA 25%  Jessner’s solution  Salicylic acid 20–30% Salicylic acid 30% Glycolic acid 50–70% Glycolic acid 70% TCA 25% Salicylic acid 30%

patients (phototypes I–III) were treated. These authors concluded that the procedure is effective and safe, with good aesthetic results; however, there were no studies in patients with higher phototypes [43]. Table 3.2 shows the main agents indicated in ethnic skin for the different types of pathology [26].

3.6

 efore and After (Figs. 3.1, B 3.2, and 3.3)

a

b

c

d

e

f

Fig. 3.1  Patient with phototype V—melasma. (a–c) Image before Jessner’s solution peel (two layers). (d–f) 22nd day after peel

3  Tip Chapter: Peels for Ethnic Skin

35

a

b

Fig. 3.2  Patient with phototype IV—photoaged skin. (a) Image before Jessner’s solution and 35% TCA medium peel. (b) Sixth day after medium peel

a

b

c

d

e

f

Fig. 3.3  Patient with phototype IV—photoaged skin. (a–c) Images before Jessner’s solution and 35% TCA medium peel. (d–f) Sixth day after medium peel

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36

3.7

 ide Effects, Complications, S and How They May Be Handled/Managed

3.8

Conclusions/Findings

Chemical peeling is an important tool for the treatment of several conditions and is considered Post-peeling complications occur more fre- a safe, effective, and low-cost procedure. Ethnic quently in patients with a higher phototype and in skin has important peculiarities that reflect in larger depth (medium and deep) peels. In general, some differences on the indication of peeling, use the factors that must be considered to avoid of materials, and various possible complications. unwanted effects are adequate pre- and post-­ Clinicians should therefore be well aware of the peeling care and proper selection of both patient safety profile and potency of the different agents, applying them and adapting them in a way that and agent used [6]. Post-inflammatory pigmentation is more com- respects the uniqueness of the ethnic skin. mon in patients with ethnic skin, usually on a long-term basis [6]. They occur between 2 and 3  days and up to 3  months after the procedure Tip Box [40]. Syndromes can be avoided with proper •  Fitzpatrick types IV, V, and VI are choice of agent and depth (greater risk with known as ethnic skin. They present greater depth) and performing correct photoprodifferences in the epidermal distributection [6]. Treatment includes topical corticostetion of melanin. roids, tretinoin, hydroquinone, and even • Despite fewer signs of photoaging, it is alpha-hydroxy acids [13]. more prone to post-inflammatory Appropriate concentrations of the agent prehyperpigmentation and melasma. vent irritation, pruritus, or burning. However, if • Indications of ethnic skin peeling: dysthey occur, the use of emollients should be chromias, acne vulgaris, post-inflammaemployed. Erythema and edema may be reduced tory hyperpigmentation (PIH), melasma, with adequate photoprotection and, if proand pseudofolliculitis barbae. • The superficial peeling can be used, longed, should be treated with topical corticothe medium depth can be indicated, steroids to prevent the onset of pigmentary and the deeper peel used in special and disorders [6]. well-selected cases, due to the high Complications such as allergic reaction or toxrisk of adverse effects. icity can be avoided with retroauricular testing •  Pre-peeling precautions include forperformed prior to peeling. Bacterial, fungal mulations containing retinoic acid and/ (Candida), and herpetic infections should be or glycolic acid, associated or not with promptly treated, noting that the use of prophydepigmenting agents, photoprotection, lactic antivirals should be used in case of history and antiviral prophylaxis. of herpetic infections [6, 13]. • Post-peeling care includes photoprotecFormation of hypertrophic scars, keloids, tors, mild emollients, and reintroducand delayed healing can be prevented with tion of bleaching agents after 1 week. adequate collection of personal and family • Glycolic acid: alpha-hydroxy acid,  history and adequate choice of agent and depth indicated for acne, melasma, and post[6, 13]. The treatment can be performed with inflammatory hyperpigmentation. intralesional infiltration of corticoid, imiqui•  Salicylic acid: beta-hydroxy acid, mod, surgical excision, laser, and silicone ­indicated for acne, post-inflammatory plates [6]. hyperpigmentation, melasma, pseudoOther possible complications are acneiform folliculitis barbae, and improvement of eruption, milia, demarcation lines, and persistent oily skin. erythema, and the latter should be treated with potent topical corticosteroids [13].

3  Tip Chapter: Peels for Ethnic Skin

37

12. Khunger N.  Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. • Jessner’s solution: adjuvant treatment 2008;74(Suppl):S5–12. for acne, pigmentary disorders, 13. Yokomizo VMF, Benemond TMH, Chisaki C, Benemond PH.  Peelings químicos: revisão e aplicaimprovement of oiliness and texture of ção prática. Surg Cosmet Dermatol. 2013;5(1):58–68. the skin, fine wrinkles, and pseudofol 14. Nanda S, Grover C, Reddy BS.  Efficacy of hydroliculitis barbae. quinone (2%) versus tretinoin (0.025%) as adjunct • TCA: indications include acne scars topical agents for chemical peeling in patients of and rejuvenation. melasma. Dermatol Surg. 2004;30:385–8. 15. Sarkar R, Bansal S, Garg VK.  Chemical peels for • Post-peeling complications occur more melasma in dark-skinned patients. J Cutan Aesthet frequently in patients with a higher Surg. 2012;5(4):247–53. phototype and in larger depth peels. 16. Wang CM, Huang CL, Hu CT, Chan HL. The effect of • Post-inflammatory hyperpigmentation glycolic acid on the treatment of acne in Asian skin. Dermatol Surg. 1997;23(1):23–9. is the major complication that can be 17. Burns RL, Prevost-Blank PL, Lawry MA, Lawry TB, avoided with proper choice of agent, Faria DT, Fivenson DP. Glycolic acid peels for postindepth, and correct photoprotection. flammatory hyperpigmentation in black patients. A • Other complications include erythema comparative study. Dermatol Surg. 1997;23(3):171–4. 18. Lee SH, Huh CH, Park KC, Youn SW.  Effects of and edema, allergic reactions, toxicity, repetitive superficial chemical peels on facial sebum infections, scars, and demarcation secretion in acne patients. J Eur Acad Dermatol lines, among others. Venereol. 2006;20(8):964–8. 19. Takenaka Y, Hayashi N, Takeda M, et al. Glycolic acid chemical peeling improves inflammatory acne eruptions through its inhibitory and bactericidal effects on Propionibacterium acnes. J Dermatol. 2012;39:350–4. References 20. Erbil H, Sezer E, Taştan B, Arca E, Kurumlu Z.  Efficacy and safety of serial glycolic acid peels and a topical regimen in the treatment of recalcitrant 1. Zaidi Z. Skin of colour: characteristics and disease. J melasma. J Dermatol. 2007;34(1):25–30. Pak Med Assoc. 2017;67(2):292. 2. Fitzpatrick TB.  The validity and practicality of sun-­ 21. Grover C, Reddu BS.  The therapeutic value of glycolic acid peels in dermatology. Indian J Dermatol reactive skin types I through VI.  Arch Dermatol. Venereol Leprol. 2003;69:148–50. 1988;124(6):869–71. 3. Taylor SC. Skin of color: biology, structure, function, 22. Javaheri SM, Handa S, Kaur I, Kumar B. Safety and efficacy of glycolic acid facial peel in Indian women and implications for dermatologic disease. J Am Acad with melasma. Int J Dermatol. 2001;40(5):354–7. Dermatol. 2002;46:S41–62. 23. Sachdeva S.  Lactic acid peeling in superficial 4. Rawlings AV. Ethnic skin type: are there differences acne scarring in Indian skin. J Cosmet Dermatol. in skin structure and function? Int J Cosmet Sci. 2010;9:246–8. 2006;28(2):79–93. 24. Sharquie KE, Al-Tikreety MM, Al-Mashhadani 5. Grimes PE. Agents for ethnic skin peeling. Dermatol SA. Lactic acid as a new therapeutic peeling agent in Ther. 2000;13:159–64. melasma. Dermatol Surg. 2005;31:149–54. 6. Salam A, Dadzie OE, Galadari H. Chemical peeling in 25. Sharquie KE, Al-Tikreety MM, Al-Mashhadani ethnic skin: an update. Br J Dermatol. 2013;169(Suppl SA. Lactic acid chemical peels as a new therapeutic 2):82–90. modality in melasma in comparison to Jessner’s solu 7. Bryan CP.  Ancient Egyptian medicine: the Papyrus tion chemical peels. Dermatol Surg. 2006;32:1429–36. Ebers [translation]. Chicago: Ares Publishers; 1974. 26. Roberts WE.  Chemical peeling in ethnic/dark skin. p. 158–61. Dermatol Ther. 2004;17(2):196–205. 8. Brody HJ, Monheit GD, Resnik SS, Alt TH. A history 27. Ahn HH, Kim IH.  Whitening effect of sali of chemical peeling. Dermatol Surg. 2000;26:405–9. cylic acid peels in Asian patients. Dermatol Surg. 9. Mackee GM, Karp FL.  The treatment of post acne 2006;32:372–5. scars with phenol. Br J Dermatol. 1952;64:456–9. 28. Grimes PE.  The safety and efficacy of salicylic 10. Eller JJ, Wolff S.  Skin peeling and scarification. acid chemical peels in darker racial-ethnic groups. JAMA. 1941;116:934–8. Dermatol Surg. 1999;25(1):18–22. 11. Fischer TC, Perosino E, Poli F, Viera MS, Dreno B, Cosmetic Dermatology European Expert Group. 29. Lee HS, Kim IH. Salicylic acid peels for the treatment of acne vulgaris in Asian patients. Dermatol Surg. Chemical peels in aesthetic dermatology: an update 2009. 2003;29:1196–9. J Eur Acad Dermatol Venereol. 2010;24(3):281–92.

38 30. Khunger N, Sarkar R, Jain RK. Tretinoin peels versus glycolic acid peels in the treatment of Melasma in dark-­ skinned patients. Dermatol Surg. 2004;30(5):756–60. 31. Kim SW, Moon SE, Kim JA, et al. Glycolic acid versus Jessner’s solution: which is better for facial acne patients? A randomized prospective clinical trial of splitface model therapy. Dermatol Surg. 1999;25:270–3. 32. Safoury OS, Zaki NM, El Nabarawy EA, et  al. A study comparing chemical peeling using modified Jessner’s solution and 15% trichloroacetic acid versus 15% trichloroacetic acid in the treatment of melasma. Indian J Dermatol. 2009;54:41–5. 33. Abdel-Mequid AM, Taha EA, Ismail SA. Combined Jessner solution and trichloroacetic acid versus trichloroacetic acid alone in the treatment of melasma in dark-skinned patients. Dermatol Surg. 2017;43(5):651–6. 34. Mangat DS, Tansavadti K, Garlich P. Current chemical peels and other resurfacing techniques. Facial Plast Surg. 2011;27(1):35–49. 35. Chun EY, Lee JB, Lee KH. Focal trichloroacetic acid peel method for benign pigmented lesions in darkskinned patients. Dermatol Surg. 2004;30(4 Pt 1): 512–6. 36. Kalla G, Garg A, Kachhawa D. Chemical peeling – glycolic acid versus trichloroacetic acid in melasma. Indian J Dermatol Venereol Leprol. 2001;67:82–4.

R. Lage 37. Costa A, Basile AVD, Medeiros VLS, Moisés TA, Ota FS, Palandi JAC. 10% thioglycolic acid gel peels: a safe and efficient option in the treatment of constitutional infraorbital hyperpigmentation. Surg Cosmet Dermatol. 2010;2(1):29–33. 38. Kontochristopoulos G, Platsidaki E.  Chemical peels in active acne and acne scars. Clin Dermatol. 2017;35(2):179–82. 39. Sarkar R, Garg V, Bansal S, Sethi S, Gupta C. Comparative evaluation of efficacy and tolerability of glycolic acid, salicylic mandelic acid, and phytic acid combination peels in melasma. Dermatol Surg. 2016;42(3):384–91. 40. Camacho FM.  Medium-depth and deep chemical peels. J Cosmet Dermatol. 2005;4(2):117–28. 41. Marrero GM, Katz BE. The new fluor-hydroxy pulse peel. A combination of 5-fluorouracil and glycolic acid. Dermatol Surg. 1998;24(9):973–8. 42. Teixeira SP, de Nascimento MM, Bagatin E, Hassun KM, Talarico S, Michalany N.  The use of fluor-­ hydroxy pulse peel in actinic porokeratosis. Dermatol Surg. 2005;31(9 Pt 1):1145–8. 43. Parada MB, Yarak S, Gouvea LG, Hassun K, Talarico S, Bagatin E. “Blepharopeeling” in the upper eyelids: a nonincisional procedure in periorbital rejuvenation FA pilot study. Dermatol Surg. 2008;34:1435–8.

4

Blepharopeel Laura Bariquelo Buratini and Sergio Talarico Filho

4.1

Materials

• A large number of different formulas of phenol intended for peeling are available in the literature. • The most commonly used is the Baker and Gordon formula, which consists of (Fig. 4.1): –– Phenol USP 88%—3 ml –– Liquid soap (Septisol®)—8 drops –– Croton oil—3 drops –– Distilled water—2 ml • It should be prepared for immediate use only. • All formulas include adjuvants to increase phenol penetration. • Solutions with high concentrations of phenol cause rapid coagulation of skin proteins, translated clinically by immediate skin frosting. The coagulated layer acts as a barrier, reducing skin permeability, thus interrupting phenol penetration and preventing phenol from reaching the reticular dermis. For this

reason, solutions with high concentrations of phenol can produce more superficial peels than one could expect. • Solutions at lower concentrations (15–20%), on the other hand, penetrate the skin more ­easily, reach drainage routes, and are rapidly metabolized. Small amounts of free phenol acting for a short time may not be sufficient for good results. However, if large volumes of these solutions are applied in an attempt to correct this problem, the saturation of disposal mechanisms increases the risk of toxicity. • Croton oil (extracted from the plant Croton tiglium) has the capacity to increase phenol absorption by intensifying the inflammatory process. • Septisol®, as a surfactant agent, reduces surface tension, delaying phenol penetration and absorption and thus providing greater uniformity in peeling.

L. B. Buratini (*) Laura Bariquelo Buratini Clinic, Botucatu, SP, Brazil S. T. Filho Talarico Clinic of Dermatology, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_4

39

L. B. Buratini and S. T. Filho

40 Fig. 4.1 Components of the Baker and Gordon formula

Destilled Water

4.2

Methods and Techniques

Even in the case of application in a restricted area, with much lower risk of toxicity, the procedure must be performed in a surgical center (which can be ambulatory with good ventilation to dissipate phenol vapors) and with the patient always monitored.

4.2.1 The Prepeeling • Laboratory: Even when it is a localized application restricted to the eyelid region: –– Hepatic function –– Renal function –– Electrolyte dosage –– Electrocardiogram • Photography: –– Face: front and oblique and profile on both sides. –– Orbital region with eyes open and closed. • Written consent post-information and guidelines: –– Detailed guidelines on the procedure to be performed, including description of the evolution and aspect of the treated area that will be experienced by the patient and all the care that should be followed.

Phenol USP 88%

Croton oil

Septisol

–– Post-informed consent should be obtained after complete clarification of the procedure, possible intercurrences, risks, possible complications, and results that should be expected. –– It is of fundamental importance that the relatives and other people of the patient’s conviviality are also prepared to support the evolution and to help the patient and the doctor. • Skin preparation: –– When peeling is applied in restricted/localized areas, such as blepharopeel, skin ­preparation is not mandatory as when performed in the whole face but might be done. –– Consists of previous use, for 3–4  weeks prior to the peeling, of products commonly recommended in protocols for home rejuvenation, such as retinoic acid, glycolic acid, vitamin C, kojic acid, etc. This may allow more uniform penetration of the chemical agent and decrease the risk of inflammatory hyperpigmentation by the use of bleaching agents. • Antiviral therapy • If the patient has a previous history of recurrent herpes simplex, prophylaxis with acyclovir (400 mg orally every 8 h, starting 2 days before the procedure and maintained for a total of 5–7 days) must be done.

4 Blepharopeel

4.2.2 The Peeling • Degreasing: –– Cleansing and disinfection with chlorhexidine solution or water and alcohol in equal parts. –– The skin is degreased with gauze soaked in acetone or ether, vigorously scrubbed, providing adequate cleaning and mild surface sanding that removes deposited debris on the skin. –– This preliminary phase is essential to achieve best results. Phenol will not be able to penetrate ideally if the skin is not properly cleaned. • Application technique: –– The solution should be prepared at the time of starting the peeling and be stirred continuously to obtain the ideal homogeneous mixture of its components, since it is an unstable solution (Fig. 4.2). –– The application should be made with a cotton swab, which should be moistened in the solution with care, always completely removing the excess. –– The application should be started at the deepest wrinkles that must be distended in order to achieve the most uniform distribution as possible, avoiding irregularities. –– In the upper eyelids, the solution should be applied until the eyelid folds and in the lower eyelids, up to 2 mm from the tarsal border. –– In the eyebrow area, the solution must be applied in the opposite direction in relation to the eyebrow hair.

Before stirring (non homogeneous solution)

Fig. 4.2  Freshly prepared solution

41

• Dressing: –– The peeling may or may not be occluded with tape. Several papers describe excellent results with both techniques, each presenting advantages and disadvantages. –– Occlusion should be done with narrow strips of adhesive tape, which should be placed immediately after peeling application. The strips should be short so that greater mobility and consequent greater adhesion are allowed. In the first layer, one or two extra strips may be applied so that the mask gains greater stability. All areas must be covered to avoid irregularities.

4.3

Clinical Follow-Up

• Almost immediately after the application, whitening of the skin is noted, which then progresses to pinkish hue and, subsequently, to grayish coloring (Fig. 4.3). • Edema can be noticed in a few minutes, wich will gain great intensity, implying difficulty of ocular opening even after 48–72 h (Fig. 4.4). • There is intense pain after application of the peeling solution, which stops after a few seconds, due to the transient neurotoxic effect of the phenol. The pain returns after about half an hour, which remains intense for more or less 8 h. • Psychological comfort and psychological support should be offered to the patient the day after the procedure. The application of ice packs may play an auxiliary role in relieving the burning sensation and reducing edema.

After stirring

42

L. B. Buratini and S. T. Filho

Fig. 4.3  Immediate whitening

Fig. 4.4  Twenty-four hours after peeling

Fig. 4.5  Large amount of fibrin

• Special attention should be given to the use of drugs that promote analgesia and the use of hypnotics to allow the patient to sleep. • The tape, when applied, should be removed after 48 h, when it is usually practically loose due to the large amounts of exudate produced. The skin should be cleaned with sterile saline solution. There is no evidence that an earlier removal (24 h) of the tape cannot be made, if desired, because of the discomfort. • The area should be washed three to five times daily with running water and soap. For com- Fig. 4.6  Two months after peeling: intense erythema fort, this can be done by standing under the shower with warm water. It is essential that fibrin crusts (Fig. 4.5) are removed mechani- • Intense erythema and great skin sensitivity cally at this stage and, if necessary, a topical remain for about 2–3  months (Fig.  4.6). The fibrinolytic agent can be used. use of cosmetics that camouflage this aspect • Antibiotic ointments may be used until comshould be recommended, as well as the use of plete re-epithelialization. The risk of infection moisturizers, which give great comfort to the is always lower when you can successfully patient. prevent the formation of scabs. • Sun exposure must be avoided for 3  months • The recommendation for the patient not to after the peeling. manipulate the skin inappropriately is vital for • Sunscreen should be used daily with rigor good healing. since complete reepithelialization has • Between 7 and 10  days, complete re-­ occurred, and it should be associated with epithelialization occurs. accessories like sunglasses, caps, and hats.

4 Blepharopeel

4.4

43

Before and After (Figs. 4.7, 4.8, 4.9, 4.10 and 4.11)

a

b

c

d

Fig. 4.7 (a) Before; (b) 24 h after; (c) 4 days after; (d) 6 months after

a

b

Fig. 4.8 (a) Before; (b) 3 days after; (c) 2 months after

c

L. B. Buratini and S. T. Filho

44

a

b

Fig. 4.9 (a) Before; (b) 6 months after

a

b

Fig. 4.10 (a) Before; (b) 11 months after

a

b

Fig. 4.11 (a) Before; (b) 18 months after

4.5

 ide Effects, Complications, S and Their Management

• Conjunctivitis –– Usually chemically induced, caused by a primary irritant, not necessarily by direct contact with the peeling agent in the conjunctiva but

due to evaporation and proximity of the eyeball to the area in which the product is applied. –– There is often lacrimation and, sometimes, secretion. –– We recommend cleaning with saline or boricated water and the use of antibiotic and corticosteroid eye drops.

4 Blepharopeel

Fig. 4.12  Hypertrophic scar, 3 months after peeling

•

•

•

•

–– In general, it improves within 1–2  days without major repercussions. Pigmentation changes –– Perhaps the most frequent of the possible complications, hyperpigmentation is usually transient and represents an excellent response to depigmenting and tretinoin treatment. –– Phenol always leads to a permanent and generalized hypopigmentation in the treated area, caused by the permanent reduction of melanin synthesis by melanocytes. It is important to take this fact into account when selecting patients. Hypertrophic scars –– Complication not very rare. –– They occur within the first 3 months after peeling and are most common in isolated sites, particularly in the perioral region (Fig. 4.12). –– They usually respond well to topical treatment with corticosteroids and, if necessary, with intralesional infiltrations of triamcinolone (Fig. 4.13). Infections –– They are not frequent. –– They may be bacterial, fungal, or viral. –– Avoiding the formation of crusts can help prevent this complication. –– Complaint of intense pain after the first day should always remind the possibility of developing viral infection. Persistent ectropion –– A mild ectropion occurs most often and is transient. It is due to intense cutaneous retraction and resolves within 1 month.

45

Fig. 4.13  The same patient in Fig. 4.12, after two intralesional infiltrations of triamcinolone, plus three sessions of treatment with Intense Pulsed Light

Fig. 4.14  Persistent ectropion post-phenol blepharopeel

Fig. 4.15  Surgical correction of the ectropion

–– A more intense and persistent ectropion (Fig.  4.14) may occur more rarely, sometimes requiring surgical correction (Fig. 4.15). –– A way to avoid this complication is to scrub the swab almost dry on the lower eyelids at the moment of peeling application. –– In patients who have previous surgical inferior blepharoplasty, the risk/benefit of peeling should be considered in this region. • Persistent erythema The patient should be aware that the erythema may last for a period of about 90 days and may extend further in some cases.

L. B. Buratini and S. T. Filho

46

Tip Box

• Patient choice: adequate psychological profile to pass safely and calmly through the postoperative period; low phototype. • Post-peeling occlusion: we observed in our clinical practice very similar results with or without occlusion. Therefore, we have no longer used it. • Formulation used: we use half amount of the croton oil (peeling penetration agent) proposed by Baker, and we have observed less post-peeling hypopigmentation as well as low incidence of hypertrophic scars. • Removal of fibrin: we advise the patient to apply a solution constituted of a glass of water with a spoon of white vinegar in a compress in the areas containing fibrin for 15  min before cleaning. This facilitates the removal of fibrin crusts that should be then achieved by gently scrubbing of the area with a gauze embedded in water with antiseptic soap. • After cleaning, we advise the use of an ointment composed of fibrinolysin, deoxyribonuclease, and chloramphenicol in these areas. This procedure should be repeated at least three times a day.

Bibliography 1. Alt TH. Occluded Baker-Gordon chemical peel: review and update. J Dermatol Surg Oncol. 1989;15(9):980–93. 2. Asken S.  Unoccluded Baker-Gordon phenol peels--review and update. J Dermatol Surg Oncol. 1989;15(9):998–1008. 3. Brody H.  Peeling profundo. In: Peeling químico e resurfacing. 2nd ed. Rio de Janeiro: Reichman & Affonso; 2000. p. 163–89. 4. Deprez P.  Textbook of chemical peels: superficial, medium and deep peels in cosmetic practice. England: Informa Healthcare; 2007. p. 193–313. 5. Fintsi Y. A novel, phenol-based peeling method resulting in improved safety. Am J Cosm Surg. 1997;14:49–54. 6. Kligman AM, Baker TJ, Gordon HL. Long-term histologic follow-up of phenol face peels. Plast Reconstr Surg. 1985;75:652–9. 7. Landau M.  Deep chemical peels for photoaging. In: Tosti A, Grimes PE, de Padova MP, editors. Color atlas of chemical peels. Germany: Springer; 2006. p. 69–88. 8. Lawrence N, Brody HJ, Alt TH. Chemical peeling. In: Coleman III WP, Hanke CW, Alt TH, Asken S, editors. Cosmetic surgery of the skin. 2nd ed. St. Louis: Mosby; 1997. p. 85–111. 9. Park JO, Choi YD, Kim SW, Kim YC, Park SW. Effectiveness of modified phenol peel (Exoderm) on facial wrinkles, acne scars and other skin problems of Asian patients. J Dermatol. 2007;34:17–24.

5

Cook Peel (70% Glycolic Acid + 70% Trichloroacetic Acid) for the Face María del Pilar Del Río Navarrete Biot

5.1

Materials

• Topical anesthetic—while some authors contraindicate its use, as it can affect the frost observation [1], others recommend it [2]. In order to minimize pain and discomfort, we always use it. • Alcohol or acetone—for degreasing • A small fan or a skin cooler • Gloves • 70% glycolic acid gel • 35% TCA solution • Tap water or 10% bicarbonate solution—to neutralize the GA • A gel mask to be used when the procedure is performed • Petrolatum product or panthenol cream—to be used after the peeling (Fig. 5.1)

5.2

• Patients with rosacea, atopic dermatitis, seborrheic dermatitis, psoriasis, vitiligo, and active retinoid dermatitis are at a greater risk of having post-procedural complications. • Fitzpatrick skin types IV to VI are not good candidates, as they have a greater risk of developing hyperpigmentation or hypopigmentation. • Check the patient’s history for medium-depth or deep chemical peels within the last 3 months, recent facial surgery with extensive undermining, treatment with isotretinoin within the last 6  months, hypertrophic scars, and keloids. These findings increase the risk of complications. Investigate a history of recurrent herpes simplex infection.

Methods and Techniques

• Medium-depth peeling is a four-step procedure: pre-peel preparation, peeling itself, recovery phase, and maintenance phase [1]. • The pre-peel preparation begins at the initial consultation, when it is important to determine the patient’s expectations, Fitzpatrick skin type, and skin conditions [2]. M. d. P. Del Río Navarrete Biot (*) Clínica Dermatológica Maria del Pilar Biot, Niterói, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_5

Fig. 5.1  Materials used for the peeling 47

48

M. d. P. Del Río Navarrete Biot

• Never forget to ask about the patient’s work • During the procedure, dry the tears, as they and social life, as there will be a downtime of may create stripes over the cheeks and carry at least 7 days. the solution to the neck. • Begin the pre-peeling preparation 2–6 weeks • TCA causes protein precipitation in the skin before the procedure. These should include resulting in frost, which is a whitish hue of the topical retinoid acid preparations, alpha skin. The depth of the peel can be correlated hydroxy acids, hydroquinone, and other skin-­ with the intensity of the frost. The developlightening agents. ment of diffuse homogeneous erythema indi• The pre-peeling preparation is important to cates epidermal penetration. A white frost thin the stratum corneum, improve active indicates coagulative necrosis of the papillary agent penetration, accelerate healing, reduce dermis and a gray–white frost, a coagulative the risk of post-inflammatory hyperpigmentanecrosis of the reticular dermis [2, 4] tion (PIH), and scarring. It contributes to • The number of coats applied and the pressure achieving a more homogeneous effect and used during the application are important facmore predictable results [2, 3]. tors influencing the depth of the peeling. • There is no need to neutralize the TCA, as the protein coagulation induced limits its penetra5.2.1 The Peeling Itself tion and prevents systemic absorption [3]. • When the desired frost is achieved, cool com• Remove all makeup, wash the face with a mild presses or a cold gel mask should be used to soap or a Syndet gel, and degrease with alcominimize the burning sensation. hol or acetone. • The patient should be sent home only after • Patients with a seborrheic, thick skin may bencomplete frost disappearance using a efit from a gentle microdermabrasion, prior to petrolatum-­based product or panthenol cream. the peeling. Be sure that all post-peeling instructions are • Apply 70% glycolic acid (GA) gel using clearly understood (Figs. 5.2 and 5.3). gloved fingers and leave it for 2–4  min. Be careful not to exceed this time interval, and be ready to neutralize it when time is over or as soon as erythema appears. • Neutralize the GA with tap water or with a 10% sodium carbonate solution [4]. • After neutralizing the GA, dry the skin thoroughly before applying the TCA. • Using a 7.5  ×  7.5-cm gauze, apply the 35% TCA solution. It can be done in two different ways: applying over the entire face at once, waiting a couple of minutes, and then applying another layer until the desired frost is achieved or segmentally, treating one anatomic region at a time and going to the next only when the final frost is achieved. In this way, the application begins on the forehead, going to the cheeks, the nose, the chin, and finally, the perioral and periocular regions [1, 4]. Do not forget to feather into the hairline and eyebrows [5]. • Be careful not to double treat the nasolabial folds when treating the cheeks and the perioral region. Within 1 cm of the lower lid eye lashes, use a small cotton swab to apply the TCA. Fig. 5.2  Final homogeneous white frost

5  Cook Peel (70% Glycolic Acid + 70% Trichloroacetic Acid) for the Face

49

Fig. 5.4  Third day post procedure

Fig. 5.3  Final homogeneous white frost

5.3

Clinical Follow-Up

• At home, the patient should wash the face twice daily with a mild soap or a Syndet gel. Dry gently without rubbing, and apply the petrolatum product or panthenol cream at least two times a day or as many times as needed to feel comfortable. • On the day of the procedure, there will be just edema and erythema. During the next 2 days, the skin will be dark and extremely dry, with an aggravation of all the spots and rhytides. • By the third day, the skin begins to crack and desquamate at the more dynamic areas of the face, beginning at the perioral region. By that day, the edema will be probably gone. • Shedding continues from the fourth until the seventh day, when it will be complete. The last areas to peel will be the pre-auricular region and the hairline.

• The petrolatum or panthenol cream should be used until the third day, when the shedding begins, and a non-comedogenic moisturizer can be prescribed. • The use of sunscreen during the first days of post-peeling is difficult and uncomfortable, but it is recommended whenever the patient has to leave home during daylight hours. In this case, the use of chemical-free products is safer, minimizing the risk of contact dermatitis. • Prophylactic treatment for herpes simplex infection with valacyclovir 500 mg twice daily or acyclovir 400 mg three times a day should be prescribed to all patients, beginning 1 or 2 days before the peeling and maintained for 10–14 days [2, 6]. • When the re-epithelialization is complete and skin appearance is back to normal, the patient can restart the treatment used in the ­preparation phase. Sun exposure has to be avoided for at least 6 weeks [4]. • The patient will return for consultation on the seventh day post-procedure, and until then a daily phone call is recommended and sending selfies is encouraged. • Generally, due to the level of injury and continued clinical improvement, one single medium-depth peel is enough. However, if necessary, it can be repeated after 3  months (Figs. 5.4, 5.5, 5.6, and 5.7).

50

M. d. P. Del Río Navarrete Biot

Fig. 5.6  Fourth day post peeling

Fig. 5.5  Third day post procedure. Desquamation beginning by the perioral region

Fig. 5.7  Fourth day post peeling

5  Cook Peel (70% Glycolic Acid + 70% Trichloroacetic Acid) for the Face

5.4

51

Before and After (Figs. 5.8, 5.9, 5.10, and 5.11)

Figs. 5.8 and 5.9  Before treatment. After two medium depth peelings

Figs. 5.10 and 5.11  Before treatment. After two medium depth peelings. Complete clearance of the forehead lentigines

M. d. P. Del Río Navarrete Biot

52

5.5

 ide Effects, Complications, S and Their Management

• Complications can occur during or post procedure. Intraprocedural complications are commonly due to improper technique or problems with the chemical agent used. Post-procedural complications are the result of inadequate care during healing, contact dermatitis, and local infections. A correct selection of the patient and the peeling agent and a good technique are essential for minimizing the occurrence of complications. • The most feared intraprocedural complication is ocular accidents, and to avoid them, some safety rules should be followed. Sit the patient in a confortable position with eyes closed. Keep the container with the peeling agent on the side of the patient to avoid inadvertent dropping. Always have appropriate eye rinse solutions ready to use in case of unintended eye exposure to the chemical agent. Specifically, saline is used to dilute TCA and bicarbonate or water to neutralize GA [2, 4]. • Post-inflammatory hyperpigmentation (PIH) remains the most common complication, especially in darker skin types [6]. It can be treated with retinoids, alpha hydroxy acids (AHA), hydroquinone, and other skin-­ lightening agents. If necessary, superficial peelings can be done. Avoiding sun exposure in the pre-procedural and post-procedural phases and preparing the skin with retinoids, AHA, hydroquinone, and other bleaching agents for at least 2 weeks before peeling and restarting this treatment as soon as possible after re-epithelialization will diminish the chances of developing hyperpigmentation. • Although rare after medium-depth peelings, hypertrophic scarring is another possible complication, and when it occurs, it is usually seen along the mandibular and perioral regions. To prevent this complication, any area of persistent erythema must be treated with topical steroids [5]. For a mediumdepth peel, the erythema should disappear in 15–30  days, and persisting erythema beyond this time is a predictor of potential scarring [6].

• Herpes simplex infection can occur after medium peelings and should be treated with antiviral agents. Prescribing valacyclovir or acyclovir to all patients, as previously described in this chapter, will reduce the risk of this complication. • Bacterial infections are rare in TCA peels, as this agent is bactericidal [6]. The use of thick occlusive ointments, prolonged use of topical steroids, and poor wound care are predisposing factors. • Contact dermatitis, milia, and areas of hypopigmentation, where the peel was deeper than planned, are other possible complications. • Frequent return visits and daily phone calls are recommended to closely monitor the healing evolution. Give the patient your personal cellphone number and encourage him to send selfies. Complications may occur, but early diagnosis and immediate treatment are essential for a good resolution.

Tip Box

• Be familiar with the procedure and the peeling agents you are using. • Work in a safe manner. Keep a bottle of thermal water and saline by your side during the application. • Never pass the peeling agent container over the patient’s head. • GA complications are related to exposure time. So, when applying the GA gel, pay attention to the watch to control exposure time and to minor changes on the skin. • TCA complications are related to the product concentration, pressure during the application, and number of coats. So, when applying the TCA solution, squeeze the gauze or the cotton swab tip, to prevent product excess, and wait a couple of minutes between the layers. • Take time to explain your patient the post-procedure evolution. • Be sure that your instructions are clearly understood. • Keep in touch with your patient, especially during the first 72 h.

5  Cook Peel (70% Glycolic Acid + 70% Trichloroacetic Acid) for the Face

References 1. Pelletier-Louis M-L.  Peelings chimiques et prise en charge du vieillissement cutané. Ann Chir Plast Esthet. 2017;62:520–31. 2. Jackson A.  Chemical peels. Facial Plast Surg. 2014;30:26–34. 3. Truchuelo M, Cerdá P, Fernández LF.  Chemical peeling:a useful tool in the office. Actas Dermosifiliogr. 2017;108:315–22.

53

4. Fabbrocini G, Padova MP, Tosti A.  Chemical peels: what’s new and what isn’t new but still works. Facial Plast Surg. 2009;25:329–36. 5. Coleman H, Futrell J.  The glycolic acid trichloroacetic acid peel. J Dermatol Surg Oncol. 1994;20: 76–80. 6. Nikalji N, Godse K, Sakhiya J, et al. Complications of medium depth and deep chemical peels. J Cutan Aesthet Surg. 2012;5:254–60.

6

Cook Peel (70% Glycolic Acid +40% Trichloroacetic Acid) for Extra-Facial Areas Carlos Gustavo Wambier

6.1

Materials

• Degreasing agent: standardized acetone–ethanol (3:1 mixture) or 70% ethanol. • Applicators: 4 × 4 gauzes (Fig. 6.1). • Peeling agents: large stock bottles of GA 70% (cosmetic grade) and TCA 40%. Pour the contents of the acids in two different shot glasses or beaker glasses with units of measure. For patients with atrophic skin, the author recommends TCA 30–35% instead of TCA 40% (Fig. 6.2). • Neutralizing agent: sodium bicarbonate solution 10% in a large glass. Dry disposable soft towels are soaked in this cup and are ready to be used. • Post-peeling regimen: Vaseline and sunscreen.

6.2

body surface to be treated with semi-soaked gauze pads. • Peeling solution application: the left hand is used for GA 70% solution and the right hand for TCA 40% solution (the dominant hand for TCA); if the author is left handed, he would change the disposition of the shot glasses and bowls as well in the table. Fold gauzes in half

Methods and Techniques

• Degreasing: the importance of removal of all make-up, sebum, beard, topical anesthetic, and sunscreen before any chemical peel is unquestionable. The physician scrubs the

C. G. Wambier (*) Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_6

Fig. 6.1  Materials. Two shot glasses for soaking 4  ×  4 gauzes, folded in half twice. After excess solution is removed from the gauze, the saturated gauze is placed in small bowls (red plastic for glycolic acid and ceramic for TCA). A large glass containing three soft towels is placed in the right side of the picture. These compressed “magic towels” are dry and compressed in individual packages (large container in the back). After each area is done, everything is refilled. Gloves used for neutralization (assistant) are changed after each neutralization to avoid cross-contamination of the neutralizing solution 55

56

Fig. 6.2  Application of 40% trichloroacetic acid solution with the dominant hand as soon as 70% glycolic acid solution has been applied with the other hand. Watch uniform layer of solution

twice, soak, and squeeze to remove excess solution. Place in each bowl one saturated gauze of each solution for every 5% of body surface area. Begin with GA, fast application to cover the whole designated area, throwing away semi-dry gauzes, and changing to a new saturated gauze. As soon as the process is over with GA, start the application of TCA with the dominant hand, starting from the same point and covering exactly the same area, changing the gauzes in the same position. • Endpoint visualization: the surgeon waits for the endpoint. For higher phototypes, above

C. G. Wambier

Fig. 6.3  Endpoint observation at 2 min. Actinic keratoses presented early frosting, which is expected; this patient’s desired endpoint at the first session was erythema, with speckled frosting over hand melanoses with denser frosting over actinic keratoses

Fitzpatrick III, due to risk of post-­inflammatory hyperpigmentation, in the first session, the endpoint is erythema. For lower phototypes, the endpoint is speckled frosting. Usually, erythema is achieved at 2 min after TCA application, and frosting starts in 3  min. Once the solution is dry, wait at least 3 min before using another application of TCA, which is always less saturated than the first application (Figs. 6.3 and 6.4). • Focal treatment: if there is a specific goal for the treatment session, for example, to remove actinic keratosis, this waiting time is the

6  Cook Peel (70% Glycolic Acid +40% Trichloroacetic Acid) for Extra-Facial Areas

Fig. 6.4  Endpoint observation at 4 min after the solution was dry revealed no frosting over hand melanoses and superficial pigmented seborrheic keratoses. This patient’s desired endpoint at first session was erythema, with speckled frosting over hand melanoses with denser frosting over actinic keratoses. Another focal layer of 40% trichloroacetic acid was applied to the melanoses

time to perform local treatments, such as cryotherapy for hypertrophic keratoses or cotton-­tipped applicator peel with 40% TCA with increased pressure and passes, over superficial keratoses, to achieve uniform frosting. • Neutralization: once the endpoints are achieved, the area treated is dried with a gauze (if still wet) and subsequently neutralized with soft towels saturated in 10% bicarbonate solution by the assistant. Three disposable towels are necessary for each limb, passing all towels at the whole area, starting with the area where there is increased frosting (hot spots) (Fig. 6.5). • Post-peeling regimen: a thick layer of Vaseline is applied to the peeled areas as soon as the desired chemoabrasion endpoints were achieved. The patient is instructed to use broadband sunscreen over the Vaseline layer twice a day if the skin needs to be sun-exposed, otherwise, only Vaseline (Fig. 6.6).

57

Fig. 6.5  Neutralization with 10% sodium bicarbonate after erythema endpoint was achieved (about 4  min). Three applications of 10% are performed to ensure complete neutralization and removal of the acids

6.3

Clinical Follow-Up

• There is pain after 2 min of TCA application, which usually lasts until complete frosting or erythema is achieved. Neutralization stops the pain almost instantly. • The skin becomes dry after about 1  week for limbs and 3 days for the neck and chest. The corneal layer becomes thick and darker after about 10 days, when it starts to peel, very slowly. For the hands and feet, expect about 3–4 weeks for peeling to start, while the shoulders, chest, and neck usually peel after about 2 weeks (Fig. 6.6). It is very important to avoid pulling or scratching the dark peeling skin because it protects deeper layers from light and chemicals. Moisturizing with either Vaseline or fragrance-free hypoallergenic creams is fundamental to avoid fissures. • Vesicles, blisters, and oozing are not expected; if any of those signs are present during follow­up, diagnosis must be made of either herpes reactivation, bacterial infections, or eczematous reactions.

C. G. Wambier

58

Fig. 6.6  Two-week follow-up. Pinching the skin reveals the thick corneal layer which will peel in about 2 more weeks. The areas which achieved frosting are darker (melanoses)

6.4

Before and After (Figs. 6.7, 6.8, 6.9, and 6.10)

Fig. 6.7  Two-week follow-up of Cook’s peel applied to the forearms and hands of a patient with multiple seborrheic keratoses and lentigines. This patient was peeled with 70% glycolic acid followed by 35% trichloroacetic acid with a large feathering area due to phototypes III–IV and concerns of demarcation marks to the arms

Fig. 6.8  Two-month follow-up of Cook’s peel applied to the forearms and hands with 70% glycolic acid followed by 35% trichloroacetic acid of a patient with multiple seborrheic keratoses and lentigines; skin texture improved, superficial actinic keratoses were removed, and most of the melanoses peeled off. The patient was scheduled for a second session after one more month

6  Cook Peel (70% Glycolic Acid +40% Trichloroacetic Acid) for Extra-Facial Areas

59

Fig. 6.9  Before and after 2 months of a single Cook’s peel with 70% glycolic acid, followed by 40% trichloroacetic acid

Fig. 6.10  Before and after 4 months of two Cook’s peels in the dorsal hands with 70% glycolic acid followed by 40% trichloroacetic acid

C. G. Wambier

60

6.5

 ide Effects, Complications, S and Their Management

• Post-inflammatory hyperpigmentation: the most common side effect of chemical peels in general. If erythema endpoint is respected for higher phototypes, this adverse reaction is minimized, along with the results; therefore, multiple treatments are recommended. • Infection: any oozing or edema must be treated with topical steroids, along with systemic antibiotics, especially in the lower limbs, where erysipelas is not rare. This peel is ­contraindicated in patients with venous insufficiency or lymphedema.

Tip Box

• Hands-on training mandatory for acquiring the correct technique, as in any peel. • In patients with atrophic skin or higher phototypes, use 30–35% TCA instead of 40% to minimize the adverse effects of hotspots. • Understand the limitations of extra-facial resurfacing treatments. Expect multiple treatments with safer interventions. • Realistic expectations and patience must be taught to every patient undergoing body peels.

7

Fluor-Hydroxy Pulse Peel for Face Erica Monteiro

7.1

Materials [1–5]

7.2

Methods and Techniques

7.1.1 Reagents

7.2.1 Patient Selection

–– Correctly labeled peeling agents in various concentrations: Jessner’s solution or 70% glycolic acid (GA) gel and 5% 5-fluorouracil (5-FU) propylene glycol emulsion. –– Alcohol and/or acetone to clean and degrease the skin. –– Syringes filled with normal saline for irrigation of the eyes in case of accidental spillage. –– Neutralizing solutions: only for glycolic acid peel.

The success of a chemical peel depends on a careful selection of patients and individualization of the treatment. Men or women with hyperkeratotic AK target lesions of moderate/severe intensity are eligible for the treatment.

7.1.2 Equipment (Fig. 7.1)

–– At first, the patient’s skin is cleaned (by ­impregnated cotton with 70% ethanol and/or acetone). –– In the next step, the solution of 70% glycolic acid gel is applied on the patient’s face with a cotton applicator. –– The forehead, the sides of the face and cheeks, chin, and nose are impregnated (Fig. 7.3). The eyes, nostrils, mouth, ears, and mucosa must be avoided. –– After 3–5 min, the glycolic acid is neutralized with water or normal saline.

–– Glass cup or beaker in which the required agent is poured. –– Head band or cap for the patient. –– Gloves. –– Cotton-tipped applicators or swab sticks. –– 2″ × 2″ cotton gauze pieces.

7.2.2 T  echnique Using Glycolic Acid Peel (Standard Fluor-hydroxy Pulse Peel for the Face)

E. Monteiro (*) Department of Humanities and Medical Sciences, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_7

61

E. Monteiro

62

2 5 3

9

1

7 6

8

4

Fig. 7.1  Materials used for the fluor-hydroxy pulse peel. (1) Alcohol-based solution of 30% salicyclic acid, (2) alcohol and/or acetone to clean and degrease the skin, (3) cold water, (4) syringes filled with normal saline for irri-

gation of the eyes, in case of accidental spillage, (5) cap for the patient, (6) gloves, (7) cotton-tipped applicators or swab sticks, (8) cotton gauze pieces, (9) ice for cooling

–– Finally, 0.5% 5-FU is full face applied. The eyes, nostrils, mouth, ears, and mucosa must be avoided. –– The treatment can be continued once a week or every 2 weeks, for 4–8 weeks. 1

7.2.3 T  echnique Using Jessner’s Solution (Alternative ­Fluor-­ hydroxy Pulse Peel for the Face)

6 5 2

–– At first, the patient’s skin is cleaned (by impregnated cotton with 70% ethanol and/or acetone). –– In the next step, Jessner’s solution is applied on the patient’s face with a cotton applicator. –– The forehead, the sides of the face and cheeks, chin, and nose are impregnated (Fig. 7.2). The eyes, nostrils, mouth, ears, and mucosa must be avoided. –– Neutralization is not necessary. –– Finally, 0.5% 5-FU is full face applied. The eyes, nostrils, mouth, ears, and mucosa must be avoided.

4

3

Fig. 7.2  Cosmetic units to treat  – First, protect the  eye area (6). Apply the chemical peel solutions following the below (1)–(5) cosmetic area. Cosmetic units: (1) forehead, (2) the sides of the face and cheeks, (3) chin, (4) peri buccal, (5) nose, (6) protect the eye area

–– The treatment can be continued once a week or every 2 weeks, for 4–8 weeks.

63

7  Fluor-Hydroxy Pulse Peel for Face

7.3

Clinical Follow-Up

7.3.1 Prepeeling Preparation (Table 7.1) –– For optimal results, preparation of the skin in the weeks before the procedure is very important. –– Topical retinoic acid preparations used daily for 3–6 weeks prior to the procedure may create better and more even penetration of the peeling solution in sebaceous and hyperkeratotic skins.

–– Standard photography and informed consent should always be obtained before the procedure for all types of peelings. –– Generally, it is not necessary to discontinue use of any of the patient’s medications including anticoagulants, aspirin, or nonsteroidal anti-inflammatory or antihypertensive drugs. –– According to our experience with superficial peeling, smoking does not have any adverse effect on post-peel healing or on the extent of the results.

Table 7.1  Pre- and post-fluor-hydroxy pulse peel recommendations [1–7]a

Considerations Priming

Infections

Photoaging Post-inflammatory hyperpigmentation Photoprotection Moisturization Fast healing

Maintenance (agents which are likely to be used in postprocedure maintenance)

Benefits/recommendations Reduces wound healing time, facilitates uniform penetration, detects intolerance to any agent, enforces patient compliance, and reduces the risk of complications Control any active infection or dermatoses In patients with history of herpes simplex posted for medium-depth and deep peels, antiviral therapy with acyclovir or famciclovir is recommended, beginning 2 days prior to the procedure and continued for 7–10 days until complete reepithelization Topical retinoids, alpha hydroxy acids Topical retinoids, hydroquinone, alpha hydroxy acids, vitamin C Broad-spectrum sunscreens and clothes Tretinoin 0.025%

Tretinoin 0.025%, glycolic acid 6–12%, 5-FU

Pre (at least 2–4 weeks prior to the procedure) +

Post (long after complete Post (immediate) reepithelization)

+

+

+

+ +

− −

+ +

+ + +

+ + −

+ + + (after reepithelization) + (after reepithelization)

Tretinoin is known to reduce healing time after resurfacing. The choice of the priming agent depends on the individual physician’s preference and individualized patient requirements

a

E. Monteiro

64

7.4

Before and After: Illustrations (Fig. 7.3)

Fig. 7.3  Before and after fluor-hydroxy pulse peel, three sessions, every 2 weeks

7.5 • • • • • •

 ide Effects, Complications, S and Their Management

Intense scaling. Xerosis. Erythema. Contact dermatitis. Small ulcers. Post-inflammatory hyperchromia.

7.5.1 Post-Peeling Recommendations (Table 7.1) [1–7] –– The goal of a chemical peel is to cause the outer layer of the skin to peel and flake, revealing the fresh, smooth layer underneath. –– Patients will experience some level of dryness and flaking for 2–5 days after treatment.

–– During this time of dryness and flaking, their skin is more sensitive (more redness and stinging), and they cannot use vitamin C, retinol, avobenzone, glycolic acid, and lactic acid. –– In this 2–5-day period, using a soothing gel or mask helps calm and soothe the skin. Other great options to use in this postprocedure time period are heparan sulfate and hyaluronic acid. –– Patients should be advised to stay out of sun and to avoid picking at dry, flaking skin. –– Exfoliating scrubs and other facial brushes and other forms of friction, including ­microdermabrasion, should be avoided during the healing process. –– Avoid any products with hydroxy acids, retinol, and 5-FU until the skin barrier has been restored. –– Use calming skincare products with anti-­ inflammatory ingredients such as green tea, argan oil, and chamomile to help alleviate any stinging or redness while the skin recovers.

7  Fluor-Hydroxy Pulse Peel for Face

Tip Box

• To ensure the best outcome from fluor-­ hydroxy pulse peel, patient education is crucial. • Retinoids should be used 2–3 times prior to procedures to speed healing. • Retinoids should not be used after the procedure until reepithelization has occurred. • Standard photography and informed consent should always be obtained before the cosmetic procedures. • The fluor-hydroxy pulse peel applied in a pulse dose regimen not only provides cosmetic improvement but, more importantly, has a therapeutic effect on ablating premalignant AKs.

References 1. Marrero GM, Katz BE. The new fluor-hydroxy pulse peel. A combination of 5-fluorouracil and glycolic acid. Dermatol Surg. 1998;24(9):973–8.

65 2. Teixeira SP, de Nascimento MM, et  al. The use of fluor-hydroxy pulse peel in actinic porokeratosis. Dermatol Surg. 2005;31(9 Pt 1):1145–8. 3. Bagatin E, Teixeira SP, et al. 5-Fluorouracil superficial peel for multiple actinic keratoses. Int J Dermatol. 2009;48(8):902–7. 4. Guimarães CO, Miot HA, Bagatin E.  Five percent 5-fluorouracil in a cream or for superficial peels in the treatment of advanced photoaging of the forearms: a randomized comparative study. Dermatol Surg. 2014 Jun;40(6):610–7. 5. Simon JC, Dominicus R, et  al. A prospective randomized exploratory study comparing the efficacy of once-daily topical 0.5% 5-fluorouracil in combination with 10.0% salicylic acid (5-FU/SA) vs. cryosurgery for the treatment of hyperkeratotic actinic keratosis. J Eur Acad Dermatol Venereol. 2015;29(5):881–9. 6. Monteiro EO. Acne e fotoproteção. RBM. 2009;66(6): 6–9. Edição Especial Dermatologia link: http:// www.moreirajr.com.br/revistas.asp?fase=r003&id_ materia=4083. 7. Monteiro EO.  Filtros solares e fotoproteção. RBM Esp Dermatol Cosm. 2010;67:5–18.

8

Fluor-Hydroxy Pulse Peel for Extra-­Facial Areas Maria Paulina Villarejo Kede and Bruna Sabatovich Villarejo Iosifovich

8.1

Materials

A 5% 5-FU solution in propylene glycol is used along with Jessner’s solution (salicylic acid 14 g, resorcin 14  g, lactic acid 14  g, ethanol qsp). Salicylic acid is photosensitive, and lactic acid absorbs the water in the air, so the solution is sensitive to light and air. Its mechanism of action is based on the keratolytic properties of salicylic acid and resorcinol and on the action of epidermolysis of lactic acid. The penetration depends on the number of layers and can reach average peelings. It causes burns and may or may not be removed with water. It can be performed on the face and in extra-facial areas, but for the risk of salicylism, evaluate the extent to be treated. It can be applied evenly with gauze or cotton. Reapply new layer after 3 or 4  min. Remove crystals of salicylic acid with water. the glycolic acid 70% gel (the highest concentration of glycolic acid is 70% and the solutions are made with water or the combination of water, alcohol, and propylene glycol) is used. It is an alpha hydroxy acid found in sugar cane or synthesized from formaldehyde. It has a variable penetration and can penetrate

M. P. V. Kede (*) Private Clinic, Rio de Janeiro, RJ, Brazil B. S. V. Iosifovich Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_8

more in sensitive areas, being little recommended for medium, deep, and combined peels. The penetration is dependent on the pH, number of layers, and time of application. The application can be made with gauze or gloved fingers quickly and evenly. The applicator should remain in the room, and the appearance of erythema, which is the endpoint, should be observed and neutralized. Neutralization is mandatory and can be done with 10% sodium bicarbonate solution.

8.2

Methods and Techniques

The author prefers the combination of 5-FU to Jessner’s solution to glycolic acid. It is a superficial and combined peeling in which a solution of 5-FU 5% in propylene glycol is applied after Jessner’s solution. Apply a layer of Jessner’s solution gauze or cotton in a uniform way. Reapply the new layer after 3 or 4 min. Remove crystals of salicylic acid with water. After a 5-min interval, a 5% 5-FU solution layer is applied in gloved-fingers propylene glycol, remaining on the skin for 12 h, depending on the tolerability. After the interval of 12 h, it is advised to remove the peeling in the domicile with water and neutral soap and the application of a Vaseline cream and photoprotection. The treatment is performed in eight pulses, and the interval between sessions can be weekly, biweekly, or monthly, depending on the tolerability of the patient. It is an effective, 67

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low-cost, and well-tolerated peeling for treatment of actinic keratoses on the face and in extra-facial areas. When it comes to extensive body areas, staggered intervals between sessions should be performed to minimize the risk of toxic complications depending on the agent used. Treatment is ideal until complete bleaching of the lesions. Hypertrophic lesions should be treated with other procedures prior to or between intervals. Squamous cell carcinoma should be excluded. Its main indication is the treatment of moderate-to-­ severe photoaging with multiple actinic ­keratoses and correlated conditions. Katz described the fluor-hydroxy pulse peel for treatment of multi-

ple actinic keratoses as a superficial and combined peeling in which a solution of 5-FU 5% in propylene glycol is applied after Jessner’s solution and compared it to the isolated use of Jessner’s solution, in eight weekly pulses. Efficacy was assessed by counting lesions and photographs. At 6 months follow-up, the difference was significant, and the combined peeling produces.

8.3

 ollow-Up at the Clinic F (Figs. 8.1, 8.2, 8.3, and 8.4)

Figs. 8.1 and 8.2  Application of three layers of solution and after 5 min, application of one layer of 5-FU solution in the neck and breastplate

Figs. 8.3 and 8.4  Skin peeling after 4 days of the combined peeling of Jessner’s solution and 5-FU

8  Fluor-Hydroxy Pulse Peel for Extra-Facial Areas

8.4

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Before and After (Figs. 8.5, 8.6, 8.7, 8.8, 8.9, and 8.10)

Figs. 8.5 and 8.6  Pre- and post-eight fortnightly sessions of combined peeling of Jessner’s solution and 5-FU on breastplate

Figs. 8.7 and 8.8  Pre- and post-eight fortnightly sessions of combined peeling of Jessner’s solution and 5-FU on breastplate

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Figs. 8.9 and 8.10  Pre- and post-eight fortnightly sessions of combined peeling of Jessner’s solution and 5-FU on breastplate

8.5

 ide Effects, Complications, S and Their Management

Allergic reactions (less than 0.1%), systemic toxicity (not done in very extensive areas by resorcinol and salicylic acid), infection, and persistent erythema, by use of Jessner’s solution, along with irritant dermatitis and 5-FU discomfort are observed [1, 2, 3–7], which must be treated with symptom-oriented products in accordance with each kind of side effect observed.

Tip Box

• The penetration of this peel depends on the number of layers • To remove the peel after 12 hours of its application on the skin. • On average, eight peel pulses are indicated and the interval between sessions a be weekly, biweekly, or monthly, depending on the tolerability of the patient • Side effects must be treated with symptom-oriented products in accordance with each kind of side effect observed

References 1. Bagatin E, Hassun KM, Teixeira SP, Talarico S. Systematic review of chemical peelings. Surg Cosmet Dermatol. 2009;1(1):37–46. 2. Brody HJ, Monheit GD, Resnik S, Alt TH.  A history of chemical peeling. Dermatol Surg. 2000; 26:405–9. 3. Kede MPV, Sabatovich O. Dermatologia Estética. São Paulo: Ed Atheneu; 2015. 4. Monheit GD.  Chemical peels. Skin Therapy Lett. 2004;9:6–11. 5. Katz BE. The fluor-hydroxy pulse peel: a pilot evaluation of a new superficial chemical peel. Cosmet Dermatol. 1995;8:24–30. 6. Marrero GM, Katz BE. The new fluor-hydroxy pulse peel. A combination of 5-fluorouracil and glycolic acid. Dermatol Surg. 1998;24:973–8. 7. Teixeira SP, Nascimento MM, Bagatin E, et  al. The use of fluor-hydroxy pulse peel in actinic porokeratosis. Dermatol Surg. 2005;31:1145–8.

9

Genital Bleaching Peel Adriana Awada

9.1

Materials

• Spectra laser (Q-switched Nd/Yag laser; Lutronic Co., Gyeonggi-Do, Korea) (Fig. 9.1) • Cool masks • Bleaching cream Dermamelan (Mesoestetic Inc., Viladecans, Barcelona, Spain) (Fig. 9.2)

Fig.  9.2 Bleaching cream Dermamelan (Mesoestetic Inc., Viladecans, Barcelona, Spain) Fig. 9.1  Spectra laser (Q-switched Nd/Yag laser; Lutronic Co., Gyeonggi-Do, Korea)

A. Awada (*) Adriana Awada Clinic of Dermatology, Santo André, SP, Brazil Brazilian Society of Dermatology, Rio de Janeiro, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_9

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9.2

Methods and Techniques [1–21]

9.4

Before and After

Before treatment • Five sessions of Spectra laser in the area, six passes each time (Fig. 9.3). • Cool down the area with ice immediately. • Apply Dermamelan mask in the area and leave there for 6–8 h. • Wash the area after that. • Apply calming cream twice a day, for 6 days.

9.3

Clinical Follow-Up [1–21]

See the patient every 7 days and when other sessions are applied, for 5 weeks.

Second treatment (after 7 days)

Fig. 9.3  Instrumental parameters of Spectra laser used in each session

9  Genital Bleaching Peel

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Third treatment (after 14 days)

Final result (after 28 days)

Fourth treatment (after 21 days)

9.5

 ide Effects, Complications, S and Their Management [1–21]

We only noticed the patient experienced a lot of pain during laser treatment, but we did not use any kind of anesthetic. We would stop and cool the area when it was too painful. No complications or side effects were reported.

Tip Box

• Respect the patient’s pain. • Cool the area before, during, and after each pass with the laser. • Apply the peeling mask all over the area and cover with plastic, so the cream remains in the skin and acts better.

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References 1. Alharbi MA. Q-switched double-frequency Nd:YAG (532 nm) laser is an effective treatment for racial lip pigmentation. J Cosmet Dermatol. 2019 Apr 9. 2. Won KH, Lee SH, Lee MH, Rhee DY, Yeo UC, Chang SE. A prospective, split-face, double-blinded, randomized study of the efficacy and safety of a fractional1064-nm Q-switched Nd:YAG laser for photoaging-associated mottled pigmentation in Asian skin. J Cosmet Laser Ther. 2016;18(7):381–6. 3. Ergun S, Saruhanoğlu A, Migliari DA, Maden I, Tanyeri H. Refractor Pigmentation Associated with Laugier-Hunziker Syndrome following Er:YAG Laser Treatment. Case Rep Dent. 2013;2013:561040. 4. Simşek Kaya G, Yapici Yavuz G, Sümbüllü MA, Dayi E. A comparison of diode laser and Er:YAG lasers in the treatment of gingival melanin pigmentation. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;113(3):293–9. 5. Ostovari N, Mohtasham N, Oadras MS, Malekzad F. 532-nm and 1064-nm Q-switched Nd:YAG laser therapy for reduction of pigmentation in macular amyloidosis patches. J Eur Acad Dermatol Venereol. 2008;22(4):442–6. 6. Poon VK, Huang L, Burd A. Biostimulation of dermal fibroblast by sublethal Q-switched Nd:YAG 532 nm laser: collagen remodeling and pigmentation. J Photochem Photobiol B. 2005;81(1):1–8. 7. Cisneros JL, Del Rio R, Palou J. Sclerosis and the Nd:YAG, Q-switched laser with multiple frequency for treatment of telangiectases, reticular veins, and residual pigmentation. Dermatol Surg. 1998;24(10):1119–23. 8. Bernstein EF, Koblenzer C, Elenitsas R. Minocycline pigmentation following carbon dioxide laser resurfacing: treatment with the Q-switched Nd:YAG laser. J Drugs Dermatol. 2015;14(4):411–4. 9. Zarzoso I, Bodet D, García-Patos V. A peculiar inheritance: the patient had a net-like pattern of pigmentation on her vulva and perianal skin. Am J Obste Gynecol. 2013;208(6):506.e1–2. 10. Loesch M, Jordan L, Honda KS, Rezaee R, Cooper K. Minocycline pigmentation of the vulva masquerading as a melanocytic lesion. JAAD Case Rep. 2016;2(4):337–9. 11. Garg S, Vashisht KR, Makadia S. A prospective randomized comparative study on 60 Indian patients of melasma, comparing pixel Q-switched NdYAG (1064 nm), super skin rejuvenation (540 nm) and ablative pixel erbium YAG (2940 nm) lasers, with

A. Awada a review of the literature. J Cosmet Laser Ther. 2019;21(5):297–307. 12. Jo DJ, Kang IH, Baek JH, Gwak MJ, Lee SJ, Shin MK. Using reflectance confocal microscopy to observe in vivo melanolysis after treatment with the picosecond alexandrite laser and Q-switched Nd:YAG laser in melasma. Lasers Surg Med. 2018. [Epub ahead of print]. 13. Choi JE, Lee DW, Seo SH, Ahn HH, Kye YC. Lowfluence Q-switched Nd:YAG laser for the treatment of melasma in Asian patients. J Cosmet Dermatol. 2018;17(6):1053–58. 14. Kwon HH, Choi SC, Jung JY, Park GH. Combined treatment of melasma involving low-fluence Q-switched Nd:YAG laser and fractional microneedling radiofrequency. J Dermatolog Treat. 2019;30(4):352–6. 15. Lee MC, Lin YF, Hu S, Huang YL, Chang SL, Cheng CY, Chang CS. A split-face study: comparison of picosecond alexandrite laser and Q-switched Nd:YAG laser in the treatment of melasma in Asians. Lasers Med Sci. 2018;33(8):1733–38. 16. Kong SH, Suh HS, Choi YS. Treatment of Melasma with Pulsed-Dye Laser and 1,064-nm Q-Switched Nd:YAG Laser: A Split-Face Study. Ann Dermatol. 2018;30(1):1–7. 17. Saleh F, Moftah NH, Abdel-Azim E, Gharieb MG. Q-switched Nd: YAG laser alone or with modified Jessner chemical peeling for treatment of mixed melasma in dark skin types: A comparative clinical, histopathological, and immunohistochemical study. J Cosmet Dermatol. 2018;17(3):319–27. 18. Alavi S, Abolhasani E, Asadi S, Nilforoushzadeh M. Combination of Q-Switched Nd:YAG and Fractional Erbium:YAG Lasers in Treatment of Melasma: A Randomized Controlled Clinical Trial. J Lasers Med Sci. 2017;8(1):1–6. 19. Ustuner P, Balevi A, Ozdemir M. A split-face, investigator-blinded comparative study on the efficacy and safety of Q-switched Nd:YAG laser plus microneedling with vitamin C versus Q-switched Nd:YAG laser for the treatment of recalcitrant melasma. J Cosmet Laser Ther. 2017;19(7):383–90. 20. Gokalp H, Akkaya AD, Oram Y. Long-term results in low-fluence 1064-nm Q-Switched Nd:YAG laser for melasma: Is it effective? J Cosmet Dermatol. 2016;15(4):420–26. 21. Alexiades M. Randomized, Double-Blind, Split-Face Study Evaluating Fractional Ablative Erbium:YAG Laser-Mediated Trans-Epidermal Delivery of Cosmetic Actives and a Novel Acoustic Pressure Wave Ultrasound Technology for the Treatment of Skin Aging, Melasma, and Acne Scars. J Drugs Dermatol. 2015;14(11):1191–8.

Glycolic Acid Peel for the Face

10

Jessica A. McCarrick and Valerie D. Callender

10.1 Materials (Fig. 10.1) 10.1.1 Glycolic Acid • Peels are available as free acids, neutralized, buffered, or esterified GA.  Buffered or partially neutralized GA is safer and recommended over free GA [1]. • GA peels are available in concentrations ranging from 20% to 70%. Peel intensity is determined by glycolic acid concentration and vehicle [5]. Typically, gel formulations are easier to control due to slower penetration [1]. • Check GA peel expiration, as potency decreases with time [7]. • Glycolic acid peels require neutralization. Neutralizing agents include sodium bicarbonate, 8–15% solution, or water. Sodium bicarbonate 10% solution is most commonly used [5]. • Other materials to be available include a gentle cleanser, timer, degreasing agent (isopropyl alcohol, acetone) hand-held fan, and a hairnet or headband (Figs. 10.2 and 10.3). J. A. McCarrick Department of Dermatology, Howard University Hospital, Washington, DC, USA

Fig. 10.1 Materials

Fig. 10.2  Glycolic acid peel procedure: glycolic acid application

V. D. Callender (*) Callender Dermatology and Cosmetic Center, Glenn Dale, MD, USA Department of Dermatology, Howard University Hospital, Washington, DC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_10

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patients to PIH [2]. The risk of PIH should be discussed. • It is advisable to take preoperative and postoperative photographs for each patient. Consider usage of a complexion analysis software, such as VISIA® Complexion Analysis System, for monitoring patients’ results.

10.2.2 Priming of Skin and Preoperative Instructions Fig. 10.3  Glycolic acid peel procedure: cleansing of the skin with a non-residue liquid cleanser

• GA peel efficacy may be optimized by proper patient selection and priming of skin. • Skin priming may be achieved with hydroqui10.2 Methods and Techniques none, topical retinoids, and products containing low concentrations of glycolic acid. 10.2.1 Patient Selection • In patients with Fitzpatrick skin types III–VI or with PIH, pretreat with hydroquinone for at least • Select patients carefully (dermatologic indica2 weeks prior to procedure [3]. In patients with tion, Fitzpatrick skin type, lifestyle) prior to skin of color, a test spot should be performed. performing GA peels. Ideal patients should be • Consider topical retinoids daily for 3–6 weeks motivated to comply with pre- and post-­ prior to GA peel [3, 5]. treatment regimens [5]. • Glycolic acid 8–12% products may be used up • Ideal candidates for GA peels may have mild to BID and may unmask a GA sensitivity in to moderate photodamage, actinic damage, some patients prior to peel procedure [3]. acne vulgaris and rosacea, and pigmentary • Stop all topicals and pretreatment products disorders (melasma, PIH). 3–5 days before peel. • GA peels should be avoided in current smok- • Total sun protection routine—educate patients ers and patients with eczema. on the necessity of sunscreen, protective cloth• It is important to assess the history of hypering, and sun avoidance every day [2]. trophic scars or keloids, along with history • Educate patients to avoid facial manipulation and dates of facelifts, laser treatments, derm(picking/scratching, buff puffs, use of OTCs) [2]. abrasion, and radiation treatments, as these • Patients should avoid waxing of the face (eyecan affect healing and predispose to scarring. brows, upper lip, etc.) 1 week prior to peel. • Assess the history of herpes simplex and pre- • Provide instructions to patient regarding the treat with prophylactic antiviral medication as night before and day of procedure. Skin should appropriate, to be continued for 10 days (pre-­ be cleansed with non-residue soap the day procedure until full reepithelialization) in a before and day of procedure. Advise patients medium-depth peel [5, 7]. In patients underto not apply cosmetics or moisturizers on the going superficial GA peels, consider valacyday of procedure. clovir 2 g po BID × 1 day as prophylaxis on the day of procedure, with the first dose given prior to peel. 10.2.3 Steps of Glycolic Acid Peel Procedure • Peels are contraindicated in patients undergoing isotretinoin therapy [5]. Discontinue isotretinoin at least 6–12 months prior to any peel [2, 5]. Glycolic acid peel procedure consists of four • Hormone replacement therapy, oral contra- main steps—cleansing and defatting of the skin, ceptives, and tetracyclines may predispose time-dependent application, and neutralization.

10  Glycolic Acid Peel for the Face

• Cleansing and defatting—Immediately before procedure, assess the skin for dry, scaly patches and open sores [1]. • Wash face with a gentle, non-residue cleanser to remove any residual make-up or moisturizers [5]. • GA is hydrophilic [1]. Thus, it is important to degrease the skin to ensure an even peel. • Degrease (“defat”) the skin using isopropyl alcohol or acetone. If using acetone, test a small area, and assess for any potential irritation. Acetone should be avoided in patients with irritation [2]. • Glycolic acid application—Patient should be in a comfortable position, keep their eyes closed, delicate areas protected, and have a hairnet or headband in place [1, 5]. • Delicate areas, such as eyes, corners of the nose, and lips, may be protected with Aquaphor®, zinc oxide paste, or damp gauze, in order to avoid irritant contact dermatitis [1, 3, 5]. • In order to avoid inadvertent spilling, keep container of GA to the side of the patient. • Peel may be applied with cotton-tip applicator, gauze, sponge, or a brush, but brush application is typically preferred [1, 3]. Apply liquid formulations using a fan brush and gel formulations with either cotton or a gloved hand. • Sequential application in the order of the forehead, cheeks, nose, chin. • GA peel depth is both time dependent and concentration dependent—highly superficial depth (GA 30–50%, 1–2-min application), superficial depth (GA 50–70%, 2–5-min application), and medium-depth (GA 70%, 3–15-min application) peels may be achieved [1, 5]. • It may be necessary to perform multiple passes in order to achieve medium-depth peeling. • Contact time should be tailored to each patient, and the first peel should last no longer than 2–3  min, followed by immediate neutralization, or sooner, if uniform erythema is seen prior to 2–3 min [1, 2]. • Other factors affecting peel intensity include amount of acid applied, vehicle, and technique used [1].

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• Patients may experience erythema or burning sensation during procedure, which can be minimized by use of a hand-held fan. • Neutralization/rinse off—Set timer to anticipated duration of peel, but it is also important to consider erythema and degree of discomfort in assessing endpoint, as frosting is unreliable [3, 5]. • Use sodium bicarbonate or water to neutralize peel. Allow patient to rinse with tepid water [2]. • Use application of cold, wet compresses until stinging and burning subside [3]. • Apply a mild steroid or an emollient cream [3]. Post-peel care, moisturization, and postoperative instructions—For patient comfort, recommend soothing cool compresses for 1–2  days after the procedure. Patients may cleanse using a bland, gentle cleanser and keep skin moist with petroleum-based emollients. Sun should be avoided and sun protection employed [2]. • Consider necessity of mild steroids or antibiotic creams as required [3]. • Instruct patient to avoid inflammatory agents for at least 1 week and to avoid sun exposure for 4–6 weeks post-peel [3]. • After complete re-epithelialization at 5–7 days, patients may restart usual regimen with topical medications (topical retinoids, bleaching creams, moisturizers, AHA creams, etc.).

10.3 Clinical Follow-Up • A series of glycolic acid peels is recommended for most patients. Usually, 6–8 peels are recommended for optimal results [2]. • Start with GA 20–30% and increase concentration with subsequent sessions. Increase the concentration by 10% with each peel as tolerated. • Repeat GA peel using 2–4-week intervals [2]. • Post-procedure visit—to assess peel response, infection, persistent erythema, early hypertrophic scars [7]. • Infection: unhealed crusting at days 7–10.

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• Persistent erythema: erythema lasting after day 14. • Scarring: raised or elevated areas at 10–14 days may herald early hypertrophic scar formation [2, 7].

10.4 Before and After See Fig. 10.4

10.5 S  ide Effects, Complications, and Their Management Anticipated side effects during peel application include burning sensation and erythema. Other complications and side effects include technical complications, infections, PIH, scarring, and persistent erythema.

10.5.1 Technical Complications • Improper application may lead to uneven peels with suboptimal results. • There is increased risk of necrotic ulceration with prolonged applications or higher concentrations of GA. • Inappropriate or inadvertent placement of GA peel may be managed with immediate neutralization [7].

10.5.2 Infection • Signs of local infection include excessive crusting, purulent drainage, and odor. This may be prevented through the use of soaks to debride crusting. Treat with appropriate antibiotic selection, topical or oral antibiotics as appropriate [7]. • Herpes simplex virus (HSV) reactivation prescribes prophylactic antivirals in patients with a history of HSV, starting either 1–2  days before peel or on the day of peel and continuing for 7–14  days until complete re-­ epithelialization [5, 7].

10.5.3 Cosmetic Side Effects and Complications • Pigmentary changes—PIH is the most common side effect of GA peels in treatment of melasma [4]. Pre-peel and maintenance therapy with topical retinoids and hydroquinone or other bleaching agents can reduce the risk of and treat post-peel PIH. • Scarring—Consider daily silicone gel and topical or intralesional steroids [7]. • Persistent erythema—Erythema lasting >3–5  days in superficial peels and >15– 30  days in medium-depth peels. Treat with daily sunscreen to prevent inadvertent and further UV exposure, along with the use of topical steroids and/or systemic steroids [7].

Fig. 10.4 African–American female with melasma treated with a series of three glycolic acid 30% peels before and after. (Photos Courtesy of Portia Love, MD)

Before

After

10  Glycolic Acid Peel for the Face

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10.5.4 Allergic Reactions and Contact Dermatitis • Glycolic acid is a reported contact allergen. Allergic reactions and contact dermatitis may be managed with topical corticosteroids [2, 7].

Tip Box

• Advantages of GA peels include minimal downtime, minimal risk, and minimal discomfort. • To reduce the risk of PIH and to increase peel efficacy, prime with topical retinoids, hydroquinone, or non-­ hydroquinone cosmeceuticals. • Stop all topicals ~5 days prior to peel. • Perform test spot in patients with skin of color. • Start low and titrate up: Start with GA 20–30% and increase concentration by 10% as tolerated with subsequent sessions. • Depth of the GA peel is dependent on both time and pH, which is determined by GA concentration. • GA peels do not exhibit frosting as a true endpoint. Monitor time, erythema, and degree of patient discomfort to assess endpoint. • Duration of contact with the skin (time from application to neutralization) affects peel depth. • Very superficial depth (GA 30–50%, 1–2-min application), superficial depth (GA 50–70%, 2–5-min application),

• • •

•

and medium depth (GA 70%, 3–15-min application). Medium-depth peels may require multiple passes. GA peels require neutralization with either water or sodium bicarbonate. Less frequent intervals between peels in patients at higher risk for post-peel complications. Hand-held fan may reduce patient discomfort.

References 1. Sharad J.  Glycolic acid peel therapy  – a current review. Clin Cosmet Investig Dermatol. 2013;6:281– 8. https://doi.org/10.2147/CCID.S34029. 2. Tung RC, Bergfeld WF, Vidimos AT, Remzi BK.  Alpha-Hydroxy acid-based cosmetic procedures. Guidelines for patient management. Am J Clin Dermatol. 2000;1:81–8. 3. Zakopoulou N, Kontochristopoulos G.  Superficial chemical peels. J Cosmet Dermatol. 2006;5:246–53. 4. Sheth VM, Pandya AG.  Melasma: a comprehensive update: part II.  J Am Acad Dermatol. 2011;65:699– 714. https://doi.org/10.1016/j.jaad.2011.06.001. 5. Fabbrocini G, De Padova MP, Tosti A.  Chemical peels: what's new and what isn’t new but still works well. Facial Plast Surg. 2009;25:329–36. https://doi. org/10.1055/s-0029-1243082. 6. Green BA, Yu RJ, Van Scott EJ.  Clinical and cosmeceutical uses of hydroxy acids. Clin Dermatol. 2009;27:495–501. https://doi.org/10.1016/j. clindermatol.2009.06.023. 7. Monheit GD.  Chemical peels. Skin Therapy Lett. 2004;9:6–11.

Glycolic Acid Peel for Extra-Facial Areas

11

Caroline Silva Pereira, Beatrice Martinez Zugaib Abdalla, and Adilson Da Costa

11.1 Materials (Fig. 11.1) • • • •

Procedural gloves Nonsterile gauze or brush 70% alcohol 30–70% GA peel (solution with water; a mixture of water, alcohol, and propylene glycol or gel) • 10% sodium bicarbonate solution

11.2 Methods and Techniques • Pre-peel anamnesis: Patients with a history of herpes simplex should take prophylactic antiviral therapy. • Skin preparation: It should be started at least 2 weeks before the procedure, since it reduces

healing time, allows a uniform absorption of the agent, and reduces the risk of post-­ inflammatory hyperpigmentation. It can be performed with glycolic acid (5–10%), associated or not with depigmenting agents, such as hydroquinone (2.5–5%), kojic acid (1–2%), or phytic acid, in vehicles suitable for each type of skin [1]. • It is mandatory to obtain the informed consent form of the patient and to perform a photographic documentation. • Different from face application, wherein imaginary aesthetic unit areas are created and GA peel is applied, generally, in a centrifuge direction, body application is done randomly since the entire area is covered by the substances and undesirable overlapping is avoided.

C. S. Pereira (*) Pontifical Catholic University, São Paulo, SP, Brazil ABC School of Medicine, Santo André, SP, Brazil Sírio Libanês Hospital, São Paulo, SP, Brazil B. M. Z. Abdalla ABC School of Medicine, Santo André, SP, Brazil 2nd Year Resident of Internal Medicine at FMABC, Santo André, SP, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_11

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Fig. 11.2  Epidermolysis pattern under glycolic acid peel application Fig. 11.1  Material used for glycolic acid peel on extrafacial areas

• Cleaning the skin with 70% alcohol-soaked gauze. • GA application is done with brush or gauze, quickly and evenly, after cleaning the skin with alcohol. • The observation of the skin must be constant and rigorous to prevent intense epidermolysis and secondary burns. The appearance of whitish-­ gray color means epidermolysis and frosting means dermal lesion (Fig. 11.2). • In case of epidermolysis or frosting, a 10% sodium bicarbonate solution is sprayed on the skin, when a mandatorily observed sparkling reaction shows up.

11.3 Clinical Follow-Up • Patient must leave the medical office with minimum-SPF-15 product on the exposed area where GA peel was applied. It’s better when it’s used in the hydrating vehicle, which needs to be reapplied every 2 h. • If scaling occurs in the next few days, a night hypoallergenic, moisturizing product can be used before going to bed. • Patients need to be evaluated after 2, 5, and 10  days to treat and/or follow-up any subsequent epidermolysis. • Another GA peel can be performed every 15 days.

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11.4 Before and After Figures 11.3 and 11.4. a

b

c

d

Fig. 11.3  Clinical improvement of skin treated with glycolic acid peel. 70% Glycolic acid peel at pH  -0.6 for post-inflammatory hypercromia. (a) Pre-peel; (b) Immediately after peel application; (c) Peel sparkles after

being sprayed with 10% sodium bicarbonate; (d) Skin appearance immediately after the first peel session; (e) After the second session (60) days. (Courtesy: Molinaro [2])

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84 Fig. 11.3 (continued)

a

e

b

Fig. 11.4  Clinical improvement of skin treated with 70% glycolic acid peel. 70% Glycolic acid peel at pH -1.5 for Civatte poikiloderma. (a) Pre-peel; (b) After the third session (45 days)

11.5 S  ide Effects, Complications, and Their Management The complications and side effects vary according to the GA’s absorption depth, professionals’ skills, and patient characteristics [3, 4], as the following:

• Pigmentary alterations from post-­ inflammatory hyperpigmentation and hypopigmentation, which may be treated with daily-use topical corticosteroids, tretinoin, hydroquinone, or alpha-hydroxy acids • Infections: bacterial (Staphylococcus, Streptococcus, Pseudomonas), viral (herpes

11  Glycolic Acid Peel for Extra-Facial Areas

• • •

•

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simplex), and fungal (candida), treated with References agents’ specific medications Allergic reactions, which can be overcome 1. Velasco MVR, Ribeiro ME, Bedin V, Okubo FR, Steiner D.  Rejuvenescimento da pele por peelwith topical or systemic steroids ing químico: enfoque no peeling de fenol. An Bras Acneiform eruptions, which can be treated Dermatol. 2004;79(1):91–9. 2. Molinaro MC.  Peelings corporais. In: MPV K, with systemic antibiotics Sabatovich O, editors. Dermatologia Estética. 3rd ed. Lines of demarcation between treated areas Sao Paulo: Editora Atheneu; 2015. p. 639. and non-treated areas, which can be improved 3. Fischer TC, Perosino E, Poli F, Viera MS, Dreno with tretinoin, hydroquinone, or alpha-­ B, Cosmetic Dermatology European Expert Group. Chemical peels in aesthetic dermatology: hydroxy acids’ daily use an update 2009. J Eur Acad Dermatol Venereol. Textural modifications, which are better 2010;24(3):281–92. treated with topical tretinoin or GA-based 4. Berson DS, Cohen JL, Rendon MI, Roberts WE, cream Starker I, Wang B.  Clinical role and application of

In general, side effects and complications can be avoided if GA peel isn’t performed during pregnancy, lactation, active herpetic lesions, bacterial or fungal infections, dermatitis at the site of application, use of photosensitizing medications, and allergies to peeling components [4, 5].

Tip Box

The following observations are important for safety when applying peels: • Avoid applying to irritated, erythematous, or inflamed skin [3]. • Always have the neutralizing substance of the chemical agent in use [3]. • Always be aware of visual signs, such as erythema and frosting, which help identify the degree of substance absorption and depth being reached [3]. • GA peel’s main indications are treatment of spots, scars, and fine wrinkles, either on the face or on body skin [6, 7].

superficial chemical peels in today’s practice. J Drugs Dermatol. 2009;8(9):803–11. 5. Mendonça MC, Aarestrup FM, Aarestrup BJ. Clinical protocol for punctuated 88% phenol peels in the treatment of photoaging: a histopathological study of three cases. Dermatol Surg. 2012;38(12):2011–5. 6. Oremović L, Bolanca Z, Situm M. Chemical peelings – when and why? Acta Clin Croat. 2010;49(4):545–8. 7. Khunger N.  Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74(Suppl):S5–12.

Jessner’s Peel for the Face

12

Vanesa Piquero, Daniela Moya, and Edgar E. La Rotta

12.1 Materials (Fig. 12.1) • Patient headband or cap • Astringent cleansing or soap solution or facial tonic • Alcohol, acetone, and degreasing lotion • Mask of cleaning clay and/or ozone vaporizer • The traditional formula of Jessner’s peeling consists of salicylic acid 14 grams, resorcinol 14 grams, and lactic acid (85%) 14 grams in 95% ethanol 100 ml • Jessner’s modified peel: 17% lactic acid, 17% salicylic acid, and 8% citric acid with ethanol base; another 5% lactic acid, 15% citric acid, 2–3% salicylic acid, and 3–5% kojic acid, also

• • • • • •

•

adding 2% hydroquinone or adding 14% resorcinol [1–3] Gloves Disposable applicators or gauze A manual fan is used Vaseline Criogel and rose or spring water [4, 5] Jessner’s peeling is often combined with other subsequent peels, such as 35% trichloroacetic acid, 3% retinoic acid or retinol, vitamin C serum, or other techniques such as microneedling, for best results Sunscreen [2, 3, 5]

12.2 Methods and Techniques 12.2.1 Prepeeling

V. Piquero (*) Clinica Leopoldo Aguerrevere Caracas, Caracas, Venezuela Clinica Dermik Barcelona, Barcelona, Spain e-mail: [email protected] D. Moya Hospital Universitario de Caracas, Caracas, Venezuela Hospital Intercultural Kallvu Llank Chile, Cañete, Región del Bío Bío, Chile E. E. La Rotta Centro Medico Buenaventura en Caracas, Guatire, Venezuela Hospital Clinic Barcelona, Barcelona, Spain e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_12

• Interrogation and physical examination: avoid in case of inflammation, dermatitis, substance allergies, infection of the area, treatment with isotretinoin, delayed healing, pregnancy, or lactation [2]. • Pre-preparation of the skin: at least 2  weeks before indicate the use of bleaching agents, topical retinoids, alpha-hydroxy acids, and/or other topical exfoliating agents, as these increase the penetration of the chemicals with which the peeling is performed. • Interrupt topical treatments 24–48  h prior to peeling application [2, 5, 6]. 87

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88 Fig. 12.1  Materials for chemical peel

• The interval between peelings is from 15 days to 1 month. • Wait at least 30 days to perform a peel if you have undergone facial surgery. • Do not perform in case of active herpes, and take precaution in case of recent herpes. • Avoid applying these peels on tanned skin or with sun exposure 15 days before. • Avoid epilation of the skin, since the skin is still sensitive [2, 7]. • Shaving on men should not have been performed on the same day of peeling. • Explain the patient’s real expectations of results and have them sign an informed consent. • Any phototype and cutaneous surface can be treated, but phototypes IV and V always have a higher risk of post-peeling hyperpigmentation [1, 5, 8]. • We must know the product that we are going to use when we are preparing for the peeling, since gelled substances or with higher pH will be smoother than alcoholic with resorcinol and pH plus acid.

• In patients with chemical contact dermatitis, we can perform a prior epicutaneous test [6, 7, 9].

12.2.2 Peeling • Remove hair from the area and put on a cap. • Remove debris from the skin area to be treated, and clean/wash with neutral cleanser or soap and/or facial tonic. • Apply a degreaser based on ethanol, alcohol, or acetone. • The eye, paranasal areas, and mouth can be protected with Vaseline. • Eye and mouth protection is with wet gauze or glasses [4, 9]. • In oily skins, ozonated water vaporizer can be recommended to dilate the pores and promote acid penetration. • Remove comedones and milia and complete facial cleansing. • Apply the peeling of Jessner with 10 × 10-cm gauze. It should be applied evenly, putting

12  Jessner’s Peel for the Face

Fig. 12.2  Uniform application of the peeling around the face; the white frosting helps us to show the places of application

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Fig. 12.4  Refresh with cold or rose water, cryogel, and apply cold soothing cream like aloe vera gel and them finish with a sunscreen

•

•

• Fig. 12.3  Use of manual fan to counteract pain and burning and use of cotton applicators to apply on comedones, lower eyelid, etc

•

•

•

•

some pressure on the skin; the gauze should be sufficiently wet but without draining the substance (Fig. 12.2). Cotton-tipped applicators are used to touch up small areas or around the eyes or papules (Fig. 12.3). A manual ventilator is given to the patient to be directed to areas where he or she feels burn [7]. This peeling is applied by layers; the greater the number of layers, the greater the depth of penetration and the greater the aggressiveness. In general, 3–5 layers are applied. It should be applied in order, for example, following the hands of the clock or by anatomical

• •

• •

•

areas (frontal, cheeks, and nasal), up to the area of hair implantation and 0.5 cm below the mandibular border [4, 9, 10]. Jessner’s solution is applied in 1–3 coats to get even frosting; the endpoint is erythema or even frosting. The greater the number of layers applied, the greater the depth of peeling. In case of erythema and intolerable burning sensation, peeling should be removed and the application discontinued [3, 10]. In the case of the modified Jessner formulas, the action of these formulas can be modified according to the concentration of the active ingredients, pH, vehicle, and the combination being less aggressive and irritating [5, 6, 10]. While the product is working, we can calm it with a manual fan (Fig. 12.2). Once the product acts, we can indicate to wash with fresh water, thermal water, or rose water. Although it does not require neutralizing by bicarbonate, it provides rapid relief. Place Criogel or a cold soothing mask, thermal water, or a firm natural yoghurt mask. In case of combined Jessner peeling, apply the following chemicals: TCA, retinoic acid, glycolic, and vitamin C serum, and follow the steps of the application of these substances Apply cool and soothing moisturizer followed by sunscreen (Fig. 12.4) [5, 10].

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12.2.3 Post-peeling • Indicate four glasses of water on the first day to avoid salicylism. • Avoid makeup for 6  h; only loose and inert powders can be used. • Use photo-protection, especially in the first 48–72 h after the application of peeling and up to 15 days. • Keep the skin moisturized, especially in the scaly stage [7]. • In case of redness, intense inflammation, or risk of hyperpigmentation, we can indicate medium-power steroids 3–5  days post peeling. • Avoid heat and saunas for 3–7 days [6, 7, 9]. • The patient will experience skin redness for 2  days and subsequent chemical desquamation; all of this is resolved within 2–7  days after application. • Firm cold yogurt mask and topical steroids post-peeling can be recommended at home. • Indicate oral acyclovir prophylactic in case of history of cold sores, particularly in cases with high relapse and last crisis less than 1 month [7, 10]. • Avoid intense physical activity and sweating for at least 5 days. • Avoid abrasive soaps and scrubs for a period of at least 7 days. • Restart topical treatment after resolved peeling symptoms (approximately 5 days). • Basic moisturizing cream and sunscreen for 5–7 days post-peeling are indicated, and then the rest of the treatment is resumed. • Peeling can be repeated between 15 days and 1 month, with an average of 3 weeks. • All these recommendations could change according to the intensity of the applied peeling, the characteristics of the skin that is treated, and climatic or environmental factors. (Figs. 12.5 and 12.6) [2, 10].

Fig. 12.5  Facial erythema after 24 h of Jessner’s peeling plus TCA 15% for acne scars

Fig. 12.6  Mild to moderate peeling after 72 h of applying Jessner’s peel for acne

12  Jessner’s Peel for the Face

12.3

91

 efore and After (Figs. 12.7, 12.8, B 12.9, 12.10, 12.11, and 12.12 ) Before:

After 7 days:

Figs. 12.7 and 12.8  Jessner’s peeling for melasma Before:

After 5 months:

Figs. 12.9 and 12.10  Results after six peelings, every 3 weeks: Jessner, Jessner combined with retinoic acid, Jessner combined with 25% TCA, Jessner plus 35% TCA, monthly sessions in addition to home treatment

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92 Before:

After:

Figs. 12.11 and 12.12  Results after four Jessner peelings alone, or combined with glycolic acid, and TCA for acne scars and melasma

12.4 S  ide Effects, Complications, and Their Management (Figs. 12.13, 12.14, and 12.15) • The most frequent side effects in the use of Jessner’s peeling solution are prolonged redness, hyperpigmentation, and solar lentigines. • Some days (3 to 7 days) after the peeling procedure the patient may feel scaly skin redness, burning. [3, 4]. • Jessner’s peeling solution is a superficial peeling, which makes it very safe in all cutaneous phototypes, but phototypes IV and V have a higher risk of post-inflammatory hyperpigmentation [2, 9, 10]. • Risk of herpetic spread in patients with herpes. • Risk of impetigo or pyoderma in patients who do not have adequate skin hygiene, environmental, makeup, exercise. • Alteration in healing in patients receiving isotretinoin, heavy cigarette smoking, history of hypertrophic scarring, connective tissue disorders, diabetics, and immunosuppression. • Risk of hyperpigmentation in patients with regular sun exposure [5, 8, 9].

• The Jessner solution is extremely safe and well tolerated despite concerns that the toxicity of resorcinol and salicylate could cause. • Resorcinol is a sensitizer that could cause allergy and induce hypothyroidism, syncope, or methemoglobinemia in high concentrations. • Resorcinol stains light brown hair with light brown surfaces (furniture, stretchers, hair bands). • The systemic effects of salicylic acid in high concentrations and extensive areas of the skin causing salicylism are tinnitus, vertigo, headache [3, 5, 10]. • In case of allergy to any of its ingredients, it can be treated with topical or systemic ­steroids according to intensity and oral antihistamines. • Excessive peeling, erythema, or post-peel irritation can be treated with low- or high-potency steroids for 5–7 days [6, 9, 10]. • Post-peeling post-inflammatory hyperpigmentation can be treated with highpotency steroids first and then with topical depigmenting. • NSAIDs or antihistamines may be indicated in case of edema, inflammation or pruritus [3, 6, 9].

12  Jessner’s Peel for the Face

Fig. 12.13  Intense facial erythema with burning sensation in the first 24 h of Jessner peeling for photoaging

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Fig. 12.15  Onset of supralabial herpes simplex and facial edema after 7 days of Jessner facial peeling

Tip Box

Fig. 12.14  Acneiform eruption and perioral eczema in Jessner peeling application area

• This peeling can be used on all skin types. • It has antiseptic effect if a single soft coat is applied. • It is especially useful on very thick and oily skins. • It is used in actinic skin, acne, and melasma. • This peeling is essential to improve the efficacy and safety of peeling with trichloroacetic acid, making use of lower concentrations of TCA. • This peeling is applied by layers, varying the depth according to its method of application, skin type, and formula used. • This peeling is not timed, it is not neutralized, it does not generate labor casualties, the result is fast, and it is easy to control its penetration.

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• Ventilation helps to reduce burning or pain and is necessary in your application. • It allows a better penetration of other substances such as trichloroacetic acid and other peeling, hence its use in combination with glycolic acid, retinoic acid, mandelic acid, citric acid, lactic acid, pyruvic acid, etc.

References 1. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B.  Evidence and considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesthet Dermatol. 2010;3(7):32–43. 2. Safoury OS, Zaki NM, El Nabarawy E, Farag EA. A study comparing chemical peeling using modified Jessner’s solution and 15%trichloroacetic acid versus 15% trichloroacetic acid in the treatment of melasma. Indian J Dermatol. 2009;54(1):41–5. https://doi. org/10.4103/0019-5154.48985.

3. Serrano G, Lloret G, Tomas R, Millan F, Janes C. Nuevos peelings con AHAs. Piel y Dermocosmetica Ibero-Americana. 1997;1:26–44. 4. Rubin MG.  Exfoliación química. España: Elsevier Saunders; 2007. 5. Grimes P. Jessner’s solution. In: Tosti A, Grimes PE, De Padova MP, editors. Color atlas of chemical peels. Berlin: Springer; 2006. p. 23–9. 6. Ortiz Y, Ortega G.  Quimiodermoexfoliaciones (Peelings). In: Perez Atamoros F, Enriquez Merino J, editors. Dermatologia Cosmética, vol. P0. Mexico: Elsevier; 2011. p. 247–62. 7. Figueiredo M, Henneberg T, Chisaki C, Henneberg P. Chemical peels: review and practical applications. Surg Cosmet Dermatol. 2013;5(1):58–68. 8. Fischer T, Perosino E, Poli F, Viera M, Dreno B, For the Cosmetic Dermatology European Expert Group. Chemical peels in aesthetic dermatology: an update 2009. J Eur Acad Dermatol Venereol. 2010;24:281– 92. https://doi.org/10.1111/j.1468-3083.2009.03409. 9. Kontochristopoulos G, Platsidaki E.  Chemical peels in active acne and acne scars. Clin Dermatol. 2017;35(2):179–82. https://doi.org/10.1016/j.clindermatol.2016.10.011. Epub 2016 Oct 27. 10. Puri N. Efficacy of modified Jessner's peel and 20% TCA versus 20% TCA peel alone for the treatment of acne scars. J Cutan Aesthet Surg. 2015;8(1):42–5. https://doi.org/10.4103/0974-2077.155082.

Jessner’s Peel for Extra-Facial Areas

13

Sarah Wilson, Howa Yeung, and Travis W. Blalock

13.1 Materials • Alcohol and acetone solutions for degreasing the skin. • Jessner’s solution—composed of salicylic acid 14 g, 85% lactic acid 14 g, and resorcinol 14 g in a 100 cc 95% ethanol base. –– Salicylic acid is light-sensitive; thus, JS needs to be stored in a dark bottle. • Applicators such as sable brush, gauze sponge, and cotton-tip applicators can be used.

13.2 Methods and Techniques [1, 2] 13.2.1 Indications • Pigmentation of the neck and chest responds well to JS chemical peels alone (Fig. 13.1) [1]. –– JS can be used as monotherapy for mild dyspigmentation of the neck and chest. –– Application of JS to the neck and chest once a month for 3 months total is an effective superficial peel schedule, as it provides predictable results in the least amount of time in this peeling category. S. Wilson · H. Yeung · T. W. Blalock (*) Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA e-mail: [email protected]; [email protected]; [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_13

–– JS is tolerated well, as opposed to some other peels in its category. In 1 study [3], 16 patients of varying Fitzpatrick skin types were treated for melasma with 70% unbuffered glycolic acid on 1 cheek and JS on the other for 3 monthly peels. Blinded clinical observation showed similar statistically significant improvement with both modalities; however, 10 of 16 patients reported more pain with glycolic acid. –– For patients with more severe actinic damage, combination with 35% TCA is usually more effective. • Actinic keratoses can be treated using a combination treatment approach [1]: –– Monotherapy with JS chemical peel is not typically effective for actinic keratoses. –– Combination therapy with JS chemical peel followed by topical 5-fluorouracil (5-FU) can enhance the depth of 5-FU penetration to allow potentially increased efficacy [4–6]. One author has anecdotally reported over 80% clearing of actinic keratosis lesions and overall improvement of photodamaged skin using this JS and 5-FU combination [4]. A similar combination treatment for actinic keratosis using glycolic acid has been described as the fluor-­ hydroxy pulse peel with 91% of actinic keratoses clearing at 6-month follow-up [5]. 95

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–– In patients with severe sun damage and multiple actinic keratoses, the use of 35% trichloroacetic acid peel after JS to areas such as the arms or legs can be considered. However, high level of caution and appropriate informed consent should be obtained since there are higher risks of dyspigmentation and scarring for medium-depth chemical peels off the facial areas due to poorer wound-healing capacity.

–– Non-vesicular exfoliation for 2–4  days afterward, mostly with flaking but rarely with peeling • The peel should be repeated to produce the best results. Some regimens include once a month for 3  months. Others suggest every 6–8 weeks [1, 8]. • Strict photo-protection should be advised following the procedure.

13.4 Before and After (Fig. 13.1) 13.2.2 Procedures on a Step-by-step Way • The skin is degreased using alcohol and then subsequently with acetone solution, both applied using cotton balls or gauze sponges. • Application with a sable brush is preferred to ensure an even, light-white frost. In our experience, frosting can sometimes be weak, slow, and/or uneven when applied using two cotton-­ tipped applicators, cotton balls, or a gauze sponge. • The extent of frosting will be evident 3–4 min after application. –– It is important to differentiate whitening from salicylic acid precipitation rather than a true frost due to tissue coagulation. ­Whitening can be wiped off easily with a damp cotton ball. • A second coat is then applied, and this process can be repeated until the end-point—a thin pale to pinpoint white frost, which evolves slowly, is reached. The patient may experience mild stinging and burning. • Neutralization is not required. • Heavier pressure and increased coats of JS applied increase the depth of penetration, as does pre-treatment with topical tretinoin leading up to the peel.

a

b

c

13.3 Clinical Follow-Up • It is important to counsel the patient about expected exfoliation and subsequent care [7]: –– Mild red-brown to streaky erythema and darkening of pigmentation for 1–3 days

Fig. 13.1 (a) Freckles and lentigines with hypopigmented macules from actinic damage and previous keratosis removal on the chest before sable brush application of two coats of Jessner’s solution. (b) Immediately after frosting. (c) Two months after two monthly peels with resulting fading of freckling and lentigines [1]

13  Jessner’s Peel for Extra-Facial Areas

13.5 S  ide Effects, Complications, and Their Management [6–9] • Similar to other superficial peeling agents, JS is generally well tolerated in a wide variety of skin types with few contraindications and very rare incidence of toxicity. However, it is contraindicated in pregnancy and during lactation [7, 8]. • Potential side effects include persistent or streaky erythema, dyspigmentation, scarring, allergic contact dermatitis, and systemic toxicity from resorcinol or salicylic acid absorption. • Rare potential side effects of resorcinol include contact dermatitis, dyspigmentation, pallor, dizziness, tremor, syncope, and hypothyroidism, described mostly with higher concentrations and repeat application [6]. Exogenous ochronosis has been described as well. • Contact dermatitis to resorcinol may occur and manifest as edema out of proportion to the peel, which can be effectively treated with oral prednisone. • Rare potential side effects of salicylic acid include salicylate toxicity or “salicylism” (e.g., pallor, fatigue, tinnitus, nausea, vomiting, dizziness, hyperpnea, and other neurologic disturbances) seen at higher concentrations and widespread exposure [7]. Increased oral fluid intake can be recommended in the first 12  h after JS peel to potentially assist with salicylic acid excretion [2]. • Because Jessner’s peel is a mixture of multiple ingredients, slight variations in efficacy or composition may be experienced depending on the manufacturer of the peel.

Tip Box

• Jessner’s solution chemical peels are safe and effective as monotherapy for pigmentation on the face and neck. • When used in combination with 5-FU or 35% TCA, Jessner’s solution can effectively treat actinic keratoses.

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• Application of JS with a sable brush may produce more uniform, light frosting more effectively than a cotton-tip applicator or gauze sponge. • The effects of each coat of JS will be evident 3–4  min after application; patients may experience tingling or mild burning. • The expected end-point of a Jessner’s peel is a thin, pale to pinpoint light frost. • It is important to counsel patients that hyperpigmentation is expected for 1–3  days, followed by non-vesicular exfoliation for 2–4 days after the peel. • Jessner’s solution is a superficial peel that is typically well tolerated in a wide variety of skin types with few contraindications and very rare incidence of toxicity.

References 1. Brody HJ. Chemical peeling and resurfacing. 3rd ed. Emory University Digital Library Publications; 2008. amazon.com and open.library.emory.edu. 2. Rubin MG. Manual of chemical peels : superficial and medium depth. Philadelphia: J.B.  Lippincott; 1995. 187 p. 3. Lawrence NL, Cox SE, Brody HJ. A comparison of Jessner’s solution and glycolic acid in the treatment of melasma in dark skinned patients: a double blind study. J Am Acad Dermatol. 1997;37:589–93. 4. Tosti A, Grimes PE, Padova MPD.  Color atlas of chemical peels. 2nd ed. Heidelberg/New York: Springer; 2012. 211 p. 5. Marrero GM, Katz BE. The new fluor-hydroxy pulse peel. A combination of 5-fluorouracil and glycolic acid. Dermatol Surg. 1998;24(9):973–8. 6. Cassano N, et  al. Peeling agents: toxicological and allergological aspects. J Eur Acad Dermatol Venereol. 1999;13(1):14–23. 7. Arif T.  Salicylic acid as a peeling agent: a comprehensive review. Clin Cosmet Investig Dermatol. 2015;8:455–61. 8. Tannous Z, Avram MM, Tsao S, Avram MR. The color atlas of cosmetic dermatology. 2nd ed. New  York: McGraw-Hill Publishing; 2011. 9. Grimes PE, Rendon MI, Pellerano J.  Superficial chemical peels. In: Grimes PE, editor. Aesthetics and cosmetic surgery for darker skin types. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 154–69.

Phenol-Croton Oil Peels

14

Fernanda Ayres de Morais e Silva Cardoso, Carlos Gustavo Wambier, and Adilson Da Costa

14.1 Materials •

•

•

•

carbolic acid 88% (from compounding pharmacies). Degreasing agent: standardized acetone-­ • Post-peeling preparation: Vaseline. ethanol (3:1 mixture) or any nail polish • Multiparameter monitor: electrocardiogram, removal solution containing acetone and no pulse oximeter, blood pressure, along with castor oil in the composition (castor oil is necessary advanced cardiologic life support derived from another Euphorbiaceae, Ricinus drugs, intravenous access, defibrillator communis, which also contains phorbols) [1]. (Fig. 14.3). The new multiparameter monitors Applicators: wooden, cotton-tipped applicaalso include heart rate-corrected Q-T interval tors (swabs or split tongue depressors) or (QTc), which is probably the most interesting 4 × 4 gauzes (Fig. 14.1). Peeling agent: freshly made mixture of stock solution (below), carbolic acid 88% (phenol 88% in water), 5.5 mL of water for injection, and 0.5  mL of Septisol, the standard soap, contains triclosan in aqueous base (Fig. 14.2). Stock solution, containing 1  mL of Croton ­tiglium oil (Delasco), mixed with 24  mL of

F. A. de Morais e Silva Cardoso (*) Department of Medicine, Facid Wyden, Teresina, PI, Brazil C. G. Wambier Department of Medicine, State University of Ponta Grossa, Ponta Grossa, PR, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_14

Fig. 14.1 Materials. Multiple cotton-tipped wooden applicators, freshly made peel solution, plastic cotton-­ tipped swabs for drying tears, and 4 × 4 gauze for drying excessive solution

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Fig. 14.3  Defibrillator, which may also include a multiparameter monitor. Another option is to have both simple defibrillator and a multiparameter monitor

Fig. 14.2 Freshly made peel solution, containing 1.6% croton oil and 35% phenol. When let still for some minutes, it presents two phases: upper phase with less phenol and lower phase with more phenol. It must be mixed before every single application for consistent results. Upper phase is too weak for achieving effects

for phenol peels, because of recent evidence of severe yet reversible within 15  min QTc prolongation during peels [2]. • Activated carbon masks: the staff and surgeon must avoid repeated inhalation of volatile organic compounds during the peels [3].

Fig. 14.4  Disposable N95 mask with activated carbon filter for volatile organic compounds

Therefore, the appropriate personal protection equipment are masks with chemical filters (Fig. 14.4).

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14.2 Methods and Techniques • Degreasing: the importance of removal of all make-up, sebum, beard, topical anesthetic, and sunscreen before any chemical peel is unquestionable. The physician scrubs the patient’s face with semi-soaked gauze pads. • Peeling solution preparation: mix phenol with croton oil first, since croton oil is completely soluble in liquid phenol. By keeping a s­ tandard of 10  mL of the final volume, to reach 35% phenol, 4 mL of this solution will be a mixture of phenol 88% and croton oil, and the remaining 6 mL will be fixed as 5.5 mL of water and 0.5 mL of Septisol. • Strength by croton oil concentration: the amount of croton oil drawn from the stock solution, which contains 4% croton oil in phenol (described in Materials), determines the inflammation and rejuvenation effects caused by its phorbol esters. This is set by the amount of stock solution in 4 mL of phenol 88%/croton oil mixture (peeling solution preparation, above). Thus, by adding only 4  mL of the stock solution, the final concentration of croton oil will be 1.6%, a very strong formula, adequate for perioral area, nose, and deep wrinkles. By adding 3 mL of stock solution to 1 mL of 88% carbolic acid, the croton oil concentration will be 1.2%, a strong formula, adequate for forehead and moderate wrinkles. By adding 2 mL of stock solution to 2 mL of 88% carbolic acid, the croton oil concentration will be 0.8%, a medium-strength formula, adequate for overall use and adequate for mild wrinkles. By adding 1 mL of stock solution to 3 mL of 88% carbolic acid, the croton oil concentration will be 0.4%, a light formula, adequate for eyelids and neck. • Application: the saturation of the applicator, pressure, and number of strokes are the main

Fig. 14.5  Application of full-face phenol-croton oil perioral peel with a cooler for patient comfort and blankets to minimize chances of hypothermia. The frosting is the endpoint for deep peels, with an even white color

variables for increasing damage by the peeling solution. The applicator is constantly rubbed with gentle yet firm pressure, while the other hand secures the skin from movement and holds a gauze pad for drying drips (Fig. 14.5). • Post-peeling regimen: a thick layer of Vaseline is applied to the peeled areas as soon as the desired chemoabrasion endpoints were achieved. The patient and family member are instructed to keep a regimen to improve healing, by total avoidance of irritants, fragrances, allergens, and sun exposure and taking diet rich in proteins and vitamins. Sunscreen must be avoided during the first 7 days of deep peels to avoid allergen sensitization.

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14.3 Clinical Follow-Up • There is intense edema for 72 h. Vesicles, blisters, and oozing may occur in the first 48  h. Purulent exudate may occur after 48–72  h. Crusts usually fall off by the 8th day. Careful debriding and crust removal are advised if there is liquid collection or localized pain. The patient may be started on systemic and topical combination antibiotic therapy if any sign of infection is observed, such as odor, pus, increase in erythema, edema, or pain. • Days 0–2: Vaseline, cold saline compresses, and thermal water sprays. Keep opioids as needed (codeine 30–60 mg q6h, tramadol 100 mg q8h, or oxycodone 10 mg q8h) (Fig. 14.6).

Fig. 14.6  Deep chemical peel. Phenol 35% with croton oil 1.6% full face and 0.4% over the neck. Intense edema on the first post-operative day

F. A. de Morais e Silva Cardoso et al.

• Days 1–3: Optional use of systemic steroids if edema is too severe. • Days 2–4: Allow facial washes with baby shampoo or non-irritant cleaning lotions (Cetaphil or similar), and change saline compresses for either boric acid 3% solutions or dilute vinegar (1 desert spoon of vinegar in 250 mL of cold, filtered water). • Days 3–8: Careful evaluation for the need of antibiotic therapy, with topical silver sulfadiazine 1% and systemic Cefaclor 750  mg bid, with temperature and pulse monitoring by the patient at home if needed (Figs. 14.6 and 14.7).

Fig. 14.7  Deep chemical peel. Phenol 35% with croton oil 1.6% full face and 0.4% over the neck. Mild edema with purulent exudate on the third post-operative day. Compresses were changed to 3% boric acid solutions, and the patient was advised to apply silver sulfadiazine 1% over the green exudative areas

14  Phenol-Croton Oil Peels

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14.4 Before and After (Figs. 14.8 and 14.9) Fig. 14.8  Close-up of unrivaled results of a single phenol-croton oil peel application to face (1.6% croton oil in 35% phenol). The rejuvenation process is so intense that even intradermal nevi become compound nevi

Fig. 14.9  Skin elastosis caused by sun damage and smoking is reversed by using the right technique. After 6 months of the application (right), the patient presented

natural skin color, which is the main difference of Hetter’s peels and Baker’s peels

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14.5 S  ide Effects, Complications, and Their Management •

•

•

•

F. A. de Morais e Silva Cardoso et al.

by anticholinergic effects and should be used even in patients with excellent pain tolerance. No applicator or chemical bottle shall pass Bronchoconstriction and lung edema: the directly above the patient’s face. Always patient is exposed to high levels of fumes of check the conjunctiva during the post-operaphenol, which may cause bronchial edema tive period for any signs of erythema or cheand asthma attacks. The office must be mosis. If it is caused by lagophthalmos, equipped with emergency crash medications exudate, or ointments, the management is (corticosteroids, epinephrine, beta-adrenergic done with moisturizing gels, lubricating eyeinhalants, such as albuterol). drops, and hygiene. Post-inflammatory hyperpigmentation: the • Prolonged erythema: erythema starts during most common side effect of chemical peels in the first week and is greater in the second general. Predisposing factors include week post-operative. The erythema must be melasma, phototype, and sun exposure. Skin regarded as normal healing process of deep preparation for 1  month with hydroquinone injury and is actually a superficial sign of colmay be used. Treatment is performed with lagen production which is undergoing in the low-fluency Q-switched Nd-YAG 1064  nm deep dermis. The patient must be warned of and cosmeceuticals (vitamin C, ferulic acid). its benign nature even before the peel and also Kligman’s formula is used only after erythemhope that it lasts for months. If erythema subatous phase, usually 4  months; superpotent sides before the first month, which is comsteroids such as clobetasol may also be used in mon in 0.4–0.8% croton oil formulas, there is severe cases. usually less neocollagenesis than the cases Hypopigmentation: usually “pseudo-­ where erythema was prolonged. Topical retihypopigmentation,” which means skin color is noids and irritants must be avoided, because actually normal but younger than the photoinflammation can cause burning sensation aged surrounding skin. Therefore, the key to and prolong erythema for longer than success with Hetter’s formulas is to always 4 months. perform long feathering zones to untreated • Ectropion and scars: when performed with areas (about 4–10 cm). Sub-epidermal fibrosis adequate technique by avoiding excessive rubfrom manipulation or excessive rubbing in bing and pressure in areas prone to hypertrodeep wrinkles may cause true focal hypomelaphic formation, such as the zygomatic arch, nosis, which is best addressed by using pre-auricular area, medial upper eyelids, and 5-­fluoruracil tattooing technique, in the same lateral lower eyelids. Some patients with way as idiopathic guttate hypomelanosis elselower eyelid wrinkles may also have laxity, where [4]. which is accessed by the snap-back test. If the Eye irritation: intraoperative exposure to voltest is negative, avoid superficial treatments, atile chemicals and accidental splash or tearwhich will induce cicatricial ectropion. Also, ing. To maximize eye safety, eyes should patients who have previously undergone plasremain shut throughout the whole peeling tic surgery and deep peels in the lower eyelids session, eyelids must remain dry with cottonmay be accessed by opening their mouth to tipped plastic swabs during the procedure, check for lower eyelid retraction. These and avoidance of general anesthesia or sedapatients, with lateral lower eyelid inferior tion, which abolish natural tearing reflex, and retraction, will present increased retraction patient’s conscience to keep the eyes closed. and ectropion or lagophthalmos after a deep A standard eye-opening procedure is done peel in this area. Evaluation by an oculoplastic with the patient in seated position, with Q-tips surgeon is mandatory in these cases. in the corners of the eyes to dry the tears • Milia: after full epidermal healing, the milia which fall. The use of opioids reduces tearing which are a common consequence of

14  Phenol-Croton Oil Peels

r­esurfacing in oily and thick skin may be removed after needle pricks. • Cardiac arrhythmias: safety pauses of 10 min between each cosmetic unit of the face (forehead, perioral, nose, periocular, each cheek) usually prevent cardiac conduction events. The authors also recommend checking all medications that the patient takes for QT-­ prolongation potential. This can be done by CredibleMeds website http://www.crediblemeds.com or smartphone apps. Withdraw all possible medications and check for QTc prolongation in the preoperative period. The presence of frequent extra-systolic beats is a signal that phenol is affecting repolarization. Give longer pauses, ventilate the room better, increase intravenous (IV) drip, and reduce area of exposure before each 10-min pause. • Infection: any systemic sign of infection or increased edema past the first 48  h must be treated promptly by coverage of Staphylococcus aureus and Pseudomonas aeruginosa; usually, antibiotic prophylaxis is not ­indicated, unless the patient has prosthesis or other conditions.

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Tip Box

• Hands-on training is mandatory for acquiring the correct technique. • Patient selection and adequate cardiology assessment before peel are the keys to a safe procedure. • Learning curve is long. Constant practice takes the dedicated physician to perfection.

References 1. Piamphongsant T. Phenol-castor oil: modified peel for dermal melasma. Dermatol Surg. 2006;32(5):611–7; discussion 617. 2. Wambier CG, Brody HJ, Hetter GP.  Comments: Hemiface comparative study of two phenol peels (bakerGordon and Hetter formulas) for the correction of facial rhytids. Surg Cosmet Dermatol. 2017;9(2):190–1. 3. Wambier CG, Beltrame FL.  Air safety and personal protective equipment for phenol-croton oil peels. Dermatol Surg. 2017;44(7):1035–7. 4. Wambier CG, Wambier SP de F, Pilatti LEP, Grabicoski JA, Wambier LF, Schmidt A.  QTc prolongation during phenol-croton oil peels. J Am Acad Dermatol. 2018;78(4):810–2.

Pyruvic Acid Peel for Face and Extra-Facial Areas

15

Bogdana Victoria Kadunc, Renan Lage, and Renata Cristina Vasconcellos

15.1 Materials

15.2 Methods and Techniques

• Acetone in a soft cotton pad or gauze for cleaning and degreasing the skin and improving its penetration. • Fifty to eighty percent pyruvic acid in hydroalcoholic solution, most recommended for being more effective, should be kept airtight in the refrigerator (2–8 °C) because it is very unstable. In addition, although the vapors are non-­toxic, they can irritate the eyes and airways, so a fan can be used during the procedure. • Soft cotton, soft brush, or a folded 4 × 4 gauze sponge, in crescent order of penetration. • 8.4% sodium bicarbonate in water solution for neutralization (Fig. 15.1).

• It is described in the literature that the penetration is usually uniform even on unprepared skin, but it is advisable to use at least 2 weeks before, once a day, topical tretinoin (0.025%) and topical bleaching agents (4% hydroquinone, 20% azelaic acid) to decrease the risk of post-inflammatory hyperpigmentation and promote wound healing [1, 2]. • The skin should be cleansed to ensure uniform penetration by removing the excess sebum of the skin with acetone in a soft cotton (Fig. 15.2). • PA is applied with a gauze, and the area was gently scrubbed for approximately 1 min and left in the skin for 10  min or until erythema appeared (Fig. 15.3) [1–6]. It must be applied in a faster manner in each cosmetic unit and neutralized with 8.4% sodium bicarbonate solution, if localized frosting areas are observed (Fig. 15.4). • After 10 min or when the erythema appears, the entire face is washed in a sink with copious amounts of water [1, 2, 5–8]. • Immediately after the procedure, a facial cream emollient can be applied.

B. V. Kadunc · R. C. Vasconcellos (*) Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil R. Lage Cosmiatric Department, Department of Dermatology of the Pontifical Catholic University of Campinas PUC Campinas, Campinas, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_15

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B. V. Kadunc et al.

108

a

b

d

e

c

f

Fig. 15.1  The materials to be used. (a) Acetone. (b) Gauze. (c) Fifty to eighty-percent pyruvic acid in hydroalcoholic solution. (d) Cotton swabs. (e) 8.4% sodium bicarbonate solution. (f) Water

Fig. 15.2  The skin should be cleansed with acetone

Fig. 15.3  The pyruvic acid should be applied with a gauze

15  Pyruvic Acid Peel for Face and Extra-Facial Areas

Fig. 15.4  The frosting areas must be neutralized with 8.4% sodium bicarbonate solution

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Fig. 15.5  The erythema persists for about 4–6 h after the procedure

15.3 Clinical Follow-Up • The erythema persists for about 4–6  h after the procedure. During this period, some patients may feel tingling or burning sensations, especially in periorificial areas (Fig. 15.5). • The skin does not get dry and scaly, unless it is combined with a second peel such as retinoic acid or trichloroacetic acid (TCA). • A mild desquamation lasting 7–10 days can be observed [5]. • During the first 3 days after peel care, facial shower or bathing should be restricted for up to two times a day with a mild cleanser lotion (Fig. 15.6). • The patients should be instructed to apply moisturizing cream twice a day for a week, avoid sun exposure, and use sunscreens daily. • Another peeling session can be performed once every 2 weeks.

Fig. 15.6  One day after de procedure. The skin usually does not get dry and scaly

• Because collagen remodeling takes 60–90 days, the final evaluation of the patient should be done after 90 days (Figs. 15.7 and 15.8) [1, 3–5, 8].

B. V. Kadunc et al.

110

15.4 Before and After (Figs. 15.7 and 15.8) a

b

Fig. 15.7 (a) Before the procedure. (b) Two months after two sessions with 60% pyruvic acid

a

b

Fig. 15.8 (a) Before the procedure. (b) Two months after one session with 80% pyruvic acid

15.5 S  ide Effects, Complications, and Their Management The effect of PA depends on the concentration used and the duration of the application before the neutralization. In general, the response occurs faster in women and in younger skin. If any frosting is observed, immediate neutralization with 8.4% sodium bicarbonate solution must be

done (Fig. 15.9), and extreme care should be taken to the hot area, with the use of healing creams and tinted, high sun protection factor sunscreens. Other side effects are: • Persistent erythema (Fig.  15.10) that can be treated with super-potent steroid gels such as clobetasol 0.05% with only few descriptions in the literature [9]. • Scarring. A very low risk is presented.

15  Pyruvic Acid Peel for Face and Extra-Facial Areas

a

111

• Post-inflammatory hyperpigmentation. It may be treated with Kligman formulas, sunscreen, oral tranexamic acid, and Q-switched 1064-­ nm laser [2, 6, 7, 9, 10]. Tip Box

b

• PA is a good alternative for the treatment of acne, oily skin, folliculitis, mild photodamage with superficial wrinkles (Glogau I–II), and superficial scarring. • Anti-inflammatory and antibiotic effects are its greater advantage. • The risk of post-inflammatory hyperpigmentation can be minimized by preparation of the skin.

References

Fig. 15.9 (a) Frosting by unforeseen deepening. (b) Neutralization with 8.4–10% sodium bicarbonate solution

Fig. 15.10  Persistent erythema

1. Ghersetich I, Brazzini B, Peris K, Cotellessa C, Manunta T, Lotti T. Pyruvic acid peels for the treatment of photo- aging. Dermatol Surg. 2004;30(1):32–6. 2. Berardesca E, Cameli N, Primavera G, Carrera M. Clinical and instrumental evaluation of skin improvement after treatment with a new 50% pyruvic acid peel. Dermatol Surg. 2006;32(4):526–31. 3. Wambier CG.  Pyruvic acid peel. In: Chemical and physical procedures. Cham: Springer; 2017. p. 1–10. 4. Bruce A, Roberts W, Teller C, Colvan L. The effects of a daily skincare regime non maintaining the benefits obtained from previous chemical resurfacing treatments. J Drugs Dermatol. 2016;15(9):1145–50. 5. Cotellessa C, Manunta T, Ghersetich I, Brazzini B, Peris K. The use of pyruvic acid in the treatment of acne. J Eur Acad Dermatol Venereol. 2004;18(3):275–8. 6. Marczyk B, Mucha P, Budzisz E, Rotsztejn H. Comparative study of the effect of 50% pyruvic and 30% salicylic peels on the skin lipid film in patients with acne vulgaris. J Cosmet Dermatol. 2014;13(1):15–21. 7. Yu RJ, Scott EJV. Alpha-hydroxyacids and carboxylic acids. J Cosmet Dermatol. 2004;3:76–87. 8. Kadunc BV. Pyruvic acid: standardization technique for the use in chemical peelings by means of experimental study. University of Sao Paulo; 1998. 9. Kontochristopoulus G, Platsidaki E.  Chemical peels in active acne and acne scars. Clin Dermatol. 2017;35:179–82. 10. Jaffary F, Faghihi G, Saraeian S, Hosseini SM. Comparison the effectiveness of pyruvic acid 50% and salicylic acid 30% in the treatment of acne. J Res Med Sci Off J Isfahan Univ Med Sci. 2016;21:31.

Resorcin Peel for Face

16

Andrezza Facci

16.1 Materials • • • • •

Hoffmann solution Resorcinol peel 22.5% Gauze Soap Physical sunscreen

16.2 Methods and Techniques The skin is scrubbed and cleansed with Hoffman Solution in order to remove the remaining surface oils, which permits a better absorption. A resorcinol peel solution of 22.5%

was applied with a gauze rubbing gently the skin. Mild tingling and burning sensation were noticed by the patients in the first minutes and then followed by paresthesia that lasts about 30 min (Fig. 16.1). In this superficial chemical peel, mild erythema and very light scaling are the usual clinical picture (Table 16.1).

16.3 Clinical Follow-Up Resorcinol peel doesn’t present any special adverse condition, with no downtime, despite absence of symptoms and scaling.

A. Facci (*) Clínica Andrezza Facci de Dermatologia, Barueri, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_16

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114

Fig. 16.1  Method to apply resorcinol peel on the skin Table 16.1  Steps of the peeling procedure Degreasing – cleansing Application of peeling agent Rinse off After all apply, Physical sunscreen

16.4 B  efore and After (Figs. 16.2 and 16.3)

Fig. 16.2  Acne patient before and after 15 days of last session of resorcinol peel for face

A. Facci

16  Resorcin Peel for Face

115

Fig. 16.3  Patient with post-inflammatory acne lesions before and after 15 days of last session of resorcinol peel for face

16.5 S  ide Effects, Complications, and Their Management Overpeeling and systemic toxicity are very rare. Complications are generally mild and do not occur often [1]. But the references listed are transitory hyperpigmentation, dizziness, sweating, pallor, and methemoglobin if in higher concentrations. I found none of them [2, 3].

Tip Box

• Benefit • Easy to perform • M  ild or no scaling • Well-­ tolerated

Clinical onset Must be repeated or combined to achieve any satisfactory result Comfortable due to absence of desquamation and burning post-peeling No skin-type restriction

References 1. Lynch BS, Delzell ES, Bechtel DH.  Toxicology review and risk assessment of resorcinol: thyroid effects. Regul Toxicol Pharmacol. 2002;36:198–210. 2. Kede MPV, Sabatovich O. Dermatologia Estética. 3rd ed: Ed Atheneu. Rio de Janeiro; 2015. p. 589–621. 3. Palermo E, et al. Tratado de CIrurgia Dermatológica, cosmiatria e laser: Elsevier. Rio de Janeiro; 2012. p. 311–32.

17

Resorcin Peel for Extra-Facial Areas Erica Monteiro

17.1 Materials [1–5]

17.2 Methods and Techniques

17.1.1 Reagents

17.2.1 Patient Selection

• Correctly labeled peeling agents in various concentrations: resorcinol solution (ethanol) 10%, 20%, or 50%. • Alcohol and/or acetone to clean and degrease the skin. • Neutralizing solutions: not required.

The success of a chemical peel depends on a careful selection of patients and individualization of the treatment. Patients with extra-facial (hands, trunk) dyschromia and photoaging. It can be useful to complement laser, IPL, and other treatment technologies (Fig. 17.2).

17.1.2 Equipment (Fig. 17.1) • Glass cup or beaker in which the required agent is poured. • Gloves. • Cotton-tipped applicators or swab sticks. • 2″ × 2″ cotton-gauze pieces.

2

1

4

3

7

6 5

Fig. 17.1  (1) Resorcinol 20% (ethanol solution). (2). Alcohol to clean and degrease the skin. (3). Glass cup or beaker in which the required agent is poured. (4). Cotton-­ gauze pieces. (5). Cotton-tipped applicators or swab sticks. (6). Gloves. (7). Sunscreen after the procedure E. Monteiro (*) Department of Humanities and Medical Sciences, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_17

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E. Monteiro

118

17.2.2 Technique Using Resorcinol 20% (Ethanol Solution) • At first, the patient’s skin is cleaned (by cotton impregnated with 70% ethanol and/or acetone). • Laser or IPL is performed. • In the next step, the solution of resorcinol 20% is applied on the hands with a cotton applicator. • Neutralization is not necessary. • Finally, sunscreen is applied. • The treatment can be repeated after 4–8 weeks, if necessary.

17.3 Clinical Follow-Up 17.3.1 Pre-peeling Preparation (Table 17.1) • For optimal results, preparation of the skin in the weeks before the procedure is very important.

a

• Topical retinoic acid preparations used daily for 3–6 weeks prior to the procedure may create better and more even penetration of the peeling solution in sebaceous and hyperkeratotic skins. • Standard photography and informed consent should always be obtained before the procedure for all types of peelings. • Generally, it is not necessary to discontinue use of any of the patient’s medications including anticoagulants, aspirin, or nonsteroidal anti-inflammatory or antihypertension drugs. • According to our experience with superficial peeling, smoking does not have any adverse effect on post-peel healing or on the extent of the results.

17.4 Before and After (Fig. 17.2)

b

Fig. 17.2 (a) Before and (b) after resorcin 20% peel. (Courtesy: Andrezza Facci, MD; Barueri, SP, Brazil)

119

17  Resorcin Peel for Extra-Facial Areas

17.5 S  ide Effects, Complications, and Their Management 17.5.1 Post-peeling Recommendations (Table 17.1) [1–6] • The goal of a chemical peel is to cause the outer layer of the skin to peel and flake, revealing the fresh, smooth layer underneath. • Patients will experience some level of dryness and flaking for 2–5 days after treatment. • During this time of dryness and flaking, their skin is more sensitive (more redness and stinging), and they cannot use vitamin C, retinol, avobenzone, glycolic acid, and lactic acid. • In this 2–5-day period, using a soothing gel or mask helps calm and soothe the skin. Other great options to use in this post-procedure

•

•

•

•

time period are heparan sulfate and hyaluronic acid. Patients should be advised to stay out of the sun and to avoid picking at dry, flaking skin. Resorcinol is an ultraviolet light absorber and can cause allergic contact dermatitis reactions. Avoiding the sun is mandatory [6]. Exfoliating scrubs and other facial brushes and other forms of friction, including microdermabrasion, should be avoided during the healing process. Avoid any products with hydroxy acids, retinol, and 5-fluoruracil (5-FU) until the skin barrier has been restored. Use calming skincare products with antiinflammatory ingredients such as green tea, argan oil, and chamomile to help alleviate any stinging or redness, while the skin recovers.

Table 17.1  Pre- and post-resorcinol 20% peel, after IPL/laser, recommendations [1–6]*

Considerations Priming

Infections Photoaging Post-inflammatory hyperpigmentation Photoprotection Moisturization Fast healing

Pre (at least 2–4 weeks prior Post to the procedure) (immediate) Benefits/recommendations Reduces wound healing time, facilitates + uniform penetration, detects intolerance to any agent, enforces patient compliance, and reduces the risk of complications Control any active infection or + + dermatoses Topical retinoids, alpha-hydroxy acids + − Topical retinoids, hydroquinone, + − alpha-hydroxy acids, vitamin C Broad-spectrum sunscreens and clothes + + + + Tretinoin 0.025% + −

Maintenance (agents Tretinoin 0.025%, glycolic acid 6–12% which are likely to be used in post-procedure maintenance)

Post (long after complete reepithelization)

+ + + + + + (after reepithelization) + (after reepithelization)

* Tretinoin is known to reduce healing time after resurfacing. The choice of the priming agent depends on the individual physician's preference and individualized patient requirements

E. Monteiro

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Tip Box

• With the advent of lasers and newer techniques, the use of some chemical peels has declined, as resorcinol peel for extra-facial treatment. • Nowadays, the use of resorcinol peel alone to rejuvenate the hands or other extra-facial areas is not common. But it can be useful to complement laser, IPL, and other treatment technologies. • Resorcinol is an ultraviolet light absorber and can cause allergic contact dermatitis reactions. Avoiding the sun is mandatory. • Retinoids should be used 2–3  weeks prior to procedures to speed up healing. • Retinoids should not be used after the procedure until reepithelization has occurred. • Standard photography and informed consent should always be obtained before the cosmetic procedures.

References 1. Khunger N, IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S5–12. 2. Faghihi G, et al. Solution of azelaic acid (20%), resorcinol (10%) and phytic acid (6%) versus glycolic acid (50%) peeling agent in the treatment of female patients with facial melasma. Adv Biomed Res. 2017;6:9. 3. Karam PG. 50% resorcinol peel. Int J Dermatol. 1993;32(8):569–74. 4. Monteiro EO.  Acne e fotoproteção. RBM Rev Bras Med. 2009;66(6, n. esp):6–9. 5. Monteiro EO.  Filtros solares e fotoproteção. RBM Especial Dermatologia e Cosmiatria. 2010;67:5–18. 6. Ongenae K, Matthieu L, Constandt L, Van Hecke E.  Contact allergy to resorcinol monobenzoate. Dermatology. 1998;196(4):470–3.

Salicylic Acid for Face (Facial Salicylic Acid Peel)

18

Mercedes Florez White

18.1 Materials A variety of formulations of salicylic acid have been used for skin care products, for chemical peeling, and for keratolytic agents.

Table 18.1  Concentrations of SA used in dermatology and cosmetics (Modified from Arif T) SA concentration 0.5–10% 3–6%

• SA has been used in concentrations from 0.5% to 50% (Table 18.1) [1]. • The most common concentrations for chemical peels are 20% and 30% in hydroalcoholic solution, as well as newer formulations with different vehicles, including one with SA 30% in a gel of polyethylene glycol, which has shown to be safer (less a­ bsorption) [1–3].

18.2 Methods and Techniques The procedure includes three stages or phases: The preparation before the peel, the actual procedure or peeling technique, and the post-peeling care and management of complications.

M. F. White (*) Department of Dermatology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_18

5–40% 50% 20–30%

Uses Topical treatment of acne (skin care products: cleansers, lotions, solutions) Topical treatment of hyperkeratotic disorders (psoriasis, ichthyoses, keratosis pilaris) Warts – corns Actinic damage Superficial chemical peeling of the face

SA salicylic acid

18.2.1 Indications and Contraindications • SA peels are useful in a variety of skin conditions. The list of these conditions is shown in Table 18.2, being acne as the main and most studied indication. • One of the advantages of the SA peel is that it is safe to be used in any skin photo-type, since Fitzpatrick photo-type I to VI. • SA peel is safe and effective in patients with skin photo-types V and VI. • They can also be combined with other procedures, such as microdermabrasion or as a part of a rejuvenating program, alternating with lasers, lights, and other technologies. • Could be used in combination with oral isotretinoin treatment showing significantly better 121

M. F. White

122 Table 18.2  Main indications of salicylic acid peels Acne Melasma Rosacea Excessive oiliness of the skin Solar lentigo Photodamage (mild to moderate) Fine lines To improve skin texture of the face

clearance of acne than monotherapy with isotretinoin and with no abnormal scarring. • SA peel is contraindicated in patients with contact dermatitis or allergy to salicylates, active infection, including viral at the site of the peeling, active dermatitis on the face, intense erythema and dryness due to retinoids or AHA, and pregnancy. A very good clinical history including all previous reactions to medications and procedures is mandatory to avoid complications.

18.2.2 Preparation Before Peeling • Proper patient selection is crucial before considering a chemical peel. • Detailed history and cutaneous examination are performed in all patients prior to chemical peeling. • Standardized photographs of the areas to be peeled should be taken, including full-face frontal and lateral views. If the condition treated requires it (e.g., melasma), UV photographs could help in the assessment of the evolution and results of the treatment. • Pretreatment with tretinoin, retinol, AHA, or poly-hydroxy acids at least 2 weeks before the procedure should be discontinued 2  days before the peel. • For patients with hyperpigmented disorders and those prone to have post-inflammatory hyperpigmentation, pretreat with 4% hydroquinone or triple combination (hydroquinone 4%, fluocinolone acetonide 0.01% and tretinoin 0.05%) for at least 2 weeks before the procedure, and stop the medication at least 2 days before the peel. • Use broad-spectrum inorganic sunscreens (UVA-UVB) with an SPF 30 or more, are

mandatory and should be applied frequently before and after the procedure. • The simultaneous use of antioxidants (e.g., vitamin C or combinations of vitamin C plus E) with sunscreens may help in preventing post-inflammatory hyperpigmentation.

18.2.3 Peeling Techniques Before starting the procedure, the physician should be having ready the following (Fig. 18.1): • The peeling compound – 20% or 30% SA peel in alcoholic solution or gel • A gentle cleanser for sensitive skin or a lipo-­ hydroxy acid (LHA) or SA cleanser for oily skin • Isopropyl alcohol to degrease the skin or acetone if the skin is very oily • Gloves • 4 × 4 non-woven gauzes to clean the skin • “Harsh” standard 4  ×  4 gauze to apply the peeling substance • 1 inch paint sponge • A surgical cap and a headband to cover the patient’s head • Petrolatum to protect sensitive areas of the face such as the lips and folds • Soothing mask (optional) • Bland moisturizer (optional) • Sunscreen • Portable handheld fan (battery operated or electrical)

Fig. 18.1  Material for salicylic acid peel procedure

18  Salicylic Acid for Face (Facial Salicylic Acid Peel)

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18.2.4 Directions • Before starting the procedure, the patient must sign an informed consent with the explanation of the procedure and post-­ procedure care, including possible complications. • Take pictures of the area that will be peeled, if not taken during a previous visit. • Patient should cover the head with a surgical cap and should also use a headband to pull back the hair from the face. • Clean very well facial skin using the cleanser according to the skin type: A gentle cleanser for a sensitive to dry skin and a cleanser with SA or LHA for oily skin. • The face is then degreased using a non-­woven gauze piece socked with alcohol or acetone. Some SA peel kits bring a pre-peel cleanser that may be used at this time instead of alcohol or acetone. • Apply a thin layer of petrolatum on sensitive areas of the face such as the lips, the nasal-­ alar cheek junction, and the preauricular fold. • Apply the salicylic acid solution or gel with a wedge sponge or a “harsh” gauze. (The author starts with 20% concentration to assess the skin reaction of the patient.) The application should be uniform on the entire face and upper neck, starting from the forehead and progressing to the zygomatic cheeks, chin, upper lip, nose, and lower eyelids. The whole application should be completed within 30 s. At this point the subject experiences a stinging and burning sensation, which increases over the next 2  minutes, reaches a crescendo at 3 minutes, and then rapidly decreases to baseline over 5  minutes after the application; this is considered the end point of the peel. The burning sensation and stinging can be reduced using a portable handheld fan. As the hydroethanolic vehicle evaporates, it leaves behind a white precipitate of salicylic acid on the surface of the face, due to the crystallization of the SA which is termed as salicylic acid frost (Fig.  18.3). This should not be con-

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fused with frosting or whitening of the skin, which represents protein agglutination. There is very little penetration of the active agent once the vehicle has volatilized. At this point, there is no burning or stinging as the agent causes a superficial anesthesia to light touch. In patients with acne, this is the time to perform the comedo extraction to take advantage of the temporary superficial anesthesia. Since SA peel is self-neutralized, patient’s face is now rinsed thoroughly with water and a bland cleanser to remove any residual of SA precipitate. Use a soothing mask – optional. (The author uses a refreshing cellulose mask for 15 minutes after the final cleansing.) Apply UVA-UVB inorganic (physical) sunscreen. Patient should be instructed to use daily sunscreen and a wide brim hat all the time, especially when the skin exfoliation starts. Give the patient a written post-procedure instructions that should be signed by the patient and a copy should be included in the patient’s chart.

18.3 Clinical Follow-Up • Use gentle cleansers and bland moisturizers for the first 48 hours. • Peeling usually begins 2  days post-peel. At this time patients can resume their topical skin care formulations, which may include topical hypopigmenting agents, topical antiacne medications, and/or retinoids, AHA or PHA. • Permanent use of an inorganic, broad-­ spectrum sunscreen is mandatory. • Antioxidants. There is enough evidence that the concomitant use of antioxidants, such as vitamin C, may minimize the effects of ultraviolet and visible light, as well as the formation of free radicals by the infrared A rays. Its use can help reducing the inflammation and, therefore, the post-inflammatory hyperpigmentation.

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• Excessive desquamation and irritation in the post-peel period can be treated with low- to high-potency topical steroids. Topical steroids are very effective in resolving post-peel inflammation and mitigating the complication of post-inflammatory hyperpigmentation. • Any residual post-inflammatory hyperpigmentation resolves with the use of topical

Fig. 18.2  Patient with acne under treatment with oral isotretinoin and three treatments with 30% salicylic acid peel in hydroalcoholic solution

Fig. 18.3  Salicylic acid precipitate (salicylic acid frost)

hydroquinone formulations following salicylic acid peeling.

18.4 Before and After Results of salicylic acid peels in acne and melasma are shown in Figs. 18.2 and 18.3, respectively.

18  Salicylic Acid for Face (Facial Salicylic Acid Peel)

18.5 S  ide Effects, Complications, and Their Management Hypergpigmentation: Which can be easily treated with daily photoprotection and combination of retinoids and hydroquinone. Prolonged erythema, exfoliation, and dry skin: Use of photoprotection and local moisturizing; in severe cases, the use of topical corticoids can be well indicated. Salicylism: Although it is a rare side effect when this peel is applied onto small skin area, as the face, if symptoms are absorbed (such as nausea, vomit, dizziness, psychosis, and stupor), to administrate 1 liter of water after finishing the peel can be a good alternative. In intense clinical manifestations, the referral to an urgent care unit is mandatory.

Tip Box Indications

• Salicylic acid 20–30% is the peeling agent of choice in acne.

Fig. 18.4 Melasma. Treatment with hydroquinone 4% and three sessions of 30% salicylic acid peel in gel

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• It is safe and effective in all types of active acne due to its comedolytic and anti-inflammatory properties. Preparation

• Pretreatment, at least 2 weeks before the procedure, is important to enhance the penetration of the SA and to prevent future complications. • Acne and photoaging are pretreated, with tretinoin, retinol, AHA, or poly-­ hydroxy acids and should be discontinued 2 days before the peel. • Hyperpigmented conditions (melasma, post-inflammatory hyperpigmentation) are pretreated with hydroquinone 4% or triple combination (hydroquinone 4%, fluocinolone acetonide 0.01%, and tretinoin 0.05%) and discontinued 2 days before the procedure (Fig. 18.4).

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Post-peeling Care

• Patients must avoid sun exposure after the procedure. • Daily use of a broadband (UVA-UVB) inorganic, mineral sunscreen with SPF 30 or more and other measures like using a wide brim hat are key to prevent post-inflammatory hyperpigmentation.

References 1. Arif T.  Salicylic acid as peeling agent: a comprehensive review. Clin Cosmet Investig Dermatol. 2015;8:455–61. 2. Dainichi T, Ueda S, Isoda M, et al. Chemical peeling with salicylic acid in polyethylene glycol vehicle sup-

M. F. White presses skin tumor development in hairless mice. Br J Dermatol. 2003;148:906–12. 3. Davies M, Marks R. Studies of the effect of salicylic acid in normal skin. Br J Dermatol. 1976;95:187–92. 4. Grimes PE.  Salicylic acid. In: Tosti A, Grimes PE, Padova MP, editors. Color atlas of chemical peels. 2nd ed. New York: Springer-Verlag; 2006. 5. Imayama S, Ueda S, Isoda M. Histologic changes in the skin of hairless mice following peeling with salicylic acid. Arch Dermatol. 2000;136:1390–5. 6. Kontochristopoulos G, Platsidaki E.  Chemical peels in active acne and acne scars. Clin Dermatol. 2017;35:179–82. 7. Lazo ND, Meine JG, Downing DT.  Lipids are covalently attached to rigid corneocyte protein envelope existing predominantly as beta-sheets: a solid state nuclear magnetic resonance study. J Invest Dermatol. 1995;105:296–300. 8. Lee HS, Kim IH. Salicylic acid peels for the treatment of acne vulgaris in Asian patients. Dermatol Surg. 2003;29:1196–9.

Salicylic Acid Peeling for Extra-­Facial Areas

19

Vanesa Piquero, Daniela Moya, and Edgar E. La Rotta

19.1 Materials • Cleaning solution, alcohol, and acetone for degreasing. • Cleansing clay mask and ozone vaporizer (optional use) [1]. • Salicylic acid concentrations ranging from 10% to 50% in solutions of ethanol, polyethylene glycol, ointment, paste, or ethyl alcohol. Amber bottle, closed. Shake before using. • 30% salicylic acid is used for chest and back acne, keratosis, and pigmented photodamage. • 40% to 50% salicylic acid is used for warts, calluses, psoriasis, and actinic lesions [2]. • 50% salicylic acid ointment with croton oil buffered with methyl salicylate is useful in

V. Piquero (*) Clinica Leopoldo Aguerrevere Caracas, Caracas, Venezuela Clinica Dermik Barcelona, Barcelona, Spain D. Moya Hospital Universitario de Caracas, Caracas, Venezuela Hospital Intercultural Kallvu Llank Chile, Cañete, Región del Bío Bío, Chile E. E. La Rotta Centro Medico Buenaventura en Caracas, Guatire, Venezuela

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photodamage in hands or palmoplantar hyperkeratosis [3–5]. Applicators or gauze (preferably disposable) or brush (not recommended for risk of contamination), are used to apply the salicylic peel. A manual fan is used to relieve burning but in corporate areas sometime is not necessary because the peeling is well tolerated. Cryogel and rose or thermal water is used [2, 6]. It can be finished by applying another substance to be taken to home, such as retinoic acid, hydroquinone, and vitamin C occluding with transparent film. If not, apply sunscreen or soothing cream of witch hazel (Fig.  19.1) [1, 7, 8].

19.2 Methods and Techniques 19.2.1 Pre-peeling • Ensure that the patient is not allergic to salicylates. • Avoid applying in dermatitis, active infections, pregnancy, tanning, and in patients with isotretinoin medications (suspended for at least 3 months). • To prepare the skin, you must consider the area and the lesion to be treated.

Hospital Clinic Barcelona, Barcelona, Spain © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_19

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Fig. 19.1 Materials

• In case of back and chest acne; is recomended the previous application (2–6 weeks) of topical retinoids or benzoyl peroxide. • For hyperpigmented lesions is recomended to previously prepare the skin with kojic acid, alpha-hydroxy acids, hydroquinone before. • In case of actinic damage, use topical retinoids before salicylic peeling [1, 2]. • Substances used for the preparation of skin conditions should be suspended 24 h prior to the application of the peeling. • A detailed consent form listing details about the procedure and possible complications should be signed by the patient [1, 9]. • Select patients from any phototype, but greater caution should be exercised in IV and V phototypes [2]. • Explain to the patient the actual peeling results, such as reinforcement of home treatment and the need for several sessions. • Photographic control of the area to be treated (Figs. 19.2, 19.3, 19.4, and 19.5).

V. Piquero et al.

Fig. 19.2  Salicylic paste for palmar hyperkeratosis. Step 1: clean/wash beforehand with cleaner

Fig. 19.3  Step 2—apply peeling agent; in this case was used salicylic acid paste at 50%

19.2.2 Peeling • Remove debris from the skin area to be treated, clean or wash with cleaner or mild soap, or apply a degreaser based on ethanol, alcohol, or acetone. • Apply the peeling of salicylic acid with 5  ×  5  cm gauze or cotton applicator, always

Fig. 19.4  Step 3—applied occlusive with clear plastic paper for 24–48  h. Come back 1 week after the procedure

19  Salicylic Acid Peeling for Extra-Facial Areas

Fig. 19.5  Application of 30% salicylic acid peeling in dorsal acne lesions

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adapting the amount applied to the skin type [1, 7, 9]. The number of layers varies between 2 and 4 layers of the product in each session. For example, in the neck and neckline usually need only two layers, for the arms and hands are necessary three layers, and for the back four layers. If the patient feels intolerable burning sensation or have an intense erythema, stop the application and the peeling must be removed [1]. Each layer should be applied uniformly, throughout the area, following an order in its application, so as not to omit an area and avoid being irregular, in a circle or in a square, for example. The time of contact with the skin will depend on the type and area of ​​skin to be treated, with an approximate of 3–5 min. After 1–3 min, the burning and itching sensations are sought to reduce using a portable hand fan or cryogel.

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• Use rose water or thermal water to reduce symptoms. • This peeling doesn’t need to be neutralized and produces a frosty product of the precipitation of salicylic acid on the skin, becoming a whitish frost. • We recommended a time of 3–4  weeks to repeat the application, although it could be every 2 weeks if the skin is not sensitive and the results were lighter than desired. • In the case of 30% salicylic acid, it is advisable not to apply in a body extension greater than 10%. As examples of extension, we can cite the whole back or both arms or middle back and chest. • In all cases, it is recommended to ingest water to avoid salicylism, during or after the procedure. • After relieving the symptoms, another chemical can be added, or the area is rinsed with thermal water, and a moisturizer and sunscreen are applied. • The 50% salicylic paste form can be applied with plastic film during 24–48 h, and the patient has to remove at home, this should be repeated 7 days after the first application in the doctors office.; this is useful in hyperkeratosis palmar or plantar.

19.2.3 Post-peeling • Use photo protection, especially in the first 48–72  h after the application of the peeling and up to about 15 days. • Keep the skin moisturized. • This peeling reddens a little and peels a lot. • It is advisable to ingest 1 l of water in the post-­ peeling hours. • The effects of extra-facial salicylic peeling not only depend on the concentration of the acid but also depend on the area to be treated, for example, in neck area, the erythema and the renovation of the skin will be slower than ­others parts of the body, while in stretch marks of the legs the effect of this peeling is smooth. [1, 4, 5, 7, 10].

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19.3 Clinical Follow-Up (Figs. 19.6, 19.7, 19.8, and 19.9) • The application of superficial peels, as is the case of salicylic acid, partially eliminates the epidermis, without reaching the basement membrane. • It causes an improvement in the skin surface and results in a smoother and cleaner skin. • The first 48–72  h will result in redness and desquamation of the treated area [8].

V. Piquero et al.

• The improvement of the treated skin can be observed up to 1 month after the application of the treatment, since the process of remodeling elastin and collagen fibers needs a period of approximately 21 days [2, 5, 8].

Fig. 19.8  Peeling for erythematous striae in the abdomen. Peeling of salicylic acid + retinoic acid 5% occlusive with transparent film for 6 h

Fig. 19.6  Peeling for back acne

Fig. 19.7  Salicylic acid peeling for back folliculitis in men

Fig. 19.9  Peeling for erythematous stretch marks—24 h post-application of salicylic peeling in stretch marks

19  Salicylic Acid Peeling for Extra-Facial Areas

• Good benefits have been proven in the treatment of comedones, inflammatory lesions, as well as photodamage and hyperkeratosis. • It is used in the treatment of acne vulgaris in the chest and back, obtaining good results in comedones as in residual hyperpigmented spots [6, 7]. • It is also used in extra-facial hyperpigmentation and lesions due to actinic damage, pilar keratosis, psoriasis, and callosity, among others. • Another indication of salicylic peeling is for red streaks, with proven effectiveness when combining microdermabrasion plus salicylic peeling plus occlusive retinol for 6 h.

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• We must inform the patient that he should contact us in case of any type of complication. • In the case of salicylic acid paste, ask patient to return in 7 days [1, 8]. • For the peeling of traditional salicylic only or combined in general, the patient is requested to return to the office within 3  weeks or 21 days of application [2].

19.4 Before and After See the Figs.  19.10, 19.11, 19.12, and 19.13. After three treatments, one peel per month, and with sun protection and domiciliary treatment, the results are very satisfactory.

Figs. 19.10 and 19.11  Before and after salicylic peeling and domiciliary treatment for hyperpigmentation post-intense pulsed light (IPL)

Figs. 19.12 and 19.13  Before and after one-session salicylic peel for chest acne

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19.5 S  ide Effects, Complications, and Their Management • Peeling with salicylic acid is safe, rarely involves adverse effects, and is not very complicated. If any complication is present, that is mild and transient [3]. • Salicylic acid may cause prolonged local erythema, exfoliation or severe flaking, and dryness. In areas such as the chest, back, hands, and forearms, the main complications are dryness and dyschromia [2, 3]. • Patients with skin phototypes IV and V are most likely to develop erythema of the treated area and should be disciplined with post-­ peeling care, since these skins types are more vulnerables to develop hyperpigmentation; hypopigmentation such as pityriasis alba occurs in these phototypes when associated with dry skin [2, 6]. • Use moisturizing creams, to soften the skin with desquamation. • In case of excessive scaling and irritation in the post-exfoliation period, topical steroids can be treated (Fig. 19.15). • The main precaution to take with body peeling is the risk of percutaneous absorption toxicity, especially if we use high concentrations in very large areas of the skin. That is why we must recommend ingesting 1 l of water after the application [2, 5–7]. • Salicylism, which may occur due to rapid absorption (especially when combined with a base or is occluded in large areas), could become toxic to the central nervous system, manifesting itself with nausea, vomiting, dizziness, psychosis, stupor, and, consequently, coma and death [2]. • Salicylism produces cellular glucose consumption with the consequences described above for the organism [2] Some locals complications can be observed in the attached figures (Figs. 19.14 and 19.15).

Fig. 19.14 Complication with salicylic paste peel—prolonged local erythema, exfoliation or severe flaking, dryness

Fig. 19.15  Complication with salicylic peel plus platelet-rich plasma for stretch marks

Tip Box

• The most frequent indications are body acne and keratosis pilaris. • This peeling can be popular in summer for plantar keratosis. • In pilar keratosis and folliculitis of men, it is a good choice. • We must be careful with the extensions of the skin to be treated. Do not apply in very large areas.

19  Salicylic Acid Peeling for Extra-Facial Areas

• Remove with water or bicarbonate immediately, in case of excessive redness. • This peeling is a good option when the patient wants to peel the skin. • The 50% salicylic paste form is applied occlusive with clear plastic paper and is useful in callus, psoriasis, and hyperkeratosis. • Another curious application of the occlusive salicylic paste is in the case of hedgehog spicules in the soles of divers; when left for 48  h and removed, the spicules are removed in a painless manner. • This peeling can be associated with others, such as making a general peel of glycolic acid and subsequent specific application of salicylic acid in the comedones or inflammatory lesions. Or you can apply salicylic acid in the entire area to be treated and then apply retinoic acid 5% with plastic film occlusive for 6 h.

References 1. Bosniak S, Cantisano-Zilkha M. Tecnicas minimamente invasivas. New York: Amolca; 2007. 2. Arif T.  Salicylic acid as a peeling agent: a comprehensive review. Clin Cosmet Investig Dermatol.

133 2015;8:455–61. https://doi.org/10.2147/CCID. S84765. 3. Fischer T, Perosino E, Poli F, Viera M, Dreno B, For the Cosmetic Dermatology European Expert Group. Chemical peels in aesthetic dermatology: an update 2009. J Eur Ac Derm and Ven. 2010;24:281–92. https://doi.org/10.1111/j.1468-3083.2009.03409. 4. Salam A, Dadzie OE, Galadari H. Chemical peeling in ethnic skin: an update. Br J Dermatol. 2013;169:82– 90. https://doi.org/10.1111/bjd.12535. 5. Grajqevci-Kotori M, Kocinaj A.  Exfoliative skin-­ peeling, benefits from this procedure and our experience. Med Arch. 2015;69(6):414–6. https://doi. org/10.5455/medarh.2015.69. 6. Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni N. Complications of medium depth and deep chemical peels. J Cutan Aesthet Surg. 2012;5(4):254–60. https://doi.org/10.4103/0974-2077.104913. 7. Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Evidence WB. Considerations in the application of chemical peels in skin disorders and aesthetic resurfacing. J Clin Aesth Dermatol. 2010;3(7):32–43. 8. Pearl E.  Grimes. Exfoliaciones con ácido salicílico. In: Rubin MG, editor. Exfoliación química. Barcelona, España: Elsevier Saunders; 2007. 9. Khunger N, IADVL Task Force. Standard guidelines of care for chemical peels. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S5–12. 10. Karia UK, Padhiar BB, Shah BJ.  Evaluation of various therapeutic measures in striae rubra. J Cutan Aesthet Surg. 2016;9(2):101–5. https://doi. org/10.4103/0974-2077.184056.

Tretinoin Peel for Face

20

Luciane Scattone

20.1 Materials The peel is prepared with powder retinoic acid (RA) dissolved in ether, alcohol, and propylene glycol solution up to the desired concentration (ranging from 1% to 12%). We can add light or dark pigment dye to mask the yellow color of the product (Figs. 20.1 and 20.2) [1, 2].

20.2 Methods and Techniques Even considering the fact that it is a superficial peeling, with epidermal exfoliation of the granular layer up to basal layer (0.45 mm), we should comply with the indication criteria for RA peel. The clinician should properly assess the patient, analyze his/her psychological profile, check the integrity of dermal barrier, and take into consideration photoaging, age, gender (in women the penetration is higher because the skin is finer), clinical presentation, skin thickness, skin phototype (type I people experience deeper penetration than the others), whether the patient can go to work showing skin desquamation, etc. [2]. When greater, faster, and more homogeneous penetration of the product is desired, the patients should prepare the skin by applying lighter acids 10 days before the peel session [2, 3].

Fig. 20.1  Material used—finger protector, brush, and peel

Fig. 20.2  RA peel with dye. (A) and RA peeling without dye (B)

L. Scattone (*) Clínica Dermatológica Dra Luciane Scattone, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_20

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L. Scattone

20.2.1 How to Apply There is no need to have previous topical anesthesia. After applying make-up remover, the entire face is cleaned with gauze soaked with chlorhexidine, ketone, or alcohol [3], to degrease the skin. The peel may be formulated as gel, lotion, cream, or propylene glycol with color dye or in its natural color (yellowish) [1]. Using a cotton swab, brush, or finger protector [2], apply the product homogeneously on the entire face, avoiding areas close to the nose, mouth, and eyelids. There is no need for neutralization; each clinician should standardize the peels preferably by buying products always by the same supplier to avoid undesirable results. The peel remains on the patient’s skin for 3–12 h, provided that it does not cause any burning sensation or discomfort. Removal of the peeling should be made with liquid soap, and moisturizer is applied only when desquamation starts as of day 3. However, if the patient needs immediate moisturizing due to discomfort, it does not affect the expected result. Daily use of broad-spectrum sun protection is recommended [2, 4, 5], as well as the use of physical protection such as caps and glasses, especially for subjects that play sports. Normally, the process of desquamation finishes in 7 days, which may vary according to skin type. According to the indication, 3–5 weekly or monthly sessions are required until the expected result is reached. The patient should necessarily be informed in writing and verbally about the post-peel care. It is important to emphasize that the patient may have to avoid social gatherings until the desquamation is over and avoid sun exposure for at least 1 month after the last serial peel. Patients with previous history of herpes may perform prophylactic antiviral therapy with acyclovir or valacyclovir (per os [PO] for 5 days) at the clinician’s discretion [2]. Photographic documentation should be made before and after each peel, always with the same lighting (Figs. 20.3, 20.4, and 20.5).

Fig. 20.3  Aspect of the skin during RA peel application with color dye (B) and without color dye (A)

Fig. 20.4  Application of RA peel with finger protector

20  Tretinoin Peel for Face Fig. 20.5  Application of RA with brush

20.3 B  efore and After (Figs. 20.6, 20.7, 20.8, 20.9, 20.10, 20.11, 20.12, and 20.13)

Figs. 20.6 and 20.7  Melanosis and photodamage after first and fifth sessions of 5% RA peel

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Figs. 20.8 and 20.9  Melasma after first and third sessions of 7% RA peel

Figs. 20.10 and 20.11  Periorbicular wrinkles before after fourth session of 5% RA peel

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20  Tretinoin Peel for Face

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Figs. 20.12 and 20.13  Melasma on the upper lip before after fourth session of 5% RA peel

20.4 S  ide Effects, Complications, and Their Management Adverse events are normally mild and transient, and the most frequent one is erythema, followed by burning sensation, desquamation, simplex herpes episodes, post-inflammatory pigmentation, and flare of rosacea [2, 4, 6, 7]. Management may include cold thermal water, topical low-power corticoid, Vaseline gel, and herpes treatment, if applicable (Figs.  20.14 and 20.15).

Fig. 20.14  Fine and marked desquamation after 3 days post-application of RA peel. 5%

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References

Fig. 20.15  Erythema, burning, and desquamation after 3 days post-application of RA peel. 5%

Tip Box

• Comply with the real indication of RA peel. • Type I people experience deeper penetration than the others. • The patients should prepare the skin by applying lighter acids 10 days before the peel session. • It is recommended daily use of broadspectrum sun protection in the following days after the peel session. • From 3–5 weekly or monthly sessions are required until the expected result is reached.

1. Kong R, Cui Y, Fisher GJ, Wang X, Chen Y, Schneider LM, Majmudar G. A comparative study of the effects of retinol and retinoic acid on histological molecular, and clinical properties of human skin. J Cosmet Dermatol. 2016;15:49–57. 2. Yokomizo VMF, Benemond TMH, Chisaki C, Benemond PH.  Chemical peels: review and pratical applications. Dermatol. 2013;5(1):56–68. 3. Guerra FMRM, Krinsk GG, Campiotto LG, Guimaraes KMF.  Applicability of chemical peels facial at treatments  – study review. Brazilian Journal of Sugery and Clinic Research  - BJSCR 2013;4(3):33–6. 4. Magalhães GM, Borges MFM, Queiroz ARC, Capp AA, Pedrosa SV, Diniz MS.  Estudo duplocego e randomizado do peeling de ácido retinóico a 5% e 10% no tratamento do melasma: avaliação clínica e impacto na qualidade de vida. Dermatol. 2011;3(1):17–22. 5. Denise S, Camila F, Mediana B, Fernanda AMS.  Treatment of melasma: systematic review. Surg Cosmet Dermatol. 2009;1(2):87–94. 6. Yildirim S, Gurel MS, Gungor S, Tekeli O, Canat D.  Comparison of efficacy of chemical peeling with 25% thichloroacetic acid and 0,1% retinoic acid for facial rejuvenation. Adv Dermatol Allergol. 2016;XXXIII(3):199–205. 7. Park SE, Kim SS, Kim CW, Her Y. A prospective split-­ face comparative study of periorbital wrinkle treatments: fractional erbium-doped yttrium aluminum garnet laser, intense pulsed light, and topical 0.1% tretinoin cream. Ann Dermatol. 2016;28(5):650–2. https://doi.org/10.5021/ad.2016.28.5.650.

Tretinoin Peel for Extra-Facial Areas

21

Renata Indelicato Zac and Adilson Da Costa

21.1 Materials • • • •

Acetone 3% in alcohol Tretinoin 5% cream Gloves Gauze

21.2 Methods and Techniques [1–7]

Fig. 21.1 Materials

• Before application, use acetone 3% in alcohol with gauze or cotton to remove all skin oils (Figs. 21.1 and 21.2). • Apply the tretinoin 5% cream as a uniform mask with gloved fingers (Fig. 21.3). • Wrap the skin with a plastic and leave the tretinoin cream on the skin for 4–6 h (Fig. 21.4). • Remove it with water and mild soap or cleansing solution.

Fig. 21.2 Preparation

R. I. Zac (*) Dermatology Department, Minas Gerais Military Hospital, Belo Horizonte, MG, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_21

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R. I. Zac and A. Da Costa

142

21.4 Before and After Figures 21.5 (before) and 21.6 (after).

Fig. 21.3 Application

Fig. 21.5 Before

Fig. 21.4 Wrapping

21.3 Clinical Follow-Up [1–7] • Do not apply over erupted or broken skin. • For the first 72  h post-peel or until all post-­ peel irritation has ceased, bland moisturizers, cleansers, and sunscreens are continued. • After this time, patient can then resume their topical skincare formulations, which may include topical demelanizing agents, anti-­acne medications, and retinoids. • Excessive desquamation and irritation in the post-peel period can be treated with topical steroids. • Hyperpigmentation remaining after the peeling procedure responds to topical hydroquinone and frequent use of sunscreens. • The peels are repeated at an interval of 2–4 weeks. • Peak results are visible after a series of 3–6 chemical peels, depending on the severity of the condition being treated and skin type.

Fig. 21.6 After

21.5 S  ide Effects, Complications, and Their Management [1–7] • Pruritus, burning, and irritation can be avoided by previously using moisturizers on dry and sensitive skin and treated with calamine lotion. • Persistent erythema can be prevented by frequently using a broad-spectrum sunscreen and attenuated by using topical steroids. • Picking, scratching, and scrubbing the skin can predispose to secondary infections. Use antibiotics as soon as crusts, oozing, pustules, or blisters appear.

21  Tretinoin Peel for Extra-Facial Areas

• Acneiform eruption can be treated with topical antibiotics or benzoyl peroxide. • Milia should be extracted. • Post-inflammatory hyperpigmentation and hypopigmentation should be prevented with adequate priming and frequent use of broad-­ spectrum sunscreen. Topical corticosteroids, hydroquinone, or alpha-hydroxy acids can be used if necessary. • Allergic reactions can be treated with antihistamines, corticosteroids, and epinephrine in severe cases.

Tip Box

• Use acetone 3% in alcohol with gauze. • Apply the tretinoin 5% cream as a uniform mask with gloved fingers. • Leave it on the skin for 4–6 h. • Remove it with water and mild soap or cleansing solution.

143

References 1. Anitha B. Prevention of Complications in Chemical Peeling. J Cutan Aesthet Surg, 2010;3(3):186–8. 2. Faghihi G, Fatemi-Tabaei S, Abtahi-Naeini B, et  al. The Effectiveness of a 5% Retinoic Acid Peel Combined with Microdermabrasion for Facial Photoaging: A Randomized, Double-Blind, PlaceboControlled Clinical Trial. Dermatology Research and Practice 2017; 3. Cucé LC, Bertino MC, Scattone L, Birkenhauer MC. Tretinoin peeling. Dermatol Surg. 2001;27(1):12–4. 4. Hexsel D, Mazzuco R, Dal’Forno T, Zechmeister D. Microdermabrasion followed by a 5% retinoid acid chemical peel vs. a 5% retinoid acid chemical peel for the treatment of photoaging - a pilot study. J Cosmet Dermatol. 2005;4(2):111–6. 5. Kang S, Kim KJ, Griffiths CE, et al. Topical tretinoin (retinoic acid) improves early stretch marks. Arch Dermatol. 1996;132:519–26. 6. Ud-Din S, Mc George D, Bayat A. Topical management of striae distensae (stretch marks): prevention and therapy of striae rubrae and albae. JEADV 2016;30:211–22. 7. Yokomiso VMF, Benmond TMH, Chisaki C, et al. Chemical peels: review and practical applications. Surg Cosmet Dermatol. 2013;5(1):58–68.

Trichloroacetic Acid Peel for Facial and Extra-Facial Areas

22

Natacha Quezada Gaón and María Isabel Herane Herane

22.1 Materials • Sterilized gauzes and cotton tips of different sizes. • Sterilized, nonmetal, and disposable recipient for the acid. • Ether, acetone, and alcohol mixed in equal proportion for facial cleansing. • Solid petroleum jelly, to protect the lips, angles, and sensitive areas. • Trichloroacetic acid-base lotion 15%, 20%, 25%, 30%, and 35%. • Cold fan. • Baking soda, 10%, acts as buffer (its efficacy is not well accepted) (Fig. 22.1).

22.2 Methods and Techniques [1–10] • Choose correctly the patient for indications such as photodamage, scars, keratoses, and others [1–3]. • Patient must have a fair-skin phototype (I–IV) and no history of keloid scars, hepatitis, HIV infection, active herpes simplex, or any other active dermatologic condition. N. Quezada Gaón (*) Department of Dermatology, Pontifical Catholic University of Chile, Santiago de Chile, Chile M. I. Herane Herane University of Chile, Santiago, Chile © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_22

Fig. 22.1  Materials: gauzes, cotton tips of different sizes, sterilized, nonmetal, disposable recipient

• Patient must be out of isotretinoin treatment for 3–6 months or no history of radiotherapy in the last 2 years. • Previous skin preparation should be with topical retinoids or Kligman formula, at least 2 weeks before the procedure. • The previous education of the patient on using photoprotection SPF 50+ to avoid complications is very important. • Detailed explanation of the procedure is necessary. Patients must be aware that a stinging sensation will be normal for 15–30  min and that a dark crust will develop that will resolve in different times in several days.

145

N. Quezada Gaón and M. I. Herane Herane

146

• An informed consent that explains the procedure, complications, and risks should be signed before. • Standard photography registry is authorized by the patient. • Start the procedure with a deep facial skin cleansing using a gauze and the degreasing solution, taking off residual cosmetics and skin grease. • Apply solid petroleum jelly in the mouth angles and other areas we would like to protect.

• Pour trichloroacetic acid in the recipient, and soak the gauze or cotton tip in the acid not letting the acid drain. • The use of TCA for performing chemical extrafacial peels has been reported mainly in two vehicles: aqueous solution and water-­soluble paste. • Apply a first layer of TCA (15–35%) in a homogeneous way considering the cosmetic units; this can be done in the whole extra-­ facial or only in the areas to be treated [4] (Figs. 22.2 and 22.3). b

a

Fig. 22.2 (a) Homogeneous application with cotton tip of TCA 35% peeling in keratosis area. (b) Homogeneous application with gauzes of TCA 20% peeling in a back of the hand in cosmetic unit

a

b

c

Fig. 22.3 (a) Homogeneous application with gauzes of TCA 15% peeling in a cheek cosmetic unit. (b) Homogeneous application with cotton tip of TCA 20% peeling in periocular area. (c) Homogeneous frosting in cosmetic unit

22  Trichloroacetic Acid Peel for Facial and Extra-Facial Areas

• For cross peel (TCA 75%–95%), cotton tips of different sizes are useful, and it must be very carefully applied depending on the area that will be treated (Fig. 22.4) [5–8]. • TCA produce stinging and burning sensation that can be minimized with the use of a cold fan. • Always remember that frosting with TCA appears very soon; we must be patient before applying a second or third layer. • Depth will depend on the percentage of acid, the number of passes, the pressure on the application, and the previous treatment of the skin. • The more homogeneous and white the frosting, the greater the penetration. • It is advisable to decide the cosmetic units to be treated with more or less intensity previously and individually. • Once you obtain the frosting and stinging is controlled, we can associate other chemical peels or laser to maximize results (Figs. 22.5, 22.6, and 22.7) [9, 10]. • If we decide not to associate other procedures, a photoprotector SPF 50+ should be applied to finish.

a

b

147

22.3 Clinical Follow-Up [1–10] • Post-procedure indications should be given in written form, pointing the importance of crust evolution. • Crusts will drop by themselves in different times leaving erythema and temporary sensitive areas (Figs. 22.8, 22.9, 22.10, 22.11, 22.12, and 22.13). • Medical staff should insist in a strict photoprotection and the regular use of a repair healing cream, moisturizing cream, or petroleum jelly. • Do not forget all patients having herpes simplex infection prophylaxis (valaciclovir 500 mg twice a day for 5 days) • If the patient has a history of recurrent herpes simplex infection, it is advisable to prescribe valaciclovir 500 mg twice a day until desquamation is over. • The use of steroids will be necessary if the peeling is too intense. Prescribe prednisone 1 mg/kg, and taper the dose every 3–7 days. • Telephone calls or visits to the clinic the following days reinforce the management. • A week control plus standardized photography post-procedure is necessary.

c

Fig. 22.4 (a) Application of TCA 90% cross peeling technique in the earlobe. (b) Frosting. (c) Before two sessions TCA peeling 90% for repair earlobe

N. Quezada Gaón and M. I. Herane Herane

148 Fig. 22.5 (a) Application of cross peeling technique in ice pick. (b) Frosting

Fig. 22.6 (a) Homogeneous application of 20% TCA peeling facial. (b) Combination of 5% retinoic acid peel facial

a

b

a

b

22  Trichloroacetic Acid Peel for Facial and Extra-Facial Areas

a

b

c

d

149

Fig. 22.7  Before (a), post-peeling TCA 30% (b), after dermabrasion (c), and 1 week later (d)

Fig. 22.8 (a) Peeling TCA 20% 1 week after with desquamation in different times. (b) Two weeks after

a

b

N. Quezada Gaón and M. I. Herane Herane

150 Fig. 22.9 (a) Three weeks after peeling TCA 30% with desquamation and erythema. (b) Four weeks later, erythema in some areas is still present. The patient does not follow the instructions

a

a

b

b

c

Fig. 22.10 (a) Before peeling TCA 20% in the cheeks. (b) Desquamation in different times, 3 days. (c) A week after

a

b

c

Fig. 22.11 (a) Before peeling TCA 30% in the cheeks. (b) Desquamation in different times, 4 days (c) A week after. Erythema in some areas is still present

22  Trichloroacetic Acid Peel for Facial and Extra-Facial Areas

a

b

151

c

Fig. 22.12 (a) Before periocular peeling TCA 20%, (b) crust 2 days after, and (c) final result after a week

a

b

c

Fig. 22.13 (a) Before. (b) After a week of peeling TCA 30% in cheeks with discrete remaining erythema. (c) After 1 year, good results are still noticeable

• Keep strict photoprotection for 3  months 22.4 post-­ ­ procedure to avoid hyper- or hypopigmentation. • Desquamation post-peeling lasts 7–15  days, leaving temporary patches that are normal. • Once desquamation is gone, a discrete-to-­ moderate erythema remains for approximately 4  weeks; if it lasts longer, we are facing a ­persistent erythema.

Before and After (Figs. 22.14, 22.15, 22.16, 22.17, 22.18, 22.19, 22.20, 22.21, 22.22, 22.23, and 22.24)

N. Quezada Gaón and M. I. Herane Herane

152 Fig. 22.14 (a) Before. (b) Four weeks after one session peeling TCA 20% in a back of the hand in a patient with photodamage

Fig. 22.15 (a) Before. (b) Four weeks after one session of cross peeling TCA 30% in keratosis of the hand

Fig. 22.16  Before (a) and after (b) three sessions TCA 90% cross peeling technique in earlobe area

Fig. 22.17  Before (a) and after (b) three sessions TCA 90% cross peeling technique in earlobe area. (Pictures in traction)

a

b

a

b

a

b

a

b

22  Trichloroacetic Acid Peel for Facial and Extra-Facial Areas Fig. 22.18  Before (a) and after (b) one session peeling TCA 35% in cosmetic units of the cheeks in a patient with photodamage

Fig. 22.19  Before (a) and after (b) one session TCA 30% in the cheeks in a patient with acne scarring and photodamage

Fig. 22.20  Before (a) and after (b) one session of peeling TCA 20% in periocular area

Fig. 22.21  Before (a) and after (b) one session TCA 30% plus dermabrasion of superior perioral area (Pictures in rest)

153

a

b

a

b

a

b

a

b

N. Quezada Gaón and M. I. Herane Herane

154 Fig. 22.22  Before (a) and after (b) one session TCA 30% plus dermabrasion of superior perioral area (Pictures in contraction)

Fig. 22.23  Before (a) and after (b) three sessions of cross peel TCA 90% in ice pick technique

a

a

b

a

b

b

c

Fig. 22.24  Before (a) and after (b) three sessions of cross peel TCA 90% in ice pick technique

22.4.1 Side Effects, Complications, and Their Management [1–10] (Figs. 22.25, 22.26, 22.27, 22.28, 22.29, and 22.30) • Immediate complications are mainly sore and pain that is different among individuals. Cold fan helps a lot.

• Hyperpigmentation or hypopigmentation can be seen after complete desquamation and even after 1  month; it can be prevented strictly. • Persistent erythema. If present over 2 months, we must use IPL or vascular lasers plus photoprotection to resolve. • Atrophic, hypertrophic, and keloid scars.

22  Trichloroacetic Acid Peel for Facial and Extra-Facial Areas

Fig. 22.25  Eight  weeks after treatment TCA 30% in a back of the hand with persistent erythema Fig. 22.27  Edema 24 h after TCA 30% treatment in the cheeks (a), control 2 weeks after (b)

a

a

155

Fig. 22.26  Four  weeks after treatment TCA 30% in a back of the hand area with persistent erythema and atrophic and hypertrophic scars

b

b

c

Fig. 22.28 (a) Before. (b) Two  weeks after treatment TCA 30% in perioral area with persistent erythema. (c) At 12 weeks and after six sessions of IPL improvement of erythema

N. Quezada Gaón and M. I. Herane Herane

156

a

b

c

Fig. 22.29 (a) Before. (b) Four weeks after treatment TCA 30% in perioral area with persistent erythema at week 4. (c) At 10 weeks and after six sessions of IPL improvement of erythema but hypopigmented areas remain

a

b

c

Fig. 22.30  Before (a) and after 2 weeks of treatment TCA 15% (b). Hyperpigmentation can be seen at 2 weeks (b) that is almost resolved 6 weeks after using Kligman’s depigmenting formula (c)

• Infections: herpes simplex infection is the most common. Secondary bacterial infection has been reported. • Acneiform reactions and milium cysts can be developed.

Tip Box

• Sectorial peel helps for a better control of the procedure. It is possible to perform a deeper peel in more affected areas and less aggressive in the rest. • Sectorial peel has a faster and better healing process.

• If a patient is phototype IV and might react with hyperpigmentation application of 3 mm, TCA 20% in preauricular area is a good proof method to confirm if hyperpigmentation might occur. • The extra-facial peeling heals slower than the facial peeling and has more risk of complication.

References 1. Rendon M, Berson D, Cohen J, Roberts WE, Starker M, Wang B.  Evidence and considerations in the application of chemical peels in skin disorders and

22  Trichloroacetic Acid Peel for Facial and Extra-Facial Areas aesthetic resurfacing. J Clin Aesthet Dermatol. 2010;3(7):32–42. 2. Orso Rebellato P, Rodrigues Lisbon Faucz L, Vilaverde Schmitt J, Araujo Scharf Pinto C.  Trichloroacetic acid peeling in the treatment of actinic melanosis in the back of the hands: a comparative randomized study between two vehicles. Surg Cosmet Dermatol. 2015;7(4):294–7. 3. Puri N.  TCA peel versus glycolic acid peel for the treatment of melasma. Indian Dermatol Online J. 2012;3(2):109–13. 4. Yildirim S, Salih Gurel M, Gungor S, Tekeli O, Canat D.  Comparison of efficacy of chemical peeling with 25% trichloroacetic acid and 0.1% retinoic acid for facial rejuvenation. Adv Dermatol Allergol. 2016;33(3):199–205. 5. Ribeiro de Oliveira AR, Cardoso de Mendonça MC, Figueiredo Machado R, Tavares Lopes Silva M, Vieira Arestrup B. Minimally invasive technique for repair-

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ing complete earlobe cleft. Surg. Cosmet Dermatol. 2011;3(3):254–6. 6. Mradula PR, Sacchidanand S. A Split-face comparative study of 70% trichloroacetic acid and 80% phenol spot peel in the treatment of freckles. J Cutan Aesthet Surg. 2012;5(4):261–5. 7. de Mendonça MC, de Oliveira AR, Araújo JM, Silva MD, Gamonal A. Nonsurgical technique for incomplete earlobe cleft repair. Dermatol Surg. 2009;35(3):446–50. 8. Garg S, Baveja S. Combination therapy in the management of atrophic acne scars. J Cutan Aesthet Surg. 2014;7(1):18–23. 9. Simões Alves F, Nakandakari S. Trichloroacetic acid matricectomy: a retrospective study. Surg Cosmet Dermatol. 2011;3(3):254–6. 10. Gomes Meski A, Cucé L. Chemabrasion for the treatment of perioral wrinkles: clinical analysis and epidermal Langerhans cells qualification. Surg Cosmet Dermatol. 2009;1(2):74–9.

Thioglycolic Acid Peel for Dark Circles Under Eyes

23

Vanessa Lucília Silveira Medeiros

23.1 Materials Thioglycolic acid (TA) or mercaptoacetic acid [1–3]. • Microruptures in the vessels lead to the accumulation of hemoglobin metabolites like iron in the skin of the eyelid. The deposition of iron in tissues activates many enzymes and has a catalytic effect by the conversion of superoxide and hydrogen peroxide into a highly active free radial (OHo) capable of damaging organic molecules. The damage stimulates melanogenesis, causing secondary melanic pigmentation. • Glycolic acid is the smallest alpha-hydroxy acid; therefore, it has the high capability to penetrate the skin. Thioglycolic acid is a derivate of glycolic acid with a higher molecular weight. • Thioglycolic acid is formed by the replacement of an oxygen atom by a sulfur atom in an acid radical of glycolic acid. This chemical reaction receives the name “Thio.” The new acid then receives the addition of this prefix to the original compound name. • It has ability to penetrate the skin between glycolic acid and trichloroacetic acid. The more limited penetration promotes a lighter

•

•

•

•

burn and cell renewal with greater safety than glycolic acid. Thioglycolic acid is classified as a carboxylic acid with a simple sulfur group and a carboxyl group. The former reacts with bases, acids, ketones, and organic halogen compounds. The latter reacts with amines and alcohols. Thus, thioglycolic acid has an antioxidant activity and the capability to eliminate iron accumulation, verified by the presence of metabolite reaction (carboxyethylcysteine). The concentration of the peeling varies with the place of application. Twenty percent acid is indicated for corporal vascular discolorations and 10% for the eyelid. The vehicle used is non-alcoholic gel. Non-sterile disposable gloves, mask, sterile gasses, swabs, 50% alcohol, and 10% gel-free thioglycolic acid are used for eyelid peeling (Fig. 23.1).

V. L. S. Medeiros (*) Department of Tropical Medicine of Federal University of Pernambuco, Recife, PE, Brazil Instituto Davan Dermatologia, Recife, PE, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_23

Fig. 23.1  Material used in the peeling 159

160

23.2 Methods and Techniques • The choice of the patient is crucial to get betters results. The best candidate is one with erythema in the eyelids (vascular discoloration), little hyperpigmentation, and slight change in skin texture (Fig. 23.2). If the patient has tear trough depression, treat first the depression and the superficial iron. • Program three to five peeling sessions with a minimum interval of 15 days. Use a whitening cream with vitamin C at least 15 days before the first session to prevent post-inflammatory pigmentation. • In the procedure, the patient should wash the face and eyelids with a gentle soap. After, clean the area with 50% alcohol to degrease the skin. Prevent the patient from opening the eyes at this moment (Fig. 23.3).

Fig. 23.2  Best patient to be chosen—eyelids with vascular discoloration without pigmentation and tear trough atrophy Fig. 23.4 Step one—clean the area with 50% alcohol

V. L. S. Medeiros

• Apply thioglycolic acid 10% and spread with a cotton swab. Start with the lower eyelid because sometimes to reach the affected area, it is necessary to ask the patient to look up (Fig. 23.4). The endpoint of the first session is a burning sensation or at most a very light frost (Fig. 23.5). The time to reach this result is between 3 and 5 min. Do not go beyond this time to get frost in the first session. • Clean the area with a dry gauze and after that with gauze soaked in 0.9% physiological solution. Repeat the process in the upper eyelid. In the end, the patient should wash the eyelids again. • Add 3–5  min in each subsequent session according to the evolution presented after the first session. The maximum time is 15  min.

Fig. 23.3  Step two—apply a thick layer of 10% thioglycolic acid and spread with a cotton ball

23  Thioglycolic Acid Peel for Dark Circles Under Eyes

The time should not be increased if the patient reaches a moderate frost or experiences increased burning sensation.

23.3 Clinical Follow-Up • In the next 1–3 days, there will be a light erythema and a descript edema in the treated area (Figs. 23.5 and 23.6). They are being progressively replaced by parchment skin. The color can range from skin color to light brown depending on the melanin content of the skin (Fig. 23.7).

161

• Skin desquamation begins on the fourth day and ends 7–10  days after the session (Fig. 23.8). In this period, the patient can use a vitamin C eyelid cream twice a day and sunscreen. • The patient should avoid sun exposure during the entire treatment. In addition to vitamin C, prescribe sunscreen and sunglasses in situations when exposure is unavoidable (e.g., driving). • After desquamation, the patient can return to the use of whitening cream until the next session.

Fig. 23.5 Step three—stop the session in the scheduled time or reach an opaque skin appearance with light erythema

Fig. 23.6  Light erythema 24 h after the session Fig. 23.8  Onset of skin peeling on the fourth day after the session

Fig. 23.7  Brownish skin with parchment-like appearance 48 h after the session

162

23.4 Before and After

V. L. S. Medeiros

23.5 S  ide Effects, Complications, and Their Management

1. Patient 1 (Figs. 23.9 and 23.10) 2. Patient 2 (Figs. 23.11 and 23.12)

Fig. 23.9  Patient 1 before—vascular discoloration with few wrinkles. Absence of pigmentation and tear trough atrophy

Fig. 23.10  Patient 1 after—improvement of vascular discoloration and skin texture

Fig. 23.11  Patient 2 before—vascular discoloration with secondary hyperpigmentation and mild tear trough atrophy

Fig. 23.12  Patient 2 after—improvement of vascular discoloration, skin texture, and hyperpigmentation

Most of the adverse effects are related to excessive skin peeling contact time. Burning sensation and frost are guides to the endpoint of the session. • Pain: The patient should not feel pain during or after the session. If the patient complains about pain, stop the application immediately and clean the area. The patient may have very thin skin or low pain tolerance. If the complaint occurs after the application, consider the possibility of infections (bacterial or herpetic). • Lead the patient to return for frequent reassessment until the cause is determined. • Burning sensation: A light burning sensation is normal and should stop within a few minutes after the end of the session. If the patient complains of increased burning, stop the application and clean the site. Prolonged burning sensation is similar to the pain of a first-­ degree burn. The treatment is to apply moisturizing, low-potency corticosteroids, or topical immunomodulators. • Edema: Some patients may experience mild swelling simultaneously with erythema after the frost. This is transient and should disappear in 24  h. If the swelling is important or persists after a few days, consider very thin skin, error in application time, or in the acid formula. If this repeats or increases in the next application, it may be due to acid sensitization. If the edema is mild to moderate, the treatment is low-potency corticosteroids or topical immunomodulators until complete improvement. If the edema is severe, the treatment is prednisone 0.5 mg/kg/day until resolution of the condition. • Erythema: Mild erythema occurs in all cases and disappears within 24–48  h. The absence of erythema indicates that the time of the acid in the skin was very short. Excessive burning of the skin may prolong the erythema and is indicative of other possible problems such as post-inflammatory hyperpigmentation. The

23  Thioglycolic Acid Peel for Dark Circles Under Eyes

treatment is low-potency corticosteroids or topical immunomodulators, sunscreen, and vitamin C cream. • Post-inflammatory pigmentation: It is an uncommon side effect. It is related to the previous melanin content of the skin or prolonged erythema after the session. Increasing the time of peeling application may not improve pigmentation and induce post-inflammatory hyperpigmentation. If the patient has a very pigmented look, first schedule treatment for that factor. If the patient develops post-­ inflammatory hyperpigmentation, the treatment is performed with bleaches such as vitamin C and inhibitors of tyrosinase activity.

163

• The protocol is three to five sessions with a minimum interval of 15  days. The use of creams with haloxyl, melanogenic inhibitors, resorcinol, and vitamin C helps to prevent complications. After the session, the patient should use eyelid cream, sunscreen, and sunglasses and avoid sun exposure. • Most of the adverse effects are related to excessive contact time. Burning sensation and frost are guides to the endpoint of the session before the planned time. Generally, the side effects can be treated with low-potency corticosteroids or topical immunomodulators, followed by vitamin C cream and sunscreen.

Tip Box

• Eyelid dark circles have many etiologies and different clinical presentations. For the correct treatment, it is important to identify the predominant type of eyelid dark circles and start treatment for it. • The blood vessel microruptures in the skin of the eyelid lead to the deposition of hemoglobin metabolites and release free radicals. This leads to eyelid vascular discoloration and causes secondary melanic pigmentation. • Thioglycolic acid has the capability to react with iron and other hemoglobin metabolites and promotes desquamation. For this reason, it is indicated for treatment of the vascular type of dark eyes circles.

References 1. Tullii R, Izzo M.  El papel del ácido tioglicólico en las pigmentaciones férricas/the role of thioglycolic acid in ferric pigmentations. Ver Panam Flebol Linfol. 2001;41:57–63. 2. Costa A, Basile DVA, Medeiros VLS, Moisés AT, Ota SF, Palandi JAC. 10% thioglycolic acid gel peels: a safe and efficient option in the treatment of constitutional infraorbital hyperpigmentation. Surg Cosmet Dermatol. 2010;2(1):29–33. 3. http://www.chemicalland21.com/specialtychem/ finechem/THIOGLYCOLIC%20ACID.htm

Thioglycolic Acid Peeling for Hemosiderin and Post-­ inflammatory Hyperchromia

24

Rossana Cantanhede Farias de Vasconcelos

24.1 Materials (Fig. 24.1) • • • • •

50–70% alcohol 0.9% saline solution Gauze or cotton pad Swabs 10–20% thioglycolic acid gel packed in dropper vials with 20  ml done in manipulation pharmacy

24.2 Methods and Techniques (Figs. 24.2 and 24.3) • Degrease the region with 50–70% ethanol. • Apply 10% or 20% thioglycolic acid gel in the area. • Allow 2 min of contact. Remove it with gauze and water or 0.9% saline in abundance.

Fig. 24.1  Materials to be used

R. C. F. de Vasconcelos (*) Dermatology Department, University of Santo Amaro, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_24

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R. C. F. de Vasconcelos

Fig. 24.4  Immediate appearance after the removal: gray48 frosting, mild erythema

24.3 Clinical Follow-up (Fig. 24.4) Fig. 24.2  Application of 10% or 20% thioglycolic acid peeling

Fig. 24.3  Removal with 0.9% saline solution

• Keep an interval of 7, 15, and 30 days between sessions. • Repeat the sessions 3–8 times, increasing the contact time by 3 min. Do not exceed 15 min of contact in the periocular area. • Stop if there is burning or adverse effects.

• The clinical results of thioglycolic acid peels to treat periocular hyperpigmentation show improvement in recent works, assessed on a scale from 0 to 10. • The use of 10% gel in the periocular hyperpigmentation had an average clinical satisfaction of 6.8, reported by Costa et al. [1] and Souza et al. [2]. • Initial results of a work in progress at the hospital of University of Santo Amaro, with peeling of 20% thioglycolic, showed an average satisfaction of 6.3. • When we evaluate only patients with pigmentary and vascular components, an increase in the average satisfaction, up to 7.05, is noticed. • This superiority in the darkest circles shows the greatest effect of thioglycolic acid in the hemosiderotic component (Vasconcelos et al. unpublished). • In the treatment of hyperpigmentation of the lower limbs triggered by venous insufficiency, Goldman et al. [3] showed 40% good or very good improvement. • In Schamberg disease, Hammerschmidt et al. [4] reported the use of 10% thioglycolic acid peeling gel resulting in improved lightening of lesions by 68.7%. • For use in post-inflammatory hyperpigmentation, Reinehr et al. [5] reported the use of 30% thioglycolic acid peels in association with topic depigmentant with good results.

24  Thioglycolic Acid Peeling for Hemosiderin and Post-inflammatory Hyperchromia

24.4 Before and After (Figs. 24.5, 24.6, and 24.7)

Fig. 24.5  Post-inflammatory hyperpigmentation before application

Fig. 24.6 Peeling appearance 1  week after the application

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24.5 S  ide Effects, Complications, and Their Management (Figs. 24.8 and 24.9) Erythema, swelling, and peeling are described as adverse effects after the procedure by Goldman et al. [3] and Costa et al. [1]. Varying degrees of erythema and edema appear immediately after application and revert on the second day, whereas mild peeling appears lasting 3–4 days. Crusting may occur in case of intense frosting or technical error. Complications are not related to the number of sessions and are rare. Some patients do not get better or have little aesthetic improvement of hyperpigmentation. These are individuals who may benefit from the most number of sessions with thioglycolic acid or combined treatment with use of other depigmentants that act more effectively on deposits of melanin. • Not related to the number of sessions. • Spontaneous reversion. • The most common are erythema, edema, and peeling. • Crusts and dyschromias may rarely occur.

Fig. 24.8  Erythema and mild flaking

Fig. 24.7  Appearance after 1 month of the last session in a total of five sessions Fig. 24.9 Mild flaking and thin crust with partial whitening

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Tip Box

• A total of 20% thioglycolic acid serial peeling for hemosiderosis and hyperchromia • Quite an advantageous option for use in office • Very common complaint • Quick method • Easy application and access • Little risk of adverse effects • Low cost • High level of patient satisfaction

References 1. Costa A, Basile AVD, Medeiros VLS, Moisés TA, Ota FS, Palandi JAC. 10% thioglycolic acid gel peels: a safe and efficient option in the treatment of consti-

R. C. F. de Vasconcelos tutional infraorbital hyperpigmentation. Surg Cosmet Dermatol. 2010;2(1):29–33. 2. Souza DCM, Ludtke C, ERM S, Rocha NW, Weber MB, Manzoni APD, Lorenzini FK. Comparação entre ácido tioglicólico 2.5%,hidroquinona 2%, haloxyl 2% e peeling de ácido glicólico 10% no tratamento da hiperpigmentação periorbital. Surg Cosmet Dermatol. 2013;5(1):4651. 3. Goldman N, Neto B, Goldman K.  Tratamento das Hiperpigmentações de Membros Inferiores Desencadeadas pela Insuficiência Venosa com o Uso de Ácido Tioglicólico. [acesso 05 jun 2009]. Disponível em: www.sbme.org.br/portal/download/ revista/14/04_Tratamento_das_Hiperpigmentacoes. pdf. 4. Hammerschmidt M, Gentili AC, Hepp T, Mukai MM.  Peeling de ácido tioglicólico na doença de Schamberg. Surg Cosmet Dermatol. 2013;5(2):165–8. 5. Reinehr CPH, Boza JC, Horn R.  Peeling de ácido tioglicólico como terapêutica para hipercromia pós-­ inflamatória. Surg Cosmet Dermatol. 2015;7(4):350–2.

Part II Botulinum Toxin

Introduction: What Is Botulinum Toxin?

25

Doris Hexsel, Fernanda Camozzato, and Carolina Siega

25.1 History Botulism was first described in the mid-1800s, but its etiologic agent, Clostridium botulinum, and mechanism of action were identified almost a century later. The botulinum toxin (BoNT) has long been considered the most poisonous of poisons, and efforts to purify, isolate, and describe the molecular structure of the botulinum toxin date back to the 1940s [1–4]. Onabotulinumtoxin A (Botox, Botox Cosmetic; Allergan, Irvine, Calif.) is the first available botulinum toxin type A (BoNT-A) preparation initially purified in the crystalline form by Dr. Shantz and adapted for clinical use by Dr. Scott [5]. In the 1970s, after promising results from preclinical trials, Dr. Alan Scott conducted clinical trials to assess the effects of BoNT-A as a nonsurgical treatment of strabismus [6]. Botulinum toxin type A was first approved in 1979 by the US Food and Drug Administration (FDA) for treatment of strabismus

D. Hexsel (*) Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil Hexsel Dermatologic Clinics, Porto Alegre/Rio de Janeiro, RS/RJ, Brazil e-mail: [email protected] F. Camozzato · C. Siega Brazilian Center for Studies in Dermatology, Porto Alegre, RS, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_25

[5] and was subsequently approved in 1989 for treating hemifacial spasm and blepharospasm. The cosmetic use of BoNT-A was first reported by Carruthers and Carruthers in 1992 [7], who have, afterward, extensively studied and expanded cosmetic indications [6]. The improvement in facial rhytids on the upper face, around the sites injected to treat hemifacial spasm and blepharospasm, led to the development of the technique to treat glabellar lines. Approximately 10 years later, the cosmetic treatment for glabellar hyperkinetic lines with onabotulinumtoxin A was approved by the Food and Drug Administration in the USA and by other surveillance health authorities from different countries. It represents one of the most important contributions to the approach for the aging face in recent years.

25.2 Botulinum Toxin Types Clostridium botulinum is an anaerobic, gram-­ positive, spore-forming bacillus that produces exotoxins grouped into eight serotypes: A, B, C, D, E, F, G, and H [8]. The latter, however, has been recently described as a chimeric toxin mainly because it was neutralized by available antitoxins, being also denominated as BoNT-FA [9]. Botulinum neurotoxins are 150-kDa proteins composed of a heavy chain (HC—100 kDa) and a light chain (LC—50 kDa). The domain structure is shared by all BoNT serotypes. The heavy chain is 171

172

composed of two functional domains, the receptor binding domain and the translocation domain. The light chain is a zinc metalloprotease that cleaves specific sites of the SNARE complex, blocking the release of acetylcholine in cholinergic nerves. BoNT types A, C, and E cleave the synaptosomalassociated protein (SNAP-25), whereas BoNT types B, D, F, G, and H (or FA) cleave the vesicleassociated membrane protein (VAMP), also known as synaptobrevin II. BoNT type C also cleaves the syntaxin [8]. The blockage of acetylcholine release is reversible, and while active, it promotes a different spectrum of action varying from muscle relaxation to muscular palsy, depending on the subtypes and doses used [8]. In addition, it has been found that the effects of BoNT-A enable not only the muscles’ chemical denervation but also neurologic modulation in sweat glands, leading to reduction or ceasing of sweating in the treated areas [10, 11]. Other effects of BoNTs have been studied and discussed, such as neurologic modulation in sebaceous glands [12], vascular regulation [13], regulation of mood states [14–18], and regulation of the expression levels of genes relevant to invasive growth in keloid fibroblasts [19, 20]. However, no definite elucidation of mechanism of action for each of these indications has been reached up to now. Currently, serotypes A and B are approved for use in humans, but only serotype A is approved for cosmetic use [8]. The BoNT serotype E is under testing in phase II in the USA [21].

25.2.1 Commercial Preparations Different formulations of BoNT-A are available worldwide, which are neither identical nor interchangeable. The commercial formulations of BoNT-A approved for cosmetic indications are onabotulinumtoxin A (ONA; Botox®, Allergan Inc., Irvine, USA); abobotulinumtoxin A (ABO; Dysport®, Ipsen, France; Azzalure® in Europe); and incobotulinumtoxin A (INCO; Merz Pharmaceuticals, Frankfurt, Germany; as Bocouture® in Europe) (Fig. 25.1) [22].

D. Hexsel et al.

Fig. 25.1 Most used commercial preparations of BoNT-A in the cosmetic field

Onabotulinumtoxin A is a homogenous 900-­ kDa complex of BoNT-A and nontoxic proteins, purified through ethanol precipitation and crystallization. Abobotulinumtoxin A is a 500–900-­ kDa heterogeneous complex of neurotoxin and protein that is purified through an ion-exchange process. And INCO is a homogenous solution of 150-kDa BoNT-A, purified through ion exchange and pH elution free from complexing proteins. The dose of BoNT-A is measured in units of biological activity (U), which is verified in animal models. The units of different products are not equivalent, but proportional doses between different products can be established to obtain similar results. A dose equivalence of up to 1:2.5  U between ONA or INCO and ABO is adopted by the most experienced physicians when using different products, as supported by the literature [23–25]. Injections of ONA and ABO at the dose equivalence of 1:2 U can also be used, as it results in similar fields of muscular and anhidrotic effects [24]. Most researchers support the dose equivalence between ONA and INCO around 1:1 [26–28]. Diffusion or the fields of anhidrotic and muscular effects are considered to be a dose-dependent effect rather than related to intrinsic characteristics of each product [29]. By using a proper dose equivalence, all the mentioned products can produce similar results in terms of duration and field of muscular and anhidrotic effects.

25  Introduction: What Is Botulinum Toxin?

25.3 Before and After Successful outcomes depend mainly on the physicians’ knowledge of facial anatomy, skill, and proper doses and technique. The aging process in the mid- and lower face is more associated with volumetric changes, more sagging, fat and skin atrophy, and laxity [30], while dynamic wrinkles are predominant in the upper face (Figs. 25.2 and 25.3). Moreover, gender and ethnic features, as well as patients’ preferences, have to be considered to reach optimal results [31–33]. Fig. 25.2 (a) Glabellar lines at baseline and (b) 2 weeks after treatment. Stronger glabellar muscles may require high doses

Fig. 25.3 (a) Upper forehead lines at baseline and (b) 2 weeks after treatment. The treatment is tailored according to each patient’s characteristics and needs

Fig. 25.4 (a) Mild asymmetric smile before and (b) 2 weeks after treatment with BoNT-A. The right side was treated with 2.5 U of ABO injected in a single point 1 cm laterally to the nasal ala

a

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Currently, the trend in rejuvenation with BoNT-A comprises the use of lower doses and techniques to deliver natural results (Figs. 25.4 and 25.5), avoiding complete paralysis of facial muscles [31, 34]. Indications are cited in Table 25.1. Combined treatments have been considered as a standard approach to obtain facial harmony [35]. The combination of BoNT-A and hyaluronic acid dermal fillers provides optimized outcomes, with better results than BoNT-A alone. Both techniques can be done at the same time [36]. Lasers, radiofrequency, chemical peels,

a

b

a

b

a

b

b

Fig. 25.5 (a) A 34-year-old patient at rest before treatment and (b) the same patient 2 weeks after treatment showing eyebrow repositioning. The treatment of glabellar muscles raises the tail of the brow

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D. Hexsel et al.

Table 25.1  Hyperkinetic lines and other aesthetic indications are treated in three-thirds of the face and also in extrafacial areas Area Indications Upper face Glabellar lines Lateral canthal lines Horizontal forehead lines Middle Infraorbital rhytids face Nasal oblique lines (“Bunny” lines) Nasal tip elevation Lower face Perioral rhytids Gummy smile Asymmetric smile Masseter overactivity Mentalis overactivity Mandibular contour or “Nefertiti lift” Extrafacial Platysmal bands Décolleté lines Leg contour (hypertrophy of the gastrocnemius muscle)

microdermabrasion, microneedling, and other superficial techniques can be used to improve results. The authors recommend the use of these techniques and the toxins at different times. The “microbotox” or “microtoxin” technique consists in delivering multiple intradermal or subdermal injections of very small doses of BoNT-A into the overlying skin and superficial layer of the facial and neck muscles [37]. It can be used to treat some aesthetic conditions, including fine lines, mild neck laxity, rosacea, and oily skin [12, 13, 37–40]. It can also slightly treat muscles that cannot be paralyzed. Recently, the treatment of keloids and hypertrophic scars with BoNT-A was reported. Results are controversial, and more evidence is needed to support its efficacy [41–44].

25.4 S  ide Effects, Complications, and How They May Be Managed Although BoNT-A injections for cosmetic use have a well-described safety profile [45, 46], side effects may occur. In general, they occur within the first few days following injection and are usually transitory. Since most of the studies assess the aesthetic effects of BoNT-A in the upper face, most frequently reported side effects concern the upper face such as headache, eye disorder, eyelid

Fig. 25.6  Erythema and edema may occur at the injection sites. They are transitory and resolve within a few hours

ptosis, and heavy eyelids [46]. The majority of the side effects can be avoided by using the consensus doses [31, 47, 48] and injection sites described in the literature, also considering the patient anatomy and the desired results. Side effects can be considered cosmetic and non-cosmetic. Whereas non-cosmetic side effects can be related to the technique, the injections, or the product, cosmetic side effects are most of the times technique related. Cosmetic side effects are related to unnatural look, an undesirable anatomic position of a facial structure or asymmetric, unwanted movements.

25.4.1 Non-cosmetic Side Effects As expected for any injection procedure, pain, discomfort, burning, erythema, edema, pruritus, and bruising may be observed (Fig. 25.6) [22, 45]. Topical anesthetics, small gauge needles, cooler systems, and cold compress [49] can be used to minimize pain and bruising. These side effects are expected and resolve within a few days. Hematomas and ecchymosis (Fig. 25.7) also can occur after any injection procedure. They can be prevented with more superficial injections and can be controlled by compression of the treated area for a few minutes when reaching a vessel. Avoiding the use inhibitors of platelet aggregation for at least 7  days before treatment prevents the formation of hematomas and ecchymosis. Paresthesia and dysesthesia in the treatment area are infrequent and may be produced by

25  Introduction: What Is Botulinum Toxin?

175

was generally higher among conditions usually treated with higher BoNT doses [51]. BoNT-A treatment for cosmetic indications is associated with a low rate of NAb formation [51, 52]. The use of the lowest effective doses, waiting for at least 16 weeks between treatments and avoiding frequent touch-ups, may prevent BoNT-A clinical non-responsiveness [52]. Blepharoptosis is usually unilateral and characterized by a 2–3 mm lowering of the affected upper eyelid. It may appear 2–10 days after the Fig. 25.7  Ecchymosis may also occur at the injection injections, lasting for up to 40  days [45]. This sites. This side effect is transitory and resolves spontane- side effect is caused by spread of the toxin ously within a few days injected at the glabellar region through the orbital septum fascia to the levator palpebrae nerve trauma. Infections are rare and can be pre- superioris. The incidence of this side effect can vented by skin antisepsis. be reduced by injecting BoNT-A at least 1  cm Headache is a common side effect after above the supraorbital ridge, using a small volBoNT-A treatment of the upper face [45, 46, 50]. ume to reconstitute the products and avoiding It is usually mild and spontaneously resolves excessive manipulation of the area. within a few days after injection. There are Blepharoptosis can be treated using ophthalmic reports of idiosyncratic severe headaches lasting solutions with alpha-adrenergic effects, such as 2–4  weeks. Headaches are managed based on apraclonidine 0.5% (Iopidine®). severity with analgesic, nonsteroidal anti-­ Brow ptosis or heavy eyelids is associated inflammatory drugs, or opioids. with overtreatment of the frontalis muscle. This Allergic reactions or immediate hypersensi- side effect is temporary and spontaneously tivity, although rare, may occur. Care should be resolves as BoNT-A effects diminish, with no taken with drugs that may potentiate BoNT-A additional treatment required. effects such as aminoglycosides, quinidine, antiDiplopia or double vision is uncommon and cholinergics, and muscle relaxants. may occur when injections are close to the ocular More severe side effects due to distant spread globe with consequent paralysis of the lateral of BoNT-A have been reported with large doses rectus muscle. and include generalized muscle weakness, dysIn the lower face, undesirable paralysis in the phagia, dysarthria, dysphonia, and respiratory musculature can occur if high doses of BoNT-A difficulties. are used, leading to incompetence of the sphincClinical non-responsiveness to BoNT-A is ter of the mouth, asymmetries, and impaired rare. It may be primary, due to individual factors, muscular support of the lower face [31]. The lowerrors related to drug preparation or administra- est efficacious doses and low volumes of BoNT-A tion, improper muscle selection, inadequate should be used in the lower face indications [53]. doses per injection site or area, or secondary to The most common side effects in the treatment of antibody formation after BoNT-A injections. A the neck are dysphagia, difficulties in flexing the recent meta-analysis [51] showed that the fre- neck, and dry mouth [31]. quency of neutralizing antibodies (NAbs) was higher in secondary non-responsive patients compared with clinically responsive patients. 25.4.2 Cosmetic Side Effects However, almost half of secondary non-­ responsive patients did not have NAbs, suggest- Frozen look or mask appearance of the face after ing other factors rather than NAbs that may cause BoNT-A treatment was quite common in the past non-responsiveness. Moreover, NAb frequency decades. Currently, the natural look of the

D. Hexsel et al.

176 Fig. 25.8 (a) Brow position before BoNT-A treatment and (b) excessive brow elevation after BoNT-A treatment. This cosmetic side effect can be resolved with a touch-up

a

patients is targeted by most of the experienced physicians. The use of low doses and partial treatment of some facial muscles, especially the frontalis muscle, may be the best option for some patients. These simple measures provide a more natural look. Excessive brow elevation (Fig.  25.8) can be avoided with an injection point at the lateral part of the frontalis muscle or at the middle pupillary line, 1  cm above the eyebrow. Excessive elevation of the malar region occurs due to injection points placed in the lower lateral parts of orbicularis oculi muscles. This is a risky area, as the effects might target the zygomaticus major muscle and provoke the drooping of mouth corners. The “Botox sign” is produced by the excessive recruitment of the nasalis muscle when a patient smiles, after BoNT-A treatment of the upper third of the face. The treatment of the nasalis muscle is recommended when treating glabellar and frontalis muscles for patients who already present these lines before treatment. Changes in the gender features give an unnatural look to patients. Toxin injections in the glabella can change the brow shape and position, giving a feminine look to male patients, with arched eyebrows or excessive elevation of the tail of the brow [33]. They can be avoided by keeping the original position and avoiding excessive elevation with linear injections of BoNT-A in frontalis muscle in men.

25.5 Conclusions More than 20 years of cosmetic use of BoNT-A consolidate it as a safe, predictable, and very effective treatment for a number of cosmetic facial and extrafacial indications. Side effects are

b

mild to moderate and usually transitory. Currently, the trend in aesthetic treatments with BoNT-A comprises the use of proper doses and techniques, giving natural results. Combinations with fillers and other procedures should also be considered for better cosmetic results.

Tip Box

• Clostridium botulinum is an anaerobic, gram-positive, spore-forming bacillus that produces exotoxins grouped into eight serotypes: A, B, C, D, E, F, G, and H. • BoNT-A blocks the release of acetylcholine causing muscles’ chemical denervation and also neurologic modulation in sweat glands, leading to relaxation of muscles and decreasing sweating in the treated areas. • Different formulations of BoNT-A are available worldwide; they are not interchangeable although are equally efficient. • The three main commercial formulations of BoNT-A approved for cosmetic indications are onabotulinumtoxin, abobotulinumtoxin A, and incobotulinumtoxin A. • BoNT-A is an effective treatment to enhance facial beauty by modulating facial muscle activity. • BoNT-A remains the gold-standard treatment for upper facial dynamic wrinkles and presents benefits for some indications at middle and lower facial wrinkles.

25  Introduction: What Is Botulinum Toxin?

• BoNT-A injection is a minimally invasive surgical procedure with good safety and tolerability profiles in aesthetic indications. • The potential side effects are usually transitory, and their incidence can be minimized with proper patient selection, techniques, and doses.

References 1. Lamanna C, McElroy OE, Eklund HW. The purification and crystallization of clostridium botulinum type A toxin. Science. 1946;103(2681):613–4. 2. Kegeles G. The molecular size and shape of botulinus toxin. J Am Chem Soc. 1946;68:1670. 3. Putnam FW, Lamanna C, Sharp DG.  Molecular weight and homogeneity of crystalline botulinus A toxin. J Biol Chem. 1946;165(2):735. 4. Putnam FW. Physical chemical properties of crystalline botulinus A toxin. Fed Proc. 1947;6(1 Pt 2):284. 5. Scott AB, Rosenbaum A, Collins CC. Pharmacologic weakening of extraocular muscles. Investig Ophthalmol. 1973;12:924–7. 6. Carruthers A, Carruthers J. You want to inject what? Dermatol Surg. 2015;41(Suppl 1):S2–8. 7. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol. 1992;18:17–21. 8. Peck MW, Smith TJ, Anniballi F, et  al. Historical perspectives and guidelines for botulinum toxins neurotoxin subtype nomenclature basel. Toxins. 2017;9(1):pii: E38. 9. Pellett S, Tepp WH, Bradshaw M, et al. Purification and characterization of botulinum neurotoxin FA from a genetically modified clostridium botulinum strain. mSphere. 2016;1(1):pii: e00100–15. 10. Shelley WB, Talanin NY, Shelley ED.  Botulinum toxin therapy for palmar hyperhidrosis. J Am Acad Dermatol. 1998;38(2 Pt 1):227–9. 11. Schnider P, Binder M, Auff E, Kittler H, Berger T, Wolff K. Double-blind trial of botulinum A toxin for the treatment of focal hyperhidrosis of the palms. Br J Dermatol. 1997;136(4):548–52. 12. Li ZJ, Park SB, Sohn KC, et al. Regulation of lipidproduction by acetylcholine signalling in human sebaceous glands. J Dermatol Sci. 2013;72(2):116–22. 13. Khan TT, Herne K, Dayan SH, Woodward JA. Facial blanching due to neurotoxins: proposed mechanisms. Dermatol Surg. 2013;39(1 Pt 1):24–9. 14. Finzi E, Rosenthal NE. Treatment of depression with onabotulinumtoxinA: a randomized, double-blind, placebo controlled trial. J Psychiatr Res. 2014;52:1–6.

177 15. Heckmann M, Teichmann B, Schröder U, Sprengelmeyer R, Ceballos-Baumann AO. Pharmacologic denervation of frown muscles enhances baseline expression of happiness and decreases baseline expression of anger, sadness, and fear. J Am Acad Dermatol. 2003;49(2):213–6. 16. Hexsel D, Brum C, Siega C, et  al. Evaluation of self-esteem and depression symptoms in depressed and nondepressed subjects treated with onabotulinumtoxinA for glabellar lines. Dermatol Surg. 2013;39(7):1088–96. 17. Magid M, Reichenberg JS, Poth PE, et  al. Treatment of major depressive disorder using botulinum toxin A: a 24-week randomized, doubleblind, placebo-­ controlled study. J Clin Psychiatry. 2014;75(8):837–44. 18. Wollmer MA, de Boer C, Kalak N, et  al. Facing depression with botulinum toxin: a randomized controlled trial. J Psychiatr Res. 2012;46(5):574–81. 19. Xiao Z, Zhang M, Liu Y, Ren L. Botulinum toxin type a inhibits connective tissue growth factor expression in fibroblasts derived from hypertrophic scar. Aesthet Plast Surg. 2011;35(5):802–7. 20. Xiaoxue W, Xi C, Zhibo X. Effects of botulinum toxin type A on expression of genes in keloid fibroblasts. Aesthet Surg J. 2014;34(1):154–9. 21. ClinicalTrials.gov [Internet]. Bethesda (MD): National Library of Medicine (US). 2000 Feb 29  – Identifier NCT02939326, Evaluate safety and efficacy of a single treatment cycle of EB-001 in subjects with Glabellar Frown Lines; 2016 Oct 11 [cited 2017 Aug 21]; [about 5 screens]. Available from: https://clinicaltrials.gov/ct2/show/study/NCT02939326?term=bo nti&rank=2. 22. Dessy LA, Fallico N, Mazzocchi M, Scuderi N.  Botulinum toxin for glabellar lines: a review of the efficacy and safety of currently available products. Am J Clin Dermatol. 2011;12(6):377–88. 23. Karsai S, Raulin C.  Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology. Dermatol Surg. 2009;35(1):1–8. 24. Hexsel D, Brum C, do Prado DZ, et al. Field effect of two commercial preparations of botulinum toxin type A: a prospective, double-blind, randomized clinical trial. J Am Acad Dermatol. 2012;67(2):226–32. 25. Carruthers J, Fournier N, Kerscher M, Ruiz-Avila J, Trindade de Almeida AR, Kaeuper G.  The convergence of medicine and neurotoxins: a focus on botulinum toxin type A and its application in aesthetic medicine--a global, evidence-based botulinum toxin consensus education initiative: part II: incorporating botulinum toxin into aesthetic clinical practice. Dermatol Surg. 2013;39(3 Pt 2):510–25. 26. Dressler D. Comparing Botox and Xeomin for axillar hyperhidrosis. J Neural Transm. 2010;117:317–9. 27. Dressler D, Mander G, Fink K. Measuring the potency labelling of onabotulinumtoxinA (Botox®) and incobotulinumtoxinA (Xeomin®) in an LD50 assay. J Neural Transm (Vienna). 2012;119(1):13–5.

178 28. Sattler G, Callander MJ, Grablowitz D, et  al. Noninferiority of incobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabellar frown lines. Dermatol Surg. 2010;36:2146–54. 29. Hexsel D, Hexsel C, Siega C, Schilling-Souza J, Rotta FT, Rodrigues TC.  Fields of effects of 2 commercial preparations of botulinum toxin type A at equal labeled unit doses: a double-blind randomized trial. JAMA Dermatol. 2013;149(12):1386–91. 30. Fagien S, Raspaldo H. Facial rejuvenation with botulinum neurotoxin: an anatomical and experiential perspective. J Cosmet Laser Ther. 2007;9(Suppl 1): 23–31. 31. Sundaram H, Signorini M, Liew S, et  al. Global aesthetics consensus: botulinum toxin Type A--evidence-based review, emerging concepts, and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 2016;137(3):518e–29e. 32. Sundaram H, Huang PH, Hsu NJ, et  al. Aesthetic applications of botulinum toxin A in Asians: an international, multidisciplinary, Pan-Asian consensus. Plast Reconstr Surg Glob Open. 2016;4(12):e872. 33. de Maio M. Ethnic and gender considerations in the use of facial injectables: male patients. Plast Reconstr Surg. 2015;136(5 Suppl):40S–3S. 34. Dayan SH, Ashourian N.  Considerations for achieving a natural face in cosmetic procedures. JAMA Facial Plast Surg. 2015;17(6):395. 35. Sundaram H, Liew S, Signorini M, et al. Global aesthetics consensus: hyaluronic acid fillers and botulinum toxin type A-recommendations for combined treatment and optimizing outcomes in diverse patient populations. Plast Reconstr Surg. 2016;137(5): 1410–23. 36. Carruthers A, Carruthers J, Monheit GD, Davis PG, Tardie G.  Multicenter, randomized, parallel-group study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/mL Smooth, Cohesive Gel) alone and in combination for lower facial rejuvenation. Dermatol Surg. 2010;36:2121–34. 37. Wu WT. Microbotox of the lower face and neck: evolution of a personal technique and its clinical effects. Plast Reconstr Surg. 2015;136(5 Suppl):92S–100S. 38. Steinsapir KD, Rootman D, Wulc A, Hwang C.  Cosmetic microdroplet botulinum toxin A forehead lift: a new treatment paradigm. Ophthal Plast Reconstr Surg. 2015;31(4):263–8. 39. Bloom BS, Payongayong L, Mourin A, Goldberg DJ.  Impact of intradermal abobotulinumtoxinA on facial erythema of rosacea. Dermatol Surg. 2015;41(Suppl 1):S9–16. 40. Rose AE, Goldberg DJ. Safety and efficacy of intradermal injection of botulinum toxin for the treatment of oily skin. Dermatol Surg. 2013;39(3 Pt 1):443–8.

D. Hexsel et al. 41. Jeong HS, Lee BH, Sung HM, et  al. Effect of botulinum toxin type A on differentiation of fibroblasts derived from scar tissue. Plast Reconstr Surg. 2015;136(2):171e–8e. 42. Shaarawy E, Hegazy RA, Abdel Hay RM. Intralesional botulinum toxin type A equally effective and better tolerated than intralesional steroid in the treatment of keloids: a randomized controlled trial. J Cosmet Dermatol. 2015;14(2):161–6. 43. Prodromidou A, Frountzas M, Vlachos DE, et  al. Botulinum toxin for the prevention and healing of wound scars: a systematic review of the literature. Plast Surg (Oakv). 2015;23(4):260–4. 44. Haubner F, Leyh M, Ohmann E, Sadick H, Gassner HG.  Effects of botulinum toxin A on patient-­ specific keloid fibroblasts in  vitro. Laryngoscope. 2014;124(6):1344–51. 45. Cavallini M, Cirillo P, Fundarò SP, et  al. Safety of botulinum toxin A in aesthetic treatments: a systematic review of clinical studies. Dermatol Surg. 2014;40(5):525–36. 46. Jia Z, Lu H, Yang X, et  al. Adverse events of botulinum toxin type A in facial rejuvenation: a systematic review and meta-analysis. Aesthet Plast Surg. 2016;40(5):769–77. 47. Ascher B, Talarico S, Cassuto D, et al. International consensus recommendation on the aesthetic usage of botulinum toxin type A (Speywood unit)--part I: upper facial wrinkles. J Eur Acad Dermatol Venereol. 2010;24(11):1278–84. 48. Ascher B, Talarico S, Cassuto D, et al. International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)-Part II: Wrinkles on the middle and lower face, neck and chest. J Eur Acad Dermatol Venereol. 2010;24(11):1285–95. 49. Hexsel DM, Dal Forno T, Soirefmann M, Porto MD, Hexsel CL.  Effective, low-cost, simple, disposable cooling tool for patient comfort in common dermatologic procedures. Dermatol Surg. 2013;39(9):1402–4. 50. Carruthers J, Rivkin A, Donofrio L, et  al. A multicenter, randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of repeated onabotulinumtoxinA treatments in subjects with Crow’s Feet Lines and Glabellar Lines. Dermatol Surg. 2015;41(6):702–11. 51. Fabbri M, Leodori G, Fernandes RM, et  al. Neutralizing antibody and botulinum toxin therapy: a systematic review and meta-analysis. Neurotox Res. 2016;29(1):105–17. 52. Naumann M, Boo LM, Ackerman AH, Gallagher CJ.  Immunogenicity of botulinum toxins. J Neural Transm (Vienna). 2013;120(2):275–90. 53. Cohen JL, Dayan SH, Cox SE, Yalamanchili R, Tardie G.  OnabotulinumtoxinA dose-ranging study for hyperdynamic perioral lines. Dermatol Surg. 2012;38(9):1497–505.

Tip Chapter: Histology and Physiology of the Skin

26

Renata Joffe, Jose A. Plaza, and Armineh Kajoian

26.1 Epidermis

26.2 Keratinocytes

The epidermis is the outermost layer of the skin. It is a stratified, squamous epithelium layer composed primarily of two types of cells: keratinocytes, melanocytes, Langerhans cells, and Merkel cells, but keratinocytes constitute the major cell population of the epidermis (80%). The epidermis commonly is divided into four layers according to keratinocyte morphology and position: the basal cell layer (stratum germinativum), the squamous cell layer (prickle cell or stratum spinosum), the granular cell layer (stratum granulosum), and the cornified or horny cell layer (stratum corneum) [1, 2]. The last three layers that constitute the living, nucleated cells of the epidermis are sometimes referred to as the stratum malpighii and rete malpighii [2]. The epidermis is a continually renewing layer and gives rise to derivative structures, such as pilosebaceous apparatus, nails, and sweat glands. The basal cells of the epidermis undergo a vertically oriented proliferation cycle that helps in the renewal of the outer epidermis.

Approximately 85% of cells in the epidermis are the ectodermally derived keratinocytes, which are cells that produce keratin. The differentiation process that occurs as the cells migrate from the basal layer to the surface of the skin is called keratinization. This process occurs for a period of about 14  days, where the epidermal keratinocytes are transformed from undifferentiated basal cells to fully differentiated cornified cells. The keratinocyte first passes through a synthetic and then a degradative phase [3]. In the synthetic phase, the cell builds up a cytoplasmic supply of keratin, a fibrous intermediate filament arranged in an alpha-helical coil pattern that serves as part of the cell cytoskeleton. Bundles of these keratin ­filaments converge on and terminate at the plasma membrane, thereby forming the intercellular attachment plates known as desmosomes. During the degradative phase of keratinization, cellular organelles are lost, the contents of the cell are consolidated into a mixture of filaments and amorphous cell envelopes, and, finally, the cell is known as a horny cell or a corneocyte. The process of maturation resulting in cell death is known as terminal differentiation [1].

R. Joffe (*) · J. A. Plaza · A. Kajoian Inform Diagnostics, Irving, TX, USA © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_26

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26.2.1 Basal Layer The basal layer, also known as the stratum germinativum, consists of a single layer of cuboidal/columnar keratinocytes that attach to the basement membrane zone with their long axis perpendicular to the dermis. These basal cells adhere to one another and to more superficial squamous cells through desmosomal junctions [2]. The basal layer is the primary location of mitotically active cells in the epidermis that give rise to cells of the outer epidermal layers. Kinetic studies demonstrate that the basal cells of the epidermis include three populations: stem cells, transit-­amplifying cells, and the committed cells. Stem cells Transit-­ amplifying cells Committed cells

Undifferentiated cells with unlimited capacity for cell division Cells with a limited capacity for mitosis before becoming committed to terminal differentiation Cells that have irreversibly lost their capacity to divide and progress along keratinization pathways

Migration of a basal cell from the basal layer to the cornified layer in humans takes at least 14  days, and the transit through the cornified layer to the outermost epidermis requires another 14 days.

26.2.2 Squamous Cell Layer The squamous cell layer or stratum spinosum overlies the basal cell layer and has a thickness of typically 5–10 cells [2]. The keratinocytes located immediately above the basal layer have a polyhedral shape and a rounded nucleus, whereas the ones present in the upper spinous layers have a generally larger size, become flatter as they are pushed toward the surface of the skin, and contain lamellar granules [3]. The granules are membrane-­ bound organelles containing glycoproteins, glycolipids, phospholipids, free sterols,

and a number of acid hydrolases including lipases, proteases, acid phosphatases, and glycosidases. Although the lamellar granules are primarily active in cells at the interface between the granular and cornified layers, they also function in cells of the upper spinous layer to deliver precursors of stratum corneum lipids into the intercellular space [4]. Intercellular spaces between spinous cells are bridged by numerous desmosomes, which promote a mechanical connection between cells of the epidermis and provide resistance to physical stresses. The spine-like appearance of the numerous desmosomes along cell margins is where the stratum spinosum derives its name [3]. Gap junctions are another type of connection between epidermal cells. These junctions allow for physiologic communication through chemical signals, which is vital in the regulation of cell metabolism, growth, and differentiation [5].

26.2.3 Granular Layer The granular layer, or stratum granulosum, is composed of flattened cells containing abundant keratohyalin granules in their cytoplasm. These cells are responsible for further synthesis and modification of proteins involved in keratinization [3]. The granular layer varies in thickness in proportion to that of the overlying horny cell layer. For example, under thin cornified layer areas, the granular layer may have thickness of only 1–3 cell layers, whereas under the palms of the hands and soles of the feet, the granular layer may have a tenfold thickness as the above-­ mentioned areas. The keratohyalin granules are deeply basophilic and have irregular shape and size, and they are necessary in the formation of both the interfibrillary matrix, which holds keratin filaments together, and the inner lining of the horny cells. Lysosomal enzymes are found at high levels in the stratum granulosum because the granular layer is a keratogenous zone of the epidermis.

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26.2.4 Cornified Layer

26.3 Melanocytes

The cornified layer comprising horny cells (corneocytes) is the most superficial layer of the epidermis. It provides mechanical protection to the underlying epidermis and acts as a barrier to prevent water loss and invasion by foreign substances [6]. The corneocytes, which are rich in protein and low in lipid content, are surrounded by a continuous extracellular lipid matrix [3]. The large, flat, polyhedral-shaped horny cells have lost their nuclei during terminal differentiation and are technically considered to be dead [2, 3]. The physical and biochemical properties of cells in the cornified layer vary in accordance with position in order to promote desquamation, with the cells moving outward. For instance, cells in the middle layers have a much higher capacity for water binding than those in the deeper layers because of the high concentration of free amino acids found in the cytoplasm of middle-layer cells. The deeplayer cells also are more densely compact and display a greater array of intercellular attachments than the more superficial layers. Desmosomes undergo proteolytic degradation as the cells progress outward, thus contributing to the shedding of corneocytes during desquamation [4].

With a neural crest origin, the melanocyte is a dendritic, pigment-synthesizing cell confined predominantly to the basal layer and the hair bulb in the skin [3]. Melanocytes come into contact with keratinocytes but do not form cellular junctions. The function of melanocytes is the production of the pigment melanin and its transfer to keratinocytes. The ratio of melanocytes to basal cells is 1:4–1:9 and varies with anatomic location on the body. Melanin varies in color from yellow to brown or black and accounts for the various skin colors within and among races. It is produced in a rounded, membrane-bound organelle known as the melanosome. Melanin is thought to protect the mitotically active basal epidermal cells from the damaging effects of ultraviolet light. Increased ultraviolet light exposure stimulates an increase in melanogenesis and a corresponding increase in melanosomes, which are transported through the dendritic processes of the melanocytes and transferred to the keratinocytes. This response, which results in the tanning of the skin, increases the ability of the cell to absorb light and thus protect genetic information in the nucleus from harmful radiation (Figs. 26.1 and 26.2).

Fig. 26.1  Histology of the normal epidermis and dermis (arm skin). (H&E 4x)

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182 Fig. 26.2  Histology of acral skin showing thickened stratum corneum (hyperkeratosis) and thickened stratum granulosum (hypergranulosis). (H&E 10x)

26.4 Langerhans Cells

26.5 Merkel Cells

Langerhans cells are intraepidermal antigen-­ processing cells involved in a variety of T-cell-­ mediated immunoreactions. Derived from the bone marrow, these cells are distributed among the squamous and granular layers with fewer cells in the basal layer. They are found in other squamous epithelia in addition to the epidermis, including the oral cavity, esophagus, and vagina, as well as in lymphoid organs and in the normal dermis. Langerhans cells are characterized by their dendritic processes, which extend between the keratinocytes extending from the granular cell layer to the dermal-epidermal junction. The cells do not form cellular junctions with neighboring cells given the absence of desmosomes and tonofilaments. Langerhans cells recognize and process soluble antigens found in the epidermal tissue and participate in delayed hypersensitivity and skin allograft reactions. In addition to mediating T-cell responses, Langerhans cells also appear to play a role in extrathymic T-lymphocyte maturation and intraepidermal differentiation [7].

Merkel cells are oval-shaped, slow-adapting, type I mechanoreceptors located in the basal layer of the epidermis, hair follicular epithelium, and mucous membranes. Their precise origin remains unknown; however, they appear to represent a modified keratinocyte with neuroendocrine features. They are present in sites of high tactile sensitivity such as digits, palms, lips, hard palate, proximal nail folds, and dorsum of the feet. Merkel cells have been shown to increase in number in sun-damaged skin. In addition to their mechanoreceptor function, Merkel cells may play a primary role in the induction of subepidermal and perifollicular nerve plexuses.

26.6 Dermoepidermal Interface The interface between the epidermis and dermis is formed by a porous basement membrane zone. It consists of a glycoprotein matrix consisting of collagen, reticulin, and fine elastic fibers, which is highlighted by a periodic acid-Schiff (PAS) stain. The basement membrane zone continues

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around all the epidermal appendages. This layer allows the exchange of cells and fluid and holds the two layers together [1]. It has been divided into four zones: Cytoskeleton Hemidesmosomes and plasma membrane of basal keratinocytes that compose the upper border of the interface Lamina Layer synthesized by basal cells of the lucida epidermis consisting mainly of type IV collagen as well as anchoring fibrils and dermal microfibrils Lamina Layer situated below the lamina lucida densa and above the papillary dermis Sublamina Located immediately below the lamina densa densa and consisting of the uppermost portion of the papillary dermis

Structural components of these four zones are responsible for binding the epidermis to the dermis. The dermal-epidermal junction not only acts as a support for the epidermis but also establishes cell polarity and direction of growth, directs the organization of the cytoskeleton in basal cells, provides developmental signals, and functions as a semipermeable barrier between layers [8].

26.7 Hair Follicles Hair follicles are found on all body surfaces except the palms and soles. Although the most important roles of the hair are providing protection from the elements and distributing sweat gland products, it has a prominent psychosocial role in social interactions. Variation in size, shape, number, and distribution of hair follicles across the body is dependent on anatomic location, race, and sex. Deep-seated anagen hairs are noted in the scalp of both sexes as well as the beard region of men. In areas such as extremities and trunk, the follicles are more superficially located with decreased density of hair. In addition, variation exists in rate of growth and response to stimuli such as sex hormones. Eyebrows and eyelashes, for example, are not stimulated by sex hormones, whereas

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during puberty, the hairs of the axilla, face, and pubic area are highly affected by such hormones. The number of hair follicles is determined during fetal development as are the phenotype and distribution of the follicles. During embryogenesis, the basophilic cells of the epidermis, located within the basal layer, undergo induction to eventually develop into a mature follicle [2]. The melanosome distribution determines the hair color of an individual. These melanosomes are located within the hair bulb. Larger melanosomes are found in individuals of African descent and smaller ones in Caucasians. As individuals age, there is a decrease/loss of these melanosomes, which results in gray hair [1]. The hair follicle is composed of three regions: • The upper segment (infundibulum) which extends from the epidermis to the insertion of the sebaceous duct. • The middle segment (isthmus) which extends from the sebaceous duct to the insertion of the arrector pili muscle. • The deep segment (bulb and suprabulb) which extends from the insertion of the arrector pili muscle to the base of the follicle. This portion contains the hair papilla, the matrix, the hair shaft, and the inner and outer root sheaths. This segment undergoes different hair cycles, whereas the other components are permanent [5]. The hair bulb, the rounded and the most inferior portion of the follicle, includes the hair matrix and the dermal papilla. The bulb contains undifferentiated cells, also known as the hair matrix. In association with the papillae, the hair shaft is formed by keratinization of the matrix cells that also provide the pigment for the hair shaft. The hair shaft has a central medulla and an outer cortex, both of which are covered by a cuticle. The inner and outer root sheaths are concentric layers surrounding and supporting the developing hair shaft. The outer root sheath is surrounded by the vitreous layer, which is enveloped by the fibrous root sheath [9].

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The hair cycle is divided into three phases (anagen, catagen, and telogen). • Anagen is an active growth phase. The hair grows approximately 0.33  mm per day. The length of this phase may vary due to age and the presence of alopecia [1]. • The catagen cycle is the involuting phase in which the follicle undergoes regression secondary to apoptosis (club hair formation) with a reduction in the hair diameter. • The telogen is a resting phase in which the hair does not grow. Approximately 84% of scalp hairs are in the anagen phase, 1–2% are in the catagen phase, and 10–15% are in the telogen phase (Fig. 26.3). Fig. 26.3  Histology of a normal hair follicle with attached sebaceous gland. (H&E 4x)

Anagen Length of cycle 3–4 years (scalp) Growth type Active growth

Catagen Telogen 2–3 weeks 3–4 months Involuting Resting

26.8 Sebaceous Glands Sebaceous glands are present throughout the body with several exceptions, including the tarsal plate of the eyelids, the mucosa of the oral cavity, the labia minora, the vermilion borders of the lips, and the mucosa lateral to the penile frenulum [6]. Regional variation is present with the face/scalp containing numerous glands. Sebaceous glands are mature at the time of delivery and during the

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perinatal period as a result of maternal hormones. They undergo involution during childhood and develop again during puberty due to the presence of androgens. Histologically, they are holocrine glands with uni- or multilobulated structures. These lobules lead to an excretory duct within the follicle. Each lobule consists of a peripheral cuboidal layer of basophilic cells. As these cells mature toward the center of the lobule, they accumulate lipid droplets, which gives the cytoplasm a vacuolar appearance. The cell cycle ends as the sebum, lipid contents of the cell, is excreted into the hair follicle. This oily, lipid-rich secretion functions as an emollient for the hair and skin (Fig. 26.4) [9].

26.9 Eccrine Glands The eccrine glands are true sweat glands, as they produce colorless and odorless sweat composed of water and electrolytes. They are involved in thermoregulation and are found in higher concentrations in the axilla, palms, soles, and forehead. The eccrine gland has three parts: • The intraepidermal duct or acrosyringium, which extends into the epidermis from the rete

Fig. 26.4  Histology of a normal sebaceous gland and duct. (H&E 10x)

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ridges in a spiral fashion and opens onto the skin surface. • The intradermal duct is composed of basophilic cuboidal cells and has a thickness of one to two cell layers. • The secretory portion of the gland is located in the deep reticular dermis and is usually surrounded by fat. The glands are composed of clear cells, dark cells, and an outer layer of myoepithelial cells (Fig. 26.5).

26.10 Apocrine Glands The apocrine glands are found in areas abundant in hair follicles, such as the axillae, anogenital area, the mammary region, eyelids, periumbilical region, the external ear canal, scrotum, and labia minora. Some authorities consider the breast as a specific type of apocrine gland due to the presence of decapitation secretion and its histopathologic similarities to apocrine glands at other sites. Apocrine glands are small and nonfunctional until puberty, at which time they enlarge and begin to secrete their product. Some authors believe that the apocrine glands are involved in scent release [2].

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Apocrine glands, like eccrine glands, have three parts and are always connected to a follicular structure: • The intraepidermal/intrafollicular duct is straight and not spiral as an acrosyringium and opens into the infundibulum above the sebaceous duct. • The intradermal duct, which has a double layer of basophilic cells. Fig. 26.5  Cross section of normal eccrine glands showing a single layer of secretory cells. (H&E 40x)

Fig. 26.6 Apocrine gland showing decapitation-like secretion and dilated lumens. (H&E 40x)

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• The secretory portion, which is much larger than the eccrine glands and is located in the subcutaneous fat. It is composed of a single layer of secretory cells (luminal cells) and an outer layer of myoepithelial cells. The luminal cells have an apical cap, which releases the secretions of the cells as part of the cytoplasm. The cells may contain lipid, iron, PAS-­positive granules, and lipofuscin (Fig. 26.6).

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26.11 Cutaneous Nerve System The skin is one of the main anatomic sites of host interaction with the environment; thus, the cutaneous nervous system is constantly responding to various types of stimuli. The cutaneous nerves function in sensory (afferent) and autonomic (efferent) modes. Autonomic nerve fibers (efferent) derive from sympathetic neurons and are confined to the dermis, blood vessels, lymphatic vessels, sweat ducts, and hair follicles. The sensory function (afferent) is mediated by a network of encapsulated (Meissner’s and Pacinian corpuscles) and nonencapsulated receptors. Sensory nerves represent the majority of nerves that innervate the skin. The distribution of receptors is regionally variable and specific with a high ­density in glabrous skin such as labia, areolae, and glans penis. The cutaneous sensory receptors/endings can be classified into two types: the corpuscular and free receptors. The corpuscular receptors are subdivided into encapsulated (located in the dermis) and nonencapsulated (located in the epidermis). Meissner’s corpuscles are responsible for touch and sensation and are located near the crests of the dermal papillae and are particularly concentrated in the dermis of the tips of the fingers and toes and along the palmar and plantar surfaces of the hands and feet, Fig. 26.7 Cutaneous peripheral nerve showing circular to ovoid configuration. The perineurium surrounds the nerve axons. (H&E, 40X)

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r­espectively. These corpuscles consist of layers of flattened laminar cells, which are modified Schwann cells that ramify axon terminals derived from myelinated nerves. Pacinian corpuscles, involved in the sensation of deep pressure and vibration, are the largest encapsulated pressure receptors in the body and are located deep in the reticular layer and the subcutaneous fat of palms, soles, and genitalia. They are ovoid structures measuring 1–2  mm. Pacinian corpuscles are lamellate in cross sections and supplied by a myelinated axon and surrounded by modified Schwann cells [9–12]. By light microscopy, the sensory fibers cannot be distinguished from autonomic fibers. Dermal nerves appear as circular to ovoid structures with undulated appearance. These structures are composed of axons, Schwann cells, and perineurial cells. The Schwann cells can be highlighted by S100; the axons are positive for neuron specific enolase (NSE), peripherin, and neurofilaments; and the perineurial cells are positive for epithelial membrane antigen (EMA). Larger nerves in the subcutis display perineurium and endoneurium; however, small nerve branches in the superficial dermis lack these layers. The small size of these nerve fibers helps one to distinguish them from smooth muscle fascicles, which have a larger size (Fig. 26.7) [13, 14].

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26.12 Cutaneous Vascular and Lymphatic System Cutaneous vessels play an important role in thermoregulation. They originate from either superficial or deep plexus. The superficial plexus is made up of interconnecting arterioles and venules that are located close to the epidermis and in the dermis. The deep plexus is found within the dermis and at the border of the subcutaneous fat and connects vertically to the superficial plexus. In the superficial plexus, capillaries loop into each dermal papilla that comprises terminal arterioles, venous capillaries, and post-capillary venules (which predominates). Larger arteries consist of three layers: an intima layer composed of endothelial cells; a media layer that contains collagen, elastic fibers, and smooth muscle cells; and an adventitia layer composed of fibrocytes, collagen, and elastic fibers. Arteries have an internal elastic membrane that separates intima from media. Smaller vessels such as arterioles have a thin intima with an internal elastic lamina and do not have an external elastic membrane. Capillaries and post-capillary venules have a single layer of endothelial cells, with or without adjacent pericytes. The small muscular venules into which the post-capillary venules drain have an intima layer made up of flattened endothelial cells surrounded by a smooth muscle layer; thus, they are similar to small arterioles but with a Fig. 26.8  Post-­capillary venules in superficial dermis lined by endothelial cells. (H&E, 10X)

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wider lumina. Veins are composed of endothelium surrounded by a thick muscle layer with an inconspicuous internal elastic lamina. Veins lack elastic fibers and are only seen in large muscular veins. In the dermis, there are arteriovenous anastomoses, which are most commonly present in the digits. These anastomoses prevent blood from entering the superficial cutaneous plexus. These specialized segments are surrounded by uniform, ovoid, specialized smooth muscle (glomus) cells that serve as sphincters, which allow capillaries to be bypassed, thus increasing the venous return from the extremities [9, 10, 15]. Skin lymphatic vessels are intimately associated with the vascular plexus, and their main role is to remove foreign material, antigenic substances, and bacteria. When the lymphatic system fails, it may alter the immune function, causing recurrent infection. The lymphatic capillaries are situated in the upper part of the reticular dermis, just beneath the superficial plexus of blood vessels. Lymphatic vessels drain into the deep dermal and subdermal plexuses and coalesce to form larger lymphatic channels, which course through numerous lymph nodes. Lymphatic vessels consist of a large thinwalled collapsed vessel lined by flattened endothelium with multiple valves. Their presence is much more obvious in obstructive situations such as lymphedema or in metastatic spread of malignant tumors (Figs. 26.8, 26.9, and 26.10) [16, 17].

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Fig. 26.9 Medium-­ sized vessel with thick media and intima lined by endothelial cells. (H&E, 20X)

Fig. 26.10  Large-­sized vessel located in the dermal subcutaneous junction. The vessel has a tick media. (H&E, 20X)

26.13 Collagen and Elastic Fibers The fibroblasts are the main cell type in the dermis, which form procollagen and elastic fibers. Collagen is synthesized by different cell types including fibroblasts, keratinocytes, endothelial cells, and smooth muscle cells. Collagen accounts for over 70% of the weight of the skin,

and ­several distinct types of collagen have been outlined. Type I collagen is the most abundant collagen in the dermis, and it comprises about 80% of dermal collagen. Type I collagen along with type III collagen forms extracellular fibers in the dermis, and their main role is to provide tensile strength to the skin. Mutations in type I and III collagens can result in connective tissue

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a­ bnormalities seen in different forms of EhlersDanlos syndrome. As much as 50% of the fetal skin is composed of type III collagen. Type III collagen is involved in the contraction of tissues including blood vessels. Type IV collagen is an important element of the basement membrane lamina densa, and it is a target of circulating IgG autoantibodies in certain autoimmune diseases. Type V collagen is present in the majority of connective tissues; however, in the dermis, it only accounts for 5% of the total collagen. The main function of type V collagen is to regulate dermal growth. A lack of type V collagen leads to abnormal collagen formation, as seen in forms of Ehlers-Danlos syndrome. Type VI collagen forms a network which serves as an anchor for maintaining the architecture of collagen fibers. Type VII collagen is produced mostly by keratocytes, from which it is transported through the basement membrane in the sublamina densa forming the anchoring filaments. Abnormalities in type VII collagen and anchoring fibrils have been observed in the dominant form of epidermolysis bullosa. Type XVI collagen, a member of the fibril-associated collagens, is located in the papillary dermis. Type XVII collagen is the target of autoantibodies in cases of bullous pemphigoid, linear IgA dermatosis, and cicatricial pemphigoid [18–20]. Elastic fibers constitute less than 1% of the weight of the dermis, but they play an important role by providing elasticity to the skin. Elastic fibers in the papillary dermis appear as bundles of microfibrils or as cross-linked elastin. Elastic fibers in the reticular dermis are horizontally orientated fibers that interconnect and appear mainly as elastin [20].

26.14 Subcutaneous Fat Subcutaneous tissue is spread throughout the body, and it is key for thermal regulation and protection from mechanical injuries. Adipocytes originate from mesenchymal stem cells and represent a specialized component of the connective

R. Joffe et al.

tissue capable of synthesis and storage of fat. The basic unit of the subcutaneous fat is the primary microlobule, which is composed of a collection of adipocytes that aggregate to form secondary lobules surrounded by thin septa of the connective tissue. The thickness of the subcutaneous fat varies from one part of the body to another, with a thinner subcutis in areas of lax skin and a thicker hypodermis in the hips and buttocks [21, 22]. Subcutaneous fat contains adipocytes, blood vessels, nerves, and fibrocytes and is embedded within the collagenous matrix of intersecting septa. These septa, which subdivide the subcutaneous fat into lobules, are thin and composed of collagen and reticulin fibers that are extensions of the dermis. This close relationship between dermal structures and subcutis may give an insight into why some dermatoses may secondarily affect the septa of the subcutaneous fat giving rise to panniculitis (such as necrobiosis lipoidica, deep granuloma annulare). Each fat lobule is supplied by a muscular artery branching from the septa to form arterioles that supply every individual primary microlobule. As expected, any interference with the arterial/vascular supply results in diffuse changes within the lobule (mostly lobular panniculitis), whereas venous disorders are manifested by alterations in the ­septal and paraseptal areas (mostly septal panniculitis) [7, 9, 23, 24]. Adipocytes are large, with a diameter of up to 100  mm, and on hematoxylin-eosin stain, they appear as empty cells with signet-ring morphology. This is because the lipid content dissolves in routinely processed specimens and the flat spindle nucleus is displaced at the periphery of the cell by a single, large intracytoplasmic vacuole, which contains fat. Frozen sections can be used to demonstrate the full histomorphology of adipocytes because of their cytoplasmic contents of essentially neutral lipids and triglycerides. Each adipocyte is separated from its neighbors by an inconspicuous matrix, and these cells express S-100 protein and vimentin, observed by immunohistochemical staining (Fig. 26.11) [13, 14].

26  Tip Chapter: Histology and Physiology of the Skin

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Fig. 26.11 Subcutaneous fat showing normal lobular architecture. The adipocytes are large and show as empty cells with signet-ring morphology. (H&E, 10X)

References 1. James WD, Berger TG, Elston DM.  Andrews’ diseases of the skin: clinical dermatology. 10th ed. Philadelphia: Elsevier Saunders; 2006. 2. Murphy GF.  Histology of the skin. In: Elder D, Elenitsas R, Jaworsky C, Johnson Jr B, editors. Lever’s histopathology of the skin. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 1997. p. 5–45. 3. Chu DH.  Overview of biology, development, and structure of skin. In: Wolff K, Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, editors. Fitzpatrick’s dermatology in general medicine. 7th ed. New York: McGraw-Hill; 2008. 4. Haake AR, Hollbrook K. The structure and development of skin. In: Freedberg I, Eisen A, Wolff K, Austen KF, Goldsmith L, Katz S, editors. Dermatology in general medicine. 5th ed. New York: McGraw-Hill; 1999. 5. Caputo R, Peluchetti D.  The junctions of normal human epidermis. A freeze-fracture study. J Ultrastruct Res. 1977;61(1):44–61. 6. Jackson SM, Williams ML, Feingold KR, Elias PM.  Pathobiology of the stratum corneum. J Ultrastruct Res. 1993;61(1):44–61. 7. McKee PH, Calonje E, Granter S.  Pathology of the skin. 3rd ed. Elsevier; 2005. 8. Stepp MA, Spurr-Michaud S, Tisdale A, Elwell J, Gipson IK. Alpha 6 beta 4 integrin heterodimer is a component of hemidesmosomes. Proc Natl Acad Sci U S A. 1990;87(22):8970–4. 9. Hood AF, Kwan TH, Mihm MC Jr, Horn TD, Smoller BR. Primer of dermatopathology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2002.

10. Ackerman AB, Roewert HJ. In: Moschella SL, Hurley HJ, editors. Dermatology. 3rd ed. Philadelphia: W.B. Saunders; 1992. 11. Hashimoto K.  Fine structure of the Meissner corpuscle of human palmar skin. J Invest Dermatol. 1973;60(1):20–8. 12. Cauna N.  The free penicillate nerve endings of the human hairy skin. J Anat. 1973;115(Pt 2):277–88. 13. Kanitakis J. Immunohistochemistry of normal human skin. Eur J Dermatol. 1998;8(8):539–47. 14. Kanitakis J.  Anatomy, histology and immunohistochemistry of normal human skin. Eur J Dermatol. 2002;12(4):390–9; quiz 400–1. 15. Johnson CL, Holbrook KA.  Development of human embryonic and fetal dermal vasculature. J Invest Dermatol. 1989;93(2 Suppl):10S–7S. 16. Skobe M, Detmar M. Structure, function, and molecular control of the skin lymphatic system. J Investig Dermatol Symp Proc. 2000;5(1):14–9. 17. Ryan TJ.  Structure and function of lymphatics. J Invest Dermatol. 1989;93(2 Suppl):18S–24S. 18. Junqueira LC, Montes GS, Martins JE, Joazeiro PP. Dermal collagen distribution. A histochemical and ultrastructural study. Histochemistry. 1983;79(3):397–403. 19. Meigel WN, Gay S, Weber L.  Dermal architecture and collagen type distribution. Arch Dermatol Res. 1977;259(1):1–10. 20. Kuivaniemi H, Tromp G, Prockop DJ.  Mutations in fibrillar collagens (types I, II, III, and XI), fibril-­ associated collagen (type IX), and network-­forming collagen (type X) cause a spectrum of diseases of bone, cartilage, and blood vessels. Hum Mutat. 1997;9(4):300–15.

192 21. Segura S, Requena L.  Anatomy and histology of normal subcutaneous fat, necrosis of adipocytes, and classification of the panniculitides. Dermatol Clin. 2008;26(4):419–24, v. 22. Lundgren H, Bengtsson C, Blohme G, Lapidus L, Sjostrom L. Adiposity and adipose tissue distribution in relation to incidence of diabetes in women: results

R. Joffe et al. from a prospective population study in Gothenburg, Sweden. Int J Obes. 1989;13(4):413–23. 23. Reed RJ, Clark WH, Mihm MC. Disorders of the panniculus adiposus. Hum Pathol. 1973;4(2):219–29. 24. Diaz Cascajo C, Borghi S, Weyers W.  Panniculitis: definition of terms and diagnostic strategy. Am J Dermatopathol. 2000;22(6):530–49.

Botulinum Toxin for Craniofacial Hyperhidrosis

27

Marcelo M. Bellini and Adriana de Cerqueira Leite

27.1 Materials (Fig. 27.1) • Topical anesthetic cream • • • • • • • •

Sterile gloves Chlorhexidine 2% solution Sterile gauze Pen marker One vial Botox 100 U One syringe 1 ml Saline solution 0.9% 0.3-ml syringes

27.2 Methods and Technique • Spread the topical anesthetic cream on the whole area to be treated. Leave it for 30 min. Do not spread the cream on the hair. In this case, it is possible to use ice to make it painless.[1]

Fig. 27.1  Picture of the materials used in Botulinum Toxin for Craniofacial Hyperhidrosis

Remove the cream and clean the area with 2% chlorhexidine solution. • Dilute the botulinum toxin vial with 2  ml of 0.9% saline solution

M. M. Bellini (*) Marcelo Bellini Clinic of Dermatology, São Paulo, SP, Brazil e-mail: [email protected] A. de Cerqueira Leite Adriana Leite Clinic of Dermatology, São Paulo, SP, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_27

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Mark the area using a pen marker (Fig. 27.2). The distance between the points is around 1 cm (Fig. 27.2). • Administer the injection by introducing the needle superficially in the skin until a small papule is seen. Inject 0.5 U of Botox per point [1]. –– It is possible to treat only the affected area, but sometimes it is necessary to balance by treating other areas to avoid an anesthetic result [1, 2]. For example, if you treat all of the frontal area, then it is also necessary to treat the glabella (Fig. 27.3). • Marking other areas for treatment (Fig. 27.4 and Fig. 27.5)

Fig. 27.4  Marking the scalp area to treat hyperhidrosis. (Courtesy: Neves [7]). Source: Copyright authorized by Samantha Neves, Beatriz C. Avè, Ayres 25. Indd 319

Fig. 27.2  Distance between the frontal area points where botulin toxin will be injected Fig. 27.5 Marking neck area to treat hyperhidrosis. (Courtesy: Neves [7]). Source: Copyright authorized by Samantha Neves, Beatriz C. Avè, Ayres 25. Indd 318

27.3 Clinical Follow-Up Reduction in sweat will be noticed after 48 h, but sometimes, we have to wait for 2 weeks. The reduction sometimes is progressive, but in other cases, it stops suddenly [3].

Fig. 27.3  Treating glabella when the entire frontal is being treated for hyperhidrosis

27.4 B  efore and After (Figs. 27.6, 27.7, 27.8, and 27.9)

27  Botulinum Toxin for Craniofacial Hyperhidrosis

Fig. 27.6  Positive starch test for hyperhidrosis in superior labial area. (Courtesy: Neves [7]). Source: Copyright authorized by Samantha Neves, Beatriz C. Avè, Ayres 25. Indd 313

Fig. 27.7  Negative starch test for hyperhidrosis in superior labial area. (Courtesy: Neves [7]). Source: Copyright authorized by Samantha Neves, Beatriz C. Avè, Ayres 25. Indd 314

27.5 S  ide Effects, Complications, and Their Management Some patients can be allergic to albumin. All kinds of botulinum toxin contain this protein. It is possible to see ecchymosis in some points after the injection [4]. It is necessary to avoid injection in the lower part of the frontalis muscle because it can increase the laxity of the upper eyelid or ptosis. There is a minimum risk of appearance of compensatory sweat in other areas with the botulinum toxin [5, 6].

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Fig. 27.8  Positive starch test for hyperhidrosis in frontal-glabellar area. (Courtesy: Neves [7]). Source: Copyright authorized by Samantha Neves, Beatriz C. Avè, Ayres 25. Indd 315

Fig. 27.9  Negative starch test for hyperhidrosis in frontal-glabellar area. (Courtesy: Neves [7]). Source: Copyright authorized by Samantha Neves, Beatriz C. Avè, Ayres 25. Indd 315

Tip Box

• The injection must be introduced with the needle superficially by seeing a small papule. • When all of the frontal area is treated, then it is also necessary to treat the glabella. • Reduction in sweat will be noticed from 48 h through 2 weeks after the procedure. • It is necessary to avoid injection in the lower part of the frontalis muscle

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References 1. Nicholas R, et  al. Treatment of primary craniofacial hyperhidrosis: a systematic review  – review article. Am J Clin Dermatol. 2015;16(5):361–70. 2. Karlqvist M, et al. Botulinum toxin B in the treatment of craniofacial hyperhidrosis. J Eur Acad Dermatol Venereol. 2014;28(10):1313–7. 3. Alsharqi A, et  al. Craniofacial hyperhidrosis in post-menopausal women. Australas J Dermatol. 2012;53(2):158–9. 4. Anders D, et  al. Craniofacial hyperhidrosis suc-

M. M. Bellini and A. de Cerqueira Leite cessfully treated with botulinum toxin type A. Eur J Dermatol. 2008;18(1):87–8. 5. Ada Regina Trindade de Almeida, Dóris Maria Hexsel  – São Paulo 2003. Hiperidrose e toxina botulínica. 6. Boger A, et  al. Botulinum toxin for treatment of craniofacial hyperhidrosis. J Neurol. 2000;247(11):857–61. 7. Neves S. Avè, Beatriz Rosmaninho Caldeira. Seção F: Facial. In: Ayres, Eloisa Leis; Sandoval, Maria Helene Lesqueves (org.). Toxina Botulínica na Dermatologia: Guia Prático de Técnicas e Produtos. 1st ed. Rio de Janeiro: Guanabara Koogan; 2016. p. 3010–6.

Botulinum Toxin for Superior Third of the Face

28

Cristina Hachul Moreno, Aline Rodrigues Bragatto, and Caroline Moreira Albrecht

28.1 Materials • • • • •

Topical anesthetic Cosmetic pencil Icepack Syringes and needles Botulinum toxin products (Botox, Xeomin, Botox, or Dysport 300 units)

28.2 Methods and Techniques [1–8]

•

• • •

patient. Perform asepsis prior to marking with aqueous chlorhexidine. Ice cubes or cold compresses can be used before or during the application to alleviate pain. The materials should be chosen to minimize the possible pain during application. Syringes of 0.3 or 1 ml. Needles 12–13 mm in length and a diameter between 0.25 and 0.3 mm, with silicone coating (Fig. 28.1).

• Creams containing local anesthetics can be used before treating pain-sensitive patients. Use standard formula and a combination of lidocaine and prilocaine or lidocaine and tetracaine. Apply cream approximately 30 minutes before the botulinum toxin application. • Use of a common eyeliner pencil permits the previous marking of reference points for sites to be treated. Present the planned image to the

28.2.1 Solution preparation:

C. H. Moreno (*) Department of Dermatology, Santa Casa of Sao Paulo University Hospital, São Paulo, SP, Brazil

A. R. Bragatto Aline Rodrigues Bragatto Clinic of Plastic Surgery, Valinhos, SP, Brazil

Cristina Hachul Moreno Clinic of Plastic Surgery, São Paulo, SP, Brazil

Department of Dermatology, Santa Casa of São Paulo University Hospital, São Paulo, SP, Brazil

• The active substance is supplied in a powder form. • Reconstitution should be made, before injection, in a saline solution (NaCl 0.9%), sterile and without preservatives. • The flask should be previously cleaned with an alcohol solution.

C. M. Albrecht São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_28

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Fig. 28.1  Material for the application

Product

Units/vial Saline ml Xeomin 100 2.5 Botox 50 50 1.25 Botox 100 100 2.5 Dysport 300 300 1.5 Dysport 300 (Half diluition) 300 3 Dysport 500 500 1.5

• NaCl solution should be inserted directly by negative pressure. • The flask should be moved with care to not create foam. • The solution should not be shaken. • Aspirate the solution for application slowly and without formation of bubbles on the plunger. • Dilution is determined by the insert in each product: –– Botox 50  units—1.25  ml of the saline solution –– Xeomin and Botox 100  units—2.5  ml of the saline solution –– Dysport 300  units—1.5 or 3.0  ml of the saline solution • The number of units in each ml of the solution is described in the table below:

Units per ml standard solution 0.0125 0.025 0.05 0.075 0.5 1 2 3 0.5 1 2 3 0.5 1 2 3 2.5 5 10 15 1.25 2.5 5 7.5 2.5 5 10 15

0.1 4 4 4 20 10 20

0.2 8 8 8 40 20 40

0.3 12 12 12 60 30 60

0.4 0.8 1 16 32 40 16 32 40 16 32 40 80 160 200 40 80 100 80 160 200

28  Botulinum Toxin for Superior Third of the Face

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28.2.2 Injection techniques:

28.2.4 Subdermal Bubble

The choice of the technique is determined by the target muscle and by clinical findings for each patient, as well as by the personal experience of each doctor: deep injections for direct injection in the target muscle and superficial ones for injection into the subcutaneous plane to migrate gently to the destined muscle.

• Needle tangential to the skin and inserted into the subdermal layer of the skin. • Solution injected forms a subdermal bubble. • Toxin reaches the target sites by diffusion (Fig. 28.4).

28.2.3 Direct

• Needle inserted parallel to the muscle fibers • Injection directly into the target of higher tension in the muscle group (Fig. 28.5)

• Needle inserted perpendicularly into the skin • Injection directly into the target muscle located through previous palpation or mobilized in the form of pinching with the thumb and index finger at the time of application (Figs. 28.2 and 28.3)

28.2.5 Directed Injection

Fig. 28.4  Subdermal bubble

Fig. 28.2  Direct injection—pinch

Fig. 28.3  Direct injection

Fig. 28.5  Directed injection

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28.3 Clinical Follow-Up [1–8] • Frontal horizontal lines—frontalis muscle –– Attention lines, formed when a person listens or exhibits interest or sympathy for something, signaling life experience. –– Indicated when the lines appear both when the person is at rest and when there is an active contraction of the muscle. –– Anatomy—occipitofrontal and temporoparietal muscles are referred to in conjunction with the epicranial muscle. –– Action of raising eyebrows producing deep lines which cross the entire frontal region and increase the eyelid cleft. –– Origin is in the anterior margin of the epicranial aponeurosis. –– Insertion into the subcutaneous portion of the skin in the eyelash region and nose root, intertwining with the procerus, corrugator, and orbicular muscle fibers of the eyes. –– Treatment plan is to reduce the lines which cross the frontal region. –– Treatment schedule in the central frontal region, administered in the form of a “v,” with direct and deep injections and in the lateral frontal region with subdermal injections.

Fig. 28.6  Frontal points

C. H. Moreno et al.

–– Determination of the inferior part of the frontalis muscle to a distance of approximately 2  cm from the orbital margin to avoid eyebrow ptosis. –– The clinical examination is fundamental to determine doses to be injected at each point in the frontalis muscle. –– Anatomical studies by Glattstein in 2010 demonstrated that the Frontal band in 39.4% of patients were completely separated from the medial line, in the manner of independent leaflets. In 30.5% of patients, they were linked 1.5 cm above the orbital edge; in 21.6%, 3 cm from the edge; and in 8.5%, 4.5 cm from the orbital edge. –– Consensus advocates between four and eight application points, with the needle positioned in a perpendicular direction to the skin, introducing it intramuscularly, injecting 2–4 units of toxin per point, totaling to 8–25 units. –– Intradermal applications can be also made, with the needle positioned at a 45-degree angle to the skin, introducing the needle intradermally, with 8–20 application points and with 0.5–1.5  units of toxin per point totaling to 8–25  units in the region (Fig. 28.6).

28  Botulinum Toxin for Superior Third of the Face

• Glabella –– Frown lines on the central front, giving an “angry” expression. –– Indicated when the lines appear both in repose and in active movement of the muscles. –– Anatomy—procerus muscles and supercilium corrugator. –– The corrugator muscle originates in the frontal bone medial portion of the surface of the supercilium arch, entering the subcutaneous portion of the supercilium skin. Its bundles run in a superior obliquely lateral manner into a deeper plane of the frontalis muscle. –– The procerus muscle originates in the nasal bone and nasal cartilage, entering the glabellar skin. –– The procerus muscle, in conjunction with the corrugator muscle, tractions the supercilium medial skin downward toward the base of the nose, determining the deep transversal lines in the skin. –– The corrugator muscle tractions the medial region toward the middle and downward, determining the vertical lines over the base of the nose. –– Glabellar lines in males are more pronounced, necessitating a larger dose in the application to achieve the desired effect. –– Treatment scheme: ⚬⚬ Procerus muscle: medial to the base of the nose, with one to two points of application above the medial line, as if stipulating an “x” at the major contraction site, with further possibility of the application at two additional points above and below this central “x,” depending on the strength of the muscle. ⚬⚬ Corrugator muscle: one injection in the medial part of this muscle, accompanying the fibers, enabling the application in lateral points, depending on the physical examination, based on the design which is formed during the contraction of this muscle, described in shapes of “u,” “v,”

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––

––

––

––

“omega,” “inverted omega,” and “convergent arrows.” Consensus advocates application in the belly of the corrugator muscle, 1 cm above the orbital ridge, with injections of 3–10 units of toxin. For the confection of complementary points, there is a dependence on the manner of contraction of these muscles. Consensus advocates intramuscular application in the procerus muscle, applying 3–5 units of the toxin. Glabellar treatment, considering the procerus and corrugator muscles, varies with applications of 12–40  units, averaging to 20 units in the region (Figs. 28.7 and 28.8).

Fig. 28.7  Corrugator muscle points

Fig. 28.8  Procerus muscle points

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28.4 Before and After (Figs. 28.9, 28.10, 28.11, and 28.12)

Fig. 28.9  Before application in the frontalis, corrugator, and procerus muscle areas

Fig. 28.10  Fourteen days after application

Fig. 28.11  Before application in the frontalis, corrugator, and procerus muscle areas

C. H. Moreno et al.

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Fig. 28.12  Fourteen days after application in the frontalis, corrugator, and procerus muscle areas

28.5 S  ide Effects, Complications, and Their Management [1–8] • In general, the use of botulinum toxin ­presents few complications, usually for up to 1  day, such as localized pain and erythema. • Bruising is also another described complication which is reversed for up to 2 weeks and can be avoided by applying ice locally and compression following each application. • Headache is described following application, and most of the time, it is resolved spontaneously after a few days; sometimes, it lasts up to 2–4 weeks and is treated with habitual antiinflammatory drugs or even opiates. • Contamination at the application site can cause local infection, but this has rarely been described and is avoided with adequate asepsis using aqueous chlorhexidine. • Paresthesia or dysesthesia is rare in facial treatment but can occur by direct trauma to the nerve. • Vasovagal episodes can occur in patients who have severe anxiety but can be avoided with adequate anamnesis and explanation preceding the treatment.

• Blepharoptosis (upper eyelid droop) is uncommon (1–5%) but is distressing for patients, as it is mostly unilateral, with a lowering of 2–3 mm of the superior eyelid, more clearly seen at the end of the day with muscle fatigue. • Blepharoptosis is caused by deep migration through the orbital septum fascia to the levator palpebrae superioris, an upper eyelid levator muscle, and it can be avoided with application at least 1 cm above the supraorbital line of the medial pupilar line during treatment of the corrugator muscle. • Blepharoptosis can be treated with ophthalmologic solutions with 0.025% alpha adrenergic naphazoline, 0.3% ­pheniramine, or 0.5% apraclonidine effect prescriptions, which cause contraction in the Muller muscle or in the adrenergic levator muscle of the upper eyelid, leading to the elevation of the upper eyelid. • Apraclonidine is reserved for cases which are refractory to habitual treatment, as this medication can cause non-symptomatic glaucoma. • Formation of antibodies (less than 1%) is another complication described which can render the Botox treatment ineffective.

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• Allergy and immediate hypersensitivity are extremely rare, with clinical presentations such as edema and local rashes treated with steroids. • The parameters related to pharmacodynamics are loss of excessive target muscle strength and the target muscle strength of the neighboring musculature depending on the dose and volume injected.

Tip Box

• Hypersensitivity to botulinum toxin • Neuromuscular diseases such as myasthenia gravis • Allergy to active principle or to excipients • Infection at the site to be treated • Coagulopathies • Treatment with anticoagulants • Medication with aminoglycoside antibiotics • Medications with neuromuscular conduction effects which can potentialize the effect (i.e., muscular relaxants of the tubocurarine type) • Pregnancy or breastfeeding

References 1. Dressler D, Saberi FA, Barbosa ER.  Botulinum toxin: mechanisms of action. Arq Neuropsiquiatr. 2005;63:180–5. 2. Wenzel RG.  Pharmacology of botulinum neurotoxin serotype A.  Am J Heath-Syst Pharm. 2004;61(suppl 6):s5–10. 3. Setler PE.  Therapeutic use of botulinum toxins:background and history. Clin J Pain. 2002;18(6suppl):s119–24. 4. Unno E, Sakato RK, Issy AM.  Estudo comparativo entre toxina botulínica e bupivacaína para infiltração de pontos-gatilho em síndrome dolorosa miofascial crônica. Rev Bras Anestesiol. 2005;55:250–5. 5. Silberstein S.  Botulinum neurotoxins: origins and basic mechanisms of action. Pain Pract. 2004;4(Suppl 1):S19–26. 6. Sundaram H, Signorini M, Liew S, et al. Global aesthetics consensus: botulinum toxin type A-evidence–based review, emerging concepts, and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 2016;137(3):518e–29e. 7. Cox SE, Adigum CG.  Complications of injectable fillers and neurotoxins. Dermatol Ther. 2011;24(6):524–36. 8. Klein AW.  Complications, adverse reactions and insights with the use of botulinum toxin. Dermatol Surg. 2003;29(5):549–56. discussion 556.

Botulinum Toxin for Middle Third of the Face

29

Loryart Marte Grullón and Javier Ruiz Ávila

29.1 Materials (Fig. 29.1)

29.2 Methods and Techniques

• The following are required for the application: BT of the professional’s preference, insulin syringes with 30 or 31G needle to make the procedure more tolerable, and a gauze or cotton in case of bleeding.

• The first step is to evaluate the patient and calculate the units and prepare them in the syringes. • Explain to the patient what is going to be done, the areas to be treated, and how the application feels.

Fig. 29.1  Materials used to the injections

L. M. Grullón Department of Dermatology, Clínica Unión Médica del Norte, Santiago de los Caballeros, Dominican Republic J. R. Ávila (*) Dermédica Clinic of Dermatology, Mexico City, DF, MX e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_29

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• Prior to the application of botulinum toxin, there must be antiseptic cleaning of the area to be treated.

29.2.1 Example #1 (Fig. 29.2) • For application in bunny lines, apply 2–5 units intramuscularly on the lateral side of the nose, in the anterior nasal angle, above the blood vessels.

29.2.2 Example #2 (Fig. 29.3) • For gingival smile correction, apply 2–5 units per side, depending on the exposure of the gum, 5 mm lateral and below the nasal wing. Fig. 29.2  Application into the bunny lines area

29.3 Clinical Follow-up • To vist the clinic 15 days after the procedure. • To avoid to contract the muscles wherein the botulin toxin was injected into for 10 days after the procedure.

Fig. 29.3  Application for gingival smile

29  Botulinum Toxin for Middle Third of the Face

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29.4 Before and After 29.4.1 Example #1 (Fig. 29.4)

Fig. 29.4  Before and after botulinum toxin infection for bunny lines

29.4.2 Example #2 (Fig. 29.5)

29.5 S  ide Effects, Complications, and Their Management • For correction of bunny lines, it is necessary to avoid injections in relatively lower portion of that lines because the upper levator of the lip and nasal wing muscle may be weakened, resulting in ptosis of the lip and epiphora. • In the correction of the gingival smile, the adverse effects are minor and temporary. The most frequent one is asymmetry in the smile, a consequence of overtreating the muscle. • Excessive elongation of the lip is an edentulous aspect. Given that, professionals should only use the necessary BT units in order to avoid such as aspect.

Fig. 29.5  Before and after botulinum toxin infection for gingival smile

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Tip Box

• Always make a photographic record of the patient to evaluate the before and after. Patients forget how they looked before and believe that they look the same. • Explain the function of the toxin, the time duration, and all the doubts that the patient has. • Use multiple syringes for each area to minimize pain and maintain the bevel edge. A 30-U syringe having a 31G needle is preferable.

L. M. Grullón and J. R. Ávila

Botulinum Toxin for Inferior Third of the Face

30

Carlos Echevarria and Denise Durand

30.1 Materials • • • • • • • •

Gauze Alcohol Sterile gloves Botulinum toxin A 1-ml syringe 3-ml syringe 30–32G sharp needle 0.9% sodium chloride vial

30.2 Methods and Techniques

•

•

30.2.1 Gummy Smile • • Prior to beginning the procedure, it is crucial to determine points of injection by careful assessment of facial anatomy. Not every patient will have the same anatomical features or share similar injection points or number of units per area. • Define whether a “gummy” smile is anterior, posterior, or mixed. When anterior, more than

•

3  mm of gingival tissue is exposed between canine teeth, whereas in a posterior “gummy” smile, exposure occurs behind canine teeth. In the mixed type, a combination of both is noted [1, 2]. Three points of injection are used when treating an anterior “gummy” smile. Two points are injected 1 cm lateral to the inferior border of the nasal ala in the levator labii superioris alaeque nasi muscle, and third point is injected in the depressor septi nasi muscle. Two to four units are used per side for the levator labii superioris alaeque nasi muscle and two units for the depressor septi nasi muscle. When treating a posterior or mixed “gummy” smile, apart from the points mentioned earlier, two other sites of injection are used. One addresses zygomatic major and zygomatic minor at the level of the nasolabial fold where there is greatest lateral contraction during the smile. The other point is 2 cm lateral to the latter point [1, 2]. Two units are used per point of injection (Figs. 30.1 and 30.2).

C. Echevarria (*) Private Practice, Dermanova Clinic, Lima, Peru D. Durand Clinica San Pablo, Lima, Peru © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_30

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Fig. 30.2  Injection points in female patient with anterior “gummy smile”

Fig. 30.1  Suggested injection points for anterior (black) and posterior (green) “gummy” smile

30.2.2 Perioral Area (Upper and Lower Lips) • First evaluate any asymmetries in perioral (“barcode”) rhytids, both of the upper and lower lips. • Upper lip: –– One to three points of injections spaced at 1 cm are used per side of the lip. These are injected superior to the vermilion border. –– Injection should be intradermal with the bevel of the needle facing upward. –– One unit is used at each injection point.3. • Lower lip: –– One injection point per side of the lip. –– Injected immediately inferior to vermilion border. –– One unit is used at each injection point.

–– Caution should be taken in this area as excessive doses can have a detrimental effect on lip function, such as drooling or being unable to drink liquids (Figs. 30.3 and 30.4) [2].

30.2.3 Elevation of the Corner of the Mouth “Marionette Lines” • Points of injection address the depressor anguli oris muscle of each side. • Start 1 cm from the oral commissure, and then trace a straight line to the mandible border. • In order to avoid asymmetry, it is preferable for the injection to be done in the inferior third of the line between the oral commissure and mandibular border. • Two to four units of the toxin are used per injection point. • Injection should be deep, approximately 1–2 mm above the periosteal plane (Figs. 30.5 and 30.6) [2, 3].

30  Botulinum Toxin for Inferior Third of the Face

Fig. 30.3  Suggested injection points for perioral rhytids, both upper and lower lips

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Fig. 30.5  Suggested injection points for elevation of the corner of the mouth

Fig. 30.6  Injection point in female patient addressing the depressor anguli oris muscle

Fig. 30.4  Injection points in female patient with perioral “barcode” rhytids

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30.2.4 Hyperactive Mentalis Muscle • Two injection techniques can be employed. One utilizes just one point of injection in the center of the mentalis muscle, at the apex. The other is two points parallel and adjacent to the center of the mentalis muscle (Fig. 30.7). • A total of 4–8 units is used. • Injection should occur in the supraperiosteal plane. • Caution should be exercised as too lateral an injection could compromise the depressor labii inferioris muscle and result in an asymmetric smile [4].

30.3 Clinical Follow-Up [5–9]

Fig. 30.7 Suggested injection points for hyperactive mentalis muscle. Two injection techniques: apex of mentalis muscle (black) and/or two points parallel (green)

• After the procedure, avoid manipulation of injected area. • Avoid rigorous activity and alcohol consumption for 4 h after the procedure. • A follow-up visit is recommended in 15 days. • After treatment for masseter hypertrophy, it is important for the patient to avoid chewing gum and other hard food.

30  Botulinum Toxin for Inferior Third of the Face

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30.4 Before and After (Figs. 30.8 and 30.9) a

b

c

d

Fig. 30.8  Improvement of platysmal bands using botulinum toxin type A. Before (a & c) and after (b & d)

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a

b

c

d

Fig. 30.9  Improvement of masseter hypertrophy using botulinum toxin type A. Before (a & c) and after (b & d)

30  Botulinum Toxin for Inferior Third of the Face

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b

Fig. 30.10  A 32-year-old female patient who was treated for “marionette lines” with 2 units of botulinum toxin type A in the depressor anguli oris muscles. (a) Smile asymmetry 1  week after procedure. Failed effect in the right

side probably caused by injecting in the wrong anatomical plane. (b) Asymmetry correction by placing 2  units of botulinum toxin type A in the depressor anguli oris muscle of the right side

30.5 S  ide Effects, Complications, and Their Management [5–9]

2. Perez Atamoros F. Botulinum toxin in the lower third of the face. Clin Dermatol. 2003;21(6):505–12. 3. Goldman A, Wollina U. Elevation of the corner of the mouth using botulinum toxin type A. J Cutan Aesthet Surg. 2010;3(3):145. 4. Wu D, Fabi S, Goldman M. Neurotoxins: current concepts in cosmetic use on the face and neck-lower face. Plast Reconstr Surg. 2015;136:76S–9S. 5. Klein F, Brenner F, Sato M, Robert F, Helmer K. Lower facial remodeling with botulinum toxin type A for the treatment of masseter hypertrophy. An Bras Dermatol. 2014;89(6):878–84. 6. Bravo B, Balassiano L, Rocha C, Bastos J, Silva P, Freitas B. Thinning of the lower third of the face using botulinum toxin in the masseter muscle. Surg Cosmet Dermatol. 2016;8(1):55–60 7. Carruthers J, Carruthers A.  Aesthetic botulinum A toxin in the mid and lower face and neck. Dermatol Surg. 2003;29(5):468–76. 8. Wu W. Microbotox of the lower face and neck. Plast Reconstr Surg. 2015;136:92S–100S. 9. Trévidic P, Sykes J, Criollo-Lamilla G.  Anatomy of the lower face and botulinum toxin injections. Plast Reconstr Surg. 2015;136:84S–91S.

• Bruising: To reduce bruising, advise the patient to stop using blood thinners 1  week prior to procedure. Management with cold compresses might help. • Facial asymmetry (Fig. 30.10). • Oral motor insufficiency. • Infections: Possible complications but generally infrequent. Treatment options are oral antibiotics and topical mupirocin. Tip Box

• It is crucial to determine the correct application plane.

References 1. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010;63(6):1042–51.

Botulinum Toxin for the Neck

31

Luciana R. Patricio Linhares and Adilson Da Costa

31.1 Materials (Fig. 31.1) • Topic anesthetic (usually not necessary) • Botulin toxin (diluted with 1–2  ml of non-­ preserved saline 0.9%) maximum dose recommended: 40–60 U • 1-ml syringe and 30G needle or insulin syringe with ultrafine needle • Procedure gloves • Gauze • Antiseptic solution • White pencil for marking • Registration method of your choice (for follow-­up; photos; videos)

Fig. 31.1  Materials numbered in sequence as follows: (1) Gauze; (2) Antiseptic solution; (3) Saline 0.9%; (4) Needle for dilution of toxin; (5) Syringe for dilution of toxin; (6) Syringe for injection of toxin; (7) Botulinum toxin; (8) Topical anesthetic; (9) Procedure gloves L. R. P. Linhares (*) Sociedade Brasileira de Dermatologia (SBD), São Paulo, SP, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_31

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31.2 Methods and Techniques • Explain in details to the patient about the expected results of the procedure and possible adverse effects. • Get the patient to sign an informed consent to the procedure. • Remove all make-up and rigorously cleanse the area to be treated. • Analyze the neck and jawline. • Assess the muscular function asking the patient to perform contraction of the platysmal bands (Fig. 31.2).

L. R. P. Linhares and A. Da Costa

• Assess the quality of the skin regarding tonus and laxity. • Mark the points of injection with a white pencil. • These are suggested doses based on the literature and personal experience. Be aware that your patient may need a personalized dosage: Platysmal bands: Mark 3–6 points per band (Fig. 31.3); apply 1–3 units per point, intramuscular or intracutaneous. Ask the patient to contract the platysma while the applicator holds its bands to direct the injection to the correct sites (Fig. 31.4). Mandibular contour: Along the jawline, mark 3–6 points, and apply 2–3 units per point, starting with the depressor anguli oris and moving backward every 1.5 cm (Fig. 31.3).

Fig. 31.2  Patient performing contraction of the platysmal bands for evaluation

Fig. 31.4  Hold the platysmal bands during application to make sure the injection is not too deep

Fig. 31.3  Points of injection in the platysmal bands as shown by the black dots. Points of injection in the jawline as shown by the green dots

31  Botulinum Toxin for the Neck

31.3 Clinical Follow-Up • Patient follow-up with this technique is identical to other procedures with botulin toxin [1]. • A return visit is scheduled in 2 weeks and, if necessary, a complementation can be done. • Sometimes a touch-up is needed to treat additional platysma bands that were not so prominent at the first visit, but once you treat the strongest ones, they become more active (Fig. 31.5). • The effect of this treatment lasts, in general, up to 6 months [1].

31.4 B  efore and After (Figs. 31.6, 31.7, 31.8, 31.9, and 31.10)

a

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a

b

Fig. 31.5  Patient before treatment (a) and after treatment showing hyperactivity of bands that were not so prominent until we denervate the lateral bands (b)

b

Fig. 31.6  Before (a) and after treatment (b) showing improvement of mandibular contour and platysmal bands

L. R. P. Linhares and A. Da Costa

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a

b

Fig. 31.7  Before (a) and after treatment (b) showing elongated and more relaxed neck

a

b

Fig. 31.8  Before (a) and after treatment (b) with better definition of the jawline. (Courtesy of Dr. Solange Pistori Teixeira, MD)

31  Botulinum Toxin for the Neck

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b

Fig. 31.9  Before (a) and after treatment (b) to correct the evident muscle asymmetry. (Courtesy of Dr. Solange Pistori Teixeira, MD)

31.5 S  ide Effects, Complications, and Their Management

Fig. 31.10  Most common complication of the procedure, bruising

The most common side effects are bruising (Fig.  31.10) and/or mild edema at the sites of injection [2]. Occasionally, there can be asymmetry, impaired smile (Fig.  31.11), dysphagia, dysphonia, neck weakness, and dry mouth, but these effects are relatively rare if the correct technique is applied and the maximum doses are respected [2]. When managing complications with botulin toxin, it is important to consider whether the complications were due to incorrect application or not. Bruising and edema usually resolve spontaneously within the first 2 weeks of the procedure, and no treatment is needed [2]. If there is asymmetry, the physician can try to fix it by applying extra units to the hyperactive muscle [2]. The side effects of the excess of toxin can be managed with physiotherapy and radiofrequency, or the follow-up alone can be an option if the discomfort is not too much [3].

L. R. P. Linhares and A. Da Costa

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a

b

Fig. 31.11  Before (a) and after treatment (b) complicating with smile assymetry due to treatment of the depressor anguli oris. (Courtesy of Dr. Solange Pistori Teixeira, MD)

Tip Box

• Make short videos of the patient talking, smiling, pulling down the platysma muscle, and in neutral position. It will make the evaluation more dynamic and the changes easier to observe. • Neuromodulation is better than denervation for more natural results; it means fewer units per point of injection. • Combine treatments for better results in enhancing neck and mandibular contour appearance (restore lost volumes, tighten skin, reduce local fat if needed). • For minimizing side effects: avoid injecting too deep into the neck and lower the maximum dose to 20  units each side if you are not very confident yet.

References 1. Sundaram H, Signorini M, Liew S, Trindade de Almeida AR, Wu Y, Vieira Braz A, et al. Global aesthetics consensus: botulin toxin type-A – Evidence-based review, emerging concepts and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 2016;137(3):518e–29e. 2. Dayan SH.  Complications from toxins and fillers in dermatology clinic: recognition, prevention and treatment. Facial Plast Surg Clin North Am. 2013;21(4):663–73. 3. Levy PM.  Neurotoxins: current concepts in cosmetic use on the face and neck – Jawline contouring/ Platysma bands/Necklace lines. Plast Reconstr Surg. 2015;136(5 Suppl):80S–3S.

Botulinum Toxin for Axillary Hyperhidrosis

32

Clarissa Prati and Juliano Peruzzo

32.1 Materials (Fig. 32.1)

Toxin dilution

Minor’s test (iodine-starch staining)

• One bottle of botulinum A toxin • 0.9% saline solution

• 3% iodine solution. • Maize (cornstarch) or potato flour. • One should be aware that the commercial povidone-iodine topical solution with 10% iodopovidone contains only 1% free iodine [1]. Anesthesia • Local topical anesthetic

Asepsis • Chlorhexidine • Gauze Toxin injection • 100 units of botulinum A toxin • Sterile 30-gauge syringes

Fig. 32.1  Material for botulinum A toxin treatment of axillary hyperhidrosis

C. Prati (*) · J. Peruzzo Sociedade Brasileira de Dermatologia, Porto Alegre, RS, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_32

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32.2 Methods and Techniques Preparation: • The patient should be placed in the lying position—without a shirt/blouse. • The room temperature must be kept high for quicker onset of sweating. • The patient should be given a hot drink. Minor’s test (iodine-starch staining) (Fig. 32.2) • Dry the affected area with absorbent paper or gauze. • Paint a layer of iodine solution on both axillae and allow it to dry spontaneously or with an absorbent paper or gauze.

• Dust the armpits with a thin film of maize. In the hyperhidrotic area, the color will completely change from yellow or white to a dark blue-black in 15 min or less. Marking (Fig. 32.3) • Use a skin marking pen to delineate the dark blue-black area and remove the flour with gauze. • Distribute, in general, 25–50 injection points as equally spaced as possible in the defined area, at 1–2 cm intervals. Asepsis • Use gauze soaked in chlorhexidine to completely remove the starch.

Fig. 32.2  Axillary Minor’s test result—On the left side after the iodine solution painting and on the right side after the maize application, showing the hyperhidrotic area

32  Botulinum Toxin for Axillary Hyperhidrosis

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Fig. 32.4  Botulinum A toxin intradermal application

Fig. 32.3  Botulinum A toxin injection points marked on the axilla

Anesthesia • Apply a thick layer of local topical anesthetic over each marked point and wait for approximately 15 min. Dilution • The dilution of botulinum toxin can vary from 1 to 10 ml of 0.9% saline solution [1]; we suggest a dilution in 1  ml, achieving a dose of 100 U/mL. • The dilution can also be made in lidocaine, which reduces the pain without affecting effectiveness [2]. Application • Remove the topical anesthetic with gauze one point at a time. • Inject 1–2  U per point intradermally using a sterile 30-gauge needle (Fig. 32.4).

32.3 Clinical Follow-Up • The anhidrotic effect will be perceived after 2–4 days.

Fig. 32.5  The anhidrotic effect of botulinum A toxin axillary treatment demonstrated by Minor’s test

• Review your patient in 3 weeks and, if necessary, make additional injections guided by the Minor’s test. • Data show that additional full treatment is normally required after 4–17 months [3]. • In our experience, the anhidrosis usually lasts 7  months, and further sessions will usually be required every 12 months. • There appears to be an increase in the duration of efficacy of botulinum toxin A against axillary hyperhidrosis with the repetition of injections (Fig. 32.5) [3–5].

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32.4 Before and After (Fig. 32.6) a

b

Fig. 32.6  Axillary hyperhidrosis treated with botulinum A toxin — (a) Before. (b) After

C. Prati and J. Peruzzo

32  Botulinum Toxin for Axillary Hyperhidrosis

32.5 S  ide Effects, Complications, and Their Management • Side effects are reported in a minority of patients and tend to be minor and transitory. • Most are related to the injection technique and include pain, paresthesia, hypoesthesia, swelling, edema, erythema, and hematomas [6]. Generally, there is no need to treat such effects. • Bruising and compensatory trunk hyperhidrosis were the most common side effects, seen in 18% and 6% of patients, respectively [7]. • Compensatory hyperhidrosis can be treated with additional botulinum A toxin injections. • Less frequently, transitory muscle weakness may develop in the upper limbs [6] and should be managed with physiotherapy.

Tip Box

• The hyperhidrotic area can be defined according to the hair-bearing area, although the hyperhidrotic area may not match the hair-bearing area in the axillary region. • A topical anesthetic should be applied after conducting Minor’s test. • Ice packs can be applied to reduce pain instead of a topical anesthetic. • 50 UI of reconstituted botulinum A toxin was found to be the minimum dose necessary to cause anhidrosis in healthy individuals, so the amount can be higher. • This treatment can be recommended for patients who also have bromhidrosis. • In terms of clinical efficacy in humans, the most commonly accepted dose cor-

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relations among products are as follows: 1  U onabotulinumtoxinA (OnaA), 1  U incobotulinumtoxinA (IncoA), 1  U BoNT-A (Lanzou), 1  U BoNT-A (Medytox), and 2,5–3 U abobotulinumtoxinA (AboA) [1].

References 1. Trindade de Almeida AR, Montagner S.  Botulinum toxin for axillary hyperhidrosis. Dermatol Clin. 2014;32(4):495–504. 2. Vadoud-Seyedi J, Simonart T.  Treatment of axillary hyperhidrosis with botulinum toxin type A reconstituted in lidocaine or in normal saline: a r­andomized, side-by-side, double-blind study. Br J Dermatol. 2007;156(5):986–9. 3. Bushara KO, Park DM, Jones JC, et  al. Botulinum toxin— a possible new treatment for axillary hyperhidrosis. Clin Exp Dermatol. 1996;21:276–8. b. 4. Brehmer F, Lockmann A, Grönemeyer L-L, Kretschmer L, Schön MP, Thoms K-M.  Repetitive injections of botulinum toxin A continuously increase the duration of efficacy in primary axillary hyperhidrosis: a retrospective analysis in 101 patients. J Dtsch Dermatol Ges J Ger Soc Dermatol JDDG. 2015;13(8):799–805. 5. Lecouflet M, Leux C, Fenot M, Célerier P, Maillard H.  Duration of efficacy increases with the repetition of botulinum toxin A injections in primary axillary hyperhidrosis: A study in 83 patients. J Am Acad Dermatol. 2013;69(6):960–4. 6. Del Boz J, Padilla-España L, Segura-Palacios JM. Botulinum toxin injection technique for axillary hyperhidrosis. Actas Dermosifiliogr. 2014;105(5): 517–8. 7. Scamoni S, Valdatta L, Frigo C, Maggiulli F, Cherubino M.  Treatment of primary axillary hyperhidrosis with botulinum toxin type A: our experience in 50 patients from 2007 to 2010. ISRN Dermatol. 2012;2012:1–5.

Botulinum Toxin for Palmar and Plantar Hyperhidrosis

33

Ada Regina Trindade de Almeida and Elisa Raquel Martins da Costa Marques

33.1 Materials The iodine-starch test: Helps to identify the correct area to be treated and also the posttreatment residual sweating. Material for the test: 3–5% iodine solution, gauze pads or cotton balls, cornstarch, beard brush, and absorbent paper (Fig. 33.1).

33.1.1 For Botulinum Toxin Application Material: 3-mL syringes, saline solution, gauze pads, ice cubes, 0.5-cc syringes with fixed 30-gauge needles, gloves, marking pen, anesthetic cream (optional), and injection adapter (Fig. 33.2). The injection adapter is obtained by cutting the needle cup at a desired length in order to allow partial exposure and penetration of the needle (usually 2.5 mm) (Fig. 33.3) [1].

A. R. T. de Almeida (*) E. R. M. da Costa Marques Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_33

Fig. 33.1  Material for the iodine-starch test

33.2 Methods and  Techniques 33.2.1 Demarcating Injection Sites Palmar: 40–50 sites 1.5  cm apart (approx. 0.6 inches). Fingers: One to two in each phalanx; three to four on the pulps (Fig. 33.4). Plantar: Total dose will vary depending on the size of the sweating area. Usually at 2-cm (approx. 0.8 inches) intervals.

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A. R. T. de Almeida and E. R. M. da Costa Marques

Fig. 33.2  Material for botulinum toxin application

Fig. 33.3  Injection adapter

33.2.2 Product Reconstitution For 100-U vials (Botox® (Allergan, Irvine,CA; Xeomin® Merz, Germany; Prosigne, Lanzhou, China), 2–4 cc of saline solution. For 500-U vials (Dysport®, Ipsen, UK), 3.2 mL of saline solution.

Fig. 33.4  Marking on different sizes of palms

33.2.3 Injection Technique 33.2.3.1 Palmar Dose: 1.5–2.0 BoNT-A U/site. Average of 100 U/ hand Larger doses per site may induce larger diffusion. The physician’s assistant holds ice cubes involved in gauze on the palmar or plantar skin for 10–30 s before injection (Fig. 33.5a–c) [2, 3].

33  Botulinum Toxin for Palmar and Plantar Hyperhidrosis Fig. 33.5 (a) Left palm with demarcated injection sites covered by anesthetic cream. (b) Ice cubes involved in gauze. (c) Injection adapter controlling needle length exposure. (d) Ice anesthesia in each injection point. (e) Injection technique

a

c

b

d

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e

Just after the movement of the ice cube to the next site, the injection is performed in the prechilled area (Fig. 33.5d).

33.2.4 Palmar Hyperhidrosis There is a risk of muscle weakness due to diffusion of the botulinum toxin to hand muscles. For this reason, each injection is performed using the adapter that is placed over the filled syringe. It limits needle penetration, allowing injection depth to be constant and increasing safety and saving time.

33.2.5 Plantar Hyperhidrosis There is no need of an adapter to control injection depth. Thick horny and epidermal layers may be as deep as 5–7 mm or more. In such cases, short needles may not reach the desired plane of injection. The use of soap and water bath before the procedure helps to soften the horny layer, making the injection easier.

A. R. T. de Almeida and E. R. M. da Costa Marques

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a

b

Fig. 33.6 (a, b) Evolution of anhidrotic halo 2 weeks and 1 month after botulinum toxin application

33.3 Clinical Follow-up

33.4 Before and After

Follow-up visits are usually scheduled to occur after 15–30 days. Iodine starch test may be applied to identify posttreatment residual sweating areas. If necessary, touch-ups may be performed at the follow-up visit. Each injection point will produce an a nhidrotic halo of approximately 2  cm ­ (Fig. 33.6a, b). Overlapping of confluent anhidrotic halos will induce absence of sweat in the entire treated area. Response rates: >90%. The effect begins 2–4 days after injection and lasts approximately 6–7 months, gradually disappearing following the reduction of the anhidrotic halos’ size. In the soles, some residual humidity is usually accepted.

33.4.1 Palmar Hyperhidrosis (Fig. 33.7)

Fig. 33.7  Comparison between treated and untreated hand

33  Botulinum Toxin for Palmar and Plantar Hyperhidrosis

233

33.4.2 Plantar Hyperhidrosis (Fig. 33.8)

Before

After 2 weeks

After 9 months

Fig. 33.8  Before; after 2 weeks; after 9 months

33.5 S  ide Effects, Complications, and Their Management Mild transient muscle weakness may occur especially on palms with thinner dermis and subcutaneous layers. Patient’s complaints are related to grip strength: difficulty in holding scissors and opening a closed bottle or a round doorknob. It may last for 2–5 weeks. Tip Box

• BoNT-A is an effective and long-lasting treatment for palmar and plantar hyperhidrosis, improving quality of life.

References 1. Almeida ART, Kadunc BV, Oliveira EMM. Improving botulinum toxin therapy for palmar hyperhidrosis: wrist block and technical considerations. Dermatol Surg. 2001;27:34–5. 2. Smith K.  Ice minimizes discomfort associated with injection of botulinum toxin type A for the treatment of palmar and plantar hyperhidrosis. Dermatol Surg. 2007;33:S88–91. 3. Weinberg T, Solish N, Murray C.  Botulinum toxin treatment of palmar and plantar hyperhidrosis. Dermatol Clin. 2014;32:505–15.

Botulinum Toxin for Special Conditions: Chemical Rhinoplasty

34

Francisco Marcos Perez Atamoros and Alberto Avila Lozano

34.1 Materials

• The muscle depressor of the septi has an important function, because it contracts the • Anatomy of the nose and the involved muscles nasal tip descends to the lips, producing a is very important to understand the sites of cross wrinkle in the nasal philtrum. application of botulinum toxin [1]. • It is localized in both sides of the midline of • The nasal anatomy has transversal and alar the upper lip, extending up to the nose septum parts, cartilage structures, and a mobile region, where it is formed by three fascicules portion. [2]. • The alar cartilages not only play an important • The medial fascicules have an equilateral trirole in the functional mechanism of the nasal angular shape, with bone insertion in the lower valve but are also extremely important in the portion of the nose spine (apex of the triangle) aesthetics of the nasal tip. and the triangle base with a free insertion in • Right above the osteocartilaginous layer, we the upper lip. find the muscles joined together by a fibro-­ • Intermediate fascicles are placed between aponeurotic system called “nasal SMAS.” medial and laterals fascicles. • The nasal muscles, the levator, depressor, • Lateral fascicles have an important role in transversal, and alar muscles of the nostrils, widening the nose. are important from a functional and aesthetic • Vascularization is given by angular arteries perspective. derived from intracranial circulation in upper • Muscles for medical and surgical minimally corner and by the lateral and columella arterinvasive techniques for treatment of botulinum ies of nose that derive from superficial toxin are muscles of nasal tip: the d­ epressor branches in external carotid. septi nasi muscle and levator labii alaeque nasi • Motor innervations derive from facial nerve, muscle. while sensitive branches derive from the second branch of the trigeminal nerve through the external nasal, the infraorbital, and the naso-­ lobar nerve. • Botulinum toxin is a neurotoxin produced by F. M. P. Atamoros (*) · A. A. Lozano strains of Clostridium botulinum. It exerts Centro Dermatologico Tennyson, its effect by acting on the neuromuscular Mexico City, DF, Mexico junction by inhibiting the release of acetyle-mail: [email protected]; [email protected] choline [3]. © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_34

235

236

• The toxin irreversibly binds to pre-synaptic neurons during the first hour of action. The paralysis has its peak of effect in up to 2 weeks. • Commercially, there are two types of botulinum toxin, A and B. Type A in the market are onabotulinum (ona), incobotulinum (inco), and abobotulinum (abo) toxins, and type B ribobotulinum (ribo) is commercially available in the USA. • Type A toxin has a duration ranging from 12 to 16 weeks [4, 5].

34.2 Methods and Techniques 34.2.1 Bunny Lines • Nose wrinkles or bunny lines are located in the upper portion of the nose resulting from the contraction of the transverse portion of the nasal muscle. It accentuates when trying to contract the glabella [2, 6]. • To treat bunny lines, apply 2–5  U of botulinum toxin type A in the upper and lateral portion of the nose on each side. • After that, you must rub gently to allow the toxin to diffuse to the upper part of the nose. • To make this application, one must be careful that the toxin does not diffuse to the alar portion of the elevator of the upper lip because this can cause weakness in this muscle and eventually cause ptosis.

34.2.2 Elevation of Nasal Tip • The septi depressor along with alar portion of the nasal muscle is responsible for the opening of the nostrils and descending the nasal tip [7]. • The application of botulinum toxin in those muscles will result in an elevation of the nasal tip.

F. M. P. Atamoros and A. A. Lozano

• The reference for the septi depressor muscle is to make the patient to squeeze the lips, at the union of the columella with the upper lip inject. • It can be helpful to pull the upper lip downward to avoid injecting the orbicularis muscle. • For alar portions, ask the patient to inhale deep and place the botulinum toxin at the maximum depression point. • The number of units needed depends on the effect we are looking for; for mild lift effect, we recommend 2  U/4  U (ono-inco/abo) on each alar part and 2 U/4 U (ono-inco/abo) in septi depressor. • For more lift, we use 4 U/8 U (ono-inco/abo) in each muscle. • It is important to remember that sometimes we have to respect the glabella to have a better lift. In patients with a history of rhinoplasty, the results may vary depending on the amount of fibrous tissue.

34.3 Clinical Follow-up • The clinical effect begins after 3–7 days after the application of botulinum toxin and it peaks after weeks 2–4; the duration of the effects depends on each botulinum toxin commercial brand [8]. • The duration of the effects is from 12 to 16 weeks. • Because of this, we recommend to see the patient between 2 and 4 weeks after the injection. In this way, we can apply more units to correct in case we do not see the desired result in the nose. • If we apply 2 U for nose lift in the next visit, we can apply 2–4  U more to get the desired effect. • With regard to bunny lines, we also recommend, especially if it is the first time the patient is applying the toxin, to begin with a low dose and apply more units in the follow­up sessions.

34  Botulinum Toxin for Special Conditions: Chemical Rhinoplasty

34.4 S  ide Effects, Complications, and Their Management • The described adverse effects of this technique are nose tip pain that can last for 2 weeks in 3% of the patients [7, 9]. • Nostril opening and diminished effect that could last less than 2 months in 5% of the patients. • When the toxin diffuses to the levator of the upper lip, it causes asymmetric smile and ptosis including loss of the action of the orbicularis muscle as well as difficulty in eating and speaking. • The application for nose lift can also cause prolonged dilatation of the nostrils, with elevation of the nose tip. • If the toxin migrates to the central portion of the upper lip, it can result in an elongated and thin lip, losing deepness of the philtrum. • If the medial palpebral portion of the eye orbicularis muscle is affected by diffusion, it will cause epiphora and diplopia. Tip Box

• Nose lift: Apply (BTxA) to depressor septi and each side of alar muscle [7]. • To inject depressor septi: squeeze the lips at the union of columella with upper lip in place. • Ask the patient to deeply enhale and inject botulinum toxin em both muscle bands. • Apply 2–4 U ona/inco or 4–8 U (abo) in each site. • Review 2  weeks after application; if needed, apply more units.

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References 1. Panfilov DE.  Simetry of the face. In: Aesthetic Surgery of the Facial Mosaic. Springer: Heidelberg; 2007. p. 29–32. 2. Radaelli A, Limardo P.  Minimally invasive procedures for nasal aesthetics. J Cutan Aesthet Surg. 2012;5:115–20. 3. Dorizas A, Sadick NS.  Aesthetic uses of the botulinum toxin. Dermatol Clin. 2014;32:23–36. 4. Benedetto AV. Botulinum toxin in clinical dermatology: Taylor and Francis; 2006. 5. Carruthers JA, Lowe NJ.  Double blind randomized placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol. 2002;46:840–9. 6. Carruthers A, Carruthers J. Botulinum toxin. Elsevier Saunders. 2005:14–5. 7. Cosmetica D, Perez Atamoros F, Merino JE, Sevier E, 2011. 8. Ericksson BP, Lee WW. The role of neurotoxins in the periorbital and midfacial areas. Facial Plast Surg Clin North Am. 2015;23:243–55. 9. Sommer B, Sattler G.  Botulinum toxin in aesthetic medicine. Berlin: Blackwell Science; 2001.

Botulinum Toxin for Special Conditions: Facial Mesotherapy

35

Eloisa Leis Ayres

35.1 Materials (Fig. 35.1) [1] • Gauze pads and antiseptic solutions. • Botulinum toxin A (onabotulinumtoxinA 100  U, abobotulinumtoxinA 500  U, or incobotulinumtoxinA 100 U). • 0.9% bacteriostatic sodium chloride solution for injection. • Syringes (5  mL for dilution and BD 0.3  mL for injection). • Topical anesthetics (optional).

35.2 Methods and Techniques [1] • Satisfactory results have been observed with superficial microdoses in areas presenting thin and flat muscles, with laxity, and also in the sagging skin. • It is also indicated where deep intramuscular injection using habitual doses can compromise the muscular functionality leading to impairment of the movements in the treated area. • The author recommends that the classic application of TB should be always performed according to the individual evaluation of each patient.

Fig. 35.1 Material

• Both techniques could be combined, whenever necessary, in certain areas where an additional benefit can be added. • Botulinum toxin A (onabotulinumtoxinA) 100 U should be reconstituted in 4 ml of saline solution (0.25  U/0.01  mL) and placed in 0.3 mL syringes. • Identify areas to be treated such as lateral frontal muscle, lower palpebral region, the middle third of the face, neck lines, and decollete.

E. L. Ayres (*) EZskin Dermatologia, Niterói, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_35

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E. L. Ayres

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• For oily skin, pores, acne, flushing, and rosacea, affected areas should be delimited. • Small dots should be marked with 5 mm distance between them within delimited area. • Microdoses of 0.25–0.5  U (0.01–0.02  mL) should be injected intradermally in each point, covering all the affected area (Fig. 35.2).

Fig. 35.2  Area of rosacea treated intradermally with onabotulinumtoxinA. Dose of 0.25 U each point

35.3 Clinical Follow-Up • Based on literature studies and the author’s experience, it is agreed that the superficial microdoses are able to offer effective results, however less intense and for shorter periods. • Its use alone for facial rejuvenation and reduction of wrinkles has a limited therapeutic response. • Results begin to be observed after 2  days of injections and improve gradually until 15 days. • An improvement is noticed not only in the wrinkles but also in the general appearance of the skin after 14–21 days. • This effect appears to be progressive and is usually longer-lasting as repeated applications are performed. • Depending on the indications, treatment can be repeated every month (acne, flushing, and rosacea) or every 4–6  months (rejuvenation and skin texture). • It is therefore suggested that it must be accompanied by other approaches available to obtain more effectiveness and long-lasting results. • Ideally, non-invasive techniques such as fillers, lasers, peelings, radiofrequency, and microfocus ultrasound may be combined to add the effectiveness of the procedures.

35  Botulinum Toxin for Special Conditions: Facial Mesotherapy

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35.4 Before and After (Figs. 35.3, 35.4, 35.5, 35.6 and 35.7) a

b

Fig. 35.3 (a) Before and (b) after 30 days of treatment for rosacea with microdoses of botulinum toxin

a

b

c

Fig. 35.4 (a) Before. (b) Intradermal points of 0.25 U to improve fine wrinkles in palpebral area. (c) After 15 days

E. L. Ayres

242

a

b

c

Fig. 35.5 (a) Before. (b) Intradermal points of 0.25 U to improve fine wrinkles in periorbital area. (c) After 15 days

a

b

c

Fig. 35.6 (a) Before. (b) Intradermal points of 0.25 U to improve fine wrinkles in chin area. (c) After 15 days

a

b

c

Fig. 35.7 (a) Before. (b) Intradermal points of 0.25 U to improve fine wrinkles in frontal, palpebral and jaw area. (c) After 15 days

35  Botulinum Toxin for Special Conditions: Facial Mesotherapy

35.5 S  ide Effects, Complications, and Their Management [2–3] • Side effects and complications are usually mild and transient. • The main adverse effects observed are bruising due to the greater number of punctures. • Side effects occur when a muscle or area not intended to be treated is affected, leading to possible asymmetries due to the involvement of unwanted muscle groups. • Asymmetries can be corrected, but as using small doses, time is the best choice to revert these undesirable side effects.

Tip Box

• Superficial microdoses of TB can offer effective results for rejuvenation and wrinkles. • When associated with traditional intramuscular injection, a global and harmonious result is perceived. • It can be an adjuvant treatment in difficult conditions such as acne, rosacea, and oily skin. • Patients should be aware of expecting results and time of duration. • This is an excellent technique to be combined with other procedures such as fillers and technologies.

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References 1. Ayres EL. Toxina botulínica em microdoses superficiais. In: Ayres EL, MHL S, editors. Toxina B otulínica na Dermatologia: guia prático de técnicas e produtos. 1a Edição ed. Rio de Janeiro: Guanabara Koogan; 2016. 2. Lee SK.  Multiple intradermal small bolus injection of botulinum toxin: the limit and the potentiality. J Cosmet Laser Ther. 2012;14(6):304–6. 3. Steinsapir KD, Rootman D, Wulc A, Hwang C.  Cosmetic microdroplet botulinum toxin a forehead lift: a new treatment paradigm. Ophthal Plast Reconstr Surg. 2015;31(4):263–8.

Botulinum Toxin for Special Conditions: Gummy Smile – Advanced Points and Indications

36

Rosemarie Mazzuco and Beatrice Martinez Zugaib Abdalla

36.1 Materials • • • • • • • •

Gauze Alcohol Sterile gloves Botulinum toxin A 0.3, 0.5 or 1 ml syringe 3 ml syringe 30–32-G sharp needle 0.9% sodium chloride vial

36.2 Methods and Techniques • Dilution and storage of BT should follow the same guidelines as for all other facial indications [1, 2]. • Dose equivalence of 2.5  units of abobotulinumtoxin, Dysport®, Galderma, Ipsen, UK, for 1 unit of onabotulinumtoxin, Botox®, Allergan, Irvine, USA [3]. • Low dilutions are preferable, especially when using BT in the middle and lower thirds of the face, preventing the risk of diffusion to adjacent muscles [4]. R. Mazzuco (*) Private Practice, Carazinho, RS, Brazil B. M. Z. Abdalla ABC School of Medicine, Santo André, SP, Brazil 2nd Year Resident of Internal Medicine at FMABC, Santo André, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_36

• The use of short and thin needles and the application of topical anesthetic prior to the injection of BT are important factors for better patient comfort [5], being routinely used. • Doses and application sites depend on the type of GS and are described below (Fig. 36.1)—to facilitate understanding, only the dose of abobotulinumtoxin (Dysport®) is mentioned: –– Anterior GS: intramuscular injection of 2.5 to 5  U of BT on each side of the nasogenian sulcus, at a point 1 cm lateral and inferior to the nasal wing, mainly aiming at LLSAN muscle relaxation. –– Posterior GS: injection in two points on each side of the malar region, in a latero-­ superior direction (coincident with the zygomaticus major and minor muscles path). The first intradermal injection point in the nasogenian sulcus, the area of ​​greatest contraction during the smile and the other point, 2 cm lateral to the first point, also intradermal, at the height of the auricular tragus. At each point 2.5 U are injected, a total of 5 U on each side of the smile. –– Mixed GS: BT is injected at all points mentioned above, with reduced dose at the point near the nasal wing, to avoid excessive ptosis of the upper lip. –– Asymmetric GS: the technique is the same as the mixed GS at the side with greatest gingival exposure. On the contralateral side, BT is also injected in a 245

R. Mazzuco and B. M. Z. Abdalla

246 Fig. 36.1  BT injection dose and injection points: anterior GS (red), posterior GS (black), and mixed (red and black)

Fig. 36.2  Dose and BT injection points for asymmetric GS correction

reduced dose or number of points in order to avoid reverse asymmetry. (Fig.  36.2) illustrates the injection points indicated for these cases. Some authors suggest the use of higher total doses: 10–15 U [6, 7]. The present authors suggest that the doses are more conservative at this location because of the greater risk for adverse effects, which will be described below.

36.3 Clinical Follow-Up –– Not to manipulate the procedural area [8]. –– Post-procedural office visit in 20–30 days. –– Botulinum toxin effects can be clinically observed around 3–5  days and can remain for 8–16  weeks, up to 20  weeks [9].

36  Botulinum Toxin for Special Conditions: Gummy Smile – Advanced Points and Indications

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36.4 Before and After (Fig. 36.3)

Fig. 36.3  32-year-­old patient with mixed GS, before and after 30 days from BT treatment

36.5 S  ide Effects, Complications, and Their Management At the recommended doses and correct points, the incidence of complications for this indication is low, but still higher than in the treatment of the upper third of the face [10, 11]. This occurs because the functions of the small muscles of the middle and lower thirds of the face are more sensitive to changes [12]. Some adverse effects in this area are often more sensed and referred to by patients than observed aesthetically: difficulty in pronouncing words, involuntary tongue bite, lip paresthesia, loss of filter design, difficulty in salivary movement in the mouth, and loss of saliva during the oratory [9, 13]. The most common visual aesthetic complications are: –– Upper lip ptosis: occurs by the use of very high doses of BT in one or all of the muscles of the upper lip lift complex. Ptosis can be uni- or bilateral, clinically evidenced as asymmetry. In older patients, it is suggested to decrease the total dose, because there is already a certain degree of muscular weakness.

–– Smile asymmetry: occurs when there is a difference in dose or application points on one side in relation to the other. Note the need to inject BT on both sides of the face, including when treating an asymmetric GS, as reverse asymmetry may occur, with consequent greater gingival exposure on the untreated side [9]. –– Ptosis of the commissure (sad smile): in patients with hyperactivity of the depressor anguli oris (DAO) muscle, the application of BT for correction of the posterior or mixed gingival smile may result in a descent of commissure, because the contractions of the zygomaticus and levator anguli muscles antagonize the effect of DAO contraction, which will not occur if the former are relaxed with BT [9]. In order to avoid this complication, if hyperactivity of the DAO muscles is evident, they should also be relaxed in the same treatment session of GS. Treatment of these complications may include motor physical therapy and electrostimulation of paralyzed muscles. However, the total resolution occurs only when the BT effect regresses.

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Tip box

• The application of BT for temporary correction of GS is a procedure already established as being simple, safe, and effective. • In cases where muscular hyperactivity is the primary cause of GS, the application of BT is the first-choice procedure. For the other causes, BT is a valuable tool for aesthetic correction until definitive treatment is made. • The knowledge of the physiological anatomy of the facial muscles, as well as the use of small doses at correctly marked points, is essential for the success of this indication, as in all others.

References 1. Klein AW.  Dilution and storage of botulinum toxin. Dermatol Surg. 1998;24:1179–80. 2. Alam M, Bolotin D, Carruthers J, Hexsel D, Lawrence N, Minkis K, Ross EV. Consensus statement regarding storage and reuse of previously reconstituted neuromodulators. Dermatol Surg. 2015;41(3):321–6. 3. Karsai S, Raulin C.  Current evidence on the unit equivalence of different botulinum neurotoxin A formulations and recommendations for clinical practice in dermatology. Dermatol Surg. 2009;35(1):1–8.

R. Mazzuco and B. M. Z. Abdalla 4. Giordano CN, Matarasso SL, Ozog DM.  Injectable ant topical neurotoxins in dermatology: basic science, anatomy, and therapeutic agents. J Am Acad Dermatol. 2017;76(6):1013–24. 5. Sobanko JF, Miller CJ. Alster. Topical anesthetics for dermatologic procedures: a review. Dermatol Surg. 2012;38(5):709–21. 6. Suber JS, Dinh TP, Prince MD, Smith PD. OnabotulinumtoxinA for the treatment of a “gummy smile”. Aesthet Surg J. 2014;34(3):432–7. 7. Nasr MW, Jabbour SF, Sidaoui JA, Haber RN, Kechichian EG.  Botulinum toxin for the treatment of excessive gingival display: a systematic review. Aesthet Surg J. 2016;36(1):82–8. 8. Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg. 2004;114(6 Suppl):1S–22S. 9. Mazzuco R, Hexsel D. Gummy smile and botulinum toxin: a new approach based on the gingival exposure area. J Am Acad Dermatol. 2010;63(6):1042–51. 10. Ascher B, Talarico S, Cassuto D, et al. International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)– Part II: Wrinkles on the middle and lower face, neck and chest. J Eur Acad Dermatol Venereol. 2010;24(11):1285–95. 11. Klein AW.  Contraindications and complications with the use of botulinum toxin. Clin Dermatol. 2004;22(1):66–75. 12. Levy LL, Emer JJ. Complications of minimally invasive cosmetic procedures: prevention and management. J Cutan Aesthet Surg. 2012;5(2):121–32. 13. Sadiq SA, Khwaja S, Saeed SR. Botulinum toxin to improve lower facial symmetry in facial nerve palsy. Eye (Lond). 2012;26(11):1431–6.

Botulinum Toxin for Special Conditions: Masseter Hypertrophy

37

Caroline Romanelli T. A. Zelenika

37.1 Materials • Diluted botulinum toxin type A 100  IU with 1.0 mL 0,9% saline solution • Nonpermanent ink pen • Procedural gloves • 2.5% lidocaine plus 2.5% prilocaine cream • Gauze • 10% povidone iodine solution

• Injection must be deeply in the masseter muscle, with keeping the safe margin 1 cm from anterior border of masseter muscle. • Four 5-7  U injections were injected deep inside the contracted muscle; each point is part 1 cm from each other (Fig. 37.1), in a total of 20–28 U on each side.

37.2 Methods and Technique • Standardized photographs should be taken before and after the application. • Botulinum toxin type A is diluted by using a 30G needle 1  cc syringe or ultrafine BD syringe is needed. • Injecting should be done in a safety area established by delimitating a line between the mouth angle and the lower implantation of the ear, with patients strongly grinding their teeth. The anterior and posterior parts of the muscles were also delimitated, with the ramus of the mandible being the lower border of the area [1].

C. R. T. A. Zelenika (*) Pontifical Catholic University of Campinas, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_37

Fig. 37.1 Sites wherein 5  U of botulinum toxin is injected into masseter muscle 249

C. R. T. A. Zelenika

250

37.3 Clinical Follow-Up • The technique of treatment of masseter hypertrophy is still in the development phase, and some authors have used different preparations and different dosages (20~90 U per side). Give that, patients must be re-evaluated after 30  days, in order to

a

observe whether any complementation is clinically required. • The treatment must be repeated every 4–6 months for 2–3 consecutive years before having stable benefits.

37.4 Before and After (Figs. 37.2, 37.3, and 37.4) b

Fig. 37.2  Before (a) and after 30  days (b) 25  U of botulinum toxin A into bilateral masseter muscle hypertrophy. (Courtesy: Kenia Calil, Marilia, SP, Brazil)

37  Botulinum Toxin for Special Conditions: Masseter Hypertrophy

a

251

b

Fig. 37.3  Before (a) and after 30 days (b) 30 U of botulinum toxin A into patient’s right side of masseter muscle hypertrophy. (Courtesy: Taciana Dal’Forno Dini, Porto Alegre, RJ, Brazil)

Fig. 37.4  Five-­month clinical follow-up of botulinum toxin A injection into bilateral masseter muscles

C. R. T. A. Zelenika

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37.5 S  ide Effect, Complications, and Their Management • Weakness of mastication force: It will generally be spontaneously solved within 1–3 months after injection [2]. • Drooping of mouth corner: A transient, collateral event when risorius muscle or zigomatic major is iatrogenically paralyzed. • Bulging: Occurs when master muscle thickness and size are massive and the paralyzed process is not reached properly. In this case, complementation of botulinum toxin type A into that area is needed.

Tip Box

• Be sure you know the local anatomy properly in order to reach risorius muscle or zygomatic major. • Be aware: Is it a real masseter muscle’s hypertrophy or any anatomical (bone issue) or parotid dysfunction? Reassure before injecting!

• The best result is reached when patient chews strongly while the injector injects.

References 1. Chang CS, Bergeron L, Yu CC, Chen PK, Chen YR.  Mandible changes evaluated by computed tomography following Botulinum Toxin A injections in square-faced patients. Aesthet Plast Surg. 2011;35:452–5. 2. Kim KS, Byun YS, Kim YJ, et  al. Muscle weakness after repeated injection of botulinum toxin type A evaluated according to biteforce measurement of human masseter muscle. Dermatol Surg. 2009;35:1902–6.

Botulinum Toxin for Special Conditions: Myomodulation to Body Contour

38

Roseli Andrade and Claudio Dias

38.1 Materials (Fig. 38.1) • • • • • •

Bottle of botulinum toxin. 1 syringe for dilution (3 cc ~ 5 cc). 22G needle 1/14 (aspiration the saline solution). Saline solution (2.5 ~ 5 ml solution). 1 ml syringe (1 ml). Insulin needles 30 ~ 31× ½ Gauge (13  mm length). • Marker pen.

Fig. 38.1  The list of materials, described in 38.2. materials (Fig. 38.1) R. Andrade (*) Clinical and Aesthetic Dermatology, Clínica Dermatológica Dra Roseli Andrade, Santos, SP, Brazil

38.2 Methods and Techniques [1–8] Trapezius: Fig. 38.2a–e. Dilution required is of 100UI/2.5  mL saline solution, and the total dose is of 50UI/side, distributed in 3–5 points of injection. Local injection: middle third of the upper trapezius, limited by the anatomical structures  – upper trapezium fibers, occipital protuberance, spinous process, and acromion. The patients need to shrug the shoulders in seated position. After that, the physician pinches the muscle immediately surrounding the point wherein botulinum toxin will be injected perpendicularly. Calves: (Fig. 38.3c–d) Dilution required is of 100UI/5  ml of saline solution, and the total dose ranges from 110UI to 150UI/side. Local injection: the lower third of the lateral and medial faces of the calves, bordered by the anatomical structures: • Medial and lateral gastrocnemius (80–90 UI each one per side), which emerges from ­femoral condyles (lateral and medial), whose action is the flexion of the foot and knee

C. Dias Clinical Aesthetic Medicine, Recife, PE, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_38

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R. Andrade and C. Dias

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a

b

c

d

e

Fig. 38.2 (a, b) Patient who needs three points in each side. (c) Patient who needs 5 points in each side. (d) Patient who needs 5 points in each side. (e) Patient who needs 5 points in each side

38  Botulinum Toxin for Special Conditions: Myomodulation to Body Contour

• Fibularis longus, which is treated when the calves have too much lateral volume (20–40 UI each muscle) • Soleus (10–20 UI each muscle), whose origin is the third medial border of tibia and fibula. Note: Do not treat soleus muscle on the first session, since it’s treated only in cases of long

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ankles and after 20  days of the first treatment. Palpate and mark the muscle contour in the standing position. Inject with patient lying supine. Inject perpendicularly using 13  mm needle.

a MILD HYPERTROPHY

MODERATE HYPERTROPHY

STRONG HYPERTROPHY

LATERAL GASTROCNEMIUM

40UI

50UI

70-90UI

MEDIAL GASTROCNEMIUM

40UI

50UI

70-90UI

SOLEUS

-

5-5UI

10-10UI

FIBULARIS LONGUS

20UI

30UI

40UI

TOTAL

100UI

140UI

190-230UI

b

plantaris

c

Fibular head

gastrocnemius caput mediale

soleus

gastrocnemius caput laterale

2/3

2/3

soleus

Lateral malleolus tendo calcaneus

Fig. 38.3 (a) Botulinum toxin dose for treatment of the calves. (b) Treatment of the calves. (c) Distribution of botulinum toxin units into the muscles of calves. (d) Distribution of botulinum toxin units into the muscles of

calves. (e) Distribution of botulinum toxin units into the muscles of calves. (f, g) Injection technique into the muscles of the calves.

R. Andrade and C. Dias

256

d

f

e

g

Fig. 38.3 (continued)

38.3 Clinical Follow-up [1–8] Muscle relaxation starts as of 48–72 h, when all patients report improvement in contraction and sensation of muscle relaxation. However, clinical improve onset can be measure as follows: • 1–2 weeks: decreased muscle strength • 2nd to 3rd month: improvement in appearance • 4 months: 50% muscle volume recovered

• 6 months: 100% muscle force recovered • 8–12  months: 100% muscle volume recovered Patients must be seen 20 days and 30–45 days after, respectively, the treatment of trapezius and the calves. At this moment, if any inadequate response is observed, 20–50% of botulin toxin could be added for each side. Treatment outcome lasts for about 6–8 months.

38  Botulinum Toxin for Special Conditions: Myomodulation to Body Contour

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38.4 B  efore and After (Figs. 38.4a, b and 38.5a, b) a

b

Fig. 38.4 (a) Before treatment. (b) Post treatment

a

b

Fig. 38.5 (a) Before. (b) After

38.5 S  ide Effects, Complications, and Their Management [1–8] Pain usually begins in 1–3 weeks when muscles lose strength and resolves spontaneously within 2–4 weeks. Exaggerated workout or lifting heavy weight can cause pain in the treated muscle; in case of severe pain in calves, cycling is recommended instead of running.

Difficulty in raising the shoulder or lifting the arms can also be observed. Foot drop – in rare cases, difficulties in climbing and walking in excessive dose use can also be observed. Avoiding motor dysfunction with loss of muscle strength can be managed when starting the treatment with 100–110UI per leg.

R. Andrade and C. Dias

258

Tip Box

Post application muscle process Muscle power

1 month

Muscle volume

2 month

3 month

4 month

6-8 months

• Muscle power:

–– Reduced within few days. –– Peak of power reduction is approximately 1 month. –– Muscle action is recovered slowly after 3–4 months. • Muscle volume:

–– Reduced with few weeks. –– Peak of volume reduction is approximately 2–3 months. –– Recovers slowly over 6–8 months.

Tip Box

• For each muscle treated there are different units to be used, specific dilution of the botulin toxin, and injection areas to be treated • Exaggerated workout or lifting heavy weight can cause pain in the treated muscle • Foot drop is rare, but can happen • Difficulty in raising the shoulder or lifting the arms can also be observed

References 1. Ahn SW, Park EH, Kim ME.  Botulinum toxin type A injection versus lidocaine injection for myofascial pain involving upper trapezius. J Oral Med Pain. 2005;30:345–51. 2. Kwanchuay P, Petchnumsin T, Yiemsiri P, Pasuk N, Srikanok W, Hathaiareerug C. Efficacy and safety of

single botulinum toxin type A injection for relief of upper trapezius myofascial trigger point: a randomized, double-blind, placebo-controlled study. J Med Assoc Thail. 2015;98(12):1231–6. 3. Vasileiadis GI, Sakellariou VI, Papagelopoulos PJ, Zoubos AB.  Posttraumatic focal dystonia of the shoulder. Orthopedics. 2012;35(6):e977–80. 4. Childers MK.  Targeting the neuromuscular ­junction in skeletal muscles. Am J Phys Med Rehabil. 2004;83(10):S38–44. 5. Kim MW, Kim J-H, Yang Y-J, Ko Y-J. Anatomic localization of motor points in gastrocnemius and soleus muscles. Am J Phys Med Rehabil. 2005;84(9):680–3. 6. Shaari CM, Sanders I. Quantifying how location and dose of botulinum toxin injections affect muscle paralysis. Muscle Nerve. 1993;16(9):964–9. 7. Cote T, Mohan AK, Polder JA, Walton MK, Braun MM.  Botulinum toxin type A injections: adverse events reported to the food and drugs administration in therapeutic and cosmetic cases. J Am Acad Dermatol. 2005;53(3):407–15. 8. Francisco GE, Tan H, Green M.  Do botulinum toxins have a role in the management of neuropathic pain?: a focused review. Am J Phys Med Rehabil. 2012;91:899–909.

Part III Hyaluronic Acid Filler

Introduction: What Is Hyaluronic Acid Filler?

39

Nelise Hans and Thais Sakuma

39.1 History: Background The first studies on filling date back to 1893 when Neuber used autologous fat to fill a facial deformity. In the 1980s, the animal collagenbased fillers came about (Zyplast® and Zyderm®; Allergan, previously known as Inamed); in March 2003, the human collagen based (Cosmoderm®, Cosmoplast®, Evolence®); and in December of that year the stabilized HA,

a

b

Fig. 39.1 (a) When dissolved in water, hyaluronic acid (HA) behaves as a fluid, with excellent biocompatibility but poor mechanical properties. (b) Modification of HA molecules by cross-linking improves mechanical properties by creating gels that have a firmer structure and are

non-animal based (NASHA) (Restylane®, Q-Med, Uppsala, Sweden). Since then, there have been other HA brands available on the market, also produced through Streptococcus sp. bio-fermentation. These represent a great evolution, as they have the advantages of longer durability, immediate use possibility without the need of previous allergy testing, and the foreseeable resourcefulness of volume reposition (Figs. 39.1 and 39.2) [3].

c

able to resist degradation. (c) Modification does not necessarily cross-link HA to other HA molecules, resulting in a pendant cross-linker. Such structures often result in softer gels. (Kablik et al. [1])

N. Hans · T. Sakuma (*) Private practice, Campo Grande, MS, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_39

261

N. Hans and T. Sakuma

262

a

b

c

Fig. 39.2  Working model of mechanical tension (stretching) induced by non-animal stabilized hyaluronic acid (NASHA) injections as a mechanism for collagen induction in human skin. Normal skin consists of an outer epidermis composed mostly of keratinocytes (KCs), and an underlying dermis consisting mostly of extracellular matrix proteins, which are synthesized by fibroblasts (FBs). (a) NASHA is shown as preferentially localizing in areas containing more highly fragmented collagen fibers,

since these regions may be more accommodating. (b) This results in stretching of existing collagen fibers (curved lines), which is sensed by nearby fibroblasts through cell surface receptors such as integrins. In response, fibroblasts become morphologically stretched (b) and activated to produce extracellular matrix components (c), including new, intact collagen fibers (red lines). (Wang et al. [2])

39.2 Physical and Chemical Features

the product. Only the reticulated HA resists the enzymatic degradation and the degradation by free radicals [1] .

The combination of different physical and chemical properties determines the product final features.

39.2.2 Reticulation

HA, in its natural state, has a half-life of 1 to 2 days. It is degraded by hyaluronidase enzyme and by free radicals, being metabolized by the liver, in water and carbonic gas. HA molecular weight is proportional to the numCross-linking is an important process to ber of repetitions of the disaccharide composed increase the duration and also because it can alter of D-glucuronic acid and N-acetyl-D-­the biomechanical features of the filler. The most glucosamine. The HAs used in the fillers manu- common reticulating agents (cross-linkers) are facturing vary from 500 to 6000 kDa. divinyl sulfone, 1,4-butanediol diglycidyl ether Concentration corresponds to the total HA (BDDE), and bi-epoxide. In true reticulation, the measured in mg/mL.  The total concentration of reticulating agent connects itself to two HA HA consists of the addition of insoluble HA gel chains. Now, in pseudo-reticulation, the reticulatand free soluble HA.  Some products have free ing agent connects itself to one HA chain only, HA as the soluble and fluid component of the gel making a pending group. to make the extrusion of the filler easier through The increase in density of reticulations (cross-­ thinner needles. Although not all manufacturers links) decreases the distance between the reticuhad added the fluid HA to their fillers, one fluid lated segments, in a way that when a force is component is always present and, in general, applied, it needs a greater force for its extrusion. brought on during the manufacturing process. Therefore, the greater the density of the reticulaThese soluble fluids are easily metabolized and tion, the greater the hardness or firmness of the do not contribute to the duration and efficiency of gel. But when a more flexible gel is desired, one

39.2.1 Molecular Weight and Concentration

39  Introduction: What Is Hyaluronic Acid Filler?

decreases the amount of true reticulation and one increases the quantity of pseudo-reticulation. The stabilized non-animal HA (Restylane®) and the Hylacross (Juvedèrm) manufacturing starts with the reticulation of smaller portions (about 200 to 300 KDa), whereas the manufacturing of cohesive polydensified matrix ones begins with the reticulation of larger portions (about 800 kDa). Besides, the last ones have non-uniform reticulation, which is achieved after a second turn of reticulation and the addition of more HA. This results in two density patterns in the product, although it continues being monophasic. The areas with greater reticulation are more firm and grant duration to the product, while the ones with less reticulation make the product more malleable [1].

39.2.3 Viscoelasticity Rheology is a branch of physics that studies how matter (e.g., HA) behaves in response to applied forces. Some physical properties of HA are so described by rheological terms. Elastic modulus (G’) is a quantitative measurement of gel hardness by an applied force. The greater the G’ of a gel is, the less it will be deformed under pressure, for example, when the filler is dispensed through the needle or cannula, or after an injection, when it is subject to the movement of facial muscles and the overlying skin. Products with high G’ are described as those with great capability of tissue lifting. For example, vulcanized rubber is an elastic matter that deforms and goes back immediately to its original form after the removal of the stressor. Viscosity modulus (G”) is the measurement for inability of a gel to recover its original format after the removal of the applied force, that is, the capability of a gel to dissipate energy when a shear force is applied to it [1, 4, 5]. For the filler to be effective, it needs to be viscoelastic. It must deform enough to be injected under high pressure and to be initially molded but elastic enough to resist the deforming forces present in the tissue. A filler that is exclusively elastic (G’) would be impossible to

263

be injected through a needle, because it would demand a much greater force by the plunger, making the application unfeasible. But a filler that is exclusively viscous would be deformed after any force is present, and it would not maintain the applicator’s desired format for a long time.

39.2.4 Turgidity The predisposition of a gel to retain water depends on the process used to hydrate it. Gels that are totally hydrated, or in equilibrium, will not retain water after being implanted. This capability also depends on the HA concentration, on the reticulation density, and on the process used to hydrate the gel [1].

39.2.5 Size of Particles and Extrusion Force The reticulated HA gel must be constituted of particles of a size that can be injected through a needle of appropriate thickness. The extrusion force may be decreased through the reduction of the size of particles [1].

39.3 Classification: Types Presently, there are three types of fillers on the market: • Biphasic; • Monophasic monodensified; • Monophasic polydensified. Biphasic fillers, which are more viscous than the others, constitute reticulated HA particles suspended in a mixture of non-reticulated HA and sodium chloride solution, which acts as lubricant, allowing the mixture to go through the appropriate needle. During the manufacturing process, gel blocks of the HA are “sieved”, thus making particles the desired size, which are then dispersed in the soluble phase. Monophasic gels

N. Hans and T. Sakuma

264

do not go through this “particularization” process and consist of homogeneous gel. The monodensified ones are homogeneous gels produced in one reticulation stage only, but the polydensified ones are reticulated in a first stage and, in a second stage, go through a new reticulation process with the addition of more HA.

39.4 Choosing the Product There are numerous brands of HA implant on the market. Each one produces specific features and important differences that need to be considered, as these may impact treatment outcomes. The combination of various properties previously described allows the manufacturing of hyaluronic acids with peculiar lifespan, degrees of viscosity, and firmness. Therefore, each one will be indicated for a specific anatomical area of the face, appropriate application plane, and different degrees of volumizing action. The monophasic polydensified HAs have less elasticity (G’) and viscosity (G”). This translates into their features, such as malleability and easy spreading ability, and correlates to the homogeneous pattern of tissue integration, after the intradermal implantation. However, the stabilized ones of non-animal origin (NASHA) have more elasticity (G’) and viscosity (G”) and correlate to a pattern of tissue integration that is bolus type. The monophasic monodensified have intermediate elasticity and viscosity.

blasts that received the hyaluronic acid implant showed a mechanically stretched look and biosynthetic phenotype, with abundance of rough endoplasmic reticulum, indicating high protein synthesis and also a greater contact surface with collagen fibers. It is concluded that the reticulated HA injection in the dermis stimulates the production of type I collagen, being hypothesized that this stimulation mechanism is induced by the mechanical stretching of the dermis.

39.6 Available Materials We cite some fillers in the table below. Table 39.1

39.7 S  ide Effects, Complications, and How They May Be Handled/Managed As with any injectable procedure, complications may occur, such as injection-site reactions (erythema, edema, pain/tenderness, bruising, itching), infection, biofilm, hypersensitivity, local tissue necrosis caused by vascular occlusion, ­persistent scaring, persistent discoloration, foreign body granuloma, lumps, asymmetries, contour irregularities caused by technique, and placement errors. After having the correct diagnosis, the therapeutics is established, and antibiotics, oral corticoids, and hyaluronidase can be included.

39.5 Biological Effect

39.8 Conclusion

Wang et al. [2] injected hyaluronic acid and vehicle (isotonic sodium chloride solution) into the photo-aging forearms of 11 volunteers and performed a local biopsy after 4 and 13  weeks. Compared to the control sample, the skin fibro-

Choosing the ideal filler must take into consideration the duration time, application plane, anatomical plane of injection, side effects, how easy it is to inject, need for a previous allergy testing, and cost-benefit both to the doctor and the patient.

17.5 mg/ml

15 mg/ml

20 mg/ml

Juvéderm VOLIFTa

Juvéderm VOLBELLAa

Juvéderm VOLUMAa

Hylacross Monophasic technology monodensified Vycross technology Monophasic monodensified Vycross technology Monophasic monodensified Vycross technology Monophasic monodensified

Juvéderm ULTRA PLUS XCb Juvéderm VOLBELLA XCb Juvéderm VOLLURE XCb Juvéderm VOLUMA XCb

20 mg/ml

17.5 mg/ml

15 mg/ml

24 mg/ml

Juvéderm ULTRA 24 mg/ml PLUS Juvéderm ULTRA 24 mg/ml XCb

Monophasic monodensified Monophasic monodensified Monophasic monodensified

Vycross technology Monophasic monodensified

Vycross technology Monophasic monodensified

Vycross technology Monophasic monodensified

Hylacross technology Hylacross technology Hylacross technology

Juvéderm ULTRA 24 mg/ml

Non-reticulated

13.5 mg/ml

Juvéderm HYDRATE

Allergan – USA

Monophasic monodensified

Hylacross technology

Juvéderm ULTRA 24 mg/ml PLUS XCa Monophasic monodensified

Type of gel Monophasic monodensified

HA Cross-linking Dermal fillers concentration technology Allergan – Brazil Juvéderm ULTRA 24 mg/ml Hylacross XCa technology

Table 39.1  Key characteristics and indications of some hyaluronic acid fillers

Deep dermis, subcutaneous, and/or supraperiosteal

Mid to deep dermis

Lips and perioral area

Mid to deep dermis

Mid to deep dermis/ lips and perioral area

Mid to deep dermis

Deep dermis, subcutaneous, and/or supraperiosteal Mid to deep dermis

Superficial to mid dermis/lips

Dermal-epidermal junction and superficial dermis Deep dermis/lips

Mid to deep dermis/ lips

Injection site Mid dermis/lips

Correction of moderate to severe facial wrinkles and folds Correction of moderate to severe facial wrinkles and folds Correction of moderate to severe facial wrinkles and folds/lip augmentation Correction of moderate to severe facial wrinkles and folds Lip augmentation and correction of perioral rhytids Correction of moderate to severe facial wrinkles and folds Restoration of facial volume – cheek augmentation

Correction of severe facial wrinkles and folds/lip augmentation Correction of superficial to moderate facial wrinkles/lip augmentation and contour Restoration of facial volume

Indications Correction of moderate facial wrinkles and folds/lip augmentation Correction of moderate to severe facial wrinkles and folds/lip augmentation and contour Skin hydration

(continued)

27G1/2″ or 25G1″

30G1/2″

30G

27G

30G

27G

30G

27G1/2″

30G1/2″

30G1/2″

30G1/6″

27G1/2″

Needle gauge 30G1/2″

39  Introduction: What Is Hyaluronic Acid Filler? 265

OBT technology

NASHA technology Biphasic

NASHA technology Biphasic

NASHA technology Biphasic

20 mg/ml

20 mg/ml

12 mg/ml

20 mg/ml

20 mg/ml

OBT technology

20 mg/ml

Restylane Silka

OBT technology

20 mg/ml

20 mg/ml

OBT technology

20 mg/ml

Restylane Lyfta

OBT technology

20 mg/ml

Emervel Touch (Restylane Fynesse) Emervel Classic (Restylane Refyne)a Emervel Lips (Restylane Kysse)a Emervel Deep (Restylane Defyne)a Emervel Volume (Restylane Volume)a Restylane Skinboosters – Vitala Restylane Skinboosters – Vital Lighta Galderma – USA Restylane

NASHA technology Biphasic

NASHA technology Biphasic

Biphasic

Biphasic

Biphasic

Biphasic

Biphasic

NASHA technology Biphasic

20 mg/ml

HA Cross-linking concentration technology Type of gel 20 mg/ml NASHA technology Biphasic

Restylane Perlane (Restylane Lyft)a

Galderma – Brazil

Dermal fillers Restylanea

Table 39.1 (continued)

Lips (submucosal layer)/perioral area

Deep dermis to superficial subcutis

Mid to deep dermis/ lips

Dermis

Mid to deep dermis

Subcutaneous and/or supraperiosteal

Mid to deep dermis

Lips

Mid to deep dermis

Deep dermis, subcutaneous, and/or supraperiosteal Superficial dermis

Injection site Mid dermis/lips

Restoration of skin hydrobalance, improvement of skin structure and elasticity of the skin Restoration of skin hydrobalance, improvement of skin structure and elasticity of the skin Correction of moderate to severe facial wrinkles and folds/lip augmentation Correction of moderate to severe facial wrinkles and folds/cheek augmentation Lip augmentation and correction of perioral rhytids

Restoration of facial volume – cheek augmentation

Correction of severe facial wrinkles and folds

Lip augmentation and contour

Correction of moderate to severe facial wrinkles and folds

Indications Facial tissue augmentation/ correction of wrinkles/lip augmentation Facial tissue augmentation, contours of the face/lip augmentation Correction of superficial rhytides

30G1/2″

29GTW1/2″ or 27GTW1/2″

30G1/2″ or 29G1/2″

30G

30G

27G1/2″

27G1/2″

30G1/2″

30G1/2″

30G1/2″

29GTW

Needle gauge 29GTW

266 N. Hans and T. Sakuma

25.5 mg/ml

26 mg/ml

Belotero Intensea

Belotero Volumea

16 mg/g

20 mg/g

24 mg/g

26 mg/g

14 mg/g 20 mg/ml

Stylage M

Stylage L

Stylage XL

Stylage HYDRO Teosyal First Lines

22.5 mg/ml

22.5 mg/ml

Belotero Balancea

Belotero Balance

20 mg/ml

Belotero Softa

Interpenetrating network-like (IPN-like) Interpenetrating network-like (IPN-like) Interpenetrating network-like (IPN-like) Interpenetrating network-like (IPN-like) Non-reticulated Resilient hyaluronic acid (RHA)

CPM technology

CPM technology

CPM technology

CPM technology

CPM technology

OBT technology

Restylane Defynea 20 mg/ml

Cristália – Brazil Stylage S

Merz – USA

Merz – Brazil

OBT technology

Restylane Refynea 20 mg/ml

Mid to deep dermis

Deep dermis or subcutis

Monophasic

Monophasic

Superficial dermis Superficial dermis

Mid dermis

Monophasic

Monophasic Monophasic

Superficial dermis

Deep dermis, subcutaneous, and/or supraperiosteal Mid to deep dermis

Mid to deep dermis

Superficial to mid dermis Mid dermis

Mid to deep dermis

Mid to deep dermis

Monophasic polydensified Monophasic

Monophasic polydensified

Monophasic polydensified Monophasic polydensified Monophasic polydensified

Biphasic

Biphasic

Correction of severe facial wrinkles and folds/restoration of facial volume Intradermotheraphy Correction of fine lines and superficial wrinkles

Correction of severe facial wrinkles and folds

Correction of moderate facial wrinkles and folds

Correction of moderate to severe facial wrinkles and folds Correction of fine lines

Correction of moderate facial wrinkles and folds Correction severe facial wrinkles and folds/contours of the face/lip augmentation Restoration of facial volume – cheek or chin augmentation

Correction of moderate to severe facial wrinkles and folds Correction of moderate to severe facial deep wrinkles and folds Correction of fine lines

(continued)

30G1/8″ 30G1/2″

27G1/2″ or 23G1/4″

27G1/2″

30G1/2″

30G1/2″

27–30G

27G1/2″ or 30G1/2″

27G1/2″

27–30G

30G1/2″

27G

30G

39  Introduction: What Is Hyaluronic Acid Filler? 267

23 mg/ml

23 mg/ml

Rennova Fill

15 mg/ml

Teosyal Meso

Rennova Lift

22 mg/ml

Teosyal Ultimate

b

a

Lidocaine 0.3% W/W lidocaine 0.3%

InnovaPharma – Brazil

25 mg/ml

Teosyal Kiss

Mid dermis Deep dermis Deep dermis, subcutaneous, and/or supraperiosteal Lips (submucosal layer)/mid to deep dermis – perioral area Subcutaneous and/or supraperiosteal

Monophasic Monophasic Monophasic

XPM Tech

Monophasic

Resilient hyaluronic Monophasic acid (RHA) XPM Tech Monophasic

Resilient hyaluronic Monophasic acid (RHA)

Mid dermis

Deep dermis or subcutis

Superficial dermis

Injection site Mid dermis

Type of gel Monophasic

Resilient hyaluronic Monophasic acid (RHA)

HA Cross-linking Dermal fillers concentration technology Teosyal Global 25 mg/ml Resilient hyaluronic Action acid (RHA) Teosyal Touch Up 25 mg/ml Resilient hyaluronic acid (RHA) Teosyal Deep 25 mg/ml Resilient hyaluronic Lines acid (RHA) Teosyal Ultra 25 mg/ml Resilient hyaluronic Deep acid (RHA)

Table 39.1 (continued)

30G1/2″

23G1″

27G1/2″

25G1″

27G1/2″

30G1/2″

Needle gauge 30G1/2″

Correction of severe wrinkles and 27G1/2″ folds/restoration of facial volume/ contours of the face Correction of moderate facial 27G1/2″ wrinkles and folds/lip augmentation

Restoration of facial volume – cheek augmentation/contours of the face, chin, nose, back of the hands Skin hydration

Indications Correction of superficial to moderate facial wrinkles Correction of moderate facial wrinkles and folds Correction of severe facial wrinkles and folds Facial tissue augmentation/ contours of the face/correction of deep wrinkles Lip augmentation and contour

268 N. Hans and T. Sakuma

39  Introduction: What Is Hyaluronic Acid Filler?

References 1. Kablik J, Monheit GD, Yu L, Chang G, Gershkovich J. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35(1):302–12. 2. Wang F, Garza LA, Kang S, Varani J, Orringer JS, Fisher GJ, Voorhees JJ. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol. 2007;143(2):155–63.

269 3. Glogau RG, Knott HM. Fillers: evolution, regression, and the future. Capitulo 2. Em: soft tissue augmentation. Editado por Jean Carruthers e Alastair Carruthers. Elsevier, 2013. 4. Sundaram H, Cassuto D.  Biophysical characteristics of hyaluronic acid soft-tissues fillers and their relevance to aesthetic applications. Plast Reconstr Surg. 2013;132(4Suppl 2):5S–21S. 5. Pierre S, Liew S, Bernardin A. Basics of dermal filler rheology. Dermatol Surg. 2015;41(Suppl 1):S120–6.

Tip Chapter: Anatomy of the Face, Neck, Hands and Genital Areas

40

Mirna Duarte Barros, Antonio Cardoso Pinto, Bianca Maria Liquidato, and Wagner Ricardo Montor

40.1 The Face The face presents a thin-layer skin with variable quantity of hair, according to the chromosome-­ determined gender, familialinherited genetics, and endogenous or exogenous hormonal influence. The thickness and rigidity of the dermis basically depend on the quantity and quality of the forming collagen. The subcutaneous adipose tissue is more abundant in children, and there is a progressive tendency for decrease with aging. The buccal pad of fat, also referred to by the eponym Bichat balls, is very prominent in children and confers them a more round-shaped face. The removal of such structures with the aim of achieving a finer appearance and more noticeable cheekbones has been the target of surgical procedures. The soft parts of the face lie on a bone structure composed of the facial skeleton (viscerocranium), the mandible, and part of the frontal bone. The bones that form the facial skeleton are the

M. D. Barros (*) · A. C. Pinto · B. M. Liquidato Department of Morphology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil e-mail: [email protected] W. R. Montor Department of Physiological Sciences, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_40

nasal ones, the palatine, the lacrimal, the zygomatic, and the maxillary, plus the inferior nasal concha and the vomer [1, 2]. A group of subcutaneous muscles, the muscles of facial mimicry, move the skin promoting facial expression according to the emotions felt. These muscles are also responsible for the opening of the oral and palpebral fissures, through the orbicularis oculi and orbicularis oris muscles (Fig. 40.1). The occipitofrontalis muscle presents two muscle bellies: the occipital part which is fixed to the superior nuchal line, with no great relevance to the face and the frontal part, and the part anterior to the coronal suture, whose fibers elevate the eyebrows, when in fear or when surprised, wrinkling the forehead transversally. It interweaves with the procerus, inserted in the nasal bones and the skin between the eyebrows, promoting vertical wrinkles in the nasal root [3]. The orbicularis oculi muscle, circular in shape and surrounding the orbital opening, has three parts, orbital, palpebral, and lacrimal. Some deeper fibers of the orbital part, which terminate in the medial half of the eyebrow, originate the corrugator muscle, which is responsible for bringing the eyebrows closer in reaction to anger and suffering. The action of the circular fibers is not sphincteric, but for bringing the eyelids closer together. The palpebral part of the muscle presents reflex contraction. 271

272

Fig. 40.1  Muscles of facial mimicry. 1. Frontalis; 2. Orbicularis oculi; 3. Levator labii superioris; 4. Zygomaticus minor; 5. Zygomaticus major; 6. Buccinator; 7. Orbicularis oris; 8. Depressor anguli oris; 9. Depressor labii inferioris; 10. Mentalis; 11. Platysma; 12. Levator labii superioris alaeque nasi

Deep to the adipose body of the cheek, the buccinator muscle originates from the pterygomandibular raphe, maxilla, and mandible and is inserted in the upper and lower lips. The intermediate fibers of the muscle cross laterally to the angle of the mouth, accompanied by the crossing of fibers of the levator and depressor anguli oris muscles. The function of the buccinator muscle is to keep the cheek in contact with the vestibular face of the teeth, which is fundamental for chewing food, helping the tongue to maintain the food

M. D. Barros et al.

between the teeth where they are crushed in the oral preparatory phase of swallowing (Fig. 40.1). The orbicularis muscle of the mouth presents a deep part, formed by the fibers of the buccinator muscle and incisive muscle bundles that are fixed in the nasal septum and the maxilla, intermediate oblique fibers that cross the thickness of the lip, going from the skin to the mucosa and a superficial part. The major and minor zygomatic muscles, the levator labii superioris and the levator labii superioris alaeque nasi muscles, originate inferiorly to the orbital margin, in horizontal line, of the zygomatic bone to the frontal process of the maxilla. Their fibers are inserted in the angle of the mouth and upper lip, reaching, medially, the nasal ala and its endings form the superficial part of the orbicularis oris muscle of the mouth. Likewise, the depressor anguli oris and depressor labii inferioris muscles are related to the lower lip (Fig. 40.1). The risorius muscle originates in the fascia parotidea and is inserted in the angle of the mouth. The mentalis originates in the mandible and is inserted in the skin of the menton [3]. The muscles described play a prominent role in the very rich range of facial expressions arising from emotions, ranging from open laughter to crying, from contempt to disdain, and from doubt to resolution. In addition, they keep the food inside the mouth and prevent its escape while eating. The auricular muscles attach to the skin of the ear and are of no significant clinical importance. The nasal muscle has a transverse part, which originates in the maxilla and is transversally inserted in the dorsum of the nose, compressing the nostrils, and an alar part, which laterally draws the nostrils, working as a dilator. All the muscles of the facial mimicry are derived from the second pharyngeal arch in the embryological development; therefore, they are innervated by the facial nerve (VII) [4]. The facial nerve emerges from the skull through the stylomastoid foramen; its trunk emits two small branches and rapidly penetrates the parenchyma of the parotid gland. Inside this gland, it divides into its terminal branches; at the same time, it separates the gland into superficial and deep parts. The terminal branches leave the parotid by its anterior margin and go to the

40  Tip Chapter: Anatomy of the Face, Neck, Hands and Genital Areas

Fig. 40.2  A.  Parotid gland; B.  Submandibular gland; C. Parotid duct. 1. Facial nerve; Branches of facial nerve; 2. Temporal; 3. Zygomatic; 4. Buccal; 5. Marginal mandibular; 6. Cervical

muscles of the respective regions. They are temporal, zygomatic, buccal, marginal of the mandible and cervical branches. Anastomoses between the branches are frequent, and there may be more than one buccal or zygomatic branch (Fig. 40.2) [2]. Sensory innervation of the facial skin is promoted by the fifth cranial nerve, the trigeminal nerve. The trigeminal ganglion is located at the petrous part of the temporal bone, and, anatomically, there are three distinct nerves: ophthalmic, maxillary, and mandibular. The trigeminal nerve is mostly sensitive, but there is also a group of motor fibers that follows the mandibular nerve and goes to the muscles of mastication. In a simplified way, if we divide the face into three parts in horizontal planes, these nerves are responsible, respectively, for the sensitive innervation of each of the thirds. More specifically, in relation to the branches of the ophthalmic nerve, the lacrimal

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nerve innervates the lateral part of the upper eyelid. Another branch of the ophthalmic nerve, the frontal nerve, gives rise to the supraorbital nerve that also innervates the upper eyelid and the skin of the forehead and scalp to the vertex and to the supratrochlear nerve that innervates the root of the nose, remaining part of the upper eyelid, and forehead. The maxillary nerve has as its terminal branch the infraorbital nerve. It emerges on the face by the infraorbital fissure of the maxillary bone and innervates the skin of the lower eyelid, nose, upper lip, and cheek. The auriculotemporal nerve, a branch of the mandibular nerve, innervates the skin of the side of the head and the upper part of the auricle. The buccal nerve, also a branch of the mandibular nerve, innervates the skin over the body of the mandible. The skin of the region of the mentum is innervated by the mental nerve, one of the terminal ramifications of the inferior alveolar nerve, originating from the mandibular nerve [2]. As for the arterial supply, the large artery responsible for the irrigation of the face is the facial artery. It is a branch of the external carotid artery, which passes through deep structures of the neck, until it becomes superficial and ­palpable on the margin of the mandible. It is sometimes located superficially, sometimes deeply in relation to the muscles of the facial mimicry. At the angle of the mouth, it sends two lip arteries, one upper and one lower. The upper one sends a branch to the most anterior region of the nasal septum. Still ascending, the facial artery sends the lateral nasal branch, which irrigates the lateral surface and the dorsum of the nose. The facial artery ends as an angular artery, close to the medial commissure of the eyelids. Other arteries contribute to the irrigation of the face. The transverse artery of the face, branch of the superficial temporal artery, crosses the face horizontally approximately at the height of the zygomatic arch. Branches of the maxillary, infraorbital, buccal, and mental arteries irrigate small areas in their regions. In addition, branches of the ophthalmic artery, which is a branch of the internal carotid artery, contribute to the irrigation of the face: the zygomaticofacial and zygomaticotemporal arteries, which irrigate the

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region of the zygomatic bone; the supraorbital and supratrochlear arteries, which emerge at the superior margin of the orbit and irrigate the most anterior part of the scalp; and especially the dorsal artery of the nose, which irrigates the dorsum of the nose. There are several anastomoses between the arteries on both sides of the face and between the branches originating from the facial, maxillary, and superficial temporal arteries and the branches of the internal carotid artery [2]. Venous drainage is mostly done by the facial vein. It forms when the supratrochlear and supraorbital veins join, thus forming the angular vein. This one descends and, following the path of the angular artery, forms the facial vein. On its way, it receives the tributaries that accompany the path of the artery and finally drain into the internal jugular vein in the neck. There is a venous anastomosis between the angular vein and the superior ophthalmic vein, which drains into the cavernous sinus. The existence of this communication is a possible and dangerous source of dissemination of simple facial infections, such as folliculitis or abscesses, to the cavernous sinus, with the risk of resulting in cavernous sinus thrombosis or intracranial infections. For this reason, a central triangular area on the face, located over the nose, is called the “dangerous area of the face” [5]. Lymphatic drainage of the face is directed to submental, submandibular, pre-auricular, and parotid lymph nodes [1, 2].

40.2 The Neck The neck, like the face, is covered by thin skin and has a layer of subcutaneous cellular tissue of varying thickness between the dermis of the skin and the superficial lamina of the cervical fascia. Located in this subcutaneous cellular tissue is the platysma, one of the muscles of facial mimicry [6]. The platysma is a laminar muscle originating from the acromion of the scapula and thoracic fasciae over the clavicle to the lower margin of the mandible. Its medial fibers intersect with

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those of the contralateral muscle and intertwine with the muscles of the mimicry related to the lower lip and risorius. Its action is to lower the angles of the mouth, to contribute in the lowering of the mandible, mainly against resistance to tension of the skin, forming vertical wrinkles. It is innervated by the cervical branch of the facial nerve (Fig. 40.1). The sensitive innervation of the skin of the neck is supplied by the cutaneous branches of the cervical plexus. The smaller occipital nerve innervates the skin of the neck and the posterosuperior part of the scalp in relation to the ear, as well as the skin of the upper third of the ear. The great auricular nerve innervates the remainder of the scalp posterior to the ear, the lower part of the skin of the medial face of the ear, and sends a branch that pierces the lobe of the ear, innervating it, and also the lower part of the concha and skin of the parotid region up to the angle of the mandible. The transverse cervical nerve emerges from the cervical plexus and follows horizontally through the neck, dividing into upper branches, which innervate the skin of the submandibular region and the anterosuperior skin of the neck, and inferior branches, which innervate the lateral and anterior skin of the neck, up to the sternum. The supraclavicular nerves send small branches to the skin over the clavicle and trapezius muscle but are also responsible for the innervation of the skin of the shoulder and upper part of the chest wall [3]. The anatomical approach of the other neck structures will be done regionally, with the aim of highlighting the main deep organs present and their projection on the surface of the neck. The trapezius and sternocleidomastoid (SCM) muscles, with their margins, are used as the delimitation of two cervical triangles (Fig. 40.3) [7]. The posterior triangle is delimited anteriorly by the posterior margin of the SCM, posteriorly by the anterior margin of the trapezius muscle and inferiorly by the middle third of the clavicle. The inferior belly of the omohyoid muscle divides this region into two smaller triangles, one occipital triangle and inferiorly an omoclavicular triangle.

40  Tip Chapter: Anatomy of the Face, Neck, Hands and Genital Areas

Fig. 40.3  Triangles of the neck and the anatomical limits. 1. Trapezius m.; 2. Sternocleidomastoid m.; 3. Posterior belly of the digastric m; 4. Anterior belly of the digastric m.; 5. Hyoid bone; 6. Superior belly of the omohyoid m.; 7. Inferior belly of the omohyoid m.; 8. Clavicula. A.  Posterior triangle; B.  Carotid triangle; C.  Sublingual triangle; D. Muscular triangle; E. Omoclavicular triangle

Among the deep structures that occupy the occipital triangle, we have the accessory nerve (XI) responsible for the innervation of the trapezius muscle and the trunks of the brachial plexus. In relation to the omoclavicular triangle, we can highlight the external jugular vein and the subclavian artery. The anterior triangle presents as limits—anteriorly the median line of the neck, posteriorly the anterior margin of the SCM, and superiorly the lower margin of the mandible. It also presents subdivisions in smaller triangles. The sublingual triangle is delimited by the anterior belly of the digastric muscle, the hyoid bone, and the median

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plane and fuses with the contralateral sublingual triangle. Its content is submental lymph nodes. The submandibular triangle is delimited by the anterior and posterior bellies of the digastric muscle and by the lower margin of the mandible. This triangle is occupied by the submandibular gland and part of its duct, submandibular lymph nodes, and by the hypoglossal nerve (XII). The carotid triangle is delimited by the superior belly of the omohyoid muscle, the posterior belly of the digastric muscle, and the anterior margin of the SCM. Its main content is the carotid sheath, which involves common carotid artery, internal jugular vein, and the vagus nerve. The muscular triangle is limited by the superior belly of the omohyoid muscle, by the anterior margin of the SCM, and by the median plane. It fuses with the contralateral muscular triangle and its content is infrahyoid muscles (Fig. 40.3) [3, 7]. The cervical viscera, which are the thyroid and parathyroid glands, larynx, pharynx, trachea, and esophagus, are deeper than the triangles described but protrude into the region of the muscular triangle. Percutaneous procedures that address these structures, such as a fine-needle aspiration, will reach the thyroid gland through the planes of the muscular triangle of the anterior cervical region. On the other hand, oncological or aesthetic surgical procedures in the topography of these planes must have correct planning regarding the depth reached, so that important structures are not injured.

40.3 Hands The upper limb is formed by four segments, the shoulder, the arm, the forearm, and the hand, articulated to produce synchronized and fine motor activities. The wide mobility of the hand is a result of the movements of the shoulder, elbow, radioulnar, and radiocarpal joints. The hand is located distally to the forearm, formed around the bones of the carpus, metacarpus, and phalanges, presenting five distal extensions, the fingers, from lateral to medial position referred to as thumb (pollex), index finger (­ digitus

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secundus manus), ring finger (digitus annularis), and little finger (digitus minimus manus). The hand has a dorsal surface, volar or palmar surface, and radial and ulnar borders, besides a proximal portion, the wrist, and the five fingers distally. In the anatomical position, the palmar surface is the anterior surface, the dorsal surface is posterior, while the ulnar border is medial and the radial border is lateral. The palm of the hand is divided into three regions: the thenar mass or eminence that overlies the thumb metacarpus, the mid-palm area, and the hypothenar mass that overlies the metacarpus of the little finger (Fig. 40.4a) [6]. The wrist or carpus, convex anteriorly and concave posteriorly, is formed by two rows of four bones each, which slide one over the other giving flexibility. They form with the head of the radius the radiocarpal joint (proximal row

a

Fig. 40.4 (a) Hand palmar surface: 1. The proximal and distal folds of the wrist related to the distal epiphysial lines of the radius and ulna; 2. Metacarpophalangeal joints fold; 3. Interphalangeal joints folds; 4. Thenar eminence; 5. Mid-palm area; 6. Hypothenar eminence. Blue line: a. Area innervated by median nerve branches; b. Area

of carpal bones), of the ellipsoid type, and the mediocarpal joint between the proximal and distal rows of the carpus, broadly reinforced by robust ligaments and whose articular capsule is firmly attached to the palmar face and loosely on the dorsal one. The bones of the distal row articulate with the metacarpal bones, firmly fixed by the palmar and dorsal carpometacarpal ligaments, delimiting amphiarthrosis-like joints in all the fingers except the thumb, where the articulation between the trapezoid and the metacarpal I, of the saddle type, allows the movements of adduction, abduction, opposition, repositioning, and in combination the circumduction [5]. Each of the fingers is formed by three phalanges, proximal, middle or intermediate, and distal, except for the thumb, where the intermediate phalanx is non-existent. The metacarpo-

b

innervated by ulnar superficial branch. (b)  Hand dorsal surface: Phalanges 1. Proximal, 2. Middle, 3. Distal; 4. “Knuckle”, head of first metacarpal bone. Green lines: a. Area innervated by dorsal branch of ulnar nerve; b. Area innervated by radial nerve branches; c. Area innervated by median nerve branches

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phalangeal joints are of the spheroid type, with loose capsules but reinforced in the palmar surface by palm ligaments and fibrous cartilage. The interphalangeal joints are in ginglymus, allowing a single axis of movement, flexion, and extension [1, 2]. The hairy skin on the dorsal surface of the hand is histologically similar, but not identical, to palmar skin, in terms of the layered structure of the epidermis (Fig.  40.4b). The epidermis is thinner on the dorsal surface, as the stratum corneum (≈0.02 mm) and the dermis. The dermis is more mobile on the dorsal hand face, because it lacks the connective and elastic elements that anchor the palmar skin to the underlying fascial planes (Fig. 40.5). This allows the stretching of the finger skin during movements, extension and flexion, and provides an important input to cutaneous mechanoreceptors [8]. The glabrous skin on the hand palmar (volar) surface is thick and bends along the flexure a

Fig. 40.5 (a, b) Dorsal surface of dissected right hand. 1.  Superficial subcutaneous tissue; 2. Deepest layers of the dorsal connective lamina with nerves and veins; 3.

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lines, when objects are held. These folds demarcate the areas of the hand where the skin is mobile compared to the adjacent areas tightly bound to the underlying tissue and bones by fibrillary tissue that connects the deep layers of dermis with the sheaths of tendons. Lines and pleats on the palmar face may be recognized, such as the proximal and distal folds of the wrist related to the distal epiphysial lines of the radius and ulna and the midcarpal joint, respectively, as well as the folds that demarcate the metacarpophalangeal and interphalangeal joints (Fig. 40.4a) [8, 9]. The palmar creases may serve as landmarks for the deeper neuro-vascular structures. The superficial palmar arch is found between the ­ t henar and proximal palmar crease and never crosses the proximal palmar crease (Fig. 40.4a) [9]. All individuals have roughly similar markings on any part of the body, but the details are unique. The lines are oriented in the general direction of

b

Superficial branch of radial nerve; 4. Dorsal branch of the ulnar nerve 5. Superficial veins; 6. Tendons of extensor muscles

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elastic tension. Countless numbers of them, deep and shallow, together with the pores, give every region of the body a characteristic topography. Like the deeper furrows and ridges on the palms, the skin lines are mostly established before birth. The fine details of each area of body surface are peculiar to each individual as fingerprints. The palms of the hands and the soles of the feet are etched by distinct alternating ridges and grooves that together constitute dermatoglyphics. The ridges follow variable courses, but their arrangement in specific areas has a consistent structural plan. Though apparently continuous, the ridges have many interruptions and irregularities, branching and varying in length. Every small area of surface has ridge details not matched anywhere in the same individual or in any other individual, even in an identical twin. The skin of the hand contains numerous eccrine sweat glands that keep skin damp and assist in controlling body temperature through evaporative heat loss [8]. The sweat glands on the palms and soles develop at about 3½ months of gestation, whereas those in the hairy skin are the last skin organs to take shape, appearing at 5–5½ months, when all the other structures are already formed. This separation of events over time may represent a fundamental difference in the evolutionary history of the two types of glands. Those on palms and soles, which appear first and are present in all but the hooved mammals, may be more ancient; those in the hairy skin, which respond to thermal stimuli, may be more recent organs [8]. Nails grow from a matrix at the base of the nail root. During the early part of their journey, matrix cells multiply and move forward, synthesizing keratin, underneath the fold of skin (eponychium) at the base of the nail. Once exposed to the surface, the nail is fully formed. The nail plate seems to glide over the nail bed, but it is firmly attached to it; the entire tissue, nail bed and plate, most likely moves forward as a unit (Fig.  40.4b). The nail bed has often been called sterile matrix, since it adds little or nothing to the nail plate. Yet under certain pathologic con-

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ditions, it assumes keratinizing activities that result in a variably thickened or deformed nail plate [8, 10]. Although less effective than claws for digging or gouging, the flattened nail is still an excellent adaptation that has added much to the development of manipulative skills. Nails not only protect the tips of fingers but also give them firmness and the ability to pick up or make contact with minute objects [10]. The bones of the hand can be palpated through the skin, except for the semilunar and trapezoid bones of the carpus. The styloid process of the ulna is more easily palpable with the hand in supine position, that is, with the palm facing anteriorly, whereas the styloid process of the radius is palpated easily on the lateral margin of the wrist with the abducted thumb. The pisiform bone is considered a sesamoid (intra-ligament) bone, palpated easily on the palmar face medially in the wrist, as well as the hamulus or hook of the hamate bone, by deep palmar compression in the medial region. The metacarpal bones and phalanges can be palpated on the dorsal side of the hand, whose bony heads form the “knuckles”, the third finger being the most prominent (Fig. 40.4b) [6]. The muscles that work in the movement of the wrist and hand joints can be located on the forearm, or their bellies may be in the palm or the back of the hand, called short or intrinsic muscles of the hand. The muscles of the forearm are divided into three groups: those that act on the movements of the hand belong to the second group, which are inserted in the metacarpal bones and move the carpal, and those of the third group are inserted in the phalanges and enable the movements of the fingers. They can also be divided into flexors, related to the palmar face, located in the anterior compartment, and extensors; related to the dorsal face of the hand, located in the posterior compartment of the forearm. In both flexors and extensors, we can differentiate muscles from the deep group and the superficial group, separated by fibrous septa [2].

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40.3.1 Muscles 40.3.1.1 Dorsal Face In the wrist region, the extensor retinaculum contains the tendons of the extensor carpi ulnaris muscles, extensor digiti minimi, extensor digitorum, extensor pollicis longus, extensor carpi radialis brevis, extensor carpi radialis longus, extensor pollicis brevis, and abductor pollicis longus, arranged from the ulnar margin to the radial margin. The extensor carpi ulnaris, radialis brevis, and radialis longus are inserted into the metacarpal bones, while the extensor digitorum and digiti minimi are inserted at the base of the intermediate phalanges, forming the dorsal digital expansion on the proximal phalanx through which they reach insertion in the distal phalanx. The abductor pollicis longus inserts into the metacarpal bone I, the extensor pollicis brevis attaches to the base of the proximal phalanx, and the extensor pollicis longus in the distal phalanx (Fig. 40.6a) [5, 6, 11].

Fig. 40.6 (a) Superficial tendons of the dorsal muscles of the hand: 1. Extensor carpi radialis longus; 2. Extensor pollicis brevis; 3. Extensor carpi radialis longus; 4. Extensor carpi radialis brevis; 5. Extensor pollicis longus 6. Extensor digitorum; 7. Extensor digiti minimi; 8. Extensor carpi ulnaris. (b) Nerves: 1. Superficial branch of the radial nerve; 2. Dorsal digital branches of the superficial branch of the radial nerve; 3. Dorsal branch of the ulnar nerve; 4. Dorsal digital branches of dorsal branch of the ulnar nerve

a

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40.3.1.2 Palmar Face In the wrist region, the flexor retinaculum accommodates the tendons of the flexor digitorum superficialis muscle, flexor digitorum profundus muscle, flexor pollicis longus muscle, and flexor carpi radialis muscle, arranged from the ulnar margin to the radial margin. Medially, there is the tendon of the flexor carpi ulnaris that is inserted in the pisiform bone and by expansion of the tendon to the hamate up to the fifth metacarpal bone. The flexor carpi radialis inserts into the metacarpal bone II.  While the insertion of the flexor digitorum superficialis is made in the intermediate phalanx of fingers two to five, the tendons of the flexor digitorum profundus surface and pass through a division of the tendons of the flexor digitorum superficialis fixating on the distal phalanges of the fingers two to five. The flexor pollicis longus also inserts into the distal phalanx of the thumb [5, 6].

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40.3.1.3 Intrinsic Muscles of the Hand The short muscles, called the intrinsic muscles of the hand, are distributed in the palm of the hand in a radial portion, forming the thenar eminence and in an ulnar portion that forms the hypothenar eminence. In the thenar eminence, there are muscles that act on the movements of the thumb, such as the abductor pollicis brevis, flexor pollicis brevis, and adductor pollicis, with two transverse and oblique heads and opponent to the thumb. In the hypothenar eminence are the muscles that act on the movements of the little finger, abductor digiti minimi, flexor digiti minimi brevis, and opponens digiti minimi (Fig. 40.7). Deep in the dorsal side of the hand are the four dorsal interosseous muscles, located between the metacarpal bones, whose belly anchors in neighboring bones and acts on the abduction of the fingers. On the palmar face, three interosseous palmar muscles that act on the adduction of the

Fig. 40.7  Palmar surface of dissected right Hypothenar eminence muscles; (b) Thenar muscles. The opened ulnar tunnel. 1. Ulnar Tendons of the flexor muscles; 3. Median Superficial palmar arch

hand. (a) eminence nerve; 2. nerve; 4.

fingers and four lumbricals, which attach to the tendons of the flexor digitorum longus. Together, the dorsal and palmar interossei and the lumbricals act in the flexion of the metacarpophalangeal joints and in the extension of the interphalangeal joints [12].

40.3.1.4 Fascia and Tendinous Sheaths The forearm is covered by a fascia strongly anchored to the posterior face of the ulna. At its dorsal end, the fascia of the forearm is reinforced by transverse bundles, forming the retinaculum of the extensor muscles. In the hand, it continues with the fibrous sheaths of the fingers, firmly attaching to the tendon connections. It is also fixed in the lateral and medial margins of the metacarpal bones [5, 12]. The carpal dorsal tendon sheaths are located in compartments formed by the retinaculum of the extensor muscles and by septa that run inferiorly until they attach to the crests of the radius and ulna. These sheaths form tendinous compartments that cover synovial sheaths for tendons of the muscles: (1) abductor pollicis longus and extensor pollicis brevis; (2) extensor carpi radialis longus and brevis; (3) extensor pollicis longus; (4) extensor digitorum and extensor indicis; (5) extensor digiti minimi brevis; and (6) extensor carpi ulnaris [2, 5]. In the dorsal subcutaneous tissue of the hand, there are three distinct fatty-areolar laminae, each separated by a fascial layer. The dorsal veins and sensory nerves reside in the middle layer, whereas the extensor tendons reside in the deepest stratum. The most superficial lamina contains no important anatomic structures (Fig. 40.5) [13]. In the palmar carpal region, tendinous fibers derived from the ulnar flexor muscle of the carpal are incorporated into the fascia of the forearm in the lateral direction and together with the fascia that lines the deep muscles delimit the ulnar tunnel. It forms the retinaculum of the flexor muscles, which continues in the palm of the hand, thickened to form the palmar aponeurosis and communicates with the palmar interosseous fascia, which covers the interosseous palmar muscles. The retinaculum of the flexor

40  Tip Chapter: Anatomy of the Face, Neck, Hands and Genital Areas

muscles completes the carpal tunnel, where the median nerve and tendons of the flexor muscles pass into three synovial sheaths: (1) flexor carpi radialis; (2) flexor pollicis longus; and (3) flexor digitorum superficialis and profundus (Fig. 40.7) [12]. The palmar aponeurosis separates the palmar region from the subcutaneous fat, protecting the soft tissues. It is formed by bundles of longitudinal collagen fibers, giving it the shape of an open hand fan in digital direction. At the base of the fingers, transverse fibers radiating from the longitudinal fascicles of the palmar aponeurosis form the superficial transverse ligament of the metacarpus, which maintains the longitudinal fascicles in position. The fibrous sheaths of the fingers are transverse fibers that form the annular ligament, divided into bands on the metacarpophalangeal and interphalangeal joints, as well as cross fibers that form the cruciate ligament. Digital fibrous sheaths surround the five synovial sheaths [5, 12].

40.3.1.5 Irrigation Irrigation of the structures of the hand is supplied by branches of the ulnar and radial arteries, which originate from the brachial artery, opposite to the head of the radius, in the inferior part of the ulnar fossa. Due to the significant mobility of the hand when it holds, carries, or apprehends an object, the irrigation of its structures is done by numerous branches that anastomose, ensuring irrigation to all the parts, in any position. The superficial location of the arterial network under the skin confers the possibility of sweating heat loss but can also reduce blood flow to the dorsal and palmar surfaces and especially to the fingertips at low temperatures, avoiding heat loss [8]. Ulnar artery pulsations can be palpated on the lateral side of the tendon of the flexor carpi ulnaris anteriorly to the ulna head. Branches of the ulnar artery irrigate the ulnar and medial nerves and the common sheath of the flexor muscles, entering the hand anteriorly to this retinaculum, between the pisiform bones and hamate, through the ulnar tunnel (Guyon’s canal) (Figs. 40.7 and 40.8). In the forearm, the ulnar artery emits the

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short common interosseous artery which branches into posterior and anterior interosseous arteries, whose terminal branches participate in the irrigation of the carpal region, together with a palmar carpal branch of the ulnar artery. Laterally to the ulnar nerve, it divides into superficial palmar branch and deep palmar branch [2, 5]. The radial artery rests on the brachioradialis muscle in the forearm up to the anterior face of the radius distally, covered only by skin and fascia, an ideal place to check the radial pulse. It contours the lateral border of the wrist and emits the palmar and dorsal carpus branches, completing the periarticular anastomosis of the wrist together with the carpal branches of the anterior and posterior interosseous arteries and the ulnar artery, where the palmar carpal arch and the dorsal carpal arch responsible for irrigation of the wrist structures is formed. Although the radial artery is the main source of irrigation of the back of the hand, the many perforating branches between the carpal arches create connections between the palm and dorsal branches [2, 6]. In the hand, the ulnar artery emits a deep palmar branch and follows curving laterally and deeply into the palmar aponeurosis, under the tendons of the long flexor muscles, crosses the palm of the hand, and anastomoses with the superficial palmar branch of the radial artery, forming the superficial palmar arch. There are several variations in the anatomy of the formation of the superficial palmar arch, which are important when there is a need for surgical ­ approaches of the hand [14]. The radial artery, on the palm of the hand, passes between the heads of the adductor pollicis muscle, in a medial direction, where it anastomoses with the deep branch of the ulnar artery, forming the deep palmar arch (Fig. 40.8). For the irrigation of the fingers, the dorsal carpal arch originates six dorsal metacarpal arteries, which are directed to the medial and lateral faces of fingers two to five and to the medial face of the thumb. Palmar metacarpal arteries are emitted by the deep palmar arch, which also originates the radial arteries of the forefinger and the main artery of the thumb.

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282 Fig. 40.8  Palmar view of the hand. (a) 1. Ulnar artery; 2. Radial artery; 3. Superficial palmar branch of radial artery; 4. Deep branch of radial artery; 5. Deep branch of ulnar artery; 6. Superficial palmar arch; 7. Deep palmar arch; 8. Common digital palmar arteries; 9. Palmar metacarpal arteries; 10. Digital palmar arteries; (b) a. Superficial branch of ulnar nerve; b. Digital branches of the superficial branch of the ulnar nerve; c. Digital palm branches of median nerve

a

The dorsal metacarpal arteries originate their own digital arteries, which irrigate the structures related to the dorsum of the intermediate and distal phalanges of fingers two to five. The palmar metacarpal arteries anastomose with the common digital palmar arteries, branches of the superficial palmar arch, which in turn give rise to the digital palmar arteries that follow the two sides of fingers two to five. In addition to the perforating branches that communicate the carpal arches, anastomotic connections between the palm and dorsal digital branches are also established. In spite of these large anastomoses, attention is drawn to radial artery approaches, since it is the largest and sometimes the only source of irrigation of the thumb [2, 5].

40.3.1.6 Venous Drainage The venous drainage of the hand is sustained by a system of superficial veins and a system of deep veins. The superficial and deep palmar artery arches are formed, and they accompany the anatomical formation and the location of the respective arte-

b

rial arches. From the lateral region of the deep palmar arch, a pair of radial veins originates, which accompanies the radial artery, and the medial region gives rise to a pair of ulnar veins accompanying the ulnar artery. These veins are responsible for deep drainage of the hand but proportionally carry little blood from this region [2, 5]. The superficial palmar venous arch contributes in part to the deep network and partly to the veins of the superficial system, whose drainage is mainly maintained by the cephalic vein. The dorsal digital veins drain into three dorsal metacarpal veins that join forming the dorsal venous network of the hand. The epifascial veins of this venous network are visible under the skin, have a very variable anatomical pattern, and receive perforating branches from the venous drainage of the palmar region. In the lateral region of the forearm, the dorsal venous network extends into the cephalic vein, which receives most of the dorsal venous drainage [13]. A small part of the venous drainage of the ulnar region returns through the basilic vein, which originates from the medial region of the dorsal venous network.

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40.3.1.7 Lymphatic Drainage Lymphatic drainage of the hand takes place through a network of lymphatics that form on the subcutaneous tissue of the palm and back of the hand. The lymphatic vessels of the palmar face of the hand ascend to the dorsal surface. The vessels of the medial side from the ulnar group of lymphatics and the lateral side join together, forming the radial group of lymphatics [2, 5, 6]. The thumb, index finger, and lateral side of the middle finger are drained by the radial group of lymphatic vessels that drain directly into the axillary lymph nodes. The other fingers drain into the ulnar group of lymphatics that end in the ulnar lymph nodes in the ulnar region. Lymphatic drainage of deep carpus structures follows the deep lymphatic vessels of the upper limb, which accompany the arteries and deep veins. Generally, inflammatory processes in the hand cause painful enlargement of the axillary lymph nodes. 40.3.1.8 Innervation The innervation of the hand is done by branches of the ulnar, median, and radial nerves, the latter only emitting sensory branches. The ulnar nerve enters the wrist through the ulnar tunnel, medially to the pisiform bone and laterally to the ulnar artery, covered by the flexor retinaculum, when it emits the palmar cutaneous branch that superficially follows the retinaculum and the palmar fascia (Figs.  40.7 and 40.8b). About 5 cm before the retinaculum emerges, the dorsal branch of the ulnar nerve, which goes deep into the flexor carpi ulnaris muscle, pierces the muscular fascia, and on the medial aspect of the dorsum of the hand, it divides into two or three dorsal digital nerves (Fig. 40.6b) [2, 5, 8]. Between the pisiform bones and hamate, the ulnar nerve divides into superficial branch and deep branch. While the superficial branch only emits cutaneous branches, the deep branch innervates the hypothenar eminence muscles, the two medial lumbrical muscles, all the interosseous muscles, and the deep head of the flexor pollicis brevis muscle, and the radiocarpal, carpometacarpal, and intermetacarpal joints.

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The median nerve enters the hand through the carpal tunnel, under the retinaculum of the flexor muscles, innervating directly or through its recurrent branch the muscles of the thenar eminence, the lateral lumbricals for the 2nd and 3rd fingers, the opponens pollicis muscle, and the head of the flexor pollicis brevis. It emits three digital palm branches and a lateral branch that innervates the 1st lumbrical. The radial nerve sensitively innervates the hand through its superficial branch, which originates in the ulnar fossa of the forearm and emerges in the wrist laterally to the radius, piercing the muscular fascia (Fig. 40.4b). The sensory innervation of the palm of the hand is made by digital branches of the superficial branch of the ulnar nerve from the medial face of the palm to a line running through the annular finger medially (Fig. 40.4a). The lateral aspect of the ring finger and all the rest of the skin covering the palm of the hand and the fingers three, two, and the thumb are innervated by the median nerve (Fig.  40.6b). The occurrence of a sensitive anastomosis demarcated by a connection between branches of the ulnar and medial nerves in the palm of the hand is common. The sensory innervation of the back of the hand is made by the dorsal branch of the ulnar nerve, from the ulnar margin to the lateral face of the middle finger. It preserves the skin covering the entire little finger, the entire medial face of the annular finger, and the lateral face of the same finger to the end of the proximal phalanx. The skin that lines the intermediate and distal phalanges of fingers two, three, and the lateral side of the four is innervated by dorsal branches of the digital palm nerves and branches of the median nerve. The remainder is innervated by dorsal digital branches of the superficial branch of the radial nerve (Figs. 40.4b, 40.5b, and 40.6b). The division of the innervation territories between the branches of the radial and ulnar nerves may have a small overlap and schemes slightly differentiated from that described above. In the palm of the hand, the nerves are located posterior (deep) to the arteries, a

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p­ osition that is altered in the fingers, where the arteries happen to be posterior to the nerves (Fig. 40.8b) [2, 5, 8].

40.4 The Genital Area 40.4.1 Pelvis and Perineum The pelvis presents the shape of a wedge formed by the sacrum and coccyx pressed between the bones of the hips. This is essentially a strong bony arch supporting the weight of the body and conveying it from the base of the sacrum to the acetabular fossae and femoral heads or ischial tuberosities in the upright or seated position, respectively. The broad wings of the ilia are walls of the greater or false pelvis, which is all the lower part of the abdominal cavity. The pelvic cavity is located in the lower or true pelvis, that is, the lower part of the bony pelvis, which includes the rest of the ilium, the ischium, and the pubis, on each side of the sacrum and coccyx [2, 5]. The sacrotuberal ligament, a thickened broad band at both ends, attaches to the ileum between the posterior iliac spines on the back and side of the lower sacrum and coccyx, from where it jumps to the medial side of the ischial tuberosity, and as a sickle-shaped process follows the branch of the ischium. Sacrospinal ligament, which is triangular, spreads from the ischial spine to the margin of the sacrum and coccyx, in front of the sacrotuberal ligament and behind the coccygeal muscle. These ligaments transform the ischial incisions into greater and lesser sciatic foramina, separated by the ischial spine and sacrospinal ligament. The greater sciatic foramen is almost filled by the piriformis muscle; through the upper hiatus pass nerves and upper gluteal vessels, and through the inferior hiatus runs the sciatic nerve, inferior gluteal nerves and vessels, posterior femoral cutaneous nerve, and the nerve to quadratus femoris muscle. Internal pudendal nerves and vessels and internal obturator nerve exit through the greater foramen, cross the gluteal aspect of the spine, and enter the lesser sci-

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atic foramen, superior to the tendon of the internal obturator [2, 5]. The lower opening of the pelvic cavity is closed by the pelvic diaphragm, consisting mainly of the levator ani muscle and its sheath fascias. In the pelvic cavity, the piriformis muscles are posterolaterally located, closing the greater sciatic foramina, and the internal obturator muscles are located anterolaterally, closing the obturator foramina without, however, being part of the pelvic diaphragm [15]. Coccygeal (ischiococcygeal) muscles extend from the medial aspect of the ischial spine and sacrospinal ligament to the sacrum and coccyx forming the posterior part of the pelvic diaphragm (10% of the total). Most of this diaphragm consists of the posterior and anterior divisions of the levator ani muscle, called the iliococcygeus and pubococcygeus muscles, respectively. The pubococcygeus muscle, in turn, is divided into pubovaginal (female pelvis), puborectal, and pubococcygeal portions. The pelvic diaphragm is an important component of the support system of the female internal genitalia. In particular, the pubococcygeus muscle, with its fascial bundle, plays an important role in the support of the pelvic viscera, as it presents its fibers arranged in U, around the urethra, vagina, uterus, and rectum, acting as support when the intra-abdominal pressure increases. The pelvic floor presents synchronous ­contraction with the muscles of the anterolateral wall of the abdomen, maintaining the bladder neck in an intrapelvic position. The superior fascia of the pelvic diaphragm, the pelvic fascia, represents the continuation of the transverse fascia (abdominal fascia) of the abdominal wall, extending over the pelvic floor. Above the pelvic fascia is the endopelvic fascia, also known as subperitoneal connective tissue, rich in adipose tissue, filling the spaces between the pelvic organs. The endopelvic fascia is in continuity with the connective tissue located between the pelvic fascia and the peritoneum and at certain thickened sites forming ligaments, which together constitute the suspension system of the female internal genitalia, as well as the urinary bladder and urethra.

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Inferior to the pelvic diaphragm, in its anterior portion, the urogenital diaphragm is located, which also supports the intrapelvic organs in the place where the levator ani muscle is relatively deficient. The urogenital diaphragm consists of the deep transverse muscle of the perineum and the external sphincter muscle of the urethra along with its upper and lower fascias, the latter called the perineal membrane. The other perineal, bulbospongiosus, ischiocavernosus, and superficial perineal muscles of the perineum lie in the superficial perineal space beneath the urogenital diaphragm. The urogenital diaphragm closes the space between the medial margins of the ischiopubic branches, reinforcing, as already mentioned, the support of the pelvic organs (Fig. 40.9). Perineum is the space that protrudes in the region of the external genitals in the form of a rhombus between the pubic symphysis, ischiopubic branches, ischiatic tuberosities, sacrotuberal ligaments, and coccyx. It is located below the pelvic diaphragm, superiorly limited by the lower fascia of the pelvic diaphragm and inferiorly by

Fig. 40.9  Perineum. (a) Female; (b) Male. Muscles—(triangles)▲ 1. Ischiocavernosus; 2. Bulbospongiosus; 3. Transversus perineal superficialis; 4. Levator ani; 5. Gluteus maximus; 6. Sphincter ani externus; 7. Perineal body. Arteries (a) – 1. Internal pudendal artery; 2. Inferior rectal artery; 3. Perineal artery; 4. Artery to bulb of vestibule; 5. Posterior labial artery (Posterior scrotal artery). Nerves (b) – ●1. Pudendal nerve; ●2. Inferior anal nerve; ●3. Branches of perineal nerve; ●4. Dorsal nerve of penis (dorsal nerve of clitoris); ●5 Posterior scrotal nerves (posterior labial nerves)

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the membranous layer of the subcutaneous tissue, called fascia of Colles. An imaginary line between the ischial tuberosity divides the perineum into two triangular regions, anteriorly the urogenital triangle and posteriorly the anal triangle. In the urogenital triangle, the perineum is divided into deep perineal space between the upper fascia of the urogenital diaphragm and the inferior fascia of the urogenital diaphragm (perineal membrane) and the superficial perineal space between the perineal membrane and the membranous layer of the subcutaneous tissue or the superficial perineum fascia. The pelvic diaphragm separates the pelvic cavity superiorly and the perineum inferiorly, forming the lower wall of the pelvis being therefore its upper membrane the lower limit of the pelvic cavity. Considering that the levator ani muscles follow medially from their origins, in the lateral walls of the pelvis, above the anus and urogenital hiatus below, gutters in the form of inverted tri-

b

a

1

7

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angles are created between the levator ani muscles and the walls of adjacent pelvis. In the anal triangle, these gutters, one on each side of the anus, are called the ischioanal fossae [7, 15, 16].

40.4.2 Female Anatomy In women, the main structures present in the urogenital triangle are the clitoris, the vestibule of the vagina, and two thin skin folds, the labia minora and, laterally to these two broad folds, the labia majora of the pudendum [2, 7]. The labia minora delimit a space called the vestibule of the vagina in which the ostium of the vagina and the outer ostium of the urethra open. The urethral glands, one on each side, open into the skin fold between the urethra and the labia minora. Posterior to the urethra lies the ostium of the vagina, which is involved by the remnants of the hymen, which originally closes it and is usually ruptured during the first sexual intercourse. The ducts of the major vestibular glands, one on each side, open into the skin fold between the hymen and the labia minora. Each labium minus bifurcates anteriorly into the medial and lateral folds. The medial folds come together at the midline to form the fringe of the clitoris. The larger lateral folds also join at the midline to form the hood of the clitoris, which covers the glans and part of the body of the clitoris. The labia majora join anteriorly to form the mons pubis, which covers the lower part of the pubic symphysis. The posterior extremities of the labia majora are separated by a depression called the posterior commissure of the labia, which is at the position of the perineal body. The perineal body is an irregular and fibromuscular mass. It is located at the junction of the urogenital and anal triangles—the central point of the perineum. This structure contains skeletal muscle, smooth muscle, and collagenous and elastic fibers. Anatomically, the perineal body lies just deep to the skin. It functions as a point of attachment for muscle fibers from the pelvic floor and the perineum itself (Fig. 40.9) [2, 17]. The female urethra is approximately 4  cm long, directed superoinferiorly from the bladder

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neck to the pudendal cleft, with slight anterior concavity behind the pubic symphysis. It can be divided into three segments: (a) initial segment, from the urinary bladder to the subpubic region; (b) medium segment, from the subpubic region to the perineal membrane, perforating the urogenital diaphragm; and (c) distal segment, from the perineal membrane to the external urethral ostium. The initial segment, although representing only 20% of the total urethral length, has great importance in the mechanism of urinary continence. The muscle and ligament tonus of this area allow increases in intra-abdominal pressure, caused, for example, by cough, to be transmitted equally to the bladder and to the initial urethral segment, preventing urinary loss. The middle segment of the urethra also participates in the extrinsic mechanism of urinary continence, through the presence in the urogenital diaphragm of the striated sphincter muscle of the urethra of voluntary contraction, which, upon contraction, would prevent involuntary urinary losses. The actual role of this muscle is not yet fully known. It is known, however, that the pressure of the middle segment of the urethra increases concomitantly with the intraabdominal pressure, as a function of contraction of the striated sphincter muscle of the urethra [18–20]. The perfect innervation of the bladder and urethra is an important factor in the physiology of urination. It is known that the smooth vesical and urethral muscles are innervated by the sympathetic and parasympathetic nervous systems, whereas the striated sphincter muscle of the urethra is innervated somatically by the perineal branch of the pudendal nerve. Therefore, a coordinated urination should result from a perfect integration between the somatic and autonomic nervous pathways [20–22]. The pelvic diaphragm muscles are innervated by nerves originating from the primary ventral branches from S2 to S4, more precisely by the perineal branch of the pudendal nerve and the perineal branch of S4. The perineal muscles, the deep transverse perineum, the bulbospongiosus, the ischiocavernosus, the superficial transverse perineum, and the striated

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sphincter of the ­ urethra, are also innervated through the perineal branch of the pudendal nerve (Fig. 40.9b) [15]. The vagina is a medial cylindrical organ that connects the uterus to the external genitalia, usually measuring 5–15 cm in length depending on the position of the uterus, which can easily dilate during intercourse and delivery. Subsequently, the cervix protrudes into its interior, delimiting the space known as fornix. In anatomy texts, the bulbs of the vestibule— formed of erectile tissue that resembles the spongy body of the penis and covered by bulbospongiosus muscles—are located posterior to the labia minora. Recent studies, however, revealed that the bulbs relate more closely to the clitoris and urethra, and there is no consistent relation to the vestibule. These studies have also demonstrated considerable age-related variation in erectile tissue size between young premenopausal women and older postmenopausal women, in whom erectile tissue is smaller [17, 23]. Autonomic innervation of the vagina arises from two separate plexuses. The sympathetic fibers originate in the intermediolateral column located between the 11th thoracic segment and the second lumbar segment, reaching the lower hypogastric plexus (pelvic plexus) after synapse in the inferior mesenteric ganglion or accessory ganglia. Parasympathetic preganglionic neurons are located in the intermediolateral column of the second, third, and fourth segments of the sacral medulla. Their axons constitute the pelvic splanchnic nerves, making synapses in nodes located near or inside the vagina [2, 20]. Sympathetic and parasympathetic fibers originate in the pelvic plexus and follow through the uterosacral and lateral cervical ligaments accompanying the vessels to the proximal two-thirds of the vagina and clitoris. Immunohistochemical studies have revealed the presence of abundant nerve fibers in the distal portion of the vagina, when compared with the proximal part. This highly innervated area plays an important role in sexual function, and surgeries performed there, such as bladder suspensions and hysterectomies, must recognize their morbid potential over female sexual function [24].

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The clitoris is an erectile organ, similar to the penis, and embryologically originates from the same structure, the genital tubercle. It consists of three parts: glans or head (which is situated in the outer portion), body or middle portion, and pillars or branches, its inner portion. Recent studies have demonstrated that the glans and the body of the clitoris measure from 2 to 4 cm in length and the branches from 9 to 11  cm. The clitoris consists of two cavernous bodies medially fused, which originate bilaterally from the branches or crus of clitoris. The glans of the clitoris is the visible portion and emerges apparently from the labia minora. These bifurcate to form the prepuce, superiorly, and the frenulum, inferiorly [17, 23]. Each cavernous body is surrounded by a thick connective tissue structure, the tunica albuginea, which covers the lacunar sinusoids, surrounded by muscle trabeculae of smooth muscle and collagen fibers. The tunica albuginea is unilaminar in the woman, unlike the bilaminar structure found in the penis. Thus, no mechanism of venous resistance exists and, during sexual arousal, clitoral turgidity rather than erection occurs. The two clitoral crura originate from the separation of the proximal portions of its body from the perineum and are attached to the medial portion of the ischiopubic branches. The main arterial supply of the clitoris comes from the common clitoral branches of the internal pudendal artery, which is the last branch of the internal iliac artery. This, after passing through the lesser sciatic foramen and emitting the perineal branch and inferior rectal artery, bifurcates in dorsal artery of the clitoris and two cavernous arteries (Fig. 40.9a). Somatosensory and autonomic innervation of the clitoris plays an important role in the response to sexual stimulation. The nerves in the clitoris form, as in the penis, an extensive network around the tunica albuginea, with a free innervation zone in the dorsal median position (12  h); large branches of the dorsal nerve of the clitoris, terminal branch of the pudendal nerve, run alongside the cavernous bodies, with greater density on the dorsal side and near the glans. The glans contains dense vascular dermis and a large number of

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s­ ensory receptors, especially Pacini’s corpuscles, which provide deep sensation and sense vibration. Pacini’s corpuscles are also closely related to the neurovascular bundles and their branches, which surround the body [17, 23].

40.4.3 Male Anatomy In men, the urogenital triangle contains the root of the penis, the testes, and associated structures. Although the testes migrate to the scrotum from the abdomen, these are evaluated along with the external genitalia [2, 7]. The scrotum, which is homologous to the labia majora, in women, is a pouch of skin, fascia, and muscles of the genital region that houses the testes, the epididymis, and the elements of the spermatic funiculus. The scrotum is divided into two independent compartments by a median raphe. The scrotum skin is thin, pigmented, and commonly thrown into folds. It contains many sweat and sebaceous glands that produce an odorous secretion and some coarse hair, the follicles of which are visible through thin skin. Under the skin of the scrotum are the following layers from the most superficial to the deepest one: (1) dartos fascia, formed by smooth muscle fibers, the dartos muscle, and the muscle fascia which is continuous with the superficial perineal fascia and superficial fascia of the abdomen; (2) external spermatic fascia, derived from the aponeurosis of the external oblique muscle of the abdomen; (3) cremasteric fascia, derived from the internal oblique muscle of the abdomen; (4) internal spermatic fascia, derived from the transverse fascia; and (5) the vaginal tunica, derived from the peritoneum, divided into two leaflets, the parietal and the visceral [2, 25]. The irrigation of the scrotum comes from (a) posterior scrotal branches of the perineal artery, branch of the internal pudendal artery; (b) anterior scrotal branches of the deep external pudendal artery, branch of the femoral artery; and (c) cremasteric artery branch of the inferior epigastric artery which is a branch of the external iliac artery (Fig.  40.9). The scrotal veins accompany

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the arteries. The lymphatic vessels of the scrotum drain into the superficial inguinal lymph nodes. The anterior surface of the scrotum is innervated by lumbar plexus branches while the lower and posterior surfaces by branches of the sacral plexus as follows: (a) genital branches of the genitofemoral nerve (L1L2) innervate the anterolateral face; (b) anterior scrotal nerve branches of the ilioinguinal nerve (L1) are responsible for the innervation of the anterior face; (c) posterior scrotal nerve branches of the perineal nerve of the pudendal nerve (S2S4) supply the posterior face; and (d) perineal branches of the posterior cutaneous femoral nerve (S2S3) are responsible for the posteroinferior face (Fig. 40.9b). Each testicle is approximately 5  cm long, 3 cm wide, 2.5 cm thick, and 30 ml in volume. They are involved by the visceral fascia overlying the tunica albuginea rich in collagen fibers and smooth muscle and vascular elements [2, 26]. The tunica albuginea thickens in the posterior region of the testis, forming the mediastinum of the testicle, the point of passage of the vessels through the capsule of the organ. Septa radiate from the mediastinum toward the inner surface of the tunica albuginea forming 200–300 lobes, each of which contains one or more convoluted seminiferous tubules. Each tubule is U-shaped with a total length of 1 m. Interstitial cells (Leydig cells) are found in the connective tissue surrounding the tubules and produce testosterone. Toward the apex of the lobes, the tubules become straight (straight seminiferous tubules) and follow to the mediastinum to form an ­anastomosed network of tubules coated by simple pavement epithelium, known as rete testis. From this network originate 12–20 efferent ducts to the head of the epididymis, which drain into a single epididymal duct of approximately 3–6 m, highly coiled, covered by a fibrous sheath that thickens toward the tail of the epididymis, rectify, and continue as a vas deferens. The testis is irrigated by three arteries: the testicular artery, a direct branch of the aorta; artery of the vas deferens branch of the internal iliac artery; and cremasteric artery branch of the inferior epigastric artery which is a branch of the external iliac artery. The testis is drained by the

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pampiniform plexus, a network of many small veins which in the region of the deep inguinal ring originates the testicular vein. The left testicular vein is a tributary of the left renal vein, and the right testicular vein drains to the inferior vena cava. Testicular veins present valves throughout their length [2, 27]. Lymphatic drainage of the scrotum is done to the superficial inguinal lymph nodes. The right testicle drains to retroperitoneal lymph nodes located along the renal pedicle and the inferior vena cava and between the inferior vena cava and the aorta. The left testicle has its lymph drained to lymph nodes along the left renal wire and the aorta. The innervation of the testis originates as a testicular plexus on the testicular artery, which contains vagal parasympathetic fibers and fibers from the lateral column of the T7 segment. Epididymis is the organ responsible for maturation, reserve, and transport of spermatozoa. It is located on the posterolateral side of the testis. It has a dilated upper portion, the head, a central portion, the body, and a tapered lower end, the tail. Three ligaments attach the upper pole of the testis to the head of the epididymis, the inferior pole of the testis to the tail of the epididymis, and the vas deferens to the tail of the epididymis. These ligaments are folds of the visceral portion of the vaginal tunica and are important for fixation of the testis and epididymis. The epididymis is irrigated by the epididymal artery, a branch of the testicular artery. Venous drainage is done by the veins that join, forming the pampiniform plexus, and lymphatic drainage is done by two routes: the lymphatic vessels of the head and body, which drain into the testicular lymph nodes, and the lymph vessels of the tail, which drain into the external iliac lymph nodes [28]. The vas deferens is the continuation of the epididymal duct, ascending medially to the epididymis, where it is surrounded by the pampiniform plexus, being the most posterior element and of hardened consistency in the spermatic funiculus. After the inguinal canal, it curves around the inferior epigastric artery and crosses anteriorly the external iliac artery, turning posteriorly and inferiorly, crossing the external iliac vessels and

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penetrating the pelvis. It crosses the medial face of the ureter, continuing in the inferior direction on the medial side of the seminal vesicle. In this region, the vas deferens becomes dilated and tortuous, and the ampulla of the vas deferens is formed. The arterial irrigation of the vas deferens is made by the deferential artery, which is a direct branch of the internal iliac artery, or indirectly by a branch of the inferior bladder artery. The venous drainage is made by a plexus that is located around the vas deferens. The ejaculatory duct, which is the continuation of the ampulla of the vas deferens, after receiving the duct of the seminal gland and penetrating the posterior wall of the prostate, ends in the prostatic urethra, in small ostia located in the anterior part of the seminal colliculus (verumontanum), laterally to the ostium of the prostatic utricle [26, 27]. The penis is an organ covered by skin and houses three erectile bodies: the spongious body, a medial body within which is the urethra, and two cavernous bodies, the main erectile penile structures. The penis skin is thin and loosely attached to the underlying connective tissue, except in the glans. The glans skin is thinner and tightly adhered with no subcutaneous adipose tissue. The skin of the penis next to the glans has numerous sebaceous glands The root of the penis consists of a dilated central end, the bulb derived from the spongious body, and two lateral portions, the branches or pillars of the penis (of the cavernous body). The bulb of the penis is located between the two branches, fixed to the inferior surface of the urogenital diaphragm, continues to the spongious body, and is surrounded by the bulbospongious muscles. The branches of the penis are elongated formations, closely adhered to the lower portion of the ischium and pubis, and are covered by the ischiocavernous muscles (Fig. 40.9) [2, 26, 27]. Below the skin, involving the cavernous body and the spongious body, it is possible to observe sequentially (a) superficial fascia of the penis, continuation of the deep perineal fascia; (b) deep fascia of the penis (Buck’s fascia), membranous and resistant; and (c) tunica albuginea of the penis, a dense fibrous covering.

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The penis is irrigated by the internal right and left pudendal arteries, branches of the respective internal iliac arteries. It sends several perineal branches and, as a common artery of the penis, sends three branches: (a) dorsal artery of the penis located between the deep fascia of the penis and tunica albuginea, (b) bulb artery of the penis that irrigates the spongious body and the urethra, and (c) cavernous artery located inside the cavernous body (Fig. 40.9). Venous drainage of the penile erectile bodies originates in small venules from the perisinusoidal spaces below the tunica albuginea, which flow into the circumflex vein tributary of the deep dorsal vein of the penis, which drains into the periprostatic plexus [29]. Lymphatic drainage of the skin and foreskin is done toward the superficial inguinal lymph nodes, while lymph from the glans and the rest of the penis drains to deep inguinal lymph nodes and to external iliac lymph nodes. The innervation of the skin of the penis and glans is supplied by the dorsal nerve of the penis, while the spongious urethra is innervated by deep branches of the perineal nerve, both branches of the pudendal nerve (Fig.  40.9b). The cavernous nerves of the penis are branches of the pelvic plexus, responsible for the autonomic innervation of the penis, innervating the penile erectile bodies [26, 27]. Acknowledgment We express our thanks to Livia Burchianti, MD, for the illustrations and to Carlos José Lazzarini Mendes, MD, for preparing the dissected specimens.

References 1. Drake LR, Vogl W, Mitchell AWM. Gray’s anatomy for students. London: Churchill Livinstone Inc; 2015. 2. Moore KL, Dalley FA, Agur AMR.  Anatomia Orientada para a clínica. Rio de Janeiro: Guanabara Koogan; 2011. 3. Lockhart RD, Hamilton GF, Fyfe FW.  Anatomia do corpo humano. São Paulo: Guanabara Koogan; 1983. 4. Som PM, Laitman JT.  Embryology, variations, and innervations of the human neck muscles. Neurographics. 2017;7(3):215–42.

M. D. Barros et al. 5. Schünke M, Schulte E, Schumacher U. Prometheus, atlas de anatomia: anatomia geral e sistema locomotor. Rio de Janeiro: Guanabara Koogan; 2013. 6. Lumley JSP.  Surface anatomy: the anatomical basis of clinical examination. New  York: Churchill Livingstone; 1996. 7. Snell RS.  Clinical anatomy for medical students. Philadelphia: Lippincott Raven Publishers, Inc; 1995. 8. Jones LA, Lederman SJ.  Human hand function. New York: Oxford University Press; 2006. 9. Kwiatkowska M, Jakutowicz T, Ciszek B, et al. Can palmar creases serve as landmarks for the deeper neurovascular structures? Surg Radiol Anat. 2014;36:495– 501. https://doi.org/10.1007/s00276-013-1211-4. 10. de Berker D. Nail anatomy. Clin Dermatol. 2013;31: 509–15. https://doi.org/10.1016/j.clindermatol.2013. 06.006. 11. Bidic SM, Hatef DA, Rohrich RJ.  Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126(1):163–8. https://doi. org/10.1097/PRS.0b013e3181da86ee. 12. Platzer W.  Anatomia: Texto e Atlas  – Sistema Locomotor. São Paulo: ArtMed; 2008. 13. Hoang D, Orgel MI, Kulber DA. Hand rejuvenation: a comprehensive review of fat grafting. J Hand Surg Am. 2016;41(5):639–44. 14. Fazan VPS, Borges CT, da Silva JH, et al. Superficial palmar arch: an arterial diameter study. J Anat. 2004;204:307–11. 15. Mácea JR.  Diafragma pélvico. Femina. 1995;23(8): 695–7. 16. Klutke CG, Siegel CL. Function female pelvic anatomy. Urol Clin N Am. 1995;22(3):487–49816. 17. Baskin LS, Erol A, Li YW, et al. Anatomical studies of the human clitoris. J Urol. 1999;162:1015–20. 18. O’connel HE, Hutson JM, Anderson CR, et  al. Anatomical relationship between urethra and clitoris. J Urol. 1998;159(6):1892–7. 19. Steers WD.  Physiology of the bladder. In: Wash PC, Retik AB, Stamey TA, Vaughan JR, e­ditors. Campbell’s urology. Philadelphia: WB Saunders Company; 1992. p. 142–76. 20. Pinto AC, Macéa JR (2010) Anatomia Cirúrgica dos Tratos Urinários e Genital. In: Nardozza A Jr, Zerati Filho M, R B Dos Reis (eds) Urologia fundamental. RB Planmark. pp 17–27. 21. Bradely WE, Scott FB, Timm GW.  Innervation of the detrusor muscle and urethra. Urol Clin N Am. 1974;1:3–8. 22. Berman JR, Berman LA, Lin H, et al. Female sexual dysfunction: new perspectives on anatomy, physiology, evaluation, and treatment. AUA Updat Ser. 2000;34:265–72. 23. O’connel HE, Sanjeevan KV, Hutson JM.  Anatomy of the clitoris. J Urol. 2005;174:1189–95. https://doi. org/10.1097/01.ju.0000173639.38898.cd. 24. HIilliges M, Falconer C, Elman-Ordeberg G, et  al. Innervation of the human vaginal mucosa as revealed by PGP 9,5 immunohistochemistry. Acta Anat. 1995;153:119–26.

40  Tip Chapter: Anatomy of the Face, Neck, Hands and Genital Areas 25. Walsh PC, Retik AB, Stamey TA, Vaughan ED Jr (eds) (2002) Campell’s urology. WB Saunders Company, Philadelphia. 2 6. Pinto AC, Barros MD, Liquidato BM.  Anatomia do Trato Genital Masculino. In: Reis RB, Zequi SC, Zerati Filho M, editors. Urologia moderna. São Paulo: Livraria e Editora Marina; 2013. p. 59–65. 27. Sampaio FJB, Favorito LA, Rodrigues HC. Anatomia do trato genital no homem. In: Carvalhal GF, Barata

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HS, editors. Urologia Princípios e Prática. Porto Alegre: Artmed; 1999. p. 36–44. 28. Robaire B, Hinton BT, Orgebin-Crist MC.  The epididymis. In: Neill JD, editor. Knobil and Neill’s physiology of reproduction. Ansterdan: Elsevier; 2006. p. 1071–148. 29. Power EM, Silberstein JL, Kulkarni GS, et  al. The dorsal venous complex (DVC): dorsal venous or dorsal vasculature complex Santorini’s plexus revisited. BJU Int. 2011;108:930.

Hyaluronic Acid for Dermic Hydration

41

Adriana de Cerqueira Leite and Marcelo M. Bellini

41.1 Materials (Fig. 41.1) • • • • •

Topical anesthetic cream (Pliaglis®). Sterile gloves. Chlorhexidine 2% solution. Sterile gauze. Pen marker.

Fig. 41.1  Materials to be used

• Wooden spatula. • Box of hyaluronic acid; in this case, Restylane Vital® that contains a 1 ml syringe and three needles.

41.2 Methods and Techniques (Figs. 41.2, 41.3, and 41.4) • Spread Pliaglis® on the whole area to be treated, using the wooden spatula. Leave it for 30 min. Then remove it and clean the area with chlorhexidine 2% solution [1]. • Mark the area using a pen marker (Fig. 41.2) • Start the HA injection form the skin surface into dermis: For medium dermis injection, 0.01– 0.02 ml HA per point until a small papule can be seen. Go to the other points until 0.5 ml is distributed per side (Figs. 41.3 and 41.4). • Massage with 2 fingers until the injected area gets uniform and the papules are smoothed (Fig. 41.5). • Apply sunscreen cream. • At home, the patient has to massage twice a day for 3 days.

A. de Cerqueira Leite (*) Adriana Leite Clinic of Dermatology, São Paulo, SP, Brazil M. M. Bellini Marcelo Bellini Clinic of Dermatology, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_41

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Fig. 41.2  To mark the area with a pen marker

Fig. 41.3  Technique to inject hyaluronic acid into the facial dermis

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Fig. 41.4  Technique to inject hyaluronic acid into the hand dermis

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Fig. 41.5  Massage appliad on the area where ­hyaluronic acid was injected

41.3 Clinical Follow-Up (Fig. 41.6) After the first session, we expect decrease of the lines of the skin and increase of hydration and elasticity. After three sessions, once a month, the fine lines will disappear, and an increase in firmness, hydration, and smoothness is noticed [2].

Fig. 41.6  Immediate aspect of the skin after injection of hyaluronic acid

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41.4 Before and After (Figs. 41.7 and 41.8)

Fig. 41.7  Before (on the left) and after (on the right) of injection of hyaluronic acid into the facial dermis

Fig. 41.8  Before (on the left) and after (on the right) of injection of hyaluronic acid into the dermis of the hands

41  Hyaluronic Acid for Dermic Hydration

41.5 S  ide Effects, Complications, and Their Management To prevent complications and side effects, a complete medical history is necessary to explore medical allergic diseases, medications used, and prior aesthetic procedures [3]. The risk of bruising is great when patients have bleeding disorders, hypertension, and anticoagulant medication. It is fundamental to check the whole area to perform a detailed assessment and to have anatomic knowledge. A correct assepsy is necessary to avoid contamination and late complications. In each injection, we have to introduce the right level and to massage to prevent the emergence of persistent nodules [4, 5].

Tip Box

• To obtain a complete medical history to avoid side effects. • To know perfectly the anamotic features of the area to be treated will avoid bruising.

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References 1. Glubanava E, et  al. 12- month effects of stabilized hyaluronic acid gel compared with saline for rejuvenation of aging hands. J Drugs Dermatol. 2015;14:288–95. 2. Tezel A, Fredrickson GH.  The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther. 2008;10:35–42. 3. Reuther T, et al. Effects of a three- session skin rejuvenation treatment using stabilized hyaluronic acid-­ based gel of non-animal origin on skin elasticity: a pilot study. Arch Dermatol Res. 2010;302:37–45. 4. Harmatmann V, et  al. Hand augmentation with stabilized hyaluronic acid (Macrolane VRF20 and Restylane Vital, Restylane Vital Light). J Dtsch Dermatol Ges. 2010;8:41–4. Article in English, German. 5. Kerscher M, et al. Rejuvenating influence of a stabilized hyaluronic acid- based gel of nonanimal origin on facial skin aging. Dermatol Surg. 2008;34:720–6.

Hyaluronic Acid for Frontal and Glabella Areas

42

Maritza L. Kummerfeldt

42.1 Materials • The interwoven mechanism of hyaluronic acid is primordial throughout hydration. • We must acknowledge the differences between the NASHA products that are available. • We choose the suitable hyaluronic acid based on the patients’ expectancies, the desired results, and the technique that is used. • When selecting the hyaluronic acid that won’t induce the Tyndall effect, we can inject it superficially or on deeper levels. • The usage of blunt cannulas 27G or 30G of different lengths is primordial for making the correct adjustments, according to the necessities of the region. • Usually hyaluronic acid fillers include small needles of 27–30 gauges.

• Its presentation is a dual-phase gel of 20 mg/ ml suspended in mitigated phosphate with saline solution in a 7 pH level. • Eighty percent interwoven with 250 mg particles and 0.3% of lidocaine.

42.1.2 Belotero Balance® [2] • Produced in Switzerland by Anteis, S.A. • A gel presentation with two cross-linked processes and polydensified matrix as a result • Prefilled 1 cc syringes with a concentration of 22.5 mg/ml and 0.3% lidocaine (Fig. 42.1)

42.1.1 Restylane® [1] • Hyaluronic acid of non-animal origin approved by the Food and Drug Administration (FDA) in the United States in 2003.

Fig. 42.1  Basic materials for the injection of hyaluronic acid M. L. Kummerfeldt (*) Clinic of Dermatology, Guatemala City, Guatemala © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_42

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42.2 Methods and Techniques 42.2.1 Pre-procedure Evaluation [2]

• We must perform a gentle massage or molding of the material and apply a cold compress to reduce the appearance of edema (Figs.  42.2, 42.3, and 42.4).

• During the initial evaluation, all real expectancies will be discussed with the patient. • Patients should avoid the use of ASA, NSAIDs, vitamin E and green tea supplements, ginseng, ginkgo biloba, and fish oil for 7–10 days. • Take pictures prior to the procedure to be used afterward, and both should be taken under the same lighting conditions. • If neuromodulators are going to be used with the patient, they can be administered 1 or 2 weeks prior or simultaneously if it is required.

42.2.2 Techniques

Fig. 42.2  Injection of the glabella area using a blunt 27G

• Meticulous techniques of antisepsis are used cannule with alcohol or chlorhexidine. • Interwoven hyaluronic acids with low or medium viscosity are used for deep or superficial implantation. • In general, the male skin is more thick and oily, with deeper wrinkles, and will require more volume for their correction [3]. • Careful injection of this region is considered because of the possibility of increase in pressure or blockage of the supratrochlear artery [3]. • During the superficial injection, lower-­ viscosity hyaluronic acids must be used. Fig. 42.3  Superficial or “blanching” technique for fron• While injecting, we must avoid irregularities tal lines and use a homogeneous distribution, as to avoid the Tyndall effect. • Intradermal implantation must be done, using small needles with micropunctures or in a ­retrograde manner, and pay attention to skin blanching. • Skin blanching will resolve itself within minutes after injecting the hyaluronic acid. • Blunt cannules of different lengths are used for deeper-type injections, according to the region, in a retrograde manner. • With this modality, the hyaluronic acid used is of low or medium viscosity, combining both one in between the other. Fig. 42.4  Digital pressure of the skin during superficial technique

42  Hyaluronic Acid for Frontal and Glabella Areas

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42.3 Clinical Follow-up • In the office cold compresses are applied to the area and the patient is instructed to continue every hour for 5 min • If necessary, a vitamin K oxide gel or arnica is used to diminish edema or ecchymosis. • The patient may resume daily activities without sun exposure, massages, chemical peels, or any other procedure in that region. • Explain to the patient that erythema and slight edema are common and it depends on the hyaluronic acid used, especially if not completely hydrated. • Instructions have to be provided to call the office if necessary. Reevaluate patient in 2  weeks, and take the posttreatment photographs (Figs. 42.5 and 42.6).

Fig. 42.5  Pretreatment of glabella lines

42.4 Before and After (Figs. 42.7 and 42.8) Fig. 42.6  Two weeks after, only the injection of neuromodulators with partial improvement of glabella lines

a

b

Fig. 42.7 (a) Before treatment. (b) After 2 weeks of hyaluronic acid injection on frontal lines

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a

b

Fig. 42.8 (a) Before treatment. (b) After 2 weeks of hyaluronic acid on glabella region

42.5 S  ide Effects, Complications, and Their Manangement • All hyaluronic acids and fillers may be associated with side effects early or later on.

42.5.1 Discomfort, Erythema, and Edema [4] • The adverse effects most commonly known are discomfort, erythema, and edema on the site of the injections. • An advantage application of lidocaine before the hyaluronic acid will alleviate patient discomfort during the procedure. • Pain is caused by the hydrostatic dissection of the tissue during the injection. • It can be minimized using cold air, ice, and local anesthetic, including the use of lower-­ gauge needles. • Edema can be caused from applying hyaluronic acid partially hydrated on the syringe (Fig. 42.9).

42.5.2 Ecchymosis • Following pre-procedure instructions will help to diminish side effects such as ecchymosis. • Avoid anticoagulant medication.

Fig. 42.9  Erythema immediately after injection

• The possibility of ecchymosis can diminish with a small-gauge needle, use of blunt cannules, technique, and speed of injection. • Arnica gel or a vitamin K oxide gel can be used to accelerate improvement.

42.5.3 Irregularities and Nodules • Irregularities in the outline or formation of papules and nodules are frequently the result of an inappropriate application. • This type of complication can be avoided by injecting the proper amount and adequate depth. • This usually resolves by using digital pressure or a light massage of the irregularity or extracting the product using a lager needle like an 18G [4].

42  Hyaluronic Acid for Frontal and Glabella Areas

Fig. 42.10  Light edema postinjection using hyaluronic acid filler on frontal lines

• If no improvement is seen, a hyaluronidase, an enzyme that hydrolyzes the non-desired material, can be used. • This enzyme can also be used if the patient presents the Tyndall effect. • A bluish tone under the skin, not usually seen, is a consequence of scattered light through the gel placed too superficially [1]. • We must keep in mind that most hyaluronidases available are of animal origin, so there is a possibility of an allergic reaction due to hypersensitivity (Fig. 42.10).

42.5.4 Infections • Early or late infections are yet another complication of inappropriate filler injections and must always be considered. • Superficial infection can manifest in the form of early and painful nodules. • Infections must be managed immediately with oral full-spectrum antibiotics. • The aspiration of fluctuant material for diagnosis and treatment could also be necessary [5]. • Late-onset infections can present themselves as red nodules with or without pain even months after injections of the hyaluronic acid. • We must keep in mind the possibility of biofilms that are the result of bacterial induction during the injection process [5].

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• During biofilms, microorganisms are encapsulated and adhered to a polymeric matrix that includes their nutrients and waste [2]. • Biofilms may present various mechanisms of antimicrobial resistance—that is why the antibiotic should be taken for several weeks [2]. • During the initial period, intralesional steroids should be avoided, as they can activate the biofilm and prolong the infectious ­condition [4]. • They may be used after the use of antibiotics. • The preparation and cleaning of the skin carried out with antiseptic techniques during the procedure will minimize the presence of infections.

42.5.5 Hypersensitivity Reactions [4] • They are extremely rare with the use of hyaluronic acid. • It is predicted that the residual proteins during the manufacturing process may be the cause in some patients. • It is managed with an intramuscular dose of dexamethasone and prednisone during a period of 5–7 days.

42.5.6 Necrosis • Arterial occlusion and consequently necrosis or blindness is the most disastrous complication that may occur when working near this area [6]. • It may be induced due to an embolism of the product or a compressive effect that interrupts vascular blood supply in this region [7, 8]. • It must be suspected while injecting the material and there is a sudden presence of color change to a spotted violet discoloration [4]. • If left untreated, it will lead to more discoloration of the skin and posterior necrosis of the tissue. • Early treatment is imperative using cold compresses, tapping the area and massaging with a nitroglycerine paste to improve blood flow [4].

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• This region can also be injected early on with a hyaluronidase to reduce edema on that region. • The management of necrosis must be treated using conventional methods. • Blurred vision and blindness have been reported due to arterial occlusion when injecting hyaluronic acid in that region. Hyaluronidase must be injected also to diminish pressure on the vessels’ wall, and treatment must be given in conjunction with an ophthalmologist [2].

Tip Box

• The hyaluronic acids used currently are of a non-animal origin, NASHA, and can be obtained in different densities [7]. • The utilization of hyaluronics in the glabella and frontal regions is part of the treatment for facial rejuvenation • Normally neurotoxins and hyaluronics should work in conjunction in order to obtain better results and longevity. • During pretreatment, all real expectancies must be discussed, and the method must be established beforehand. • These techniques of superficial injections with skin blanching can be used in this region or deeper injections with the use of cannules for higher safety. • Side effects and complications can occur when working in the glabella or frontal regions. • We must keep them in mind for a prompt diagnosis and treatment. • Side effects associated with injections of hyaluronic acid in this region are similar to other regions.

• They include erythema, edema, and discomfort. Their initial management is with cold compresses. • Erythema nodules and/or painful, initial treatments are oral full-spectrum antibiotics. • If biofilm is suspected to be present, the suggested treatment is antibiotics the cover acid-fast bacteria, like clarithromycin, for several weeks. • Posterior intralesional steroids can be considered and hyaluronidase enzyme can be used as a treatment of residual nodules.

References 1. Kummerfeldt M.  Rellenos Estéticos. In: Perez F, Enriquez J, editors. Dermatología Cosmética, vol. 11. Mexico: Elsevier; 2011. p. 307–26. 2. Carruthers J, Carruthers A, Dover JS, Alam M. Soft tissue augmentation. 3rd ed. London: Elsevier; 2013. 3. De Maio M, Rzany B. The male patient in aesthetic medicine. Berlin/Heidelberg: Springer; 2009. 4. Jones D.  Injectable fillers. Principles and practice. Chichester: Wiley-Blackwell; 2010. 5. Sadick NS, Carniol PJ, Roy D, Wiest L.  Ilustrated manual of injectable fillers. Informa Healthcare. 2011. 6. Glaich N, Cohen J, Goldberg L, et  al. Injection necrosis of the glabella; protocol for prevention and treatment after use of dermal fillers. Dermatol Surg. 2006;32:276–81. 7. Solish N, Beer K.  Hyaluronic acids: basic science. In: Jones D, editor. Injectable fillers, vol. 3. Hoboken: Wiley-Blackwell; 2010. p. 19–26. 8. Salasche SJ, Bernstein G, Senkari M.  Forehead and temple. In: Perez F, Enriquez J, editors. Surgical anatomy of the face, vol. 14. Norwalk: Appleton & Lange; 1988. p. 163–82.

Filling Temporal and Eyebrow Areas

43

Karina Colossi Furlan

43.1 Materials Surgical alloplasty, autologous fat transfer, and soft tissue filler injections have been used for temporal augmentation [1]. The following products are the most studied and recommended: hyaluronic acid (HA) fillers, calcium hydroxylapatite (CaHA), and poly-L-lactic acid (PLLA). Currently, none of the fillers have a Food and Drug Administration (FDA) indication for augmentation of the temples, so the use is considered off-label and patients must be informed [2]. • HA fillers: There are many different subtypes of HA fillers with variable molecular weights. The products guarantee immediate augmentation, have a soft and natural appearance under the skin, and last for approximately 12 months [3]. They are considered to be safe, with few serious adverse effects reported in the literature. • PLLA (Sculptra Aesthetic; Sanofi-Aventis, Bridgewater, NJ) is also commonly used for temporal augmentation and provides a gradual effect over several months. Advantages of PLLA include a natural, soft look that incorporates the endogenous collagen.

Disadvantages include cost and the need for several treatments [2]. • CaHA (Radiesse, Merz Aesthetics, San Mateo, CA) is considered a biostimulatory filler with effects that develop gradually over time. HA products are the fillers of choice for the brow and upper eyelid; however, calcium-based products and PLLA and autologous fat are described as alternatives [4]. The following options of HA fillers are currently recommended for eyebrow augmentation: • The NASHA (nonanimal stabilized HA) products (Restylane and Perlane – Medicis). • Hylacross products (Juvederm Ultra and Ultra Plus – Allergan). • Cohesive Polydensified Matrix HA (Belotero Balance – Merz). These three product families all have a high total HA concentration, between 20 and 24 mg/ mL, and therefore a high water-binding capacity [5]. The authors have a good experience using Hylacross products; however, controlled, evidence level II articles show that all the mentioned products have comparable safety, efficacy, and longevity [6].

K. C. Furlan (*) Rush University Medical Center, Chicago, IL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_43

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43.2 Methods and Techniques 43.2.1 Temporal Fossa 43.2.1.1 Anatomical Considerations The temporal fossa is a large, concave area located on the lateral surface of the skull that extends almost to the end of the parietal bone and is bordered by the superior temporal line, zygomatic arch, and zygoma [1]. The superficial temporal artery and vein course through and are the vascular supply to the temporoparietal fascia, which is immediately deep to subcutaneous fat and is the equivalent of the superficial musculoaponeurotic system (SMAS) below the zygomatic arch. Superiorly, the temporoparietal fascia integrates with the epicranial aponeurosis of the forehead and scalp. The temporal branch of the facial nerve, which innervates the frontalis, corrugator supercilii, procerus, and obicularis oculi, also traverses the temporal fossa, where it lies within the temporoparietal fascia [7]. 43.2.1.2 Temporal Fossa Augmentation • Patients should be evaluated and the area of interest marked in an upright sitting position. • Photograph before and after procedure. • Use a 1 or 3 mL syringe with 28–30 gauge and 1.0–2.0 inch needle. • Plane of injection is deep, just above the periosteum with aspiration before injection [2]. • The needle is inserted perpendicular to the skin. • Once passed through the dermis, the angle of application should be changed, so that the product can be placed on the surface of the superficial temporal fascia (Fig. 43.1) [8]. –– Possible injection techniques: anterograde, retrograde, and depot injections. –– A depot bolus technique is preferred. Typically, a variable number of injection points are needed for adequate augmentation [2].

Fig. 43.1  Site of injection for temporal augmentation. The needle should be positioned perpendicular to the skin with an oblique rotation after the insertion

• At the initial visit, one to two vials are used with no more than two vials used in a single visit. • One author successfully described a “dilution solution” of HA with saline in a ratio of 2:1 (saline to filler). The author used 2  mL per side with a good result and no significant side effects [9].

43.2.2 Eyebrow Area 43.2.2.1 Anatomic Considerations The eyebrows are composed of a pigmented terminal hair and serve as a site for both frontalis and orbicularis oculi insertion. A fat pad exists in a split in the muscle sheath, allowing for eyebrow movement [10].

43  Filling Temporal and Eyebrow Areas

43.2.2.2 Eyebrow Area Augmentation • Patient should be evaluated and the area of interest marked in an upright sitting position. • Photograph before and after procedure. • Use a 1  mL syringe with 25–28 gauge and 1.0–2.0 inch needle. • Prefer a micro-threading technique to restore volume. • Very small volumes of filler (no more than 0.1  mL each side) can be implanted directly into the upper eyelid (Fig.  43.2). The injec-

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tions should not go inferior to the border of the orbital bone where it is very easy to create irregularities [4]. • Fillers must be implanted in the deep dermis to avoid contour irregularities. • Lambros [4] suggests a trial of local anesthetic in the upper lid to demonstrate the visual effect of the filling in the upper lids and brow.

43.3 Clinical Follow-Up • Ice packs are applied post-procedure. • Over-the-counter analgesics can be prescribed if needed. • Subsequent visits are timed 1 month apart. • Patients are instructed to massage the area 3 times a day for 5 days. –– For patients treated with HA filler, application of gentle pressure to the temple intermittently throughout the first evening after injection may reduce the chance of bruising and contour irregularities [9]. • One month follow-up is the best timing for touch-up. • In case of irregularities, hyaluronidase may be needed. Small amounts of 0.1–0.3 mL should be used to smoothen the skin surface. Skin prick testing is generally recommended before the use of hyaluronidase because of rare cases of anaphylaxis [11]. • It is believed that the use of supplements, such as Arnica montana, bromelain, and vitamin K, may reduce postinjection ecchymosis [12].

Fig. 43.2  Point of injection (arrow) for lateral eyebrow augmentation

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43.4 Before and After (Figs. 43.3, 43.4, 43.5, and 43.6)

Fig. 43.3  Before and after 2 mL of hyaluronic acid to the temporal area. (Credits: Credits: Thais Sakuma, MD, Campo Grande, MS, Brazil)

Fig. 43.4  Before and after 2 mL of hyaluronic acid to the temporal area. (Credits: Credits: Viviane Reis, MD, Bauru, SP, Brazil)

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Fig. 43.5  Before and after 0.4 mL of hyaluronic acid to the eyebrow area. (Credits: Credits: Viviane Reis, MD, Bauru, SP, Brazil)

Fig. 43.6  Before and after 0.3 mL of hyaluronic acid to the eyebrow area. (Credits: Credits: Viviane Reis, MD, Bauru, SP, Brazil)

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43.5 S  ide Effects, Complications, and Their Management A minimal downtime is expected after temporal or eyebrow augmentation. A mild swelling is usually observed. • Temporary swelling can be observed following the injection. The incidence and extent can be minimized by the following measures: –– Cold compresses or ice packs before and after injection –– Adequate compression –– Oral supplements, such as Arnica montana • Bruising is a common complication after injection of any of the soft tissue fillers. The use of cannulas rather than needles decreases the rates of bruising; however, the traditional technique for temporal and eyebrow augmentation uses needles. • Contour defects is another complication of temporal and eyebrow augmentation with fillers and it is the result of overcorrection [2]. The use of hyaluronidase is crucial in this scenario. Small amounts of the enzyme can smooth the surface and correct product imperfections. • Vascular compromise is the most feared complication of soft tissue augmentation. This can occur either by direct intravascular injection or via compression of the vasculature when high volumes are injected. The superficial temporal artery is generally easily palpable and thus can be avoided. Aspiration should be done before injection, although this may be difficult depending on the material used. –– Signs of intravascular injection include blanching of the skin followed by blue-­ gray discoloration and pain. –– If vascular occlusion is suspected, treatment measures should be promptly initiated: (1) application of warm compresses, (2) nitroglycerine paste covering 3 cm of the surrounding area and subcutaneous hyaluronidase, and (3) subcutaneous injections with low molecular weight heparin to prevent thrombosis. The use of

hyperbaric oxygen has also been reported as effective in halting impending necrosis and is performed daily for a minimum of 30 sessions [11]. • The risk of accidental nerve damage can be minimized with the knowledge of facial anatomy and with the use of techniques that are appropriate for the selected filler products and the regions to be injected [6]. • Filler migration after subdermal implantation can also be minimized by avoidance of large bolus injections and instead the use of serial threading technique [6]. • Acute or subacute infection may present as erythema, swelling, or tenderness of an area previously injected with a soft tissue filler. If infection and biofilm are suspected, initiation of systemic antibiotics is the first line of ­treatment; macrolide antibiotics, such as clarithromycin or azithromycin, should be chosen [6]. Tip Box Temporal fossa augmentation

• Recognize area of treatment: shallow depression on the side of the skull limited by the temporal lines and zygomatic arch. • Define severity: mild, moderate or severe. • Plan two or three sessions. • Treat with 1–2 vials each session using a perpendicular depot-injection technique. • Follow-up every 30  days for touch-up and photograph. Eyebrow augmentation

• Recognize area of treatment: lateral and medial portion of the eyebrow. • Treat with small amounts with a microthreading technique. • Avoid excessive volume and contour defects. • Follow-up every 30  days for touch-up and photograph.

43  Filling Temporal and Eyebrow Areas

References

1. Jones D, Hardas B, Murphy DK. Temple reflation in Jean and Alastair Carruthers. Soft tissue augmentation. 4th ed. Edinburgh: Elsevier; 2018. 2. Rose AE, Day D. Esthetic rejuvenation of the temple. Clin Plast Surg. 2013;40(1):77–89. 3. Ross JJ, Malhotra R.  Orbitofacial rejuvenation of temple hollowing with Perlane injectable filler. Aesthet Surg J. 2010;30(3):428–33. 4. Lambros V. Volumetric treatment of the brows in Jean and Alaistair Carruthers. Soft tissue augmentation. 4th ed. Edinburgh: Elsevier; 2018. 5. Kablik J, Monheit GD, Yu L, Chang G, Gershkovich J. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35(Suppl 1): 302–12. 6. Sundaram H, Kiripolsky M.  Nonsurgical rejuvenation of the upper eyelid and brow. Clin Plast Surg. 2013;40(1):55–76. 7. Sykes JM.  Applied anatomy of the temporal region and forehead for injectable fillers. J Drugs Dermatol. 2009;8(10 Suppl):s24–7.

311 8. Moradi A, Shirazi A, Perez V.  A guide to temporal fossa augmentation with small gel particle hyaluronic acid dermal filler. J Drugs Dermatol. 2011;10(6):673–6. 9. Lambros VA.  Technique for filling the temples with highly diluted hyaluronic acid: the “dilution solution”. Aesthet Surg J. 2011;31(1):89–94. 10. Beer KR, Bayers S, Beer J. Aesthetic treatment considerations for the eyebrows and periorbital complex. J Drugs Dermatol. 2014;13(1 Suppl):s17–20. 11. Kassir R, Kolluru A, Kassir M.  Extensive necrosis after injection of hyaluronic acid filler: case report and review of the literature: injection necrosis. J Cosmet Dermatol. 2011;10(3):224–31. 12. Lizzul PF, Narurkar VA. The role of calcium hydroxylapatite (Radiesse) in nonsurgical aesthetic rejuvenation. J Drugs Dermatol. 2010;9(5):446–50.

Hyaluronic Acid for Periocular Area

44

Rodrigo Amaral de Lima and Adilson Da Costa

44.1 Materials (Fig. 44.1) • • • • • • • •

Juvederm Volbella®; Emervel Classic®; Teosyal Touch Up®; Belotero Soft®; Steril gauze; Alcohol 70 °; 25G 16 mm needle; 25G 50 mm microcannula.

44.2 Methods and Techniques (Fig. 44.2) • Position patient to 45° in a well-lit place. • Mark area to be injected. • Perform antisepsis with sterile gauze and alcohol 70%. • Make a hole with 25G 16 mm needle on the side of the pupillary line. • Insert microcannula to 45° up to subcutaneous plane. • Insert small volumes in retroinjection (total of 0.1–0.5  ml each side) just up to a little bit before taking out the microcannula. • Massage the area lightly in order to settle the product.

Fig. 44.1  Materials used to inject hyaluronic acid into the periocular area

R. A. de Lima (*) Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_44

313

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a

b

c

d

Fig. 44.2 (a) Area to be filled; (b) marked area; (c) cleaning the area with an antiseptic material; (d) making a hole with the need through the cannula will be introduced by; (e) introduction of the cannula through the already

made hole; (f) introduction of the cannula underneath the area to be filled by the hyaluronic acid; (g) massaging the area wherein the filler was just injected

44  Hyaluronic Acid for Periocular Area

e

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f

g

Fig. 44.2 (continued)

44.3 Clinical Follow-Up • Hyaluronic acid’s main feature is to be able to draw water molecules to an extracellular matrix from the injection point, which provides tissue increase, making the area voluminous [1]. • Another advantage is the dissolution by the hyaluronidase enzyme, making it possible to rectify overcorrection mistakes and even to totally remove the product in cases of serious and adverse effects [2].

• Hyaluronic acid is biocompatible and is reabsorbed in about 1 year after the application. • The patient must be seen in 3–4  weeks after the procedure and should be observed if there have been any side effects.

44.4 Before and After (Fig. 44.3)

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a

b

Fig. 44.3 (a) Immediately after hyaluronic acid injection; (b–f) after 30 days of injected hyaluronic acid

44  Hyaluronic Acid for Periocular Area

c

d

Fig. 44.3 (continued)

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e

f

Fig. 44.3 (continued)

44  Hyaluronic Acid for Periocular Area

44.5 S  ide Effects, Complications, and Their Management • Ecchymosis: most commonly observed when the procedure is performed with needles. It is advised to apply immediate compression on the area and cold compress. It can last, in average, up to 10 days (Fig. 44.4) [3]. • Edema: The ingestion of prednisone is indicated, (0.5  mg/kg/day) up to 3  days, along with local massage. • Erythema: side effect that goes away in 1–2 days. • Granuloma: rare effect, which should be treated with intralesional infiltration of corticosteroid. • Hypersensitivity reactions: may occur in up to 0.02% of patients; treatment depends on the severity of hypersensitivity. • Tyndall effect: bluish-gray tinting which is observed in superficial injections and that can be corrected with the hyaluronidase application [3, 4].

Fig. 44.4  Echmosis observed after injection of hyaluronic acid in periorbicular area

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Tip Box

• In order to avoid bruising, do the proceeding preferably with microcannulas. • Check for the microcannula placement inside the correct application plane. It will avoid shallow injections and the nodule formation. • Use the appropriate product for the periocular area. Very thick products could cause edema and an undesirable aesthetic result. • Know well the local periocular anatomy in order to avoid filling into incorrect planes.

References 1. Braz AV, Aquino BO. Filling of the nasojugal fold and the lateral infraorbital depression with a 30 G microcanula. Surg Cosmet Dermatol. 2012;4(2):178–89. 2. Hirmand H.  Anatomy and nonsurgical correction of the tear trough deformity. Plast Reconstr Surg. 2010;125(2):699–708. 3. Croco EI, Alves RO, Alessi C.  Adverse events in injectable hyaluronic acid. Surg Cosmet Dermatol. 2012;4(3):259–63. 4. Balassiano LKA, Bravo BSF.  Hyaluronidase: a necessity for any dermatologist applying injectable hyaluronic acid. Surg Cosmet Dermatol. 2014;6(4): 338–43.

Hyaluronic Acid for Malar Area and Zygomatic Arch

45

Karina Colossi Furlan

45.1 Materials Injectable fillers have become one of the most popular choices for noninvasive facial augmentation. These include a wide variety of fillers with new products that have been introduced over the past several years. The most studied filler and known for its safety and efficacy is the HA.  However, other products such as calcium hydroxylapatite and polymethylmethacrylate can be used depending on the expertise of the cosmetic surgeon.

45.1.1 Hyaluronic Acid Fillers • HA fillers can be characterized by physical properties, HA content, and cross-linking. Less hydrated fillers have a lifting function as they absorb larger amounts of fluid after placement. This feature can be an advantage for midface injections since smaller volumes are used [1]. • The longevity of HA filler depends on various aspects and may last up to 18 months [2]. • A thick HA gel is the ideal choice for midface augmentation (Juvederm Voluma® and Restylane SubQ®).

K. C. Furlan (*) Rush University Medical Center, Chicago, IL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_45

• Some authors describe Juvederm Voluma® as the best option due to its lifting capacity. The versatility to inject it both into subcutaneous and supraperiosteal level, easy-to-mold property, and mainly reversibility are characteristics that make this product unique [3]. • Other areas of the face can be simultaneously treated with another filler, if desirable. However, the 3D configuration should always be observed as the lifting effect produced after the midface augmentation can recreate facial anatomy. • One week after the midface augmentation, the final appearance will temporarily de-volumize and then slowly improve in the following 12 weeks.

45.2 Methods and Techniques Soft tissue volume restoration of the upper mid-­ lateral cheek overlying the zygomatic arch (zygomatic malar complex) simultaneously restores cheek definition and lifts ptotic periorbital structures [3]. The big challenge when doing midface augmentation is to correct the shape creating a round contour and avoiding the overcorrection which is not uncommon due to the patient’s and surgeon’s anxiety for a perceptible result. • The aesthetic endpoint should be assessed with the patient in a full smile as sometimes there could be a bump created for excessive 321

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product delivered to the region. Excessive cheek lifting or “sausage-like fold” on the cheek should be avoided. • Fear of unnatural appearing results is a common concern voiced by patients. In fact, natural-­looking results are desirable to both the patients and the physicians treating them [3].

45.2.1 Practical Procedural Tips • Remove make-up. • Clean the area with antiseptic solution. • Use topical or injectable anesthesia in the treatment area. • Ice can be used before and after treatment. • Needles with 24 or 26-G should be preferred. • Cannulas of 22–25-G and 40 mm long are safe alternatives due to its blunt tip. • Aspiration before injection is always recommended for both cannulas and needles. • Micro-depot is the administration technique. • Retrograde and/or anterograde injections can be used to place the product. • 1–2  mL of the filler should be placed every session. • The product can be diluted in normal saline in a 1:2 proportion (saline: filler). • Immediate sub-dermis is the target area. • After injection, reassess the desired 3D contour convexity; if this has not been achieved, additional subdermal product should be administered.

45.2.2 Areas of Injection The malar area is the first point of injection for midface anterior projection; however, the zygomatic bone and the lateral maxillae augmentation contribute to the final shape. Extension to supe-

rior, inferior, and lateral portions of these bones may be necessary to create a harmonic result. The 3D configuration of the face should be always respected looking for a natural result.

45.2.3 Malar Area • Malar injections can be done immediately onto the periosteum. • Small boluses should be placed avoiding lumps, nodules, or visible material. • Since the material is placed in an avascular space, there is less bruising and lower embolic potential [4]. • More viscous filler is injected in the deeper plane in micro-depot aliquots of 0.1  mL to provide a rigid foundation for accentuating the cheeks [5]. • The sites of injection can be oriented by the location of the IOF [4]. One injection should be done medially to the infraorbital nerve, perpendicular to the skin approximately 1  cm beneath the inferior orbital rim (Fig. 45.1a). • A second injection is lateral to the infraorbital nerve (Fig. 45.1b). • A third is at the malar eminence. • The technique using cannula is performed with only one external opening lateral to the IOF. • The material is molded gently after injection to achieve a smooth result. • The purpose of molding is to smooth and manipulate the filler into the area of volume deficiency. The ultimate objective is a smooth blending between the lower eyelid, nasolabial fold, and the cheek [4]. • All bleeding points are treated with immediate and sustained direct pressure. • Post-injection ice packs and head elevation are employed.

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Fig. 45.1  Points for midface injections. (a) Points of injection are marked medial and lateral to the IOF. (Red: IOF, Green: Medial point of injection, Blue: Lateral point

of injection, Black: Vectors for injections) (b) A third point of injection is in the malar eminence. (Red: IOF, Green: Malar eminence, Black: Vectors foe injections)

45.2.4 Zygomatic Area

• Patients should be evaluated after 4 weeks. • Additional fillers can be administered (up to 2 mL per malar) if the patient is experiencing one of the following: –– Asymmetry in malar region –– Only small improvement • In case of irregularities, hyaluronidase may be needed. Small amounts of 0.1–0.3 mL should be used to smooth the skin surface. • All patients are encouraged to take post-­ treatment vitamin C and zinc supplements for 3 months [3]. • It is believed that the use of supplements, such as Arnica Montana, bromelain, and vitamin K, may reduce post-injection ecchymosis.

• The zygomatic area can be easily identified lateral to the malar area, in the prominence of the zygomatic bone. • Small micro-depot injections should be preferred. • After injection, the area should be molded looking for a smooth surface.

45.3 Clinical Follow-up • Ice packs are applied post-procedure. • Over-the-counter analgesics can be prescribed if needed. • Patients are instructed to massage the area 3 times a day for 5 days.

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45.4 Before and After (Figs. 45.2, 45.3, 45.4, and 45.5)

Fig. 45.2  Before and after injection of 2 mL of hyaluronic acid in the malar and zygomatic eminence. (Credits: Thais Sakuma, MD, Campo Grande, MS, Brazil)

Fig. 45.3  Before and after injection of 2  mL of hyaluronic acid in the malar and zygomatic eminence. (Credits: Rodrigo Amaral de Lima, MD, Rio de Janeiro, RJ, Brazil)

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Fig. 45.4  Before and after injection of 1.5 mL of hyaluronic acid in the malar and zygomatic eminence. (Credits: Rodrigo Amaral de Lima, MD, Rio de Janeiro, RJ, Brazil)

Fig. 45.5  Before and after injection of 1.0 mL of hyaluronic acid in the malar and zygomatic eminence. (Credits: Rodrigo Amaral de Lima, MD, Rio de Janeiro, RJ, Brazil)

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45.5 S  ide Effects, Complications, and Their Management • Swelling, bruising, erythema, pain, itching, discoloration, and tenderness: These could be injection related or substance related. Injection-­related adverse effects are more common. Resolution is spontaneous within 1 or 2  days and incidence and extent can be minimized by the following measures: –– Cold compresses or ice packs before and after injection –– Adequate compression –– Oral supplements, such as Arnica Montana. • Substance-related adverse effects: Swelling and induration at the implant site. A short course of oral steroids or intradermal hyaluronidase may be needed [6]. • Asymmetry: Caused by swelling or overcorrection. If the asymmetry persists after 4 weeks of the procedure, the product should be dissolved with intradermal hyaluronidase 0.01–0.3 mL. • Cellulitis: Persistent swelling, erythema, and tenderness are symptoms of localized ­infection. If infection or biofilm is suspected, initiation of systemic antibiotics is the first line of treatment; macrolide antibiotics, such as clarithromycin or azithromycin, should be chosen. • Vascular compromise: The angular artery can be compromised directly or indirectly after midface augmentation. Signs include blanching followed by blue-gray discoloration, pain, vesiculation, and erosion. If vascular occlusion is suspected, treatment measures should be promptly initiated: –– Application of warm compresses for 5–10 min every 1–2 h –– Nitroglycerine paste 2% immediately after suspected necrosis and then for 5 min every 1–2 h –– Prednisone 20–40 mg each day for 3–5 days –– Aspirin 325 mg: 1 under the tongue immediately and then daily –– Sildenafil 50 mg: 1 per day for 3–5 days –– Hyperbaric oxygen: should be started as soon as possible with continued treatments until the area has improved [7].

• The risk of accidental nerve damage can be minimized with the knowledge of facial anatomy and using techniques that are appropriate for the selected filler products and the regions to be injected. • Filler migration can be minimized by avoidance of large bolus injections.

Tip Box

Hyaluronic acid for malar and zygomatic arch: • Recognize patients’ need using 3D evaluation of the face • Define area of treatment localizing the infraorbital foramen • Choose hyaluronic acid with high density • Photograph the patient before and after procedure • Injection should be medial and lateral to the IOF • Use micro-depot technique with maximum 2 mL per session • The treatment area should be molded to avoid irregularities • Follow-up in 4 weeks

References 1. Stocks D, Sundaram H, Michaels J, Durrani MJ, Wortzman MS, Nelson DB. Rheological evaluation of the physical properties of hyaluronic acid dermal fillers. J Drugs Dermatol. 2011;10(9):974–80. 2. Raspaldo H.  Volumizing effect of a new hyaluronic acid sub-dermal facial filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther. 2008;10(3):134–42. 3. Cotofana S, Schenck TL, Trevidic P, Sykes J, Massry GG, Liew S, et  al. Midface: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136(5 Suppl):219S–34S. 4. Funt DK.  Avoiding malar edema during midface/ cheek augmentation with dermal fillers. J Clin Aesthet Dermatol. 2011;4(12):32–6. 5. Tung R, Ruiz de Luzuriaga AM, Park K, Sato M, Dubina M, Alam M. Brighter eyes: combined upper cheek and tear trough augmentation: a systematic

45  Hyaluronic Acid for Malar Area and Zygomatic Arch approach utilizing two complementary hyaluronic acid fillers. J Drugs Dermatol. 2012;11(9):1094–7. 6. Vedamurthy M.  Soft tissue augmentation--use of hyaluronic acid as dermal filler. Indian J Dermatol Venereol Leprol. 2004;70(6):383–7.

327 7. Beer K, Downie J, Beer J.  A treatment protocol for vascular occlusion from particulate soft tissue augmentation. J Clin Aesthet Dermatol. 2012;5(5):44–7.

Hyaluronic Acid for Pre-auricular Area

46

Liza R. Braun, Maxim Polansky, and Travis W. Blalock

46.1 Materials • Several major manufacturers (Belotero®, Juvederm®, Restylane®) of cross-linked hyaluronic acid (HA) gels exist in the market today. • Major differences between products include degree of HA cross-linking, particle size, and final concentrations, thus altering approved indications for each product. –– Each filler has its own elastic modulus (G’) which correlates to resistance of skin tension. By maintaining its ability to retain its shape, a filler with higher G’ suggests a greater resistance to skin tension forces and is believed to be optimal when trying to lift and volumize areas with high muscle activity [1]. • Below we list salient highlights and notable differences between various available HA fillers.

L. R. Braun · M. Polansky · T. W. Blalock (*) Emory University School of Medicine, Department of Dermatology, Atlanta, GA, USA e-mail: [email protected]; maxim.alexander. [email protected]; [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_46

Belotero Balance • HA cross-linked with 1,4-butanediol diglycidyl ether (BDDE) and has variable densities (manufactured via cohesive polydensified matrix technology) which creates a more homogeneous spreading pattern when compared to Juvederm® and Restylane® [2]. Final concentration 22.5  mg/mL.  Used for mid-to-deep dermis for moderate-to-severe facial wrinkles and folds. Lasts up to 6 months. Elevess • Concentration of 28 mg/mL. Used for mid-to-­ deep dermis injections for correction of moderate-­to-severe facial wrinkles. Juvederm • Absolute contraindication to this product line is history of severe allergies with anaphylaxis as the formulations may contain trace gram-­ positive proteins. • Juvederm Ultra XC and Ultra Plus XC: highly cross-linked HA at concentration 24  mg/mL with 0.3% lidocaine. Used for mid-to-deep dermis for moderate-to-severe wrinkles. Ultra XC can also be used for lip augmentation. Lasts up to 18 months. • Juvederm Voluma XC: highly viscous with HA concentration of 20  mg/mL and 0.3% lidocaine, made with VyCross® technology, which is touted to improve cross-linking. 329

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Used for subcutaneous or supraperiostal injection for cheek augmentation and correction of age-related volume loss of midface and lasts up to 18–24 months. • Juvederm Volbella XC: based on VyCross® technology with HA concentration of 17.5 mg/ mL. Has low G’ and used to treat perioral lines and lip augmentation. Perlane • Larger particle size (940–1090um) than Restylane and indicated for severe facial folds. Lasts 6–12  months. Not cross-linked with BDDE. Restylane • All products are cross-linked hyaluronic acid with BDDE component at concentration 20 mg/mL. • Restylane/Restylane-L: medium-sized particles (400um) and concentration 20  mg/mL with 0.3% lidocaine. Used for mid/deep dermis implantation for moderate-to-severe facial wrinkles such as nasolabial folds. Maximum dose per treatment is 1.5  mL.  Lasts up to 12 months. • Restylane Lyft with lidocaine: HA cross-­ linked with BDDE with concentration of 20 mg/mL with 0.3% lidocaine. Used for deep dermis/superficial subcutis for severe facial/ nasolabial folds and subcutaneous/supraperiosteal implantation for age-related midface contour loss and cheek augmentation. The recommended maximum dose 6 mL per treatment session. • Restylane Silk: smaller-particle HA cross-­ linked with BDDE and concentration 20 mg/ mL with 0.3% lidocaine. Used for perioral wrinkles and lip augmentation. The maximum

volume is 1.5 mL per lip and 1 mL for perioral rhytids. • Restylane Refyne/Defyne: approved as of December 2016. HA without BDDE cross-­ linking component. Refyne is recommended for moderate-to-severe facial wrinkles and Defyne is recommended for moderate-to-­ severe deep facial wrinkles and laugh lines.

46.2 Methods and Techniques 46.2.1 Methods The primary goal of the pre-auricular augmentation is to reshape specific areas that provide a youthful round softness where aging has otherwise allowed for bone and fat pad loss. • The first step is to prepare the patient with appropriate anesthetics or pain management techniques: –– Ice –– Topical anesthetics –– Infraorbital nerve block with 0.5–1 mL of lidocaine • Avoid excessive lidocaine infiltration to prevent concealing facial depressions [3]. • May also relax facial muscles making full animation difficult to attain [3]. • Identify four primary points of injection (See Fig. 46.1) –– V1: zygomatic arch –– V2: zygomatic eminence –– V3: anteromedial cheek –– V4: submalar • Clean the skin with antiseptic (chlorhexidine is commonly used though controversial given

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• Most fillers come in prefilled syringes; however, ensure use of 26G or 27G needle for deeper supraperiosteal injections where aspiration is required. Needles may also need to be replaced periodically as they may dull with serial injections.

46.2.2 Techniques (see Fig. 46.2)

1 2

3 4

Fig. 46.1  Injection grid for malar augmentation. (Image from Matarasso et al. [4])

contraindication for use on head and neck). 70% alcohol is also appropriate. Be aware that you are injecting a foreign substance and therefore need a clean field.

• Linear threading: Utilizes a single point of entry with a cannula which is then inserted and filler injected in a retrograde fashion. Anterograde injections are possible but a less common approach. –– Fanning: multiple linear threads in a fanning or “windmill”-like pattern from a single point. These can be done in a single or multiple layers. –– Cross-hatching: Linear threads are deposited in a parallel and then perpendicular pattern. • Vertical supraperiosteal depot technique (VSDT): A needle is injected at 90° to the underlying periosteum. Once needle is on the bone, small aliquots are directly deposited. These aliquots can be massaged or molded to form. • Tower technique: Subdermal injections that are injected at 90° to the skin directly into the defect. Small aliquots are slowly injected as the needle is withdrawn to produce a “pyramid”-like deposition of filler.

L. R. Braun et al.

332 Fig. 46.2 Various injection techniques are illustrated, including serial puncture (1), retrograde linear threading (2), aterograde (3), fanning (4), and cross hatching (5). Images from Sherman [5]

1. Serial puncture

Static needle

2. Retrograde linear threading (tunneling)

Direction of needle when injecting

3. Anterograde

Static needle

Arrow indicates direction of filler flow

4. Fanning

Arrow indicates direction of needle when injecting

5. Cross-hatching (grid pattern)

Injections are retrograde and overlapping

46  Hyaluronic Acid for Pre-auricular Area

46.3 Clinical Follow-Up • There are over-the-counter supplements available that some clinicians suggest may optimize post-treatment outcomes including oral supplements like vitamin C and zinc. One author suggests supplementation with vitamin C and zinc for 3 months [6]. • Arnica, a common homeopathic supplement, can be used for bruising.

333

• Can consider two additional treatments at 4and 10-week follow-up to modify or layer upon prior treatment. • Advise patients that some injectables have anesthesia (lidocaine) which may result in a few hours of post-treatment numbness.

46.4 B  efore and After (Figs. 46.3 and 46.4)

a

b

Fig. 46.3 (a) Voluma to pre-auricular area (before). (b) Voluma to preauricular area (after). (Images from Jones [7])

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After

Fig. 46.4  Complement of intradermal, superficial injection of HA filler to eliminate superficial skin folds (Courtesy: Doris Hexsel, Porto Alegre, RS, Brazil)

46.5 S  ide Effects, Complications, and Their Management •

•

•

•

–– Multiple major vessels run through this area including zygomaticofacial and infraorbital FDA-approved hyaluronidase (Hylenex®, –– A significant number of filler-associated Halozyme Therapeutics) used for degradablindness have occurred with autologous tion of HA and its effect lasts approx. 48 fat transfers [9] hours [8]. • Caution patients on anticoagulants about the risk Juvederm Voluma® has a highly specific of hematoma or ecchymosis. Areas that have increased risk of a delayed inflammatory reacprior treatment with permanent filler should be tion thought to be due to retained post-­ avoided to prevent inflammation and infection [3] synthesis byproducts possibly from the new • Hypersensitivity reactions VyCross® process. –– Type 1 reactions are more likely attributThe main concerns with Restylane are mild able to lidocaine (topical or compounded in reactions in situ (swelling, redness, tenderHA syringe) [9]. ness) and pain during injection. • Infection is extremely rare with HA injection. The risk of intravascular occlusion or extraAs noted above in methods, suggest antiseptic vascular compression: prior to injection. Avoid injecting into active

46  Hyaluronic Acid for Pre-auricular Area

infections or areas believed to be infected for this elective procedure. • Nodular or uneven distribution of HA –– Can be resolved with massage or hyaluronidase. We suggest keeping and maintaining non-expired hyaluronidase. Tip Box

• Assess patient in various facial expressions including full smile [6]. • Photo documentation with multiple viewpoints to document pre-treatment areas and post-treatment evaluation [3]. • Patient should be sitting upright to evaluate effects of gravity throughout the procedure. • Evaluate patient periodically with ability to see both sides of the face. This will allow you to maintain, achieve, and/or monitor for symmetry. • Keep materials on hand that may need to be utilized in emergent situations (see chapter “Clinical emergency during aesthetic procedures”). • Assess before and after results (Fig. 46.3) with patients to review efficacy of product, your planning, your execution, and the patient’s satisfaction [7].

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References 1. Kablik J, Monheit GD, Yu L, et  al. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35(suppl 1):302–12. 2. Tran C, Carraux P, Micheels P, Kaya G, Salomon D. In vivo biointegration of three hyaluronic acid fillers in human skin: a histological study. Dermatology. 2014;228(1):47–54. 3. Carruthers J, Rzany B, Sattler G, Carruthers A. Anatomic guidelines for augmentation of the cheek and infraorbital hollow. Dermatol Surg. 2012;38(7pt2):1223–33. 4. Matarasso A, Nikfarjam J, Abramowitz L.  Incorporating minimally invasive procedures into an aesthetic surgery practice. Clin Plast Surg. 2016;43(3): 449–57. 5. Sherman RN.  Avoiding dermal filler complications. Clin Dermatol. 2009;27:S23–32. 6. Cotofana S, Schenck T, Trevidic P, Sykes J, Massry G, Liew S, Graivier M, Dayan S, de Maio M, Fitzgerald R, Andrews J, Remington B. Midface. Plast Reconstr Surg. 2015;136:219S–34S. 7. Jones D. Volumizing the face with soft tissue fillers. Clin Plast Surg. 2011;38(3):379–90. 8. Cavallini M, Gazzola R, Metalla M, Vaienti L.  The role of hyaluronidase in the treatment of complications from hyaluronic acid dermal fillers. Aesthet Surg J. 2013;33(8):1167–74. 9. Vanaman M, Fabi S, Carruthers J.  Complications in the cosmetic dermatology patient. Dermatol Surg. 2016;42(1):1–11.

Hyaluronic Acid for Ear Lobe

47

Adriana de Cerqueira Leite and Marcelo M. Bellini

47.1 Materials (Fig. 47.1) Filler (in our demonstration we use Vollift/Allergan). Needles – inside the box 30G1/2 or 27G1/2. Gauze. Chlorhexidine solution. Gloves. Pen marker. Topical anesthetic4.

47.2 Methods and Techniques • Take pictures for the area to be treated. • The patient must use a disposable cap. • Apply topical anesthetic cream and let it remain for 30  min (time varies by the brand and concentration; observe the chart). • Some fillers have lidocaine mixture in their composition either. They use to be more comfortable for the patient. • Clean up the area and apply chlorhexidine solution with gauze [1]. • Wear gloves and isolate the area with disposable surgical field. A. de Cerqueira Leite (*) Adriana Leite Clinic of Dermatology, São Paulo, SP, Brazil e-mail: [email protected] M. M. Bellini Marcelo Bellini Clinic of Dermatology, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_47

Fig. 47.1  Materials to be used

• Use the pen marker to emphasize the defects that will be corrected.

47.2.1 Preparing the Filler Take out of the box the syringe to be used; it must be sealed to guarantee sterilization. After having removed syringe tip cap attach the needle properly turning it one quarter to the left until it locks (observe that different brands and presentations varies; attention to be sure it is locked to not unattached during the t­reatment) Pull of the needle shield (Fig. 47.2) [2]. Keep the tip of the needle down, observing the flow amount. 337

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Fig. 47.2  Depth of the needle when injected into the ear lobe

Fig. 47.4  Fanning technique injection

Fig. 47.3  Puncture technique injection

Start applying a small amount around the earring ear hole, as serial puncture technique (Fig. 47.3). Fanning technique also can be used (Fig. 47.4). It should be injected slowly. The quantity to be injected depends on the correction to be achieved. Avoid overcorrection (Figs. 47.5 and 47.6 ). For the best performance of the product, it should be injected into the superficial to middermis (Fig. 47.7). Massage gently to spread the product uniformly. After each point is done, compress the area to manage bleeding. It disappears spontaneously as soon as the injection is finished (Fig. 47.8). Dressing is not needed after [3].

Fig. 47.5  Injection of the hyaluronic acid into the dermis of the inferior half of the lobe

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Fig. 47.6  Injection of the hyaluronic acid into the dermis of the superior half of the lobe

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Fig. 47.8  Immediate aspect of the ear lobe after hyaluronic acid injection

47.3 Clinical Follow-Up Most of the patients refer that they have small swelling and bruising that disappear spontaneously in 5–10 days. The patients should avoid sun exposure and sauna for 2 weeks after the treatment. They can wear earrings in a week after the treatment. Pain is rare and patient can complain of discomfort for 3–5 days after the injection. If any different symptom onset is observed, patient must return to the office to be evaluated. Contraindications:

Fig. 47.7  Injection of the hyaluronic acid into the superficial to mid-dermis

Pregnant or breast feeding women. Any known hypersensitivity the one of the components of the product. Patients with hypertrophic scars or cheloids history.

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47.4 Before and After (Fig. 47.9)

Fig. 47.9  Before (left) and after (right) injection of hyaluronic acid into the ear lobe

47.5 S  ide Effects, Complications, and Their Management As described above, the common side effects are swelling, bruising, and discrete pain. If the patient reports any side effects that lasts more than a week, it must be evaluated. Rare, but not impossible, is to present nodules, redness, and discoloration of the treated area. It can be resulted by using a big amount of the product or if the patient has permanent or semipermanent fillers previously injected into that site. In case of that, HA should not be injected. Given that, a complete anamnesis is mandatory to avoid late complications. As long as HA is a temporary filler, in most of the cases, with proper orientation, complications can be solve easily and/or spontaneously [4]. If ear lobes present swelling and bruising, avoid heat and massage gently twice a day with anti-inflammatory cream/ointment. Nodules: If they persist more than a month and it is visible, it could be treated with hyaluronidase. If it is just palpable, most of them do not need to be treated because it is expected to have this texture enhancement.

Tip Box

• It is mandatory to choose the appropriate hyaluronic acid concentration to achieve natural results. For ear lobes, 20–22.5 mg/ml HA of concentration is the best choice. (It varies by brand.) • Always keep the needle tip clean and if it touches another surface, change the needle to avoid infection.

References 1. Qian W, et al. Clinical application of earlobe augmentation with hyaluronic acid filler in the Chinese population. Aesthetic Plast Surg. 2017;41(1):185–90. 2. Fallacara A, et al. Hyaluronic acid fillers in soft tissue regeneration. Facial Plast Surg. 2017;33(1):87–96. 3. Lannitti T, et al. A new highly viscoelastic hyaluronic acid gel: rheological properties, biocompatibility and clinical investigation in esthetic and restorative surgery. Int J Pharm. 2013;456(2):583–92. 4. Pickrell BB, et  al. Partial ear defects. Semin Plast Surg. 2017;31(3):134–40.

Hyaluronic Acid for the Nose

48

Carlos Echevarria and Denise Durand

48.1 Materials • • • • • •

Gauze. Alcohol. Sterile gloves. Dermal filler. Blunt microcannula 25G × 2. 23G × 1¨ sharp needle.

48.2 Methods and Techniques • Prior to beginning the procedure, it is crucial to determine points of injection by observing nasal angles. Not every patient will have the same anatomical features or the same injection points. • Generally, injections begin at the nasal dorsum with 0.2–0.4  mL of HA between the hump and the nasal root in an imaginary medial line. • When injecting the nasal dorsum, cannulas are preferred in order to prevent injuring the dorsal nasal artery and other vascular structures.

• When trying to correct the nasolabial angle, we use between 0.2 and 0.4 mL of HA. Need or cannula entrance point can be either the distal third of the columella or at the level of the nasolabial angle close to the nasal ­pyramid . • The final area of injection should be the nasal tip, where no more than 0.2 mL should be utilized (Fig. 48.1). • For the nasal tip, we use a technique coined “arrow tip,” where the nose is pictured as the tip of an arrow pointing in a specific direction (Figs. 48.5 and 48.6). • In the latter technique, the needle/cannula entrance point is the caudal third of the nasal dorsum, the area of union between middle third and caudal third of the nasal tip. • Filler should be injected in a deep dermal plane. • To avoid product migration, the nasal tip area needs to be contained by applying direct pressure using one’s thumb, index, and middle finger of the non-dominant hand. • Soon after injection, apart from the above compression to limit product diffusion, the

C. Echevarria (*) Private Practice, Dermanova Clinic, Lima, Peru D. Durand Clinica San Pablo, Lima, Peru © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_48

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A

B

a

b

c

Fig. 48.1  Before (A) and after (B) injection rhinoplasty using three-point injection technique. (a) Dorsal injection preferably with microcannula, (b) injection of columella, and (c) injection of nasal tip

other hand is used to mold the product to form the sharpest nasal tip possible. • After the previous application point, the nasal tip should not be manipulated. • When addressing the nasal tip, overcorrection is recommended, as the result will diminish after the first few days after application. • To potentiate the effect of this nasal tip technique, current recommendation is that of injecting 2–5 units of botulinum toxin to the depressor septi nasi and the alar portion of the nasalis bilaterally (Figs. 48.2 and 48.3).

48.3 Clinical Follow-up • After the procedure, application of ice to the affected area is recommended. • Manipulation of the injected area should be minimal. • Avoid using glasses that offer fixation to the nasal dorsum. • The effect of injections will diminish after a few days; thus, a follow-up visit is recommended in 7–10 days, once inflammation has partly subsided.

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a

b

c

d

Fig. 48.2  Step-by-step process of injection rhinoplasty. To avoid product migration, the nasal tip area needs to be contained by applying direct pressure using one’s thumb, index, and middle finger of the non-dominant hand (c, d)

Fig. 48.3  Improvement of nasal profile. Before (a) and after (b) injection rhinoplasty

a

b

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48.4 Before and After (Figs. 48.4, 48.5, and 48.6) a

b

Fig. 48.4  Improvement of nasal tip. (a) Before and (b) after injection rhinoplasty

Fig. 48.5  “Arrow tip” technique. *Measurements in mm

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Fig. 48.7 Edema rhinoplasty

and

erythema

after

injection

48.5 S  ide Effects, Complications, and Their Management

Fig. 48.6  “Arrow tip” technique. *Measurement in mm

• Bruising: Common side effect of filler injections. To reduce bruising, advice patient to stop using blood thinners 1 week prior to procedure. Management with cold compresses might help (Fig. 48.7). • Granuloma or nodule formation: Formed by the accumulation of immune-mediated response-related cells. Clinically, lump formation is noted. Management is with corticosteroid injections or surgical excision [1]. • Vascular compromise and necrosis: Arterial embolization or compression from excessive injection affecting the three main branches of nasal blood supply – Lateral nasal artery (most important), dorsal nasal artery, and nasal septal artery (least important) (Fig. 48.8). • Visible implant: When filler is injected to superficial. • Infections: Possible complications but generally infrequent. Treatment options are oral antibiotics and topical mupirocin.

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Tip Box

• Patients with thick oily skin may be more difficult to work with. These patients more often present with post-­ procedural edema.

Reference 1. Moon HJ.  Use of fillers in rhinoplasty. Clin Plast Surg. 2016;43(1):307–17.

Fig. 48.8  Vascular compromise of the nose

Hyaluronic Acid for Nasolabial Folds

49

Aline Rodrigues Bragatto, Caroline Moreira Albrecht, and Cristina Hachul Moreno

49.1 Materials The most common dermal fillers used in this region are biodegradable and contain hyaluronic acid (HA) and autologous fatty tissue.

49.1.1 Hyaluronic Acid • It is a glycosaminoglycan, a substance which occurs naturally in the extracellular matrix of the dermis [1] and progressively reduces the aging of the skin. • Its most important characteristic is the elevated capacity for the retention of water, providing support and volume to the skin [2]. • It has been successfully used since 1996 to correct cutaneous alterations [2]. • There are formulations with high, medium, and low viscosity, indicated for deeper to more superficial fillings, respectively. A. R. Bragatto Aline Rodrigues Bragatto Clinic of Plastic Surgery, Valinhos, SP, Brazil Department of Dermatology, Santa Casa of São Paulo University Hospital, São Paulo, SP, Brazil C. M. Albrecht São Paulo, SP, Brazil C. H. Moreno (*) Department of Dermatology, Santa Casa of São Paulo University Hospital, São Paulo, SP, Brazil Cristina Hachul Moreno Clinic of Plastic Surgery, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_49

• Formulations associated with a local anesthetic, lidocaine, confer it with greater comfort during application. • Medium viscosity fillers are more frequently used for the nasolabial groove, as they supply adequate filling without superficial marking and are associated with lidocaine, which diminishes the necessity for anesthesia. Some examples are Juvéderm ultra XC, Juvéderm ultra plus XC, Restylane-L, and Belotero balance lidocaine. • Some products have softer effects, like Juvedérm ultra XC; others, like Juvéderm ultra plus XC and Restylane-L, have stronger results. • It is biocompatible, applicable to various parts of the body, noninfectious, and associated with minimum discomfort during and following injection, remaining at the site after terminating injection and providing a natural appearance with a good cost-benefit ratio.

49.2 Methods and Techniques 49.2.1 Preparation • There must be full understanding of the patient’s complaint, evaluation of expectations for the procedure, a correct physical examination, a careful choice of dermal filler, the execution of the adequate technique, and post-procedure care. 347

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• The patient is placed in a supine position, with the head elevated and all makeup removed to avoid contamination. • Skin antisepsis, gloves, and sterilized materials are a must.

49.2.3 Application

• For the filler infiltration, syringes prepared with HA and coupled to 0.5-inch 30G needles and/or blunt cannulas are used. • Pain control: Rigorous clarification should be made to the patient of the procedure steps, formulas with lidocaine or topical anesthetics (EMLA®, PLIAGLIS®) should be used, and ice should be amplied to the site. In less cases, it can be done anesthetic buttons at the needle’s place of entrance or lateral to the groove may also be used, taking care to use low volume so as not to distort the site being treated (Fig. 49.1).

• A needle is positioned at the point most distal to the groove, at an angle of 30° to the skin, and introduced along the extension of the groove towards the nose. • The infiltration of the filler is performed in the medium and deep dermis by retroinjection, or in other words, the hyaluronic acid is injected as the needle is being withdrawn. • During the injection into the medium and deep dermis, there is some resistance as the needle advances through the skin and its tip is not visible. • The first approach is made at the most distal point of the groove; the second, 1 cm ahead of the first; and the third, 1 cm ahead of the second, with an application fanning out along the nasal ala (Figs.  49.2, 49.3, 49.4, and 49.5). • Make sure the needle is properly attached to the syringe before starting the injection. • It’s important to release the syringe plunger pressure before withdrawing the needle from the skin to avoid dispersion of the product in the epidermis. • The applications should be medial to the nasolabial groove, as lateral applications can increase the groove.

Fig. 49.1  The topical anesthetic and the syringes prepared with HA and the needles

Fig. 49.2  The first approach, at the most distal point of the groove, with the needle at an angle of 30° to the skin

49.2.2 Materials

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Fig. 49.5  The needle puncture sites and the fan in the nasal ala

Fig. 49.3  The second point of application 1 cm ahead the first point

suggestion: start with one syringe and evaluate the results [1]. • Immediately after the infiltration, a modeling of the filler should be performed with local massage, the thumb being on the skin and the index finger placed intrabucally or with compression against the bone. • The maximum doses for treatment with HA vary according to the manufacturers and are listed on the product inserts [1].

49.2.4 Care Following the Procedure • Sun exposure should be avoided and sunscreen should be applied.

49.3 Clinical Follow-Ups

Fig. 49.4  The third point of application 1cm ahead the second point

• Light grooves generally require 0.8 ml; moderate grooves require 1.6 ml, and accentuated grooves require 2.4 ml of HA-lidocaine. Our

• HA is an absorbed long-lasting dermal filler with a 6–12-month duration. • Maximum effect occurs within 3 weeks. • It is well tolerated, with few side effects or complications. • Formulations with medium viscosity can be used for most of nasolabial folds. • It can be repeated or discontinued, according to satisfaction with results obtained (Figs. 49.6 and 49.7).

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49.4 B  efore and After (Figs. 49.6 and 49.7)

Fig. 49.6  Before view

Fig. 49.8  Bruise treated with solar protection

• Sunscreen should be applied and it’s necessary to avoid sun exposure (Fig. 49.8).

49.5.3 Allergic/Anaphylactic reactions [1, 2]

Fig. 49.7  After view (imediatly)

49.5 Side Effects and Complications 49.5.1 Erythema and Edema • They are expected soon after the application. • They can be progressive in the initial days, beginning to subside after 1 week. • Physical activity should be avoided during this period.

49.5.2 Bruising in Tissue or Dermis • It tends to decrease with local compression and cold compresses.

• Rare. • More frequent with agents which contain local anesthesia. • Treatment is like another allergic reaction: Discontinue the use of the product, withdraw the product if possible, use antiallergics and/ or corticosteroids, and provide life support in severe cases (Fig. 49.9).

49.5.4 Nodulations • They can occur immediately or in the initial days. • Treatment: local massage. • If they persist, the necessity for hyaluronidase may be evaluated.

49.5.5 Hypocorrection or Overfilling • Both of them indicate inadequate evaluation and/or technique.

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larize the site with vigorous massage, application of hot water bottles, administration of 2 chewable 325  mg aspirins, application of a vasodilator (salve or nitroglycerin), monitoring vital signs, evaluating the use of hyaluronidase along the pathway of the vessels (previous cutaneous exam should be performed), and contacting a plastic surgeon if rapid resolution does not occur. • The use of a cannula should be considered.

Fig. 49.9  Skin allergy after application of topical anesthetic. It was treated with the removal of the product and administration of topical and oral corticosteroids

• In the hypocorrection, can be complemented. • In overfilling, if massages are not enough, the use of hyaluronidase can be considered.

49.5.6 Infection • Bacterial, viral, or fungal infections require biopsies and cultures. • Recurrence of herpes in the perioral region requires adequate treatment; evaluate the use of prophylactic antivirals.

Tip Box

• A common complaint can have immediately visible results with a minimally invasive procedure. • Hyaluronic acid: Readily available, safe, minimum incidence of side effects and repeatable. • Detailed knowledge of facial anatomy is essential for a natural look and minimal complications. • Undesirable results disappear with temporary fillers. • The nasolabial fold is a normal facial feature in youth and should not be completely effaced. Indication

49.5.7 Foreign Body Granulomas • Foreign body granulomas are generally of late onset. • They are more frequently associated with permanent fillings and intradermal injections.

49.5.8 Ischemia and Necrosis [1–3] • The nasal ala and tip are vascularized by the lateral nasal artery, which is very close to the nasolabial groove, 2–3 mm above the alar groove. • Ischemia at these sites may occur due to intravascular injection or extrinsic compression of these vessels. • It should be treated with urgency so it does not lead to nasal ala necrosis. • Recommendations: The discontinuance of application immediately, attempts to revascu-

• Softening of static lines: It is important to point out that the groove should be attenuated, but not erased, in order to achieve a harmonic and natural result. • Reduction of nasolabial grooves of diverse depths: More accentuated grooves and/or less elastic skin may present more limited results and require additional procedures. In cases of greater dermal flaccidity, they may not be substitutes for surgical procedures. Absolute Contraindications [1, 2]

• Active infection or chronic dermatitis in the site to be treated. • Allergy to any of the components in the filler agent. • Pregnancy and breast-feeding (or the intention of becoming pregnant during the period in which the filling is present).

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• Systemic autoimmune reactions. • Unrealistic expectations and lack of understanding of the technique and the expected results. Relative Contraindications [1, 2]

• Immunosuppression. • Aged under 18. • Predisposition to hypertrophic or keloid scarring. • Use of nonsteroidal anti-inflammatory drugs. • Fine and atrophied skin. • Use of anticoagulants or coagulation deficiencies.

References 1. Small R, Hoang DA. Practical guide to dermal filler procedure. San Francisco: Lippincott Williams & Wilkins; 2012. 2. Sattler G, Gout U. Illustrated guide to injectable fillers  – basics| indications| uses. Quintessense. 2017. pp. 1–72, 170–87. 3. Scheuer JF, Sieber DA, Pezeshk RA, Gassman AA, Campbell CF, Rohrich RJ. Facial danger zones: techniques to maximize safety during soft-tissue filler injections. Plast Reconstr Surg. 2017;139:1103–8.

Hyaluronic Acid for Lips and Perioral Fine Lines and Wrinkles

50

Luca Piovano

50.1 Materials • Nowadays reabsorbable fillers (hyaluronic acid with different cross-linking properties) are the preferred options, which can be found on commerce in combination with lidocaine in order to better manage treatment pain.

50.2 Methods and  Techniques • Well-focused pretreatment photographs should be taken, not only for the assessment of treatment effects and any adverse effects but also for medicolegal purposes. Pictures should be taken in anteroposterior and lateral projection, both in static and dynamic (smiling and whistling) features, and any asymmetries should be properly analyzed and addressed. • Proper cleaning with antiseptic solution is always advisable.

threading technique is always preferable instead of large bolus. It is generally performed from the medial to lateral side (5 mm laterally to the commissure), and each hemi-­lip is compared for symmetry. According to the no-touch technique [1], we divide the upper lip in thirds and treat its central portion by injection along the philtrum lines through Cupid’s bow. • NLF and bar code can also benefit from fanning injection technique, providing the area with good fullness. • To our experience, blunt cannulas (Fig. 50.1) are preferably used when a relatively easy case to treat occurs. In fact, a simple lip enhancement can be properly addressed with blunt cannulas, allowing to treat a major area with less invasiveness and trauma. However, when a finer treatment is required, the use of needle (Fig.  50.2) is almost mandatory as it allows a more spreading injection and helps deal with refinements and mild asymmetries.

50.2.1 Lip Enhancement and Contour Definition • As in any filler injection, it is better to avoid product accumulation; thus, a retrograde linear L. Piovano (*) University of Camerino, Camerino, Italy Plastic Surgeon, Rome, Italy e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_50

Fig. 50.1  Injection technique by using cannula 353

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Fig. 50.2  Injection technique by using needles

• Anesthesia dramatically helps to provide the patient with minimal discomfort during procedure. There are different techniques, ­ ranging from local infiltrations, topical anesthesia, and ice cooling to regional blocks. The choice depends on several factors: the sensitivity of the region, patient’s tolerance level or history of needle fear, and necessity to prevent from alteration of the regional anatomy. • In certain cases the mere aesthetic medicine is not enough, and the surgeon has to resort to prior surgery. In lip enlargement, it is advisable to perform an upper lip lifting such as, in very thin lips, a v-y-shaped eversion should be the best propaedeutic choice.

Fig. 50.3  Marking supra-labial wrinkles

Fig. 50.4  Injection technique by using needles for NFL Linking Up technique

50.2.2 Perioral Finishes • Oral commissure lift-up: filling in a pyramidal technique down to the mouth corner. With a little amount of soft hyaluronic acid (HA), it can be easily lifted up. To achieve a successful lift, the needle must be in the superficial dermis with the distal third of the needle immediately adjacent to the vermillion border. Very deep injections in this area worsen the oral commissure’s downward position. • NLF Linking up it consist in radial infiltration to accompanying new lip assessment on the face (Figs. 50.3 and 50.4). • Bar code correction: in our experience, the best treatment for this clinical condition is superficial intradermal microdoses of botulinum toxin, which will be properly discussed in a specific chapter (Fig. 50.5).

Fig. 50.5  Injection technique by using needles for supralabial wrinkles: Bar code

50.3 Clinical Follow-up • After each kind of treatment, the patient is evaluated after 1 week to eliminate edema due to injection. • Lip enhancement: symmetry is the main aim to look to.

50  Hyaluronic Acid for Lips and Perioral Fine Lines and Wrinkles

• Wrinkle treatment: severity is analyzed and improvement evaluated by using Lemperle wrinkle severity scale.

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50.4 B  efore and After (Figs. 50.6 and 50.7)

Fig. 50.6  Before and after 30 days of injection of hyaluronic acid in lips and perioral area to project lips to upfront

Fig. 50.7  Before and after 30 days of injection of hyaluronic acid in the lips and perioral area to give volume to the lips

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50.5 S  ide Effects, Complications, and Their Management • Complications may be part of practice when dealing with facial fillers. Firstly, they can be due to technical errors [2, 3]: –– Volume: too much or too little filler –– Depth of treatment: filler injected too superficially or too deeply –– Location: unfavorable anatomic location or asymmetry, or injection into the incorrect anatomical location • During these kinds of treatments, ecchymosis and skin flogosis occurred in many patients due to the great amount of capillaries present in this area. Treatment of ecchymosis involves the use of heparin-based creams. • In case of hypo-correction, further injections of minimal products may be beneficial. In other way, when an excessive amount of injected filler is delivered, or it is released too superficially, such as vigorous massage, dissolution with hyaluronidase, or even extrusion with needle puncture, lumps and nodules arise. This may be due to technical errors or to overestimation of patients’ aesthetic needs.

• Lumps and bumps from overfilling in a particular area often respond to simple massage. If they persist more than two weeks, they can be dissolved with hyaluronidase (a mucolytic enzyme that hydrolyzes both natural and cross-linked hyaluronic acid dermal fillers) which may represent a very useful tool. • Inflammatory reactions may be also elicited either by infectious agents or mediated by the immune system. Delayed edema surrounding the areas of hyaluronic acid injection is a notable phenomenon because of its hydrophilic nature and osmolality. Chronic prolonged edema can also be related to a type 4 hypersensitivity reaction. If it is unresponsive to antihistamines, it may need to be dissolved with hyaluronidase. • Immediate bacterial infections are thought to be caused by the introduction of bacteria from the skin surface. A proper topical disinfection and absence of makeup are advisable. In case of first signs of infection, oral antibiotics should be administered. In case of known previous herpes infection, proper antiviral therapy should be prescribed. • The most dangerous complication is represented by an erroneous intra-arterial embolization or vascular compression (Fig.  50.8).

Courtesy: Dr. Andrezza Facci, Barueri, SP, Brazil

Fig. 50.8  Example of intra-arterial embolization or vascular compression with necrotic areas

50  Hyaluronic Acid for Lips and Perioral Fine Lines and Wrinkles

Clinically, patients manifest with significant pain and ischemic pallor, eventually leading to necrosis and atrophic changes. Hot compresses, massage, hyaluronidase, aspirin, and possibly oral steroids should be immediately considered. Otherwise, skin necrosis is an inevitable consequence. Of course, adequate knowledge of anatomy of the region is mandatory in order to avoid such accidents. Moreover, the method of injection also contributes to the overall result. Slower injection of smaller volumes as well as aspiration before injection is always preferable. Tip Box

• Patients’ expectations must be managed, so they do not have an unrealistic outcome, and they must be made aware of the limitations and risks of dermal fillers. • The right way to approach the problem of “bar code” is to make a preliminary assessment of the severity of pre-­ existing damage. • Hyaluronic acid (with different cross-­ linking properties) is the preferred option to the lip antiaging approach, combined with lidocaine to better manage treatment’s pain.

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• Pictures should be taken, not only for the assessment of treatment effects and any adverse effects but also for medicolegal purposes. • To avoid product accumulation, thus a retrograde linear threading technique is always preferable instead of large bolus. • Simple lip enhancement can be properly addressed with blunt cannulas, allowing to treat a major area with less invasiveness and trauma. • In our experience, bar code correction is better treated with superficial intradermal microdoses of botulinum toxin. • Hyaluronidase is still the best treatment for asymmetric outcomes as the consequence from excessive material injection.

References 1. Surek C, Beut J, et  al. No touch technique for lip enhancement. Plast Reconstr Surg. 2016;138:603e–13e. 2. De Lorenzi C. Complications of injectable fillers, Part I. Aesthet Surg J. 2013;33:561–75. 3. Woodward J, Khan T, Martin J.  Facial filler complications. Facial Plast Surg Clin N Am. 2015;23: 447–58.

Hyaluronic Acid Fillers for Treating Temporal Area Volume Loss

51

Francisco de Melo and Carmelo Crisafulli

51.1 Materials For treatment of the temporal area, we propose (Fig. 51.1): • Sterile gauze. • Sterile gloves. • Chlorhexidine or povidone-iodine solution for disinfection. • Skin marker. • Local anesthetic: lidocaine 2% with adrenaline 1:80000 (for entry points, 1  ml total). Alternatively, we can consider topical anesthetic cream. • Hyaluronic acid (HA): 1–3 ml. • Needle: 30/27 or 25G (accordingly to the filler viscosity and usually included in the filler package). • Cannula 22/25Gx50mm (optional). • Ice packs.

51.2

Methods and Techniques [1–8]

A complete medical history should be obtained prior to any medical treatment, and in this case, F. de Melo (*) ZO Skin Centre, Dubai, UAE e-mail: [email protected] C. Crisafulli IMG Clinic, Dubai, UAE © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_51

particular attention should be taken regarding previous soft tissue filler treatments, which areas were treated, when they were treated, which products were used, result quality and longevity, eventual complications, or unwanted results as a consequence of the prior treatments. Although it might be quite difficult to obtain detailed information, it is of utmost importance to guide the physician in choosing the filler and the technique for this particular treatment. Avoiding to take these factors into account adds an increased potential for complications. • The treatment plan should be discussed with the patient, including the after care and eventual risks. • A detailed informed consent should be obtained. • The areas to be treated should be extensively cleaned and a clean technique should be used. This is the most effective way to avoid infection. We, generally, don’t prescribe prophylactic or post-treatment antibiotics ­ when using soft tissue fillers. • Patient should be marked in a standing position; the areas to be addressed must be highlighted and mark the points of entry. • In the majority of cases, the temporal hollowness is not symmetric; the patient should given an estimate of the volume to be added. 359

F. de Melo and C. Crisafulli

360 Fig. 51.1 Instruments and material set: sterile gloves, sterile gauze (5 × 5 cm), hyaluronic acid filler, microcannula, and opening needle; 27/30G needle (included in the filler package)

For the temporal area, there are two different approaches and anatomical planes that can be used: 1. Using the natural plane of the temporal fat pad (superficial to the temporalis muscle). 2. The pre-periosteal plane (deep into the temporalis muscle).

51.2.1 Superficial to the Temporalis Muscle (Fig. 51.2)

––

–– –– ––

–– • Pros: –– In our opinion this is the optimal plane for filler in the temporal area, as the deformity is created by the temporal fat pad atrophy. –– It lies beneath the superficial temporal fascia, offering a good coverage and avoiding contour irregularities. –– This is not a virtual space (limited by the superficial and deep temporal fascias and

––

––

––

zygomatic arch) and can be easily filled with a blunt micro-cannula, reducing trauma. A 22 or 25G cannula is preferred, as its rigidity allows a better control and assures a correct and uniform placement of the filler. A low-pressure molding is enough to assure even distribution. The zygomatic arch limits any inferior displacement of the filler. It is easy to approach from the hairline or from the temporal crest (caudal to the superficial temporal artery). At this level there are no important vascular structures. The frontal branch of the nerve runs deep and caudal in this space, close to the orbital rim, and injury can be avoided by using a micro-cannula. It doesn’t need much filler quantity or volume to correct the defect (rarely more then 1 ml per side). The superior orbital rim can be addressed through the same approach.

51  Hyaluronic Acid Fillers for Treating Temporal Area Volume Loss

361

a

b

c

d

e

f

Fig. 51.2  Superficial to the temporalis muscle technique; (a) marking the defect and the entry point; (b) local anesthesia in the entry point; (c) opening of the entry point with a 20–23G needle through the skin, superficial fat, and superficial temporal fascia (ask the patient to open the mouth, if the needle moves, it means the tip is at the muscle level); (d) with a rotational movement (like drilling),

introduce the cannula (22–25G) under the superficial temporal fascia; (e) in the right plane, the cannula slides without effort or pain and can start retrograde fanning injection; (f) immediate result (blanching is due to the local anesthesia with epinephrine). Notice that the superficial veins are more evident (transient effect) and the lateral one-third of the eyebrow is more elevated

• Cons: –– It has a longer learning curve and requires proper anatomy knowledge. –– It requires the use of local anesthesia in the entry point. –– There is risk of superficial filler placement, if the superficial temporal fascia is not identified. –– Transient superficial vein visibility occurs.

51.2.2 Deep Temporal Plane • Pros: –– This is the most commonly used technique for treating the temporal area, with a shorter learning curve, and is easy to perform. –– The filler is placed deep into the temporalis muscle, superficial to the periosteum.

F. de Melo and C. Crisafulli

362

a

b

c

Fig. 51.3 (a) Deeper to the temporalis muscle technique; (b)  Deep bolus injection to the supra-periosteal plane. Commonly 3–5 boluses are enough, depending on the volume loss and area size. (c) Immediate result

–– Using a bolus technique, the filler is placed through several boluses, between 3 and 6, and then massaged with enough pressure to assure an even distribution. –– This does not require local or topical anesthesia. • Cons (Fig. 51.3): –– This technique usually needs more filler quantity (more volume) for being able to lift the temporal muscle from the periosteum, to which it is strongly attached.

–– It can cause more discomfort to the patient due to the pressure involved in the injections and the muscle stretch. –– It can lead to an increased possibility for bleeding and suffusion/hematoma (intramuscular injection). –– There is increased risk for filler migration and displacement due to the increase in pressure, muscular action, and continuity to the pterygomaxillar and infratemporal fossa (Fig. 51.4).

51  Hyaluronic Acid Fillers for Treating Temporal Area Volume Loss Fig. 51.4 Anatomical representation for the different layers at the temporal level: sagital cut

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Skin Subcutaneous tissue Superficial temporal fascia Subgaleal fascia Temporalis fascia

Superficial layer of temporalis fascia Deep layer of temporalis fascia Superficial temporal fat pad Temporalis muscle Facial nerve Zygomatic arch

51.3 Clinical Follow-Up [1–8] After treatment, the use of topical ice packs is advised. In the strong majority of cases, there is no need for oral analgesics or antibiotics. The patient must keep the face clean with no makeup, avoid exposing the treated area to heat and radiation (sauna, sun), and avoid swimming/bathing and alcohol consumption for the first 24  h. Also, the patient must be informed that a transient swelling for the first 48–72  h

after treatment is expected; a transient block of the frontal branch of the facial nerve in case HA fillers with lidocaine were used is expected. Follow-up is done usually 2  weeks after the treatment, assessing the improvement, volume, and symmetry. Treatment of this area can be combined with other treatments, namely, neurotoxins, either in the same stage or in different ones, and it is a good combination protocol to obtain a nonsurgical eyebrow lift.

F. de Melo and C. Crisafulli

364

51.4 Before and After (Figs. 51.5, 51.6, and 51.7) a

b

c

d

Fig. 51.6  A 51-year-old patient; (a, b) before treatment of the temporal; (c, d) after treatment (2 weeks) with soft tissue fillers (superficial to the temporalis muscle technique); total volume 1 ml (0.5 ml per side)

Fig. 51.5 (a, b) Before and after (3 months) treatment of the temporal area with soft tissue fillers (superficial to the temporalis muscle technique); total volume 2 ml (1 ml per side)

51  Hyaluronic Acid Fillers for Treating Temporal Area Volume Loss

a

b

c

d

Fig. 51.7  A 47-year-old patient; (a, b) before treatment of the temporal and (c, d) immediately after treatment with soft tissue fillers (deep to the temporalis muscle tech-

51.5 S  ide Effects, Complications, and Their Management [1–8]

365

nique); total volume is 1.5 ml (0.9 on the right side and 0.6 ml on the left)

the use of sharp needles and deep intramuscular injection, and it builds a higher pressure gradient due to the bolus, increasing the soft With a proper planning and a good aseptic techtissue trauma. nique, the possibility of unwanted results or com- • Transient vein visibility: This results from the plications is significantly reduced. The main increased underlying pressure caused by voladverse effects (not complications) are: ume augmentation. This is more common when using the superficial technique and usu• Swelling that can persist beyond the third day: ally resolves in a week. more associated with the deep bolus injec- • Asymmetry: This usually result from a preextions, due to the tissue trauma and high-­ isting asymmetry that went unnoticed or the pressure injection. It can be avoided by inability to replace the required volume on reducing the injection pressure, using a slower both sides. injection technique, and building the pressure • Under correction: The temporal area requires gradient in a more paced way. a considerable amount of volume and is easily • Bruising and hematoma: It’s not common in under evaluated in the assessment. It is advisthis area, although it can happen using sharp able, as a rule of thumb for the beginners, to instruments like needles. Again the deep add 0.5 ml to the initial prevision in order to placement technique is more prone to it due to correct the defect.

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The possible complications are in general the same as for other areas, except that: • There is a low risk of intravascular injections while using the recommended techniques. However it’s a risk that needs to be taken in consideration for every treatment and proper knowledge of anatomy, and detailed planning can avoid major vascular complications. • Filler displacement: This is a particular risk to this area due to the anatomy and continuity to the infratemporal fossa. Concern should be raised when using HA fillers in a deep bolus injection, since there is no tissue integration or encapsulation and the filler can be “squeezed” by the muscular action into the infratemporal fossa and midface.

Tip Box

• Pay attention to the temporal area when assessing the patient. • Proper knowledge of the topographic anatomy of the temporal area is required. • Correct planning of the treatment is required. Mark the areas to be treated and pay attention to asymmetries. • Inform the patient of the volume that will be needed to correct the defect. It usually takes more volume than expected. • Choose a good clean technique and use a low-pressure injection (cannula or needle) to reduce tissue trauma, swelling, and bruising and give comfort to the patient. • Follow up with the patient to access the quality of the result and to perform the necessary corrections.

References 1. Ueland HO, Nilsen RM, Rødahl E, Jensen SA. Hyaluronic acid is superior to autologous fat for treatment of temporal hollowing after lateral orbital wall decompression: A prospective interventional trial. J Plast Reconstr Aesthet Surg. 2019;72(6):973–81. 2. Gün T, Boztepe OF, Atan D, İkincioğulları A, Dere H. Comparison of Hyaluronic Acid Fat Graft Myringoplasty, Fat Graft Myringoplasty and Temporal Fascia Techniques for the Closure of Different Sizes and Sites of Tympanic Membrane Perforations. J Int Adv Otol. 2016;12(2):137–41. 3. Juhász ML, Marmur ES. Temporal fossa defects: techniques for injecting hyaluronic acid filler and complications after hyaluronic acid filler injection. J Cosmet Dermatol. 2015;14(3):254–9. 4. Chundury RV, Weber AC, McBride J, Plesec TP, Perry JD. Microanatomical Location of Hyaluronic Acid Gel Following Injection of the Temporal Hollows. Ophthalmic Plast Reconstr Surg. 2015;31(5):418–20. 5. Pimentel de Miranda A, Nassiri N, Goldberg RA. Engorgement of the Angular and Temporal Veins Following Periorbital Hyaluronic Acid Gel Injection. Ophthalmic Plast Reconstr Surg. 2016;32(2):123–6. 6. Beer KR, Julius H, Dunn M, Wilson F. Remodeling of periorbital, temporal, glabellar, and crow’s feet areas with hyaluronic acid and botulinum toxin. J Cosmet Dermatol. 2014;13(2):143–50. 7. Moradi A, Shirazi A, Moradi J. A 12-month, prospective, evaluator-blinded study of small gel particle hyaluronic acid filler in the correction of temporal fossa volume loss. J Drugs Dermatol. 2013;12(4):470–5. 8. Moradi A, Shirazi A, Perez V. A guide to temporal fossa augmentation with small gel particle hyaluronic acid dermal filler. J Drugs Dermatol. 2011;10(6):673–6.

Hyaluronic Acid for Chin

52

Nark-Kyoung Rho

52.1 Materials 52.1.1 Physical properties of a filler required for chin augmentation • In many cases, the projection, rotation, and repositioning necessary for improving the aesthetics of the anterior chin cannot be effectively accomplished with filler injection alone. This is because of several anatomic factors of the chin. • To overcome these anatomic factors to improve the aesthetic outcome, fillers for the chin should have supreme viscosity and elasticity. • Unfortunately, currently available fillers are not as hard as implants of prostheses; therefore, the filler may lose its rigidness or migrate by the action of the mentalis muscle over time [1]. • High viscosity confers the advantage that the filler will tend to remain where it is injected rather than spreading out, allowing for precise sculpting; high elasticity means the ability of a gel to resist against applied forces [2]. • High cohesivity, along with high viscoelasticity, is another desirable physical property of a filler to provide structural support and N.-K. Rho (*) Leaders Aesthetic Laser & Cosmetic Surgery Center, Seoul, South Korea © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_52

“lifting effect” in the correction of retruded chin [2]. Examples of hyaluronic acid filler products for chin augmentation • • • • •

Juvéderm® Voluma XC (Allergan, Inc.) Belotero® Volume (Merz Aesthetics, Inc.) Teosyal® Puresense Ultra Deep (Teoxane SA) Stylage® XL (Vivacy) Restylane® SubQ (Galderma)

52.2 Methods and Techniques 52.2.1 Physical examination and facial analysis • Physical examination of the chin should include both inspection and palpation of the chin, lips, nose, and teeth. The entire face should be observed at rest and during animation to evaluate the mentalis muscle and the chin soft tissue mound and its support [3]. Below are checkpoints for evaluation before chin injection. –– General contour of the face –– Facial symmetry –– Jawline symmetry –– Mentolabial creases –– Jowls

367

368

• Most importantly, lower face asymmetry should be evaluated before planning chin injection because asymmetry is often conserved throughout the population. Left-sided chin weakness is an example of well-­preserved anatomical asymmetry [4]. • An orthodontic evaluation is sometimes required to find out whether the patient’s demands can be met by filler augmentation or the dental treatment should be performed.

52.2.2 Evaluation of the chin • The high demand for the chin filler augmentation in the Asian population could attribute to the prevalence of a recessed chin in Asians and the increasing demand for a “V-line” face [5]. • Traditionally, the chin is evaluated in three dimensions: horizontal (anteroposterior), vertical, and transverse. Injectable fillers are good options if horizontal and transverse chin deficiency is the main complaint of the patient. Vertical deformities are often not easily corrected by injectable fillers because of the strong compression and active movement of the chin’s soft tissue [6]. • The mentum is relatively easily augmented in the sagittal plane, whereas the chin height is not effectively prolonged in many patients [6]. The primary indication of chin filler injection is a retruded chin. • A retruded or recessed chin, which is frequently found in the East Asian population, refers to a lack of projection of the tip on the chin. This not only accentuates the protrusion of the mouth but also produces an angry or unsatisfied appearance. For certain patients, the degree of retrusion may also influence the patient’s jaw mobility [5]. –– Observe the Ricketts aesthetic line from the nasal tip (pronasale) to the most anterior point of the chin (pogonion). –– It is regarded that the Ricketts line completely aligning with a line drawn from the nose to the vermilion border of the lower

N.-K. Rho

lip is aesthetically pleasing in the Asian population (Fig. 52.1). –– If the retruded chin is associated with the long mandible, filler augmentation of the chin is not recommended because it may make the mandible longer. A frontal view accompanied by a lateral view of the chin gives better insight into the projection and elongation of the patient’s chin [6]. • Proportions –– Upper face: Midface: Lower face. –– The length and proportion of the mandible against the lower facial dimension. –– Proportions should be judged based on the ethnicity, age, and gender of the patient. For example, East Asian females tend to

Fig. 52.1 Ricketts aesthetic line (E-line) (a three-­ dimensional image was generated using Morpheus™3D, Korea)

52  Hyaluronic Acid for Chin

have the lower face shorter with a ratio of 1:1:0.8 instead of 1:1:1—the ideal Western artistic facial ratio. –– In East Asian patients, the chin length should be adjusted after examining the general contour of the face, rather than automatically applying the “ideal” facial ratio to 1:1:1. • The actual patient evaluation may need to be more comprehensive than a physical examination alone and sometimes involves bony ­structure analysis including dental and cephalometric examinations. 52.2.3 Design • Since the chin augmentation improves chin shape and forward projection, creating a more tapered appearance and changing the contours of the lower face [1], the goal of chin augmentation should be the reposition and rotation of a rigid soft tissue envelope to a more projected position along the inferior border of the mandible [7]. • The position of the chin at the center of the face makes it highly susceptible to asymmetry in the case of incorrect placement of filler materials. It is very important to mark the proper centerline of the face prior to the procedure [5]. • Mark the extent of the injection to provide volumes adjacent to the central pogonion. –– Development of filler products with sufficient lifting capacity has brought out the necessity of augmenting both the central pogonion and the lateral paragonial region. –– This area is often overlooked when augmenting the chin proper. Improving the overall chin shape, as well as augmenting the chin in profile, is important to get natural results and attractiveness of the face. –– Relative volume deficiency of the prejowl sulcus should be addressed and marked. Oblique views of the face are useful to reveal the paragonial deficiency.

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52.2.4 Anesthesia • Filler injection is a relatively simple procedure that can occur under topical or local anesthesia without sedation [3]. • Mental nerve block can be used if the filler product does not contain lidocaine. • In most cases, use of a topical anesthetic cream (EMLA) is enough to reduce pain during injection if the filler product has preincorporated 0.3% lidocaine. Slow injection is mandatory to minimize the injection pain. 52.2.5 Injection • Before injecting into the chin, the degree of retrusion, tension of the tissue, and the subcutaneous fat volume should be confirmed again. • Inject 1.5–3 ml of a highly viscoelastic hyaluronic acid filler product using sharp needles. • The upper limit of chin projection that can be aesthetically increased by the injection is estimated to be 3–5  mm, as the researchers have clinically observed. Exceeding that extremity through injection may result in an unaesthetic unnatural appearance and chin ptosis [6]. • The tissue layers that compose the chin can be defined as the skin, the subcutaneous tissue, the mentalis muscle, and the mandible. Anatomically, the soft tissue of the chin is a dense structural entity that has limited mobility or ability to expand [7]. –– The amount of subcutaneous tissue between the deep dermis and underlying mentalis muscle is minimal. –– The mentalis muscle is not only attached to the mandible but also intimately intertwined into the soft tissue of the chin. –– The anterior mental and more lateral mandibulocutaneous ligaments hinder the leverage necessary to expand and dissociate the soft tissue envelope from the underlying bone. Due to the medial fibers of the men-

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talis forming a dome-shaped chin prominence in the posterior aspect, there is vacant space interspersed with fat and ligamentous structure between the muscle fibers [5]. –– Initial step for the injecting chin is to fill the space between the periosteum and the mentalis muscle. If this is insufficient to create enough projection, additional injection into the subcutaneous layer is performed. –– When the tension is significantly high and there are not enough spaces for filler injection, stop the injection and wait for a few weeks before the tissue expands more. When sufficient space is made, perform the second injection session. • Insertion of the needle at three points (Fig. 52.2) is the standard technique for augmentation of the chin. Vertical depot injection is recommended. • Although the use of sharp needles is primarily recommended when injecting fillers into the chin, blunt cannulas are also frequently used to minimize the risk of bruising when treating larger areas. –– The injection layers of the cannula are not different to the needle injection: supraperiosteal, intramuscular, and subdermal. –– When using blunt-tip microcannulas, the recommended entry point is the apex of the

Fig. 52.2  Standard “three-point” needle injection technique of the chin augmentation using hyaluronic acid fillers

N.-K. Rho

chin (Fig. 52.3). Fanning technique is used when the augmentation is performed using cannulas. –– Alternatively, cannula approach can be from the lateral margin to the center of the chin (Fig. 52.4).

Fig. 52.3  Filler injection technique for chin and jawline augmentation using blunt microcannulas (central-to-­ lateral approach)

Fig. 52.4  Filler injection technique for chin and jawline augmentation using blunt microcannulas (lateral-to-­ central approach)

52  Hyaluronic Acid for Chin

–– The use of cannulas is associated with more pain during the blunt dissection of the tense fibrous structures of the chin. Mental nerve blocks prior to the procedure is often helpful to reduce the injection pain. • After injecting half of the planned amount, bimanual con.firmation of the amount of injected filler is helpful to estimate the final dosing of the filler for satisfactory end results. • At the end of the procedure, the injected filler should be massaged meticulously to create symmetry and natural tapering.

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ance in the prejowl area. In many patients, fillers should be injected here too when the chin is augmented. –– Because the prejowl sulcus is a complex anatomic structure that results from several age-related changes in the lower face, other aesthetic procedures such as liposuction, radiofrequency, or focused ultrasound tightening and thread lifting are performed in combination with volume augmentation of the chin, providing better clinical results.

52.2.6 Adjunctive procedures

52.3 Clinical Follow-Up (Fig. 52.5)

• Botulinum toxin injection –– Bimaxillary protrusion, common in Asians, causes a greater tension in closing the mouth; therefore, the hypertrophy of the mentalis muscle often leads to a cobblestone appearance of the skin on the chin [5]. This commonly aggravates the lower chin retrusion in a subset of patients. –– In this situation, the combined usage of botulinum toxins and fillers are best indicated. Detailed techniques of botulinum toxin injection are discussed elsewhere in this book. • Jawline rejuvenation –– Filler injection into the chin may cause or aggravate a relatively depressed appear-

• Typically, the patient is checked for several weeks after the procedure to find out any asymmetry or unnatural results. • Since hyaluronic acid is completely absorbed in the tissue, the augmentation effect does not persist over a year. A yearly injection plan is suggested. • Hyperactive contraction of the mentalis muscle also induces the migration of filler material into the superior direction, and duration of the filler is prone to be short [5]. • The use of a highly viscoelastic filler product, along with adjuvant botulinum toxin injection, will lengthen the duration of the injected product in the chin.

Fig. 52.5  Three-dimensional contour line profile views of a 30-year-old Korean female with retruded chin: baseline (left), immediately after (center), and 6 months after

(right) the injection of 2 ml of hyaluronic acid on the chin (three-dimensional images were generated using Morpheus™3D, Korea)

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N.-K. Rho

52.4 Before and After (Figs. 52.6 and 52.7)

Fig. 52.6  Chin augmentation before and after injection of 2.5 ml of hyaluronic filler with high visco-elasticity

Fig. 52.7  Photographs of the patient before and after injection of 2 ml of hyaluronic acid filler on the chin

52  Hyaluronic Acid for Chin

52.5 S  ide Effects, Complications, and Their Management 52.5.1 Visible nodules, unnatural results • Injected filler materials may be visible with contraction of the mentalis muscle if implanted too superficially. • Overcorrection in the bony inferior aspect can lead to an unnatural appearance (Fig. 52.8) [1]. • When the chin is severely retruded, the superficial fat tissue may be absent, and the injected fillers can cause an irregular surface. In this case, injection of hard fillers deep onto the periosteum at the center of the chin is recommended. • A caution should be paid in order to prevent a rugged surface when injecting the lateral side of the chin due to the thin subcutaneous fatty layer of this location [5].

52.5.2 Vascular complications • The injector must be aware of a number of smaller blood vessels near the apex of the chin, which may be associated with vascular complications. • The chin contains the mental artery that passes through the mental foramen and the inferior labial artery from the facial artery. Injecting

Fig. 52.8  Overtreatment should be avoided when injecting the chin because it tends to result in unnatural results

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just above the periosteum minimizes the risk of an intravascular injection. • In rare cases, the inferior labial artery originates from the submental artery at the submental triangle and supplies the lower lip. In patients with this anatomic variation, arterial injury may occur after filler injection [5]. • However, the chin is regarded as a ‘relatively’ safe area for filler injection in terms of arterial obstruction. Bruising is common when using sharp needles (Fig. 52.9). 52.5.3 Immunologic problems • Due to the high tension of the chin tissue, over-injection sometimes triggers lateonset inflammatory reaction which is related with the chemical properties of the filler product. • In case of mild inflammation, symptomatic medications such as systemic steroids and antihistamines for 3~5 days are enough for the management. • If the inflammatory reaction repeats over time or lasts longer, complete removal of injected fillers using hyaluronidases is recommended. Broad-spectrum antibiotics for weeks are recommended to prevent possible biofilm-related complications.

Fig. 52.9  Bruising is a common side effect of the chin filler injection when sharp needles are used

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Tip Box

• To observe the real and feasible aesthetic outcome to be provided to the patient in order to avoiding any unreal expectation. • To understand the anatomic aspects of the chin and be conscious not to inject more material than the area can get. • The asymmetric or hypercorrected volume after the procedure cannot wait to be corrected and all the available techniques for that must be used. • In the worst scenario, to inform the patient that that result is temporary and any disliked result will be naturally reverted after some months.

References 1. Rho NK, Chang YY, Chao YY, Furuyama N, Huang

N.-K. Rho PY, Kerscher M, et  al. Consensus recommendations for optimal augmentation of the asian face with hyaluronic acid and calcium hydroxylapatite fillers. Plast Reconstr Surg. 2015;136:940–56. 2. Sundaram H, Voigts B, Beer K, Meland M. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Surg. 2010;36:1859–65. 3. Sykes JM, Fitzgerald R.  Choosing the best procedure to augment the chin: is anything better than an implant? Facial Plast Surg. 2016;32:507–12. 4. Aston SJ, Smith DM. Taking it on the chin: recognizing and accounting for lower face asymmetry in chin augmentation and genioplasty. Plast Reconstr Surg. 2015;135:1591–5. 5. Kim J, Lee HK, Kim HJ.  Clinical anatomy of the lower face for filler injection. In: Kim HJ, Seo KK, Lee HK, Kim J, editors. Clinical anatomy of the face for filler and botulinum toxin injection. Singapore: Springer; 2015. p. 153–74. 6. Wang Q, Guo X, Wang J.  Autogenous fat grafting for chin augmentation: a preliminarily clinical study of cosmetic outcome. J  Craniofac Surg. 2015;26:e625–7. 7. Binder WJ, Dhir K, Joseph J.  The role of fillers in facial implant surgery. Facial Plast Surg Clin North Am. 2013;21:201–11.

Hyaluronic Acid for Neck Wrinkles

53

Caroline Romanelli T. A. Zelenika and Adilson Da Costa

53.1 Materials (Fig. 53.1)

53.2 Methods and Techniques

• • • • • •

• The first step is to evaluate and photograph the patient in vertical position. • It includes the application of topical anesthetic, 2.5% lidocaine plus 2.5% prilocaine cream, for 30 min. • It is required to perform asepsis with 10% povidone-iodine solution and mark the wrinkle lines with a nonpermanent ink pen. • Using a 0.3 cc insulin syringe (31G × 8 mm needle), 0.02  mL of HA filler per point shot is injected into the reticular dermis in a beside-­to-­ besides micro-bolus technique (Fig. 53.2); some authors prefer the continuous retro-­injection of about 0.04 mL per each 8 mm-­length, parallel-toskin retro-injection. Generally, 1 mL is required per each neck side (2 mL for the total neck). • Basically, 20–50 shots are needed per each session. • Injecting large volumes at the same point is not recommended.

2 mL of cross-linked hyaluronic acid Nonpermanent ink pen Procedural gloves 2.5% lidocaine plus 2.5% prilocaine cream Gauze 10% povidone-iodine solution

Fig. 53.1  Materials used for the treatment of neck wrinkles with hyaluronic acid filler. (Courtesy: Dr. Rodrigo Amaral, Rio de Janeiro, RJ, Brazil) C. R. T. A. Zelenika (*) Pontifical Catholic University of Campinas, São Paulo, SP, Brazil

53.3 Clinical Follow-Up • A complementation session may be required after 4 weeks.

A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_53

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C. R. T. A. Zelenika and A. Da Costa

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Fig. 53.2  Immediate injection of hyaluronic acid filler into neck wrinkles in a beside-to-­beside technique. (Courtesy: Daniel Coimbra, Rio de Janeiro, RJ, Brazil)

53.4 Before and After: Fig. 53.3 a

b

Fig. 53.3 (a) A patient before and (b) 60 days after the intradermal injection of hyaluronic acid filler. (Courtesy: Daniel Coimbra, Rio de Janeiro, RJ, Brazil)

53.5 S  ide Effects, Complications, and Their Management

53.5.2 Bumping Irregularity (Fig. 53.4)

53.5.1 Swelling and Redness

If it appears, manual molding can be helpful. However, if it remains longer than expected, injections of hyaluronidase may be required.

They disappear completely within few days up to 7 days, which can be improved with regularly applied ice pads 48 hours after the procedure.

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53.5.5 Grayish, Bumped Accentuation of the Neck Lines (Tyndall Effect) Most of the times, , the injection of 30–70 units of hyaluronidase is required [1] to solve such a too-superficial injection of hyaluronic acid. Tip Box Fig. 53.4  Bumping skin irregularity lasting after 3 weeks of hyaluronic acid retro-injection

53.5.3 Hypersensitivity Reaction Most of the times, it is due to the cross-link substance and not by the hyaluronic acid per se, and injection of hyaluronidase is required.

53.5.4 Bruising It spontaneously disappears within 7–10 days.

• Pre-tunneling before injection must be avoided in order to block side effects of bruising, redness, and swelling. • Other procedures can be added, such as botulinum toxin injection into platysma, threads, and superficial chemical peels. We recommend lasers or micro-focused ultrasound to be performed before the hyaluronic acid injection, if either or both are needed

Reference 1. Martin K.  Management of Tyndall effect. J Clin Aesthetic Dermatol. 2016;9(11):E6–8.

Hyaluronic Acid for Hands

54

Tatiana Basso Biasi and Ricardo Limongi Fernandes

54.1 Materials

skin filler in Europe [1]. Since then, there are many brands of HAs available in the market 54.1.1 Hyaluronic Acid with different and particular specificity. Because of its safety and efficacy, HA fillers • Hyaluronic acid is a polysaccharide present in became the commonest type of filler currently the extracellular matrix of connective tissue, used [2]. hyaline cartilage, synovial fluid, intervertebral • Besides its use as a filler and as a volumizer, it disc, vitreous humor, umbilical cord, and is known that cross-linked HA can stimulate other tissues. It is found in all vertebrate anicollagen synthesis, restoring the dermal mals and has no antigenic specificity for spematrix. It can also hydrate the dermis, improvcies or tissues. This makes HA biocompatible ing skin quality [2]. with low potential for allergic or immuno- • The duration of the effect varies according to genic reaction, and there is no necessity of product presentation but normally is estimated skin testing for allergy [1]. between 12 and 18  months. Its use demon• The natural form in the tissue has a short half-­ strates a correction longevity that goes beyond life of 1–2  days. With cross-linking of the the time expected for the degradation of the molecules, it becomes a stable and cohesive product [2]. gel and resistant to the enzymatic degradation. The resultant gel is hygroscopic, which means that it has a great capacity of absorbing water. 54.2 Methods and Techniques It is estimated that 1 g of HA can bind up to 6 l of water [1]. • The product chosen in this chapter is a volu• HA was first used in medicine in 1962 in ophmizing hyaluronic acid-based filler, monophathalmology. In 1996, it started to be used as a sic gel 22 mg/g with high cross-linking level, indicated for subdermal or pre-periosteal use in volume recovery for wide areas (Teosyal® T. B. Biasi Ultimate, Teoxane SA - Geneve). Brazilian Society of Dermatology, • The materials used in the procedure are illusFlorianópolis, SC, Brazil trated in Fig. 54.1 and described below: e-mail: [email protected] –– Needle for carpule. R. L. Fernandes (*) –– Lidocaine 2% with epinephrine solution Brazilian Society of Dermatology, American for carpule. Academy of Dermatology, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_54

379

380

Fig. 54.1  Materials for the procedure

• •

•

•

• •

–– Carpule. –– Chlorhexidine 0.2% aqueous solution. –– Hyaluronic acid filler. –– 18G needle. –– 18G cannula 70 mm long. –– Gauze. –– Saline solution. –– Procedure gloves. –– Lotion for massage. The first step pre-treatment is to photograph both hands. Pictures must be standardized to help result evaluation. The use of cannulas (18–22G) is highly recommendable for volumizing the back of the hands. We usually deal with great amounts of HAs in the back of the hands. It behaves, then, like any other implant in contamination risk. An extra care on antisepsis is mandatory for the safety of this procedure. Topical anesthesia or anesthetic buttons (0.1  ml of lidocaine each) at the entrance of the cannulas (region between the heads of metacarpal bones  – Fig.  54.2) are usually enough to make it comfortable. Although it is not a very painful area [3], we must remember that, as a rule, the volume injected is substantial, so we should inject gently and slowly to avoid quick painful tissue expansion. Anesthetics with epinephrine helps reducing bleed and bruise risk. The cannulas must be long enough to reach the area in between the basis of the metacarpal bones. In general, 70  mm long is a good measure.

T. B. Biasi and R. L. Fernandes

Fig. 54.2  Anesthetic buttons (0.1  ml of lidocaine with epinephrine each) at the entrance of the cannulas (region between the heads of metacarpal bones)

Fig. 54.3  Hole with needle for the entrance of the cannula

• A hole with needle (1G lower than the cannula, e.g., a hole with a 21G needle to introduce a 22G cannula) is performed in each anesthetized area (Fig. 54.3). • The cannula is introduced until it reaches the region between two metacarpal bones (Fig. 54.4). At this moment, it is interesting to palpate the extremity of the cannula to double-­ check the right position. • There are three fat layers in the dorsum of the hand: dorsal superficial lamina (DSL), dorsal intermediate lamina (DIL), and dorsal deep lamina (DDL) (Fig. 54.5) [4]. • The DSL has no apparent structures traveling within the plane, but high cohesive gels may be palpable in superficial plains. • The DIL is where the large, visible veins and the sensory nerves in the dorsum of the hand are located, so it is not the ideal plain to inject. • The DDL contains the extensor tendons, the fascial floor of this lamina, and the dorsal deep fascia and also covers the dorsal interosseous

54  Hyaluronic Acid for Hands

• •

•

•

381

muscles and metacarpal bones. They are all very resistant structures. In this plan, with a cannula, the risk of trauma is minimum; therefore, it is the preferential plain to inject (Fig. 54.5). You will be in the right plan if you feel tendons under and vessels above the cannula. In case of nodular areas after the injection, to perform a gentle massage is an easy way to flatten irregularities. There is no need to massage treated areas when immediate results seem good. The skin will be more projected the less flattened the HA is. The amount of HAs injected per patient is variable. On average, amounts around 2.5–3 ml (for both sides) are good cost/perfor-

•

•

• •

mance volumes. Depending on individual factors, higher volumes can be considered. After the procedure, it is recommended to use ice application and hand elevation, associated with massage if there are palpable or visible nodules [5]. Complementary intradermotherapy with a non-cross-linked or very low cross-linked HA (1 ml for both hands per session) may be interesting to hydrate and redensify photodamaged skin. Saline solution is used to clean residual blood on the skin. Immediate standardized posttreatment pictures should be taken at the end. Sometimes, immediate results look poor.

54.3 Clinical Follow-up • Some early adverse events (AEs) are expected in any volumizing. They can be caused either by the injection itself or by the implanted HA. Palpable material, slight asymmetry, slight hyper- or undercorrection, swelling, pain, tenderness, erythema, bruising, induration, and itching are the most common related AEs. They tend to disappear within 1 or 2 weeks spontaneously or with symptomatic treatment. • Reassessment of the patient within 2–4 weeks to evaluate the need of complimentary dose of HA.

Fig. 54.4  Extremity of the cannula correctly positioned in the region between two metacarpal bones. Ready to retroinject Fig. 54.5 Topographic anatomy of the dorsum of the hand. Schematic drawing. The cannula is introduced in the dorsal deep lamina 1

8

2 3 4

5

7 6

10 9

1 - Dorsal superficial lamina 2 - Dorsal superficial fascia 3 - Dorsal intermediate lamina 4 - Dorsal intermediate fascia 5 - Dorsal deep lamina 6 - Dorsal deep fascia 7 - Extensor tendon 8 - Vein 9 - Bone 10 - Interosseous muscle

Reproducao: Arte Clovis Medeiros

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• New standardized pictures should be taken at the end of the procedure. • Duration of effects is multifactorial and very difficult to predict. It depends on individual characteristics, quality of skin, kind of filler, and amount of filler used. Effects may vary from a few months to more than 4 years. A good dialogue with the patient is mandatory. • New injections can be performed whenever necessary.

54.4 Results Pre-Post (Figs. 54.6, 54.7, and 54.8)

Figs. 54.6, 54.7, and 54.8  A 65-year-old female patient before (Fig.  54.6), immediately after (Fig.  54.7), and 1 month after HA filler (Fig. 54.8) in the back of the hands (total 1.5 ml on the right and 1.5 ml on the left side)

T. B. Biasi and R. L. Fernandes

54.5 S  ide Effects, Complications, and tTheir Management • A detailed medical history is the first step to avoid undesirable side effects. This is particularly important for elderly people, whose vessels are tortuous and fragile. It’s important to evaluate the history of bleeding disorders and the use of drugs with anticoagulant effects [5]. • Many factors are known to influence the occurrence of adverse effects (AEs). They include the quality of the material, investigator experience, speed of injection, injection technique, and injection volume [6]. • Some AEs can occur and most are transitory. They include erythema, swelling, induration, tenderness, pain, itching, hematoma, ­asymmetry, and hyper- or undercorrection [6]. The most common are detailed: • Hematoma. The risk can be minimized by a good history associated with extra care during the application to avoid vein injury and the use of cannulas instead of needles (6). • Redness and pain. Their occurrence is described after the application of HA in hands and usually is only transitory. • Swelling. Patients may be instructed to sit on their hands immediately after the procedure to avoid swelling. They should also avoid exercise for a day and elevate their hands as much as possible (Fig. 54.9) [7]. • Foreign body granuloma. The first step is to use antibiotics (at least two-drug therapy)associated hyaluronidase. If the result is not satisfactory, the last option is surgical excision. The indications for surgical excision are (1) a previous history of failure with nonsurgical therapies; (2) a chronic inflammatory lesion that is well demarcated; (3) evidence of severe infection as tissue necrosis, sensory, or motor impairment; and (4) psychological problems caused by granuloma(s) [5]. • Blue discoloration of the skin. This can be seen if the product is injected too superficially by Tyndall effect. It is advisable to put the product in the correct plane to avoid this complication. It can be treated with a blade puncture and extraction of the nodule or by using hyaluronidase [7].

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•

•

• •

•

Fig. 54.9  A 55-year-old female patient with swelling 50  days after HA filler in the dorsum of the hands. She was managed with clarithromycin for 7  days and prednisolone for 21 days with good resolution. She had already received some HA injections in her face, with no complications

Tips Box

• Results may be bad in patients with extremely thin (cadaverous) hands. • Results may be bad in patients with extremely thin skin (severely photodamaged skin). • Results may be bad in patients with extremely thin fingers. • Needles usually bring big bruises in hands. Prefer cannulas. • Prefer volumizer HAs than regular HAs for the back of the hands. Tissue expan-

sion and durability are higher with this kind of HA. Always inject subdermally. Volumizers are very cohesive gels, their spreadability is low, and they become visible or palpable when too superficial [6]. Immediate results sometimes may be poor. Hygroscopy of HA enhances results in 2 weeks. Avoid overcorrection. To sit on the hands after procedure can be useful to avoid swelling and bruising. It is also recommendable to elevate the hands and avoid physical effort on the next day. The great advantage of choosing HA as a filler for the hand is its reversibility with hyaluronidase enzyme.

References 1. Monheit GD, Coleman KM.  Hyaluronic acid fillers. Dermatol Ther. 2006;19:141–50. 2. Landau M, Fagien S. Science of hyaluronic acid beyond filler: fibroblasts and their response to the extracellular matrix. Plast Reconst Surg. 2015;136:188S–95S. 3. Brandt FS, et al. Long-term effectiveness and safety of small gel particle hyaluronic acid for hand rejuvenation. Dermatol Surg. 2012;38:1128–35. 4. Bidic SM, Hatef DA, Rohrich RJ.  Dorsal hand anatomy relevant to volumetric rejuvenation. Plast Reconstr Surg. 2010;126:163–8. 5. Park TH, Yeo KK, Seo SW, Kim J, Lee JH, Park JH, Rah DR, Chang CH. Clinical experience with complications of hand rejuvenation. J Plast Reconst Aesthetic Surg. 2012;65:1627–33. 6. Fernandes RL. HA filler for malar area. In: Botulinum toxins, fillers and related substances, Clinical Appro­ aches and Procedures in Cosmetic Dermatology, vol. 4. https://doi.org/10.1007/978-3-319-20253-2_20–1. 7. Fathi R, Cohen JL.  Challenges, considerations and strategies in hand rejuvenation. J Drugs Dermatol. 2016;15(7):809–17.

Hyaluronic Acid for Genital Area

55

Shirlei Schnaider Borelli, Mariana Isis Wanczinski, and Nátalie Schnaider Borelli

55.1 Materials (Fig. 55.1)

55.2 Methods and Techniques

• Camera – photograph the pretreatment and the immediate posttreatment. • Topical anesthetic. • Pen to mark and delimit the treatment area. • Sterile fields. • Gauzes. • Chlorhexidine. • Physiological saline. • Filler with a concentration of 17,5 mg/mL of hyaluronic acid. • Needle 23-G 25 mm. • Cannula 25-G 40 mm.

The treatment consists in the following steps: • Define and mark the area to be filled according the patient’s needs (Fig. 55.2).

Fig. 55.1  Materials to be used during the procedure

S. S. Borelli (*) · M. I. Wanczinski · N. S. Borelli Brazilian Society of Dermatology, Private Office in São Paulo, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_55

Fig. 55.2  Marking the area to be filled 385

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Fig. 55.3  Antisepsis with chlorhexidine

• Apply topical anesthetic. • Use antisepsis with chlorhexidine (Fig. 55.3). • A small amount of anesthetic should be performed at the cannula entrance site. • With a 23-gauge (G) common needle, a small hole for cannula insertion is punctured in the insertion sites. • A 25-G cannula is introduced through the insertion site (Fig. 55.4). • The filler is applied in retrograde injections in small doses. • The site of injection is the subcutaneous tissue of the marked areas. • It is recommended to avoid injections of boluses and large volumes to prevent capsulation of the material and nodule formation. • Avoid injecting large amounts of hyaluronic acid, especially in the first session. • If additional volume is needed, the treatment can be repeated later after 3–4 months, if there

Fig. 55.4  A 25-G cannula is introduced through the insertion site

are no side effects from the previous injections.

55.3 Clinical Follow-Up • Photographic documentation is necessary to evaluate the improvement. • Immediately after the procedure erythema, hyperemia and edema may be observed, which resolve spontaneously, in most cases. • Local sensitivity may be reported, especially in the first days. • Ecchymosis and hematomas around the insertion sites may be observed in the first week. • Clinical improvement can already be observed in the first few days. • If additional volume is needed, the treatment can be repeated later after 3–4  months (Figs. 55.5 and 55.6).

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Fig. 55.5  Before (a) and after (b) 1 week of the procedure with filler with a concentration of 17.5 mg/ mL of hyaluronic acid

a

b

a

b

c

Fig. 55.6  Preoperative photograph of a 67-year-old woman. The patient received 0,5 mL of hyaluronic acid divided into right and left labium. (a) Immediately post-procedure photograph (b) and the result after 1 week of treatment (c)

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55.4 Before and After (Figs. 55.7 and 55.8) a

b

Fig. 55.7  A 63-year-old woman affected by hypotrophy of labia majora. Preoperative photograph (a) and the result after 3 months (b). The patient received HA-based filler (Macrolane VRF 20; Galderma Labs, Fort Worth, TX)

a

b

Fig. 55.8  Hyaluronic acid injection for labia majora augmentation. Before (a) and 1 month after (b) photograph of a 59-year-old woman

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55.5 S  ide Effects, Complications, and Their Management The arterial supply of the vulva is derived from the external and the internal pudendal arteries [1], with their branches: anterior labial and posterior labial arteries, respectively. The veins drain into the internal iliac vein. The anterior labial nerves provide the innervation for the anterior area while posteriorly the innervation is provided by the posterior pudendal branches. The pelvic plexus, pudendal nerve, and dorsal clitoral nerve innervate the clitoris, and the perineal nerves innervate the vestibular bulb [2–5]. Rapid cutaneous discoloration, reticulated erythema, and pain are possible early complications of excessive, too superficial, or non-­ homogeneous infiltration. Intravascular injections may result in vascular occlusion, embolization, and cutaneous necrosis. In these cases the use of hyaluronidases is indicated. It is important to mention, that although it’s rare, pulmonary embolism has also been described [6, 7]. The use of appropriate techniques, knowledge of the local anatomy, and injecting slowly and gently minimize the risk of intravascular injection and its complications. Another way to avoid these side effects is the use of cannulas, and if it is performed with a needle, another tip is to always aspirate to verify any possible vessel incannulation. Before the application, it is important to ask about possible allergies and previous reactions to fillers and history of herpes simplex and herpes zoster because generic complications of hyaluronic acid infiltration like reactivation of the virus may occur. For these patients adequate prophylactic therapy is indicated. Immediately after the procedure, erythema, hyperemia, and edema may be observed, which resolve spontaneously, in most cases. The injection in the subcutaneous plane is crucial to avoid palpable nodules and bumps. They may appear only 1–2 months after the procedure because of capsule formation around the injected material. These can be treated with intralesional corticosteroids or hyaluronidase but can also present spontaneous resolution [6].

Fig. 55.9  Erythema immediately after the procedure

In summary the possible complications are: [7] • Ecchymosis and hematomas around the insertion sites • Erythema immediately after the procedure (Fig. 55.9) • Edema (Fig. 55.10) • Palpable nodules (Fig.  55.11), granulomas, and chronic inflammations • Allergies • Reactivation of herpes simplex and herpes zoster • Infection • Vascular occlusion, embolization, and cutaneous necrosis Hyaluronic acid infiltration of the labia majora is able to provide a significant rejuvenation with a simple outpatient procedure. The treatment is repeatable and has virtually no complications and low risk of allergic and immunogenic reactions,

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and it is reversible with hyaluronidase. So when compared with other filler products, it has many advantages. When compared to surgery, there are no additional risks of wound dehiscence and flap necrosis [5, 8].

Tip Box

• • • • •

Knowledge of the anatomy. Good selection of the filler. Proper cannulas. Injecting slowly and gently. Do not apply large volumes, specially in the first session. • Motivations and expectations of the patient should be investigated.

References

Fig. 55.10  Edema 7 days after the procedure with hyaluronic filler

Fig. 55.11  Palpable nodule after 3 months of procedure

1. Hexel D, Dal’Forno T, Caspary P. Tissue augmentation with hyaluronic acid filler for labia majora and mons pubis. Dermatol Surg. 2016;42(7):911–4. 2. Signorello LB, Harlow BL, Chekos AK, Repke JT.  Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol. 2001;184(5):881–8; discussion 888–90. 3. Harvey MA.  Pelvic floor exercises during and after pregnancy: a systematic review of their role in preventing pelvic floor dysfunction. J Obstet Gynaecol Can. 2003;25:487–98. https://doi.org/10.1016/ S1701-2163(16)30310-3. 4. Bourguignon LY.  Matrix hyaluronan-activated CD44 signaling promotes keratinocyte activities and improves abnormal epidermal functions. Am J Pathol. 2014;184(7):1912–9. 5. Aguiar P, Hersant B, et al. Novel technique of vulvo-­ vaginal rejuvenation by lipofilling and injection of combined platelet-rich-plasma and hyaluronic acid: a case-report. SpringerPlus. 2016;5(1):1184. 6. Tezel A, Fredrickson GH.  The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther. 2008;10(1):35–42. 7. Park HJ, Jung KH, Kim SY, Lee JH, Jeong JY, Kim JH.  Hyaluronic acid pulmonary embolism: a critical consequence of an illegal cosmetic vaginal procedure. Thorax. 2010;65(4):360–1. 8. Felicio Yde A.  Labial surgery. Aesthet Surg J. 2007;27:322–8.

Part IV Threads in Cosmetic Procedures

Introduction: Threads in Cosmetic Procedures

56

Thaísa Saddi Tannous Silvino, Ellem Tatiani de Souza Weimann, and Lissa Sabino de Matos

56.1 History/Background Anchored threads have been used in medicine for a long time in orthopedic surgeries for tendon fixation. However, the use of these threads for facial rejuvenation and lift was first described only in 1998 by a Russian surgeon called Dr. Mali Sulamanidze, though the method was patented with the name of Aptos (Anti-Ptosis) [1]. Dr. Sulamanidze’s technique has been improved and later new methods have been described: Woffles thread lifting, Isse unidirectional barbed thread lifting, MIZ lift, Contour Threads, and Silhouette lifting [1]. Cosmetic thread lift plastic surgery has developed considerably in the last two decades, used as a minimally invasive procedure to lift ptotic tissue for facial rejuvenation purposes [2]. Other studies using thread lift procedures for facial rejuvenation were conducted by Keller [3], De T. S. T. Silvino (*) Universidade Federal do Mato Grosso do Sul – UFMS, Campo Grande, MS, Brazil E. T. de Souza Weimann Universidade Federal de Roraima – UFRR, Boa Vista, RR, Brazil Children’s Hospital Santo Antônio, San Antonio, RR, Brazil L. S. de Matos Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_56

Cordier [4], and Sasaki and Cohen [5] and published in 2002. They were followed by reports from Isse and Lee [6] in 2005 of very encouraging results, which were confirmed in more recent publications [7–10]. The suture suspension lifts were done with so-called barbed sutures, made out of a permanent thread with barbs cut into the suture that radiates outward from the center. Evolving from this idea, the latest suspension threads are called “silhouette sutures” (Kolster Methods, Inc., Corona, CA, USA) and consist of a nonabsorbable polypropylene 3/0 suture equipped along the distal segment with ten small knots separating reabsorbable flexible cones consisting of polylactic acid (82%) and glycolic acid (18%) [2].

56.2 Genesis The lift techniques, surgical or not, are based on replacing and fixation of the tissues in their original places. When compared with the surgical lift, the support through the threads presents some important differences that sometimes behave as an advantage and sometimes as a disadvantage: they are applied with less need of tissue dissection and smaller incisions. However, the fact that it requires less tissue dissection results in a lower tissue inflammatory reaction with less tissue scar formation, which helps to support the tissue in its new place. Therefore, when generating less tissue 393

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damage, it allows a less stable lift with a shorter duration [11]. Thread lifting, through the body’s reaction to the inserted foreign substances, uses the tension of the thread to remove wrinkles and promote collagen regeneration; in this technique, absorbable or nonabsorbable thread can be used [12]. Consiglio et al. [13] had a twofold purpose in their study: (1) to ascertain the index of resistance (tensile strength, yield strength, elongation at break) of silhouette sutures 12  months after their placement and (2) to determine whether scar tissue develops around the threads, cones, and knots. Histologic examination showed a progressive increase in scar tissue around the suspension sutures, with reductions in the quantity of inflammatory cells and an increase in collagenous tissue. By 12  months, there was complete reabsorption of the cones of lactic acid and glycolic acid. The hyaline fibrous tissue (which is composed of collagen and elastin fibers) underwent gradual remodeling until 12  months after suture placement (end of study). Findings of the physical study confirmed weakening of the thread structure by 1 year, which led to a reduction in traction resistance. Relative to the unused sutures, there was a 16.7% reduction in yield and tensile strength. By the way, the anatomy of adipose fascial tissue in the abdomen differs substantially from that in cervico-facial areas. Although these differences may limit the interpretation and this experimental model would be difficult to replicate in patients who are candidates for face lifts. However, the basic scarring process is similar for all parts of the body. These factors must be considered when attempting to draw accurate conclusions from the results [13]. Studying the properties of any materials, for face lifting, Kwon et  al. [14] founded that Prolene® (polypropylene) was shown to be a monofilament with a smooth surface, although a few scratch marks and some impurities were observed. Its diameter was measured to be 201  ±  2  μm. Four of the materials—Prolene®, Supramid Extra® II, Mersilene® mesh, and Ptose-Up—exhibited similar force–strain curves, with a steep linear increase in force up to about

50–100% in strain. Increasing the displacement rate from 1 to 750, or to 1500 mm/min, significantly increased the elastic limit, ultimate tensile stress (UTS), and elastic modulus (pb 0.05) for Prolene®. Prolene® tested at 1500  mm/min displacement rate showed a globular appearance on the fracture surface with a V-notch sticking out. Although the cross-sectioning procedure seemed to have caused slight deformation on the filaments, approximately 50 filaments, each having a fairly regular diameter of 23 ± 2 μm and circular shape, were observed to be enclosed in a smooth outer sheath. Each filament appeared to stay in place, being evenly distributed within the outer sheath of diameter 235  ±  3  μm since each filament could be distinguished [14].

56.3 Classifications/Types • Nonabsorbable threads –– Golden threads –– Nylon threads –– Polypropylene threads • Absorbable threads –– Polylactic acid threads –– Caprolactone threads –– Polydioxanone (PDO) threads

56.4 Available Materials 56.4.1 Polypropylene 56.4.1.1 APTOS® Technique Initially, the first experiments were performed with a polypropylene thread containing unidirectional barbs and attached to a long guide needle. Through a small incision in the temporal area, several strands were inserted into the subcutaneous, and then what was left of the thread was cut off and they were slightly pulled. The most superficial thread was sutured to the temporal muscle fascia. In the submaxillary and cervical areas the technique was similar and fixation was done in the periosteum of the mastoid process [15]. In 1998 this technique was improved, and a thread that was different from the first was devel-

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395

Fig. 56.1  APTOS Threads

oped, which was not coupled to a needle. This thread contained convergent barbs and was developed to be introduced in the subcutaneous tissue through a guide needle (Fig. 56.1). This made it no longer necessary to perform a previous incision. The barbs anchor in the subcutaneous tissue when they are tractioned, converging toward the center, and act as vectors that prevent the thread from migrating through the tissue, producing the lift effect [15, 16]. Initially this technique was used for all areas of the face, but after long experience and reassessment of the results, the authors concluded that the technique was better indicated to improve the contour of the central area of the face and to lift the ment area. To achieve the chin lift, the threads were inserted parallel to the mandible. In the midface region, the threads were inserted into the subcutaneous tissue forming relatively steep arches followed by a traction alignment of their final portions. The results were better when applied this way, compared with the first method [15]. In 2002, again the technique was improved, based on the initial idea of the thread being connected to a needle. They developed a thread with converging barbs that was attached to two needles, one at each end (Aptos Thread 2G®). This thread was coupled by a temporary weld so that in this position its pointed tips constituted a single whole. In this method, no prior incision was also necessary. The two needles were placed on the skin through the same pertuite and were separated into the skin when they were already in the proper plane and then advanced in opposite directions [15]. This new thread made possible a greater lifting power. Nevertheless, the results in the middle portion of the face were moderate, but good results were achieved in the eyebrows and chin lift [15]. After gaining more experience, they realized that some sites required a lace- or purseshaped suture and the thread should be soft

Fig. 56.2  Aptos Springs

enough so that the tissue could slide over it. Based on this they developed a double-ended needle with a soft wire attached to it (Aptos Needle®) and were able to work in the central area of the face and other areas such as submaxillary and neck, chin, ear lobes, and mammary ptosis [15]. More recently, they have reshaped the material, combining the capabilities of Aptos Thread 2G® with Aptos Needle® (Aptos Needle 2G®). The Aptos Needle 2G® thread is made up of several barbs attached to two double-pointed needles, as in the Aptos Needle® [15]. With this new material, they achieved an even stronger and more stable lift, and the authors indicate this method mainly for central-facial zone lift [15]. The application technique is basically the same as that used with Aptos Thread 2G®. In 2003, they developed a special thread to treat kinetically active regions, such as puppet lines and mouth angle ptosis (Aptos Spring Method®) (Fig.  56.2). It is a heliciform thread, made of polypropylene, with a special technology. To carry out the lifting of the puppet lines, it is necessary to insert a thread on each side, perpendicularly to the wrinkle [15]. In 2009, Sulamanidze and Sulamanidze published the 10-year result of the APTOS® method. They observed, among other things, that the results held for 1 year or more and the best results were achieved using the Aptos needle® and Aptos needle 2G® thread. Regarding the best indications of the procedure, they observed that the method is especially effective in the central area of the face, improving the nasolabial folds, softening the lacrimal portion, raising and moving laterally the subcutaneous tissue, and improving the contour of the bucozygomatic region [15].

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As for the submandibular and cervical regions, in recent years they have only used the Aptos Needle® method and observed that even after 3–4 years, they had not yet seen complete return of the skin to what it was before. In cases where there was some weakening of the thread after 1–3  years, a correction through the traction of one of the areas was performed, anchoring in a higher position [15].

tion in the temporal region, the MIZ technique, like the one described by Isse, is more invasive, by performing a temporal dissection, with separation of the superficial and deep tissue planes and suturing the threads below the temporal fascia [17]. The thread is made of a soft and fragile polypropylene segment containing smaller and bidirectional barbs in greater numbers [1].

56.4.1.2 Woffles Lift The APTOS technique, by Dr. Sulamanidze, was the pioneer. In 2002, Woffle developed his own suture, with the polypropylene forming a curve made by bidirectional barbs which were welded among them and added a fixation point in the region of the deep temporal fascia that generated a greater lifting power. This technique was initially called WAPTOS, but later changed its name to Woffles Lift® [17]. In the Woffles initial technique (Woffles Lift Version 1®), the thread curve was positioned in the distal part of the face, with the two free ends coming out at the temple, where the nodes for fixation were realized. In 2004, this method was changed, because it occasionally caused complications such as extrusion and palpable nodes. Woffle then inverted the curvature to be positioned in the superior part of the temporal fascia, with the two free exits oriented distally, in which better results and the lowest incidence of complications were conferred (Woffles Lift Version 2®) [17, 18].

56.4.1.5 Micro-shuttle Lifting The Micro-Shuttle technique is based on the conception of loop suspensions that are different from single-point suspension techniques. They are shown to be effective and long lasting either as a part of an open technique [19] or as a stand-­alone procedure [20, 21]. In a loop suspension, the force affecting one point on the loop is counterbalanced by another force on the opposite side. The better the loop that can be created to carry the tissue, the less the sheer force is effective on each point on the loop. For example, for neck lifting, in this technique, the threads suspending the neck are not interlocked but rather are running without interruption from one ear to the other, thus preventing cheese wiring and creating a smooth bridge for the sliding neck system. The older patient group who did not want any open surgery under any circumstance was content even with suboptimal results [22]. This is accomplished through the use of a double-­ sided reusable needle, which has two sharpened ends together with a centrally placed eye for any chosen suture material; the use of this type of needle also decreases the cost of the procedure. Both ends of the needle can be utilized; thus, when keeping one end of the needle inside the skin, it is possible to smoothly carry the thread in the subcutaneous tissues without drawing the skin [22]. The use of this double-sided reusable needle was first described by Wilson, and its patent application was made by the year 1986 [23]. And it has been popularized by Sulamanidze and Sulamanidze [24]. The device is a surgical alteration of a shuttle or micro-shuttle, the ancient

56.4.1.3 Isse In 2004, Isse developed his technique using threads with unidirectional barbs, anchored in the temple through surgical dissection and used along with the endoscopic face lift technique he had already developed. Subsequently, the thread developed by Isse was acquired by the Contour Thread Company [17]. 56.4.1.4 MIZ Lift It is a support technique with threads, developed in 2014 by Park and coworkers. Although it uses the concept developed by Woffle to have a fixa-

56  Introduction: Threads in Cosmetic Procedures

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spindle-shaped device holding the thread in tatting, knotting, or netting, which is utilized in weaving to carry the thread back and forth between the warp threads [25, 26]. The long-lasting efficacy of open/closed loop suspension techniques has a firm physical explanation: by creating a carrier loop in the tissue, we basically have tissue resistance work against itself to balance the sheer forces. Therefore, the more perfect the loop is, the less the sheer force will be affecting opposing suspension-tissue junctions [22]. The advantages of micro-shuttle lifting compared with the other techniques are that it is a quick procedure that can be accomplished even with local anesthesia, it does not require hospital admission, it has a short recovery period, and it has inconspicuous punctures. The financial cost of any proposed product is also worth considering. The fact that the surgeon has no product cost and needs to use simple needles and polypropylene sutures effectively reduces the cost of this technique. More importantly, micro-shuttle lifting is a safe procedure. Facial nerve injury, skin slough, hematoma, and postoperative numbness are not very likely to occur [27, 28].

12.60 mm2 and sustentation area of 12.60 mm2. The use of the hollow cannula permits accurate planning of the final position of the thread, assuring traction according to the desired vector. An overcorrection is necessary because there is always a little drop of the suspended tissue in the postoperative period [31]. The supraperiosteal undermining is limited compared with other facial suspension techniques, reducing complications such as prolonged edema caused by extensive undermining in the subperiosteal plane and preventing the palpation and possible extrusion of the threads. The technique can be performed under local anesthesia and sedation in an outpatient setting, reducing morbidity and cost [30]. A disadvantage of the static techniques, even with the use of multiple threads and the round-­lifting technique, is that the pull is only in two vectors, whereas the face moves along several vectors based on the underlying facial musculature. The polypropylene threads run the risk of infection and extrusion. This procedure involves minimal discomfort and has a quick postoperative healing time of approximately 7 days [30].

56.4.1.6 Beramendi Threads In 2004, a Bolivian doctor living in Brazil, José Antonio Encinas Beramendi, enhanced this thread, with inclusion of double and triple barbs, increasing its traction and support, and started to use it to correct the hemiface deviation consequent to delayed facial palsy. Moreover, the delayed reaction to these threads also showed an increased synthesis of collagen and elastin around them, increasing their support [29]. The 3C semirigid self-sustentation triple-­ convergence polypropylene thread™ (Indermo_ System, Rio de Janeiro, Brazil) is a monofilament of polypropylene and a transparent, nonabsorbable, and bidirectional thread that features double-­convergent cog-like anchors that have the ability to be fixed to stationary tissue points. This creates a suspension effect that lifts and provides support to the tissue [30]. It has total traction of

56.4.1.7 REEBORN Recently, novel polypropylene barbed threads sealed with distal mesh and temporal fixation mesh were introduced in the market with the name REEBORN (Prestige Medicare, South Korea). The REEBORN threads consist of five parts from distal to proximal as follows: (1) a smooth part that is used as a guidance for the insertion to the needle, (2) a segment with cogs, (3) mesh segment, (4) proximal cog segment, and (5) a smooth segment for fixation to the mesh and deep temporal fascia [32]. The advantages of the REEBORN barbed threads are increased tensile strength and the placement in the sub-SMAS plane. The tensile strength apart from the cogs is ensured by the distal mesh, which with a pore size of more than 1  mm allows for less extensive scar formation. Furthermore, a separated segment of mesh is provided for the fixation to the deep temporal fascia,

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increasing the stability of the threads and the longevity of the lifting effect. The thread placement in a deeper plane compared to other threads reduces the suture extrusion and also the traction line during rest, and animation is avoided [32]. The procedure can be performed under local anesthesia and sedation. For midface correction, four threads on each side of the face are indicated: two on the midface for malar fat pad lifting and nasolabial fold correction and two on the lower face for jowl correction. After a 2-cm incision in the temporal area, inside the hair-bearing skin to be invisible, a sub-superficial muscular aponeurotic system plane is created with a trocar, and the threads are passed with a needle through a cannula. The proximal end of the threads is fixed to a mesh, and the deep temporal fascia and the distal free ends were cut [32].

56.4.1.8 Silhouette Threads This suture is composed of an 8-inch (20-cm) straight needle attached to a 14.7-inch (37.3-cm) 2-0 and 3-0 polypropylene suture. In the distal part of the suture are 8 (2-0) or 9 (3-0) knots that span 8  cm at approximately 10-mm intervals. Each knot is intercalated with an absorbable cone to compose a series of eight or nine engaging elements (Fig. 56.3). The cones are hollow, with an outer diameter of 1.27  mm at the base and 0.46 mm at the top, and a length of 2.53 mm. The cones are made with a polymer composed of L-lactic acid and glycolic [13]. The physical and chemical configuration of the silhouette suture allows the repositioning of the facial tissue exercising immediate traction and repositioning of the facial tissue and formation of new collagen fibers around its structure, adding support to the tissue against the gravitational force. The initial traction is produced by the existing cones and reinforced by the neoformation of collagen. After absorp-

Fig. 56.3  Silhouette threads

T. S. T. Silvino et al.

tion of the cones, the tension of the tissue is maintained by the collagen formed around the nodes in the thread. The silhouette soft suture is available as a complete device with two straight 12-cm steel suture needles pre-attached at each end of the suture. The cones are held in place by a PGLA suture. A total of 4–8 cones are positioned on one side of the central space suture. Each set of cones faces the opposite direction and points to the end of the suture, hence the bidirectional term. The thread presentations are shown in the table. Application technique First, determine the areas to be treated and the vectors of the thread. The entry and exit points should respect the distances of 6 cm for the suture with 8 cones, 9 cm for the suture with 12 cones, and 11 cm for the suture with 16 cones. The area to be treated should be disinfected with chlorhexidine and a sterile field should be used. Anesthesia should be done with lidocaine 1% with adrenaline at the entry and exit points, performing a 0.5  cc anesthetic button at each point. After anesthesia, an entry point should be done with an 18-G needle, and the silhouette soft sutures are inserted in the subcutaneous tissue. Through the entry point the first tip of the suture needle is inserted vertically into the subcutaneous tissue, until the black line of the needle disappears. Then, position the needle horizontally and move it along the subcutaneous tissue to the exit point. When the last cone is inserted, the traction will stop and the insertion of the second half of the suture will begin. After the suture is fully implanted, the compression of the adipose tissue is performed; this is the stage where the treated area is modeled. With all the fingers of one hand, squeeze the tissue with light pressure and at the same time draw the exposed ends of the sutures with the other hand so that the cones attach to the tissue. Once you have compressed the adipose tissue, the free ends of the sutures should be cut out of the exit points.

56  Introduction: Threads in Cosmetic Procedures

The application techniques recommended by the manufacturer are described for three areas: face and mandibular line, neck, and eyebrow. For the midline and mandibular regions, three application patterns are described: –– Straight pattern: Two eight-cone parallel threads with a distance of 1–4  cm between them are used in each hemiface. –– Combined Pattern: Two threads of 8  cm or 12 cm are used, applied angularly, and straight in each hemiface. –– “U” pattern: Two 12-cm or 16-cm threads are used, applied in a “U” shape on each hemiface. The Rein technique and the straight pattern are described for the neck. In both techniques 12 or 16 cones are used parallel in a distance of 1.5–2 cm between them. For the eyebrow, the “L” technique is described, in which an eight-cone thread is used for each eyebrow.

56.4.2 Happy Lift Threads It is characterized by a thread composed of polylactic acid and caprolactone that are fully absorbed in 12–15 months. The thread presents on its entire surface small barbs that when inserted in the subdermal tissue causes a tissue reaction stimulating fibrosis, fibroblasts, collagen, elastic fibers, and hyaluronic acid increase [33]. The types of existing threads are: –– Free floating sutures which have little bidirectional convergent cogs. When the threads are inserted under the skin, the cogs open and gather into the surrounding tissue, creating a supporting structure for soft tissue in the face. –– Double needle which is a bidirectional convergent barbed thread with non-traumatic straight twin driver needles attached to both ends.

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–– Anchorage is a unidirectional barbed thread with an attached, at one end, straight non-­ traumatic driver needle for the insertion and, at the other end, a cylindrical needle for anchoring. –– Needles is a bidirectional convergent barbed thread with two special needles to be inserted into the subdermis to tighten and suspend the loose skin on the neck. In a 2015 study, 37 patients, aged between 37 and 65  years old with aging signs, undergo the procedure with Happy Lift. The study utilized only lifting threads, in particular, free floating for the zygomatic and mandibular area, Double needle was used for the eyebrow and neck area and anchorage for midface lifting (zygomatic malar) in patients over 60  years. In the majority of patients (89%), the results obtained were considered satisfactory. The incidence of complications was low [33].

56.4.3 Polydioxanone Threads Polydioxanone (PDO) threads for facial rejuvenation can be categorized into three different types. Mono-PDO thread is a monofilament, non-­barbed, and thin (0.07–0.15 mm). Spring or twin thread, made from a twined single monofilament or two monofilaments braided together, is more tensile than mono-PDO thread. Cog PDO thread has barbs, which cling to tissues for lifting effects when inserted. Depending on the direction of the spikes, cog PDO thread is categorized as unidirectional, bidirectional, or multidirectional [34]. The thread, when inserted to a needle, forms a V-shape within an inner half inserted in the caliber of the needle and the other half on the outside. After insertion of the needle or cannula, removal of the needle or cannula alone results in the thread remaining intact in the tissue [34]. In 2015, a retrospective chart review was conducted over a 24-month period. A total of 31

T. S. T. Silvino et al.

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thread lifting procedures were performed. On each side, five bidirectional cog threads were used in the procedure for the flabby skin of the nasolabial folds. And, the procedure was performed on the marionette line using two twin threads. In most patients (87%), the results obtained were considered satisfactory. Consensus ratings by two physicians found that objective outcomes were divided among “excellent,” “good,” “fair,” and “poor.” Texture-wise, the outcome ratings were 13 for excellent and 9 for good. Lifting-wise, ratings were 11 for excellent and 6 for good. The incidence of complications was low and not serious [34]. In 2016 a new study evaluated the use of PDO threads with unidirectional barbs in the face lift of patients from moderate to very severe values of the Wrinkle Severity Scale (WSRS), in 3 and 7 months after procedure. Twelve PDO threads were inserted with unidirectional barbs on each hemiface of 36 patients, subcutaneously, from the nasolabial groove and border of the mandible to the margin of the scalp. Specific anatomical points were used for the measurements, through a scanner for 3D reconstruction and ultrasound to measure the thickness of the dermis. Facial volume decreased by 7.6 ± 1.2% at the end of the third month and 8.7 ± 5.0% in the seventh month. The mean dermal thickness increased from 1.30 ± 0.37  mm to 1.87 ± 0.20  mm at the end of the third month and remained under evaluation after 7  months (Fig. 56.4) [35].

56.5 Selection of the Ideal Candidate Ideal candidates for thread lifts include patients with minimal signs of aging, gaining prominence of the jaw, deeper nasolabial folds, and ptosis of the malar fat pad [32]. Choosing the ideal candidate for the procedure is very important to obtain a satisfactory result in the end. Absorbable threads are best suited for patients with ptosis of the face and neck tissues, with flaccid and poorly defined contours of the face, with

a Mono Thread b Spring Thread

c Twin Thread

d Uni-direction cogged thead

e Bi-direction cogged thread

f Multi-direction cogged thread

Fig. 56.4  PDO threads device. (a) Mono thread, (b) spring thread, (c) twin thread, (d) unidirectional cogged thread, (e) bidirectional cogged thread, (f) multidirectional cogged thread

low body mass index, aged between 35 and 50  years, with an adequate facial volume, and with a moderate center facial ptosis and who desire a procedure without scars and do not want to undergo a surgical procedure [11]. Facial lipoatrophy is a relative contraindication, since mainly in the central facial area the desired effect is the elevation of the fat compartments. It is also not well indicated for patients who have a broad face, with thick skin, a lot of fatty tissue, and very oily skin [11, 36]. It should also be avoided in patients with very thin skin, since the implant can be palpable even if it is very thin (e.g., 0.1 mm). The requisite two-stage operation is the definite shortcoming of mesh lifting. Patients can be burdened by the two operations, even though each procedure is very simple and takes a short amount of time. In all cases, sufficient preoperative counseling is important. As in conventional

56  Introduction: Threads in Cosmetic Procedures

face lifting surgery, facial asymmetry can occur after mesh lifting, which can be corrected by additional lifting procedures [12].

56.6 S  ide Effects, Complications, and How They May Be Handled/Managed In general, the incidence of complications is small, and most often they are not serious events. It is considered a safe procedure by several authors [7, 15]. The most observed complications are moderate bruising, erythema, and edema. Facial asymmetry can occur, and it can persist from about 1 to 2 weeks and in this period nothing needs to be done to correct it. Ripples on the surface of the skin can occur when the thread is introduced very superficially, and remain for an extended period, so the introduction into the correct plane is very important [7, 15]. Infection, migration, formation of scar tissue, and extrusion of the thread may also occur but less frequently [7, 15].

56.7 Conclusions The search for the maintenance of youth gains great allies with every advance of medicine, which in this context occurs in the field of tools used by dermatology and plastic surgery. Patients seek effective treatment that has a long-term response, can provide rapid accomplishment, and, above all, is less perceptible. The aging process produces facial ptosis, which for many years has been corrected through facial surgery called face lift. Nowadays, to meet the demands of the patient, the so-called thread lifts are used, which are barbed threads wherein insertion under the skin produces a repositioning of the region of the face to be treated. This procedure can be done in the doctor’s office, with minimal skin incision and fewer side effects. It’s quick and not painful, meeting the needs of patients.

401

Tip Box

• Thread lift is a safe and simple application technique, with low incidence of complications. • There are various types of threads and techniques. The doctor should choose which one has a greater experience.

References 1. Park TH, Seo SW, Whang KW.  Facial rejuvenation with fine-barbed threads: the simple Miz lift. Aesthet Plast Surg. 2014;38(1):69–74. https://doi. org/10.1007/s00266-013-0177-2. 2. Maschio F, Lazzaro L, Pizzamiglio R, Perego F, De Biasio F, Parodi PC.  Suspension sutures in facial reconstruction: surgical techiques and medium-term outcomes. J Craniofac Surg. 2013;24(1):31–3. https:// doi.org/10.1097/SCS.0b013e3182688d96. 3. Keller GS, Namazie A, Blackwell K, et al. Elevation of the malar fat pad with a percutaneous technique. Arch Facial Plast Surg. 2002;4(1):20–5. 4. De Cordier BC, de La Torre JL, Al-Hakeem MS, et al. Rejuvenation of the midface by elevating the malar fat pad: review of technique, cases and complications. Plast Reconstr Surg. 2002;110(2):1526–36. 5. Sasaki GH, Cohen AT.  Meloplication of the malar fat pads by percutaneous cable-suture techinique for midface rejuvenation outcome study (392 cases, 6  years experience). Plast Reconstr Surg. 2002;110(2):635–54. 6. Lee S, Isse N. Barbed polupropylene sutures for midface elevation: early results. Arch Facial Plast Surg. 2005;7(1):55–61. 7. Garvey PB, Ricciardelli EJ, Gampper T.  Outcomes in threadlift for facial rejuvenation. Ann Plast Surg. 2009;62(5):482–5. https://doi.org/10.1097/ SAP.0b013e31818c18ed. 8. Kaminer MS, Bogart M, Choi C, et al. Long-term efficacy of anchored barbed sutures in the face and neck. Dermatol Surg. 2008;34(8):1041–7. 9. Gamboa GM, Vasconez LO. Suture suspension technique for midface and neck rejuvenation. Ann Plast Surg. 2009;62(5):478–81. 10. De Benito J, Pizzamiglio R, Theodorou D, et  al. Facial rejuvenation and improvement of malar projection using sutures with absorbable cones surgical technique and cases series. Aesthet Plast Surg. 2011;35(2):248–53. 11. Flynn J.  Suture suspension lifts: a review. Oral Maxillofac Surg Clin North Am. 2005;17(1):65–76. 12. Pak CS, et al. A multicenter noncomparative clinical study on midface rejuvenation using a nonabsorb-

402 able polypropylene mesh: evaluation of efficacy and safety. Arch Plast Surg. 2015;42(5):572–9. 13. Consiglio F, Pizzamiglio R, Parodi PC, De Biasio F, Machin PN, Di Loreto C, Gamboa M.  Suture with resorbable cones: histology and physico-mechanical features. Aesthet Surg J. 2016;36(3):122–7. 14. Kwon KA, et al. Microstructure and mechanical properties of synthetic brow-suspension materials. Mater Sci Eng C. 2014;35:220–30. 15. Sulamanidze M, Sulamanidze G.  APTOS suture lifting methods: 10  years of experience. Clin Plast Surg. 2009;36(2):281–306. https://doi.org/10.1016/j. cps.2008.12.003. 16. Khan DM, Shaw RB.  Overview of current thoughts on facial volume and aging. Facial Plast Surg. 2010;26(3):350–5. 17. Wu WTL.  Commentary on facial rjuvenation with fine barbed threads: the simples-MIZ litf. Aesthet Plast Surg. 2014;38(1):75–7. 18. Sasaki GH, Komorowska-Timek ED, Bennett DC, Gabriel A. An objective comparison of holding, slippage, and pull out tensions of eight suspension sutures in the malar fat pads of fresh-frozen human cadavers. Aesthet Surg J. 2008;28:387–96. 19. Tonnard P, Verpaele A, Monstrey S, et  al. Minimal access cranial suspension lift: a modified S-lift. Plast Reconstr Surg. 2002;109(6):2074–86. 20. Giampapa V, Bitzos I, Ramirez O, Granick M. Long-­ term results of suture suspension platysmaplasty for neck rejuvenation: a 13-year follow-up evalution. Aesthet Plast Surg. 2005;29(5):332–40. 21. Tiryaki KT. Shuttle lifting of the face: a percutaneous purse string suture suspension method for facial rejuvenation. Melbourne: s.n., 2008. Presented at the 19th International Society of Aesthetic Plastic Surgery. 22. Tiryaki KT, Aksungur E, Grotting JC.  Micro-shuttle lifting of the neck: a percutaneous loop suspension method using a novel double-ended needle. Aesthet Surg J. 2016;36(6):629–38. 23. Wilson L.  Surgical needle. 1986, European Patent Register. Patent Number: EP0205811.

T. S. T. Silvino et al. 24. Sulamanidze MA, Sulamanidze GM. Surgical suture material. 2011, European Patent Register. Patent number: EP2020209. 25. Tonnard PL, Verpaele AM. The MACS-lift short-scar rhytidectomy. St. Louis: Quality Medical Publishing; 2004. 26. Coleman SR. Facial recountouring with lipostructure. Clin Plast Surg. 1997;24(2):347–67. 27. Baker DC.  Complications of cervicofacial rhytidectomy. Clin Plast Surg. 1983;10(3):543–62. 28. Matarasso A, Elkwood A, Rankin M, Elkowitz M.  National plastic surgery survey: face lift techniques and complications. Plast Reconstr Surg. 2000;106(5):1185–95. 29. Perrone M.  Utilização de fio de polipropileno de autossustentação de tripla convergência para a correção do desvio de hemiface causada por lesão do nervo facial. Rev Col Bras Cir. 2012;39(5):368–72. 30. Citarella ER, Sterodimas A, Green AC, Sinder R, Pitanguy I. Use of triple-convergence polypropylene threadTM for the aesthetic correction of partial facial paralysis. Aesthet Plast Surg. 2008;32:688–91. 31. Adant JP. Endoscopically assisted suspension in facial palsy. Plast Reconstr Surg. 1998;102(1):178–81. 32. Sapountzis S, Nikkhah D, Kim JH, Seo JD.  Novel polypropylene barbed threads for midface lift— “REEBORN”. Plast Reconstr Surg Glob Open. 2014;2(11):e250. 33. Savoia A, Accardo C, Vannini F, Di Pasquale B, Baldi A. Outcomes in thread lift for facial rejuvenation: a study performed with happy lift™ revitalizing. Dermatol Ther (Heidelb). 2014;4(1):103–14. 34. Suh DH, Jang HW, Lee SJ, Lee WS, Ryu HJ. Outcomes of polydioxanone knotless thread lifting for facial rejuvenation. Dermatol Surg. 2015;41(6):720–5. 35. Kim J, Kim HS, Seo JM, Nam KA, Chung KY. Evaluation of a novel thread-lift for the improvement of nasolabial folds and cheek laxity. J Eur Acad Dermatol Venereol. 2017;31(3):e136. 36. Isse N.  Silhouette sutures for treatment of facial aging: facial rejuvenation, remodeling, and facial tissue support. Clin Plast Surg. 2008;35(4):481–6.

Tip Chapter: Anesthesia in Cosmetic Procedures

57

Gaurav P. Patel

As noted in the other chapters, minimally invasive skin procedures are becoming more and more popular. Often, these procedures can cause discomfort, and certain patients may not be able tolerate these procedures without some use of anesthesia. Anesthesia in these procedures are broadly categorized into topical (or noninvasive) and injected (invasive) forms of anesthesia. This latter form includes both intravenous sedation, infiltrative and nerve blocks, and general anesthesia.

and does not allow pain signals to be sent from these dermal nerve fibers to the central nervous system [2]. The topical anesthetic is placed on the bare skin in the area of the procedure and must be absorbed through the stratum corneum to provide actual analgesia and numbness. Oftentimes, some of these medications are combined with epinephrine to help with duration of action [1, 3]. The most common type of topical anesthetic is a eutectic mixture of local anesthetics, also known as EMLA (Astra Pharmaceuticals). EMLA cream is a mixture of 2.5% prilocaine and 2.5% lido57.1 Topical/Noninvasive caine. It also contains an emulsifier that helps with skin absorption [4]. Various different studies Anesthesia show that a depth of 3 mm is attained after 1 h and Topical anesthesia involves layering the superfi- a maximum depth of 5 mm is attained after 2 h of cial skin layer with local anesthetic with the hope application [3, 4]. EMLA if often placed by the that some of this medication will absorb into the practitioner or can be given as a prescription to the skin and allow the practitioner to perform the patient for self-application prior to arrival for the procedure without much discomfort or pain [1]. procedure. Of note, the prilocaine in this mixture Topical anesthetics are simple and effective and can lead to allergic reaction in patients susceptible are often performed with the use of over-the-­ to such reactions [1, 4]. counter or higher concentration prescription Other compounds useful for this type of anesmedication. These medications are local anes- thesia are plain lidocaine mixtures that are availthetics by definition and work by blocking the able in 4% and 5% concentrations [1, 2]. Often, it dermal nerve fibers by inhibiting voltage-gated is thought that the EMLA is noted to be absorbed sodium channels. This prevents the sodium influx more quickly and potently than plain lidocaine compounds; however, recent studies have shown that this may not be the case and that plain lidoG. P. Patel (*) caine may be just as efficacious in providing Department of Anesthesiology, Emory University appropriate levels of anesthesia/analgesia for School of Medicine, Atlanta, GA, USA minor procedures [1]. e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_57

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With topical anesthesia, the general rule should be to avoid placement in damaged, inflamed, or infected skin. Also, one should not place these topical anesthetics on large surface areas as the risk of systemic toxicity exists [1, 4]. Systemic toxicity of local anesthetics is briefly discussed later. Other problems with topical anesthesia are variable absorptions and incomplete numbness is possible [1]. Cryoanesthesia is one other form of noninvasive anesthesia that can be used alone or in combination with topical anesthesia. It involves making the epidermis very cold and thus allowing for local anesthesia to occur at the site of chilling. Cryoanesthesia is often used with topical anesthetics to buttress analgesia and length of anesthesia. One of the biggest limitations of this type of anesthesia is the patient’s ability to tolerate cold temperatures. Often, some patients are unable to deal with the cold temperatures required to provide significant levels of analgesia. Of course, frostbite and skin changes can occur with repeated or lengthy use [2].

57.2 Invasive Anesthesia Multiple invasive methods for anesthesia exist. All of these methods require the use of needles and can therefore be less accepted by the patient and the practitioner since the patient will likely have the use of needles or other instruments for the actual surgical procedure. Of note, the use of ANY of these methods should also involve placement of an intravenous line (IV), as they can very easily lead to toxicity which can sometimes require invasive medications [1]. Please see Table 57.1 for a list of potential local anesthetic medications and theoretical maximum dosages.

57.3 Infiltrative Anesthesia and Nerve Blocks Infiltrative anesthesia is exactly that—a specific region or area is infiltrated into the dermis with local anesthetic until the appropriate level of anesthesia/analgesia is obtained. The anesthetic

medication (be it lidocaine or other) is infiltrated into the tissue surrounding the particular surgical area [5]. For some very small procedures, infiltration of the area is very useful and can be done very quickly to great effect. However, for some procedures, very high doses of medications are used to obtain appropriate levels of anesthesia for a procedure [1–3]. Further, for some areas, these very high levels of medication approach toxic levels and must be used with caution or even avoided [1]. Of note, because of the volume of local anesthetic that is used, the anatomy can sometimes be distorted and can cause issues with the actual procedure [2, 6]. A related type of anesthesia with infiltration is tumescent anesthesia. In this type of anesthetic, a large volume of diluted local anesthetic is infiltrated into the subcutaneous fat compartment [2]. This originally began as a method for liposuction but has now progressed to specific other procedures, including facial resurfacing and other minor surgical procedures. Because fat has less nerve endings and less vascular structures, a high amount of local anesthetic can be infiltrated into this area [1, 7]. It has slower systemic absorption in comparison to other infiltrative techniques and in comparison to nerve blocks [1]. As such, doses higher than the theoretical maximum doses of local anesthetics (Table 57.1) are used. Nerve blocks, depending on the site of the procedure, are also possible anesthetic options. These are often considered under the umbrella of regional anesthesia (where a specific region is Table 57.1  Common local anesthetics and maximum doses (not for tumescent anesthesia) Local anesthetic agent Chloroprocaine Procaine Tetracaine Bupivacaine Ropivacaine Lidocaine Prilocaine Mepivacaine

Maximum dose (mg/kg) 12 12 3 3 3 4.5 (without epinephrine); 7 (with epinephrine) 8 4.5 (without epinephrine); 7 (with epinephrine)

Information adapted from Refs. [1, 7]

405

57  Tip Chapter: Anesthesia in Cosmetic Procedures

made numb to provide optimal surgical conditions). Nerve blocks are when local the anesthetic is infiltrated on or near the nerve [1, 2]. These have been routine in some laser procedures and other minimally invasive methods of surgery. Most studies show that nerve blocks can often lead to almost complete anesthesia in a particular area with minimal complications [2]. Going into detail about specific nerve blocks is beyond the scope of this chapter, but it is important to note that these nerve blocks can often provide a good alternative with fewer complications than other infiltrative forms of anesthesia. Local anesthetic toxicity is a possibility in all of these forms of anesthesia and must be taken seriously. Cardiac and neurologic issues are the hallmarks of this form of toxicity and carry a high mortality if the cardiac symptoms are not recognized and appropriately managed [7].

57.4 Sedation, Monitored Anesthesia Care, General Anesthesia Other more invasive forms for anesthesia involve sedation (both conscious and deep) and general anesthesia. Both conscious and deep sedation can fall under the concept of monitored anesthesia care or MAC (where an anesthesiologist or midlevel anesthetist is present during the entire procedure and provides care). In certain centers, minimal levels of conscious sedation can be ordered by the physician performing the case and administered through an intravenous line or orally by a nurse assisting the proceduralist. Other centers require an anesthesia provider. Deeper levels of sedation should always involve an anesthesiologist and/or a midlevel anesthetist (certified registered nurse anesthetist or anesthesiologist assistant). Conscious sedation involves the administration of oral or IV medications to hold the patient in a depressed level of consciousness [1, 2, 7]. The patient is able to maintain their own airway (without assistance from another provider) and can follow commands [7]. This often provides the patient anxiolysis and analgesia. This can be

Table 57.2  Anesthetic agents commonly used for MAC or general anesthesia Propofol Ketamine Fentanyl Midazolam Etomidate Alfentanil Remifentanil Diphenhydramine Hydromorphone/morphine Sevoflurane/desflurane/isoflurane/nitrous oxide (inhalational anesthetics)

combined with topical or infiltrative anesthetics as well. Medications that be used for this are midazolam, ativan, fentanyl, or oral versions of benzodiazepines. Conscious sedation can be also be elicited by an anesthesia provider with the use of propofol, with or without the other medications noted and various other medications (such as ketamine, etc). A list of possible agents to be used in MAC by anesthesia providers is noted in Table 57.2. Deeper levels of sedation (a true MAC) are almost always created in conjunction with an anesthesiologist with or without a care team model. Often, a higher infusion of propofol is used in conjunction with other medications. These patients are not able to follow commands but should be spontaneously ventilating [1, 2]. The anesthesiologist may use a variety of airway techniques to allow a patent airway in certain deeper levels of sedation. It is important to note that even under deep levels of sedation with this type of MAC, the patient may still move and may have recall about that procedure. General anesthesia is the only type of anesthesia that can prevent movement and minimizes the risk of awareness (though still possible) [2, 7]. During all forms of sedation, including conscious sedation provided by a non-anesthesia provider, vital signs should  be monitored [7]. Standard American Society of Anesthesiologists (ASA) monitors should be used in all circumstances—this involves the measurement of pulse oximetry, blood pressure, electrocardiogram (EKG), capnography, and temperature [2]. The last three are often only used by anesthesia pro-

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viders, but it is the opinion of the author of this chapter that it should be used in all forms of sedation if the providers feel comfortable interpreting the data. The most invasive form anesthesia is general anesthesia [2]. And this is always, of course, provided by anesthesiologist and/or an anesthetist. General anesthesia involves induction with an agent of choice (often propofol) and airway management, often with an endotracheal tube or for some procedures with a laryngeal mask airway (LMA). There are risks associated with general anesthesia, and patients with specific comorbid conditions can often have higher risks. General anesthesia is often administered in hospitals and ambulatory surgery centers. So its use requires many more resources [1].

57.5 Summary Anesthesia for minimally invasive skin procedures is interesting in that it encompasses almost all forms of anesthesia available, from topical/ cryoanesthesia, to nerve blocks and infiltrative anesthesia, to sedation/MAC and general anes-

thesia. The latter forms require more monitoring and resources but also provide a higher depth of anesthesia than the other forms. Regardless of the form of anesthesia used, it is always important to appropriately monitor the patient and remain within the appropriate doses of the medications that are used.

References 1. Butterworth JF, Mackey DC, Wasnick JD. Morgan & Mikhail’s clinical anesthesiology. 5th ed. New York: McGraw Hill; 2013. 2. Gaitan S, Markus R.  Anesthesia methods in laser resurfacing. Semin Plast Surg. 2012;26(3):117–24. 3. Bjerring P, Arendt-Nielsen L. Depth and duration of skin analgesia to needle insertion after topical application of EMLA cream. Br J Anaesth. 1990;64(2):173–7. 4. Evers H, et al. Dermal effects of compositions based on the eutectic mixture of lignocaine and prilocaine (EMLA). Studies in volunteers. Br J Anaesth. 1985;57(10):997–1005. 5. Pay AD, Kenealy J.  The use of nerve blocks in the laser treatment of cutaneous lesions. Br J Plast Surg. 1997;50(2):132–4. 6. Bing K, et  al. Regional anesthesia with monitored anesthesia care for dermatologic laser surgery. Dermatol Clin. 2002;20(1):123–34. 7. Barash PG, Cullen BF, Stoelting RK.  Clinical anesthesia. 6th ed. Philadelphia: Lippincott; 2009.

Eyebrow Thread Lifting

58

Iñigo de Felipe

58.1 Materials (Fig. 58.1)

58.1.3 Thread Types

Three things are needed apart from a semi-sterile field, gauze, and a nice room to work in:

Thread types can be classified according to the following categories:

58.1.1 Anesthesia • For monofilament PDO threads: topical anesthesia such as EMLA cream or faster acting topical anesthesia such as 6% tetracaine, 6% lidocaine, and 6% hexacaine. • For PDO-cogged threads 23G and above or Silhouette SoftTM (SS): anesthesia is used at the entry point. • Entry point needle has to be larger than the cannula or needle attached to the thread. A 19G or 18G needle is needed for the introduction of the thread. Sometimes, a scalpel is used to make a small incision. • Epinephrine is recommended to be added to the mixture of anesthesia. • Nerve block can also be induced into the supraorbital nerve and supratrochlear nerve.

58.1.2 Needle for Entry Point An 18G or 21G needle, always larger than the size of the cannula or thread, is needed. I. de Felipe (*) Clinica Dermatológica De Felipe, Barcelona, Spain © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_58

A. Materials used to synthesize the threads • Only organic materials are used for making threads for eyebrow lift: • Polydioxanone (PDO) • Polylactic acid (PLA) • Polyglycolic acids (PGA) B. Cannula or needle used to insert the thread • Cannulas have been proved to be more comfortable and less painful and bear less adverse effects or complications, and they are more widely used presently. Cogged or beaded threads are currently confined into a cannula of size wider than that of the thread. • Needles are easier to pass but can produce more bruises. In the case of the Silhouette Soft™, an entry point and an end exit point are needed, which means that anesthesia is to be injected at both points. C. Shape of the thread • Simple filament (monofilament) • Barbed or cogged with spines along the same axis • Barbed or cogged with spines that rotate along the axis of the thread itself • Cogged with cones • Cogged with arrow-shaped spines 407

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Fig. 58.1  (Left) Typical look of the eyebrow in youth. (Central image) Lateral eyebrow ptosis (LEP). In this type of aging, the lateral portion falls much more [1].

(Right) Full-length eyebrow ptosis (FLEP). This consists of the falling of the complete segment of the eyebrow

A2 A3 A1

B

C

D

Fig. 58.2  Histological image of PLLA thread (SS) in the dermal tissue. (Courtesy of Pizzamiglio E)

• The preferred method for using threads is with a barbed suture to secure a lift. D. Direction of the cogs or cones: Unidirectional or bidirectional. E. Duration of each material: The half-life of PLLA is 450  days, whereas the half-life of PDO is 42 days. The longer the duration, the more the collagen is synthesized (Fig. 58.2).

58.2 Methods and Techniques Threads can be placed following these techniques: Vertical Technique or “11” Technique (Fig. 58.3) • Indicated for the FLEP • Used for PDO-cogged threads

Fig. 58.3  Direction of the insertion of the threads indicated on the forehead of a patient undergoing the “11” technique. A1, A2 and A3 are the insertion points. B, C, D are the final points

• “11” refers to the fact that threads run parallel between them. • Use of several threads to lift the complete length of the eyebrow. • Entry point is indicated as An, where n is the number of threads used, the more the better. Use at least two threads per side.

58  Eyebrow Thread Lifting B A

C

D

Fig. 58.4  Direction of the insertion of the threads indicated on the forehead of a patient undergoing the “U” technique. The needle is inserted at point C and comes out at point D. Then on end of the thread is passed from C to A and the other one from D to B

• The thread is passed from points A1 to B, A2 to C, and A3 to D downward. “U” Technique (Fig. 58.4) • This technique is indicated both in LEP and FLEP and is one of the most common techniques used with the SS thread (Fig. 58.4). • Anesthesia with epinephrine is injected along the eyebrow. • An 18G needle is passed from points C to D. • The distance between points C and D should be 2  cm or less, which is the segment of the thread without cogs. • The thread emerging from point C is then inserted again with its needle through this entry point and passed into point A where it emerges again onto the surface. The same applies to the other end that tunnels the skin from points D to B. • Advantage: The surgeon can decide whether to move points A and B more medially or laterally to provide the best result.

409

• Disadvantage: Underneath the corrugator muscle of the eyebrow, the supraorbital vein runs along and over the orbital border; care should be taken not to insert deep into the skin and produce bruises. “n” Technique (Fig. 58.5) • This technique is indicated in both LEP and FLEP • This is the most common technique used with the Silhouette SoftTM thread. • Anesthesia with epinephrine is injected in points A and B. • An 18G needle is inserted into the skin from points A to B. The distance between points A and B should be 2 cm or less, which is the segment of the thread without cogs. • The thread emerging from point A is then inserted again with its needle through this entry point and passed into point C where it emerges again onto the surface. The same is done from points B to D. • Advantage: Fewer vessels in the scalp area. • Disadvantage: Thread emerges and enters again within the hairs of the scalp; more difficult to manage than with the “U” technique. Fan Technique (Fig. 58.6) • This technique is used in any type of eyebrow ptosis. • Only one point of entry is used in the scalp or frontal hairline (point A). • It is recommended for the unidirectional PDO-cogged threads. • The entry point (A) is anesthetized and then opened with an 18G needle or the tip of a number 11 scalpel. • Several threads are passed under the skin or the galea and then pulled upward. • The position of the entry point (A) can be more lateral or medial according to the type of eyebrow, being more lateral for LEP than for FLEP. “O” Technique (Fig. 58.7) • The thread is passed from points A to C and then from points C to D, D to B, and B to A where both ends are knotted together underneath the skin.

I. de Felipe

410 B

C

B

A

A

D

Fig. 58.5  Direction of the insertion of the threads indicated on the forehead of a patient undergoing the “n” technique. The needle is inserted at point A and comes out at

C

D

point B. The thread goes inside this needl coming inside at A and outside at B. Then on end of the thread is passed from A to C and the other one from B to D

A A

B

D C

B

D C

Fig. 58.6  Direction of the insertion of the threads indicated on the forehead of a patient undergoing the Fan technique. A is the insertion point. B, C, D are the final points towards which the cannula has to move

58  Eyebrow Thread Lifting

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B A A

C

D

Fig. 58.7  Direction of the insertion of the threads indicated on the forehead of a patient undergoing the “O” technique. A is the initial point of entry, B, C and D are the points for the thread to come out and in again until the thread arrives back to point A where it is sutured with the other end

• A scalpel has to be used to make the entry point (A) larger in order to be able to earth the knot. • Used with Silhouette SoftTM • Advantage: Results last longer according to these authors. Lateral Technique (Fig. 58.8) • This technique is indicated only in LEP, as it only pulls the edge. • It is used with Silhouette SoftTM. • The entry point would be the lateral edge of the eyebrow, (B) • Each of the needles is introduced through the entry point B, from which they are inserted toward the medial edge of the eyebrow (C) and the upper lateral corner of the hair frontline (A). • Advantage: Corrects eyebrows when there is an important loss of volume in the temples. It is recommended to combine it with volume enhancers or inducers such as PLLA or polycaprolactone in this area.

B

C

Fig. 58.8  Direction of the insertion of the threads indicated on the forehead of a patient undergoing the Lateral technique. B is the entry point and A and C the coming out points

• Disadvantages: It does not correct the elevation of the eyebrow. It is more often associated with bruises as the needles pass through the vascular area of the frontal branch of the midtemporal artery and vein.

58.3 Clinical Follow-Up • Prior to the procedure, avoid nonsteroidal anti-inflammatory drugs, vitamin E, or aspirin to avoid excessive bruising. • It is helpful in reducing the risk of bruising: apply creams containing iron chelators, vitamin K, or arnica. • After the procedure, do not massage the area for 7 days. • Take mild anti-inflammatory drugs in case of some pain or edema. • Patients can be treated again anytime, but usually 3 months is an adequate period for a second treatment if the patient requires further lift. • Avoidance of sauna, exercise, and sunlight has been recommended, with no evidence of benefit to the patient.

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I. de Felipe

58.4 Before and After (Fig. 58.9)

Fig. 58.9  Above: The patient who has undergone the “U” technique with Silhouette Soft™, before (left) and after 1 month (right). Below: “O” technique with Silhouette Soft™, before (left) and after 1 month (right)

58  Eyebrow Thread Lifting

58.5 S  ide Effects, Complications, and Their Management • About 69% of the patients might experience different complications or adverse events. • Bruising: It is more common in the areas of the forehead than in the neck of mid and lower face. Use of cannulas instead of needles to insert the thread has reduced this risk to a great extent. Two of 39 patients experienced bruising with PDO threads used for facelift [2]. The problem of bleeding in forehead exists probably closer to a 25% rate. • Extrusion: It is much more common with nonbarbed sutures and very rare with barbed ones [3]. • Pain: 17% of the patients experience pain during the first 5 days after the treatment, mainly in the anchoring points. • Dimpling: It is caused by passing the thread very close to the surface of the skin. It can be corrected with time [4]. • Asymmetry or change in the position or shape of the eyebrows. Asymmetry is also corrected with time [5]. • Granulomas and nodules: These are extremely rare when using PDO or PLLA.  Treat with intralesional corticosteroids, oral corticosteroids, intralesional bleomycin, or surgery. • Infection is very rare.

Tip Box

• It can be performed concomitantly with botulinum toxin injections, filler injections, or nonablative lasers. This author has performed these combinations and did not observe a higher incidence of adverse events or complications. • Results are clearly visible at least for 3 months [6]. Rachel noted that 45% of the patients treated had an early recurrence of their laxity [7]. Other authors consider that results can last for up to 6 months [8].

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• Threads induce fibrosis around the materials used, infiltration of inflammatory cells and fibroblasts, and increase in type 1 collagen and TGF-β1 throughout a 7-month period. • Thread lift of eyebrows is a safe, minimally invasive, fast, and easy-to-do treatment in comparison with surgical eyebrow lift. • We cannot expect it to be as effective as surgical procedures.

References 1. Park J, Yun S, Son D.  Changes in eyebrow position and movement with aging. Arch Plast Surg. 2017;44(1):65–71. 2. Kang SH, Byun EJ, Kim HS.  Vertical lifting: a new optimal thread lifting technique for Asians. Dermatol Surg. 2017;43(10):1263–70. 3. Sulamanidze M, Sulamanidze G. APTOS SPRING – a new concept of lifting. J Jpn Soc Aesthet Surg. 2005;42:183. 4. Sulamanidze M, Shiffman PT, Sulamanidze G. Facial lifting with APTOS Threads. Int J Cosmet Surg Aesthet Dermatol. 2001;3:275–81. 5. Sulamanidze M, Sulamanidze G.  Lifting of soft tissues: old philosophy, new approach  – a method of internal stitching (Aptos needle). J Jpn Soc Aesthet Surg. 2005;42:182. 6. Vestita M, Filoni A, Bonamonte D, Giudice G.  The Home-made Biostimulating thread lift. Plast Reconstr Surg Glob Open. 2016;4(9):e1015. 7. Rachel JD, Lack EB, Larson B. Incidence of complications and early recurrence in 29 patients after facial rejuvenation with barbed suture lifting. Dermatol Surg. 2010;36(3):348–54. 8. Han SE, Go JY, Pyon JK, Oh KS.  A prospective evaluation of outcomes for midface rejuvenation with mesh suspension thread: “REEBORN lift”. J Cosmet Dermatol. 2016;15(3):254–9.

Threads for the Middle Third of the Face

59

Tatiana Caloi

59.1 Materials 59.1.1 Silhouette Soft • The so-called Silhouette Soft (Silhouette Lift, Inc., CA, USA/Sinclair Pharmaceuticals, Chester, UK) is a bidirectional, absorbable, biocompatible 3.0 thread suture (100% polylactic acid) with flexible cones (82% polylactic acid and 18% glycolic acid) attached to two 32G 12-cm long needles. • It comes in a sterile package (one pair of needles) and needs to be stored at temperatures between 0 and 8 °C. The manufacturer brings the product in three presentations, 8, 12, or 16 cones, and they can be used on the face, neck, and body (Fig. 59.1a, b).

59.2 Methods and Techniques [1–10] Examination of the patient is important to determine the ideal candidate for the use of threads and the number of sutures to be used in order to achieve the best early and late results. • The technique is best suitable in middle-aged patients who begin to complain of a more evident nasolabial fold, loss of volume of the malar region, and loss of contour of the mandibular arch. • It can also be indicated as a complement after a surgical lift in an older patient. • The skin laxity should be light to moderate and the quality of the skin good. We should avoid heavy faces with too much subcutaneous tissue and also patients with thin skin and too much photo aging. The procedure is performed as an outpatient setting, using sterile technique. • Pre-op markings: The key points for midface lifting are the nasogenian and buccal groove distally and the preauricular and malar regions

T. Caloi (*) Tatiana Caloi Clinic of Plastic Surgery, São Paulo, SP, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_59

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a

b

Fig. 59.1 (a) Silhouette Soft package containing one pair of sutures with bidirectional needles. (b) Polylactic acid sutures with eight cones

•

•

•

•

•

proximally. Palpation of tissues and definition of the vectors for the lift are the most important factors, followed by the choice between the various techniques for placing the threads. The number of sutures to be used depends on the degree of tissue ptosis, and frequently, more than one area of the face can be treated simultaneously (midface, jaw line, and neck). It is important to measure the distance between the entry and exit points to select a suture with the appropriate number of cones. If the distance is too short, some cones will be lost during the traction, as they will come out of the skin and will be trimmed after the finalization of the procedure. Insertion of the sutures: Cutaneous disinfection is made with chlorhexidine, followed by local anesthesia only at the entry and exit points with lidocaine 1% together with adrenaline 1:200,000. After skin vasoconstriction is evident, creation of an entry point with an 18G needle is made, thereby facilitating the entrance of the suture needle and the cones. The needle of the thread is inserted vertically at the entry point followed by horizontal insertion of the needle through the subcutaneous tissue, parallel to the skin. The needle will exit

onto the surface of the skin following the pre­op markings. As the suture has two needles, the second step is the introduction of the second half of the suture following the surgical plan (Fig. 59.2a–c). • There are various ways to insert the sutures; it can be done longitudinally or in a U, V, or L mode. Evaluation of the patients during the entire course of time is the best way to improve results and get experienced with the use of thread sutures. • Traction of the threads: Once all sutures are inserted, the needles are cut and traction on the skin is made, moving the tissues over the cones. It is better to traction the threads with the patient in the supine position to obtain a more symmetrical lift and avoid over traction of them. At this point, some skin dimpling can occur, and it usually disappears in the next few days (Figs. 59.3 and 59.7). • To finish the procedure, the sutures are cut at the exit points.

59.3 Clinical Follow-up [1–10] • After the procedure, slight edema and bruising can appear and it is advised the use of a light

59  Threads for the Middle Third of the Face

a

417

b

c

Fig. 59.2 (a) Insertion of the suture needle through an 18G needle to allow the U technique to be performed. (b) Insertion of the first suture needle in the U technique.

Fig. 59.3  Light dimpling of the preauricular skin after traction of the skin over the cones

(c)  Insertion of the second suture needle, exiting just before the nasogenian groove

compressive bandage, cryotherapy and analgesics for 2 to 3 days. • Sensibility of treated areas is common, and it improves after a couple of weeks. It is important not to massage the face for 10–15  days after the procedure, to avoid movement of the cones. Moderate to intense exercises also should be avoided. • Laser and radiofrequency treatments should be avoided for at least 6 months after the procedure, to avoid early degradation of the thread and interference with polylactic collagen induction.

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59.4 Before and After (Figs. 59.4, 59.5, and 59.6) • The use of threads offers an immediate mechanical lifting of the tissues, with little pain and fast recovery.

Fig. 59.4 (a) Pre-op. (b) Markings—one thread inserted at the nasogenian area using the U technique and one thread at the mandibular area using the L technique. (c) Six months post insertion of threads

a

c

• Stimulation of new collagen by the polylactic acid within the sutures can improve face volume with time (Figs.  59.4, 59.5, and 59.6). • The procedure can be repeated over time, and the material is fully absorbed after 2 years.

b

59  Threads for the Middle Third of the Face Fig. 59.5 (a) Pre-op. (b) One year post insertion of two threads at the nasogenian(U) and mandibular (L) regions

Fig. 59.6 (a) Preop. (b) Three months post insertion of two threads at the nasogenian (U) and mandibular (L) regions

419

a

b

a

b

59.5 S  ide Effects, Complications, and Their Management [1–10] The use of absorbable threats minimized complications due to extrusion and palpation of the sutures. Currently, the morbidity of the procedure is low, and minimal side effects are seen. • The insertion of threads can cause little edema and bruising, especially at the entry and exit needle points. It can be treated with a light compressive bandage for a couple of days, cryotherapy and topic ointments to improve bruising.

• Pain after the procedure is low and can be managed with rest, analgesics, and anti-­ inflammatory drugs, if needed. It is important not to massage the area for at least 2 weeks. • Infection is rare and can be treated with anti-­ inflammatory drugs, oral antibiotics, and clinical observation. • Slight dimpling of the skin can be seen immediately after traction of the sutures. It is important not to manipulate the area. The wrinkling usually disappears in the first 2 weeks after the procedure (Fig. 59.7).

T. Caloi

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• During insertion of the sutures on hairy areas, it is important not to let the hair get into the entry points to avoid strange body reactions and infection at these sites. This is the main cause of inflammatory signs in these areas. • Careful instructions of rest during the first week can avoid early breakdown of sutures. This includes avoiding facial massages and aesthetic treatments. High-impact sports should be stopped for at least 2 or 3  weeks after the procedure.

References

Fig. 59.7  Skin dimpling immediately after traction of the sutures

Tip Box

• The use of thread sutures is not suitable for heavy faces, and when there is too much skin laxity. The traction achieved by the technique is slight and a good examination and indication favor for best results. • The more skin laxity you have, the more sutures you will have to use, but the limits of the technique are dictated by physical examination and experience with the technique. • Anesthetic infiltration should be done only at the entry and exit points of the needles on the skin to avoid distortion of tissues and less traction of the threads. • The entry point needs to be broad to permit the cones to slide gently into the skin. If the cones get stuck, forcing them can cause a suture breakdown.

1. Patil SB, Kale SM, Jaiswal S, Khare N, Math M. Effect of aging on the shape and position of the eyebrow in an Indian population. Aesthet Plast Surg. 2011;35(6):1031–5. 2. Sclafani AP, Jung M. Desired position, shape, and dynamic range of the normal adult eyebrow. Arch Facial Plast Surg. 2010;12(2):123–7. 3. Park J, Yun S, Son D. Changes in eyebrow position and movement with aging. Arch Plast Surg. 2017;44(1):65–71. 4. Kang SH, Byun EJ, Kim HS. Vertical lifting: a new optimal thread lifting technique for Asians. Dermatol Surg. 2017;43(10):1263–70. 5. Sulamanidze M, Sulamanidze G. APTOS SPRING – a new concept of lifting. J Jpn Soc Aesthet Surg. 2005;42:183. 6. Sulamanidze M, Shiffman PT, Sulamanidze G. Facial lifting with APTOS Threads. Int J Cosmet Surg Aesthet Dermatol. 2001;3:275–81. 7. Sulamanidze M, Sulamanidze G. Lifting of soft tissues: old philosophy, new approach – a method of internal stitching (Aptos needle). J Jpn Soc Aesthet Surg. 2005;42:182. 8. Vestita M, Filoni A, Bonamonte D, Giudice G. The Home-made Biostimulating thread lift. Plast Reconstr Surg Glob Open. 2016;4(9):e1015. 9. Rachel JD, Lack EB, Larson B. Incidence of complications and early recurrence in 29 patients after facial rejuvenation with barbed suture lifting. Dermatol Surg. 2010;36(3):348–54. 10. Han SE, Go JY, Pyon JK, Oh KS. A prospective evaluation of outcomes for midface rejuvenation with mesh suspension thread: “REEBORN lift”. J Cosmet Dermatol. 2016;15(3):254–9.

Threads for the Inferior Third of the Face

60

Flávio Rezende and Aline Vieira

60.1 Materials (Fig. 60.1) • Absorbable or nonabsorbable threads and barbed threads using cone technology made of different components (polylactic acid or polydioxanone) • 18G needle • Marking pen • Ruler • Sterile scissors • Sterile field • Sterile gauze • Chlorhexidine 0.2% • Anesthetic lidocaine with epinephrine 2.0% • Disposable needle and syringe • Sterile gloves • Surgical mask

60.2 Methods and Techniques • The face is washed with soap to remove makeup and clean the skin.

F. Rezende (*) Brazilian Society of Plastic Surgery (SBCP), International Society of Aesthetic Plastic Surgery (ISAPS), Rio de Janeiro, RJ, Brazil

Fig. 60.1  Material needed to perform procedure

• Using pens, the skin is marked for the procedure. • Chlorhexidine is applied followed by chlorhexidine dihydrochloride. • A sterile field is placed over the area where the threads will be inserted. • Local anesthesia is administered only at the entry and exit points of the thread with 0.5 cc of lidocaine 2% and 1:200.000 adrenaline at each point. • As a general rule, it is ideal to use a minimum of two threads for each side and region of the face. For this technique, the 8- or 12-cone thread can be used. • For the inferior third, we can use the combined pattern: straight and angle (Fig. 60.2).

A. Vieira Brazilian Society of Dermatology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_60

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–– The inferior third procedure begins with the creation of the entry point using an 18G needle, making sure to reach the subcutaneous tissue below the skin. –– When inserting the thread, the doctor must be careful to insert the needle at a 90° angle until it reaches the subcutaneous tissue and the needle marking disappears (5 mm). This prevents the pinching of the dermis and the formation of dimples. Subsequently, position the needle horizontally and continue to move it, always careful to stay in the subcutaneous, until you reach the previously marked exit point. Then, perform the same procedure with the other half of the thread [1, 2]. –– The straight thread, placed on top, enters through a point in the capillary line near the upper pole of the ear, with half thread positioned toward the imaginary line from the labial commissure to the mandible to create traction and lift effects and the other half

Fig. 60.2 Conventional technique using straight and angle patterns combined

F. Rezende and A. Vieira

placed inside the scalp for better anchorage of the thread. –– For the second thread using the angle pattern, the entry point is created behind the angle of the mandible, passing half the thread in front of the body of the jaw and the other half preauricular, exiting in the scalp. –– After all threads have been inserted, the face markings and skin are cleaned. –– Finally, the traction is made by manipulating the skin against the cones. Hold one end of the thread to create traction with one hand while gently moving and pressing the skin against the cones with the other.

60.2.1 Authors’ Personal Technique: Double Z Technique (Fig. 60.3) • This technique creates triple anchorage. • The threads are positioned in a Z pattern which makes it more difficult for them to move after being placed.

Fig. 60.3 Authors’ personal technique: Double Z technique

60  Threads for the Inferior Third of the Face

• Both threads are entwined in the middle cone-­ less section creating a strong hold in the precapillary region. • It positions half of the threads in the preauricular region and the other in the mastoid region, restoring the contour of the jawline while providing stronger anchorage.

60.3 Clinical Follow-Up The main advantages resulting from the use of support threads are the repositioning of facial volume with the correction of tissue ptosis, more definition of the treated area, and greater firmness. In the inferior third of

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the face we use the threads to soften the marionette lines and ptosis of the Bichat balls, besides improving the jawline by treating “bulldog” cheeks [3]. In general, this treatment lasts an average of 18 months, but results do vary depending on the degree of sagging, the thickness and weight of the subcutaneous tissue, the mobility of the skin, the number of threads inserted, and the technique used. Best results are obtained when the correct indication is associated with the expertise in the techniques.

60.4 Before and After (Figs. 60.4, 60.5, 60.6, and 60.7)

Fig. 60.4  Clinical improvement of the depth of marionette lines, improvement of sagging due to repositioning of the skin, and greater jawline definition after 1 year

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Fig. 60.4 (continued)

Fig. 60.5  Clinical improvement of a patient with significant flaccidity after great weight loss. Use of threads in the malar region, jawline, and neck employing the conventional technique: two linear and parallel threads in the

malar, one linear and one angular thread for jawline, and two linear threads in the neck. Observe greater definition of jawline and facial contour, as well as a softening of nasolabial folds

60  Threads for the Inferior Third of the Face

Fig. 60.6  Before and after photos of 7-month treatment with threads in malar, jawline, and neck using the double Z technique

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Fig. 60.7  Before and after photos of 1-year treatment with threads in malar and jawline using the double Z technique. This case also exhibits resurfacing, fillers in lips, and botox

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Fig. 60.8 Rippling after immediate treatment, only 1 week advised for observation

Rippling is temporary, on average 5–7  days, but if it perpetuates after 15 days, it is most often due to a very superficial passage and pinching of the dermis. In these cases, massages are advised. Pain, edema, and ecchymosis are temporary. If necessary, administer oral painkillers for pain and topic medication for bruising. Infections are rare, but in case they occur, the treatment is local hygiene and topical and oral antibiotics. Tip Box

60.5 S  ide Effects, Complications, and Their Management Possible side effects: • • • • • • •

Depression at the point of entry Rippling (Fig. 60.8) Pain Edema Bruises Infection Hypersensitivity to polylactic acid

The depression at the point of entry is caused by a technique error when the needle is inserted without respecting the 90° angle until the marking disappears and reaches the subcutaneous tissue. In these cases, it is necessary to massage the point of entry before tractioning the threads, or after treatment, a lidocaine 2% infiltration can be attempted to release retraction through hydrodissection, and if it persists, a subincision can be performed.

• To observe the real and feasible aesthetic outcome to be provided to the patient to avoid any false clinical outcome. • To have experience in all the techniques used for this procedure to combine all of them for the best aesthetic approach of the inferior third of the face. • To choose the best threads on the Market for you to have reliable, safe, and reproductive results in all the patients you will be treating.

References 1. Benito J, Pizzamiglio R, Theodorou D, Arvas L. Facial rejuvenation and improvement of malar projection using sutures with absorbable cones: surgical technique and case series. Aesthetic Plast Surg. https://doi. org/10.1007/s00266-010-9570-2. 2. Gamboa MG, Vasconez OL. Suture suspension technique for midface and neck rejuvenation. Souteastern Society of Plastic and Reconstructive Surgeons. 3. Aston SJ, Steinbrech SD, Walden JL. Cirurgia Plástica Estética. Elsevier; 2009. p. 53–71; 411–33.

Threads for Chin Lifting

61

Claudio Dias and Roseli Andrade

61.1 Materials

61.2

Methods and Techniques [1–3]

Skin disinfection with antiseptic solution is required. Mark treated areas

Dermographic pen Antiseptic solution Sterile gloves Anesthetic cream Sterile gauze pads Polydioxanone threads: length is according to the treatment area Sterile scissors

C. Dias Clinical Aesthetic Medicine, Recife, PE, Brazil R. Andrade (*) Clinical and Aesthetic Dermatology, Clínica Dermatológica Dra Roseli Andrade, Santos, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_61

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Needle insertion in the dermic layer is recommended.

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Gently pull needle upward to check if needle is in the dermic layer

Turn the needle clockwise three to four times.

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Withdraw needle.

Try Skin compression if bleeding occurs. Check if thread is completely inserted, and any visible thread should be cut to skin level.

61.3 Clinical Follow-Up [1–3]

Avoid physical activity for 24 h. Do not massage the area for 24 h. Avoid sunlight, and regular sunscreen use is recommended. Mild edema and ecchymosis may occur.

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61.4 Before and After

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61  Threads for Chin Lifting

61.5 S  ide Effects, Complications, and Their Management [1–3] Thread extrusion: Cut visible tread or remove using tweezers.

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Infection: Systemic or topic antibiotics Granulomatous tissue in entry point: Cauterization, excision using punch, or triamcinolone injection Visible thread is placed too superficially. Remove it with tweezers. Tingling sensation: Patient may feel minor discomfort in the following few days. No treatment is necessary. Bruises and ecchymosis: Avoid sun exposure. No specific treatment is recommended. Skin irregularities will resolve with time. No treatment is recommended.

Tip Box

• Use as many threads as possible; a larger number of threads will grant better results. • Threads may be implanted in many sessions just a few days apart for patient comfort. • After treatment, double check for apparent threads and cut them off.

References 1. Lopandina I.  PDO lifting threads: new approach to skin rejuvenation. Northern Cyprus: Reachback Ltd; 2014. 2. Suh DH, Jang HW, Lee SJ, Lee WS, Hwa JR. Outcomes of polydioxanone knotlesse thread lifting for facial rejuvenation. Dermatol Surg. 2015;(41):720–5. 3. Swaminathan V.  Polydioxanone thread lifting: considerations and patient expectations. J Aesthet Nurs. 2016;5(2):70–3.

Threads for the Neck

62

Paola Rosalba Russo and Gerhard Van Niekerk

62.1 Materials • The bidirectional polylactic acid threads with opposing cones are composed of a reabsorbable thread (polylactic acid) of a length of about 30 cm with 8, 12, or 16 cones. • The cones are hollow and are inserted along the length of the threads, blocked by two knots at a distance of about 5  mm (for 8 cone threads) and at about 8  mm (for 12 and 16 cone threads). • The cones are made of glycolide/lactic acid in the ratio 82:18. The central part of the threads is free of cones for a length of about 1.5 cm (Figs. 62.1, 62.2, and 62.3). • From this point there is a series of four, six, or eight opposing cones at each end of the thread. The tip of each cone is oriented toward the extremity of each thread, hence the term bidirectional threads. • At the end of each thread is a 23G needle, 12 cm long, which is necessary for the insertion of the suture. • Botulinum toxin type A (BoNT-ONA 100 Speywood units; BoNT-ABO 500 -units:

Fig. 62.1  Eight-cone suture

Fig. 62.2  Twelve-cone suture

P. R. Russo (*) Modena, Italy G. Van Niekerk Medical Aesthetic Clinic, Somerset West, South Africa © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_62

Fig. 62.3  Sixteen-cone suture 433

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BoNT-INCO 100 -units) is used for muscle relaxation prior to the procedure. • The main botulinum toxins that are currently produced in Europe for therapeutic indications are Botox made by Allergan; Dysport, made by Ipsen; and Xeomin, produced by Merz. • The various types of botulinum toxins that are currently available may vary in unit quantities according to the different countries in terms of reconstitution.

62.2 Methods and Techniques 62.2.1 Lateral Sagging • This technique utilizes two entry points situated at the back of the neck at a distance of about 1.5  cm from each other (Fig. 62.4). • The exit points are located at a distance of about 10–11 cm in the paramedian area of the neck, about 2  cm below the mandibular line (1) (Figs. 62.5, 62.6, and 62.7). • Local anesthetic is used at the entry and exit points as well as along the path of the sutures. This area contains many nerves and can be painful. • Two 16 cone sutures are usually used. • The entry point is prepared by using an 18G needle after pinching the skin.

P. R. Russo and G. Van Niekerk

• The first suture needle is inserted vertically to a depth of about 5 mm which is indicated by a black line on the needle. • The needle is then rotated 90 degrees and is delicately inserted under the skin toward the first exit point. • The second suture needle is inserted in the same way. • Once the sutures have been inserted correctly the needles are then cut. • The skin is then collected and repositioned at the back of the neck and is anchored by the lifting effect provided by the suture cones.

Fig. 62.5  Exit point on the left side in the middle of the neck

Fig. 62.6  Exit point on the right side in the middle of the neck

Fig. 62.4  Reins technique. Entry point at the back base of the neck

Fig. 62.7  Insertion of the second suture at a distance of 1 cm

62  Threads for the Neck

• A plaster is usually put over the entry points for about a week after treatment to deter the patient from turning her neck too much. • Approximately 15–20 days prior to the procedure, botulinum toxin is injected at an ­intramuscular level to relax the hypermobility of the platysmal bands. • By asking the patient to contract the muscle the injection area is identified and marked directly onto the patient’s face and neck. • Starting from the jawline, an inverted ­triangle is marked and is composed of a sequence of 4,3,2,1 injection points (Fig. 62.8a, b). • For hypermobility of the anterior platysmal bands, five injections are performed in a vertical line for each band [1, 2]. • Each injection dose is about 1 or 2 Speywood units. • Ten days after the initial procedure, another two sutures are inserted in the anterior part of

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the neck. Eight or 12 cone sutures are used (2 sutures per side). The entry point of the sutures is located laterally to the anterior platysma bands ­ (Fig. 62.9a, b). The distal exit point is situated at about 6 cm (for 8 cone sutures) or 9  cm (for 12 cone sutures) from the entry point. The distal exit point corresponds to the mastoid area. The proximal exit point coincides with the entry point of the contralateral suture. The two sutures are inserted at a distance of about 1 cm from each other [3].

62.2.2 Central Sagging • This technique uses two entry points centrally in the midline of the neck. • A total of 16-cone sutures are preferred in this part of the technique (sling).

Fig. 62.8  Insertion point of the Botulinum Toxin on the platysma bands

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Fig. 62.10  Placement of 1st suture

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Fig. 62.9  Entry and exit point at the front of the neck with an eight-cone suture (a) and a twelve-cone suture (b)

• The first suture placement aims to correct and enhance the jawline (Fig. 62.10). • The second suture aims to create a proper mento-cervical angle (Fig. 62.11a, b). • Determination of the distal vectors for the specific individual is paramount. • Communal exit points on the mastoid fascia posterior to the implant of the sternomastoid muscle are of uttermost importance. This will ensure proper fixation and anchoring of the sutures. • A third suture is inserted with the entry point utilizing the same exit point of the first two sutures (Fig. 62.12). • A fixative leg is inserted inferiorly to the mento-cervical suture, with the proximal anchoring leg stretching behind the ear in the postauricular mastoid fascia.

b

Fig. 62.11 (a, b) Placement of 2nd suture

• When the subdermal tissue is repositioned in the sling sutures, it is advisable to only engage the first four medial cones and to perform proper contraction on the lateral four cones. This will prevent undesirable tissue accumulation in the midline.

62  Threads for the Neck

• Repositioning of tissue in the third suture is done as normal. • The anatomical thickness of the subdermal tissue in the neck necessitates correct plane placement of the sutures. Special care should

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be taken crossing the sternomastoid muscle. Insertion through the fascia, muscle, or epimysium will result in a painful movement of the neck. After insertion of the needle from entry to exit point, request the patient to turn the head against resistance to the contralateral side. Pain with movement will alarm an incorrect placement. Withdrawing and reinsertion of the needle is possible before the suture is inserted. • Pre-procedural treatment of the hyperdynamic neck and lower-face depressor muscles with botulinum toxin is imperative. • Excellent results rely on proper patient selection, correct plane placement, and patient compliance to aftercare.

62.3 Before and After Fig. 62.12  Placement of 3rd suture

Figures 62.13a–b, 62.14a–b and, 62.15a–d

a

Pre-procedure

Post-procedure

Fig. 62.13  Before and after the treatment from a frontal, three quarter and lateral perspective

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b

Pre-procedure

Post-procedure

Fig. 62.13 (continued)

a

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Fig. 62.14  Before the treatment and four months after lower-face and neck treatment

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Fig. 62.15  Before the treatment and four months after lower-face and neck treatment

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62.4 Clinical Follow-Up • The patient is usually asked to return to the clinic after about 15 days and then successively after 1  month, 3  months, and 6 months. • The first objective is to evaluate whether the desired result has been achieved. If not, there is the possibility of inserting a further suture. • The second checkup is to judge the overall result of treatment and to determine the patient’s level of satisfaction. • The final two check-ups are used to judge whether the result has been maintained over time. • In cases where botulinum toxin has been used in combination with the sutures, the 3-month check-up is used to inject further doses (if needed) as the effect of the toxin may have worn off.

62.5 S  ide Effects, Complications, and Management Thereof The insertion of the suture is fairly straightforward, and therefore any possible complications are minor and only temporary. However, possible complications can be divided into two groups: those regarding technical errors and those regarding unforeseeable reactions [4]. • Incorrect insertion can lead to skin dimpling at the entry point in about 4–5% of cases. Too superficial insertion results in cutaneous dimpling (Fig. 62.16). • Cutaneous folds, pain, and edema are also commonly experienced as minor complications (Fig. 62.17). • All abovementioned complications are of a temporary nature and normally disappear

•

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•

•

•

•

without the necessity of any kind of therapy after 1–3 weeks. Unforeseeable reactions, like echymosis and hematoma, are observed in about 8% of patients. Infections occur in about 0.01% of patients and asymmetry, in 1.5%. The risk of suture breakage which could be caused by friction at the entry point or along the path of the suture insertion (due to the presence of fibrosis or scar tissue) is a very rare possibility. In such cases it is important to perform a contraction of the skin with your free hand rather than exerting more tension on the suture. A risk of the final cone of the suture remaining stuck horizontally at the entry point exists. In such cases, elevation of the cone vertically with the blunt end of a previously cutoff ­insertion needle is used to aid in cone insertion (Fig. 62.18a–h) Where insertion at a too superficial level was performed, removal of the dimple caused by the cone can be done with a needle, or simply wait for its reabsorption. Excessive doses of botulinum toxin reaching the sternocleidomastoid muscle may lead to difficulty in raising and lowering the head for about 20 days (reported in literature but highly unlikely).

In cases of infection it is advisable to prescribe antibiotics and if necessary painkillers. During the first week after treatment, the patient shouldn’t undergo any dental treatment, massages, or any other kind of beauty treatments. The patient should avoid any kind of sporting activity and should sleep in a supine position for at least 10–15 days. Furthermore the use of a horseshoe-­ shaped cervical pillow is recommended to limit night-time movements.

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Before

After 1 day

After 2 days

After 3 days

Fig. 62.16  Dimplings at entry point with resolution after few days

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442 Fig. 62.17  Dimplings at entry point with resolution after few days

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Fig. 62.18  How to solve the problem if the cone gets stuck horizontally

62  Threads for the Neck

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h

Fig. 62.18 (continued)

Tip Box

• Correct patient selection is fundamental for achieving satisfactory results. Patients with excessive subcutaneous tissue or extreme thin skin are considered unsuitable for treatment. • Remember that the age of the patient does not compromise the result of treatment while an incorrect patient selection may do so. • Regardless of the patient’s age or type of skin, it is important to clarify with the patient what her expectations are. Unachievable expectations should be directed toward a surgical lifting. • A correct diagnosis of the neck should include an analysis of skin quality, the

•

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•

distribution of subcutaneous fat, and the relationship between superficial muscle and overlying skin. It is necessary to warn the patient that she may notice a sensory loss in the earlobes for a couple of days due to the anesthesia. To avoid this complication, the physician should aim to inject 6 cm vertically below the earlobe. Treatment should be performed with the patient in a seated position and not lying down. The patient should be told to avoid sudden movements of the neck immediately following treatment. When inserting the suture it is useful to use a snakelike movement of the needle

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tip. This movement ensures insertion in the subdermal fatty layer until the exit point has been reached. • Once the exit point is reached with the insertion needle, lift the needle ­manually to be sure of a correct insertion level under the skin. • Select the suture with the most cones possible to fit the space.

References 1. Iozzo I, Tengattini V, Antonucci AV.  Multipoint and multilevel injection technique of botulin toxin A in facial aesthetics. J Cosmet Dermatol. 2014;13(2):135–42. 2. Iozzo, I. Botulinum Toxin, See Acta Medica Editrice, Parma. 2016. 3. De Benito J, Pizzamiglio R, Theodorou D, Arvas L. Facial rejuvenation and improvement of malar projection using sutures with absorbable cones: surgical technique and case series. Aesthetic Plast Surg. 2011;35(2):248–53. 4. Helling ER, Okpaku A, Wang PT, Levine RA. Complications of facial suspension sutures. Aesthet Surg J. 2007;27(2):155–61.

Threads for Corporal Areas: Upper and Inferior Limbs

63

Gabriel Aribi, Cidia Vasconcellos, and Monica Aribi

63.1 Materials 63.1.1 Silhouette Soft • It consists of 100% poly-L-lactic acid (PLLA) bidirectional thread with cone technology (82% PLLA, 18% glycolic acid) that provides safe and effective lifting and anchoring [1]. • Poly-L-lactic acid is an aliphatic polyester and a lactic acid polymer, and it is a biocompatible, fully absorbable, and immunologically inert substance [2]. • The PLLA mechanism of action consists in the stimulation of fibroblasts [3, 4] that follows a subclinical tissue inflammation. The dermis thickness can increase 4–6 mm [3, 5].

G. Aribi (*) Department of Dermatology of Hospital Ipiranga, São Paulo, SP, Brazil Department of Dermatology of Centro Universitário Lusíada, Santos, SP, Brazil C. Vasconcellos Department of Dermatology of Hospital Ipiranga, São Paulo, SP, Brazil Department of Dermatology of the University of São Paulo, São Paulo, SP, Brazil M. Aribi Department of Dermatology of Hospital Ipiranga, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_63

• The PLLA is eliminated from the body between 18 and 24 months [6, 7]. After this period, it is degraded into lactic acid monomers, which are broken into CO2 and H2O [3]. • The clinical effects last for 2 or more years [3, 6]. • Silhouette Soft® comes in boxes of five packs that must be stored at a minimum temperature of 0 °C and maximum temperature of 8 °C. • Each pack contains two sutures. Only the plastic pouch inside of the pack is sterile. • There are three types: the 8-cone device, the 12-cone device, and the 16-cone device. • There is a minimum length between the entry and the exit points for each device: 10 cm for the 8-cone, 16 cm for the 12-cone, and 20 cm for the 16-cone device.

63.1.2 Materials (Fig. 63.1) • • • • • • •

Surgical pen. Surgical pencil. Chlorhexidine aqueous solution. Chlorhexidine alcoholic solution. Surgical mask. Surgical gloves. Lidocaine 2.0% (20 mg/mL) with epinephrine (1:100.000). • Sterile gauze. • Large sterile field. 445

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• • • •

Sign the consent form. Before photo. Material preparation. Determine the number of sutures depending on patient’s indications.

63.2.2 Patient Preparation (Fig. 63.3)

Fig. 63.1  Materials used for the procedure

• • • • •

Syringe 5 mL. Two 18G × 1½ needles. 26G × ½ needle. Sterile surgical scissors. Micropore.

63.2 Methods and Techniques • The threads are useful in the rejuvenation of the skin of the anterior, medial, and posterior arms, the medial thighs, and the upper knees. • The dual action of this particular suture: the lifting action, by redefining the focused area by compressing the tissue, and the PLLA regenerating action. • The skin in the arms and legs is thicker and heavier, so the lifting action needs to be stronger. For this reason, a higher number of threads are used. • The straight technique is the best option for treating these specific areas of the upper and inferior limbs, because of its stronger traction and anchoring. • The straight technique consists in the parallel disposition of the threads, with a distance of 2 cm between each thread. • The number of threads depends on the patient’s indications, but normally 3–5 threads are used in each area (Fig. 63.2).

63.2.1 Pretreatment Process • Understand patient’s needs and expectations. • Explain the procedure and the posttreatment care.

• • • •

Determine the area to be treated. Determine the vectors of traction. Draw patterns using a ruler. Choose the size of the sutures according to the length between the entry and exit points of the suture. • The patient must be lying down.

63.2.3 Technique (Fig. 63.4) • Put on your sterile gloves. • Clean and disinfect the area with chlorhexidine aqueous solution. • Cover the surrounding area with a sterile field. • Inject only the entry and exit points of the suture with Lidocaine 2% with adrenaline 1:100.000. The insertion technique is always the same. • Take one suture at each time out of the pouch and prepare it with a slight traction to tighten the knots (Fig. 63.4a) [1]. • Create the entry hole with an 18G needle (Fig. 63.4b) [1]. • Insert the point of the first suture perpendicularly to the skin through the entry point to a depth of 5  mm into the subcutaneous tissue (Fig. 63.4c) [1]. • There is a black line at the point of the suture that indicates precisely 5  mm. This way, the thread will be displayed in the subcutaneous layer (Fig. 63.4d) [1]. • Turn the needle horizontally and guide it parallel through the subcutaneous tissue [1]. • To obtain a better result in these particular areas, the thread should be displayed in a superficial depth of the subcutaneous tissue, subdermal. • Follow the pattern at the same depth all the way until the exit point.

63  Threads for Corporal Areas: Upper and Inferior Limbs

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Fig. 63.2  (a) Bidirectional PLLA thread and the cones (82% PLLA and 18% glycolic acid). (b) The cone technology for anchoring and lifting the tissue

Fig. 63.3  The straight pattern. The red dots represent the entry points, and the blue dots represent the exit points of the suture. (a) Straight pattern for the medial thighs. (b) Straight pattern for the arms. This aims to reduce the circumference of the arm. (c) Straight pattern for the arms aiming to mark the division between the biceps and the triceps. (d) Straight pattern for the knees

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Fig. 63.4  The technique. (Photos taken by the authors)

• Extract the needle through the first exit point. • Gently pull it and by way of traction, the first series of cones will enter the adipose tissue. • When the last cone is inserted, stop the traction and start with the insertion of the second half of the suture. • Introduce the needle located at the second end of the suture, perpendicularly to the skin in the same entry hole, allowing the depth of 5 mm. • Proceed in the direction of the second exit point. • Extract the needle at the pre-established exit point, with a gentle pull so the second series of cones penetrates the tissue (Fig. 63.4f) [1]. • The needles may be cut off leaving a portion of the device exposed out of the skin.

• The entire suture has now been implanted (Fig. 63.4g) [1]. • The next phase is the modelling phase, applied to the treated area. With all the fingers on one hand, pinch the tissue while applying gentle pressure. • At the same time, pull the exposed ends of the sutures with the other hand, so that the cones connect with the tissue to maintain compression. • Check symmetry. • Use the tips of the scissors to gently pull back the skin in order to trim the suture at a deeper level and prevent extrusion of the device (Fig. 63.4h) [1]. • Clean the treated area again. • Leave the area with micropore for 14  days. This action will help maintain the compression of the skin.

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63.2.4 Posttreatment Recommendations • • Explain that a slight edema or bruising may occur. • Sometimes, a slight depression or skin irregularity may appear at the entry points. These disappear a few days after the treatment. • Take simple analgesia in case of pain (paracetamol) for 2–3 days. • Avoid massaging the area. • Avoid sports for 3 weeks. • Do not use saunas for 3 weeks. • Avoid excessive movement that evolves the area of the treatment for 3 weeks.

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63.3 Clinical Follow-Up

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• Silhouette Soft® is a fully absorbable thread that can last in the body between 18 and 24 months. • The treatment provides two different clinical effects: lifting and compression of the tissue

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c

d

Fig. 63.5  Follow-up of one case. The aim was to reduce the circumference of the arm. (a) Before the procedure. (b) Immediately after the procedure. (c) Two months after

and the increase of skin’s thickness and firmness. The lifting effect on arms and legs can last between 6 and 18 months and will depend on the severity of the flabbiness and the weight of the tissue. The PLLA lasts up to 24  months, but the increase of the dermis thickness and its clinical effect can last longer [2, 3, 8]. Overweight patients and patients with severe flabbiness are not good candidates for this kind of treatment. Patients with light to moderate skin laxity are ideal. Some patients may be dissatisfied with the treatment if the number of threads is lower than necessary. Abrupt movement of the arms or legs in the first 2 weeks can affect the clinical result. Patients that do not follow the posttreatment recommendations may experience a poorer clinical effect (Figs. 63.5 and 63.6).

the procedure. (d) Seven months after the procedure. (Photos taken by the authors)

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a

b

c

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Fig. 63.6  Four threads on each knee. (a) Immediately after the procedure. (b) One month later. (c) After 3 months. (d) After 4 months. (Photos taken by the authors)

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63.4 Before and After (Figs. 63.7, 63.8, 63.9, and 63.10) a

b

Fig. 63.7  (a) Moderate flabbiness requires five threads to a satisfactory result. (b) The result after 2 months. (Photos taken by the authors) Fig. 63.8  (a) Knee rejuvenation: usually four threads are enough to treat the area. This patient’s medial thigh was also treated with four threads on each side. (b) The result after 1 month. (Photos taken by the authors)

a

b

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a

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Fig. 63.9  (a) Each knee was treated with four threads. (b) Knee area immediately after the procedure. (Photos taken by the authors)

a

b

Fig. 63.10  Five threads were used to treat each arm. (a) Before treatment. (b) After 10 months. (Photos taken by the authors)

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63.5 S  ide Effects, Complications, and Their Management 63.5.1 Pain • The most commonly reported side effect is pain in the first 3 days after the procedure. • Simple analgesia can relieve the pain.

63.5.2 Bruises • Bruises are the second most common side effect of the procedure. • This complication may occur when, during the local anesthesia or the procedure itself, the needle reaches a vessel. • Bruises are a benign complication and in most cases do not need any management (Fig. 63.11).

63.5.3 Skin Depression at the Entry Points • This is a common complication that happens at the entry point of the suture. • As the dermis of the arms and legs is thick, the depression can last longer (2–4 weeks). • No management is required (Fig. 63.12).

63.5.4 Foreign Body Granuloma • Foreign body granuloma is a rare complication. • It is more frequent due to poor technique, e.g., if a cone is inserted in the dermis. • It usually occurs from 1 to 3 months after the procedure. • Treatment of choice is the injection of corticosteroids (triamcinolone or betamethasone). • Another option of treatment is subcision. This action aims at releasing the cone before the granuloma is formed.

Fig. 63.11  Bruises appear immediately after the procedure. Skin depression at the entry points. (Photos taken by the authors)

Fig. 63.12  Bruises and skin depression. Overweight patients are not good candidates for this kind of treatment. (Photos taken by the authors)

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Tip Box

• Silhouette Soft is a fully absorbable, safe product that can last in the skin for 18–24 months. • Lifting effects in arms and legs can last for 18  months, but the new collagen fibers last longer than 2 years. • Patients with light to moderate laxity are better candidates for the procedure. Severe flabbiness: poor clinical effects. • The upper and inferior limb’s skin is heavy and thick: the best option is to use a PLLA bidirectional thread with cones. • The straight technique allows better lifting and anchorage, being the best for these particular regions.

References 1. Sinclair Pharma website. http://silhouette-soft.com. Accessed 25 Nov 2017. 2. Coimbra DD, Amorim AGF. Poly-L-lactic acid in the rejuvenation of the medial and anterior arms. Surg Cosmet Dermatol. 2012;4(2):182–5. 3. Machado Filho CDS, Santos TC, Rodrigues APLJ, Cunha MG.  Poly-L-lactic acid: a bio stimulating agent. Surg Cosmet Dermatol. 2013;5(4):345–50. 4. Lowe NJ, Maxwell CA, Lowe P, Shah A, Patnaik R.  Injectable poly-l-lactic acid: 3 years of aesthetic experience. Dermatol Surg. 2009;35(Suppl 1):344–9. 5. Narin RS.  Minimizing adverse events associated with poly-L-lactic acid injection. Dermatol Surg. 2008;34(suppl 1):S100–4. 6. Rendon MI.  Long-term aesthetic outcomes with injectable poly-l-lactic acid: observations and practical recommendations based on clinical experience over 5 years. J Cosmet Dermatol. 2012;11(2):93–100. 7. Mazzuco R, Hexel D. Poly-L-lactic acid for neck and chest rejuvenation. Dermatol Surg. 2009;35(8):1228–37. 8. Cunha MG, Daza F, Rezende FC, Machado Filho CDS.  Poly-L-lactic acid in sagging body skin. Surg Cosmet Dermatol. 2016;8(4):322–7.

Threads for Abdomen

64

Denise Rocha Luna Barcelos and Cyro Hirano

64.1 Materials • Anesthesia (1% lidocaine with adrenaline 1:2000.000), 30G needle, 5.0 cc syringe. • An 18G needle, sterile gauze, sterile surgical gloves, sterile surgical, sterile scissors, skin disinfectant (chlorhexidine digluconate 0.5%). • 2 suture Silhouette Soft 12 cones, 2 suture Silhouette Soft 16 cones (Fig. 64.1).

64.2 Methods and  Techniques In the first-step procedure, it is recommended that preoperative marking be performed with orthostatism in order to establish the position and pathway of the sutures [1, 2]. The initial marking is 1  cm above the umbilical region, and two suture Silhouette Soft 12 cones are performed 2 cm equidistant and parallel, medially. The other two suture Silhouette Soft 16 cones are performed lateral diagonally in the U-technique, as shown in the next illustration (Fig. 64.2). The procedure is performed under local anesthesia (1% lidocaine with adrenaline1:2000.000)

D. R. L. Barcelos (*) Denise Barcelos Clinic of Dermatology, Rio de Janeiro, RJ, Brazil C. Hirano Cosmetic Dermatology Unit, Policlínica Geral do Rio de Janeiro, Rio de Janeiro, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_64

Fig. 64.1 Materials

Fig. 64.2  Pretreatment marking of the abdominal region helps in determining the position and direction of the sutures in every area that is to be treated, according to patient patterns 455

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Fig. 64.3  Anesthesia is performed only at the entry and exit points

Fig. 64.4  Preparation of the entry point with an 18G needle

with infiltration at the entry point of 0.5 cc, as well as at the two exit points, with 0.5 cc each (Fig.  64.3). After thorough disinfection with chlorhexidine digluconate 0.5%, we create the entry point with an 18G needle in a vertical position to facilitate the insertion of the cones; then the suture is inserted through the entry point introduced through a hole made perpendicularly to the skin surface (Fig.  64.4) [3]. There is a black line that guides us to indicate that we have reached the correct subcutaneous depth, which is approximately 5 mm (Figs. 64.5 and 64.6). Once the subcutaneous tissue has been reached, the needle is rotated parallel to the skin and is inserted toward the first exit point. Once the first six cones have been inserted, the needle is cut away, and the insertion of the ­second half of the same suture is performed (Fig. 64.7) [4, 5].

D. R. L. Barcelos and C. Hirano

Fig. 64.5  From the tip of the needle, there is a black line that guides us to correct insertion depth 5 mm

Fig. 64.6  The needle penetrates in the entry hole perpendicularly to the skin

Fig. 64.7  The needle advances in the subcutaneous layer, above SMAS, and exits at the exit point

Once the suture has been inserted, the tissue is compressed until desired result; then the sutures are positioned, pressing a little bit with the tips of the scissors to ensure that the sutures remain positioned inside the subcutaneous plane (Fig. 64.8) [6].

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64.3 Clinical Follow-up No special clinical follow-up is required for the procedural-submitted patients. Immediate temporary drawbacks can be considered a normal sign of the procedure. Bleeding at the introduction or exit points is common. Lumps, edema, hematoma, nodules, inflammation, bruising, swelling, extended pain, dimples, and patient sensitive to suture are expected adverse effects. Fig. 64.8  Upon conclusion of the treatment, the sutures are cut; then the skin is compressed until the desire result is obtained

64.4 B  efore and After (Figs. 64.9, 64.10, 64.11, and 64.12)

Fig. 64.10  Immediately after treatment Fig. 64.9  Patient pretreatment

Fig. 64.11  Before and after 1 month of treatment

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Fig. 64.12  Before and after 2 months of treatment

64.5 S  ide Effects, Complications, and Their Management There is no significant difference between the adverse effects of face threads and the threads we use in the abdomen. The majority of the cases reported were considered minor adverse events. Among the side effects that can be observed, infection at the entry or exit points (probably due to insufficiently sterile conditions), potential foreign body, asymmetries immediately after treatment (Fig. 64.13), and visible or palpable threads or cones can be observed. Very rarely, paresthesia and injury to the superficial nerves and vessel may be observed. However, most complications are probably related to bad technique use, with insertion being very superficial in the dermis or too deep [7]. Tip Box

• Satisfactory results are obtained through an ideal patient selection. Localized fatfree laxity is the best indication. A good indication is avoiding unrealistic patient expectations [2].

Fig. 64.13  Presence of skin hollowing and transient overcorrection after procedure

References 1. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques. Clin Plast Surg. 2006;33(3):321–32. 2. Russo PR, Fundaró SP.  The invisible facelift: manual of clinical practice. 2nd ed. Firenze: Officina Editoriale Oltrarno. p. 202. 3. Allen D, et al. Assessment of the biological safety of Silhouette Soft Suture: biological safety risk assessment. Alderley Edge: ChorleyConsulting; 2015. p. 42.

64  Threads for Abdomen 4. American Society of Plastic Surgeons. Dermal fillers: polylactic acid. Minimally invasive procedure. 2016 26th July, 2016; Available from: http://www.plasticsurgery.org/cosmetic-procedures/dermal-fillers-polylactic-acid.html#content. 5. Palm MD, et  al. Cosmetic use of poly-l-lactic acid: a retrospective study of 130 patients. Dermatol Surg. 2010;36(2):161–70.

459 6. De Benito J, Pizzamiglio R.  Suspension of the gluteal region with silhouette sutures. Aesthet Surg J. 2013;33(3(suppl)):825–95. 7. Helling ER, Okpaku A, Wang PT, Levine RA. Complications of facial suspension sutures. Aesthet Surg J. 2007;27(2):155–61.

Threads for Special Conditions: Buttocks

65

Adriana Vilarinho, Raquel Cavalcante, and Renata Marques Sitler

65.1 Materials Marking pen, 18G needle, ruler (in cm), suture scissor (sterile), sharps bin, white coats for the doctors (sterile if possible), sterile gauzes, sterile gloves, normal antiseptic liquid (chlorhexidine or Betadine), lidocaine 1% with adrenaline 1:200.000, and syringes [1, 2]. The threads: for the lifting of the gluteal region, it is necessary for the technique with Silhouette Soft to use at least three threads on each side, for satisfactory results.

A. Vilarinho (*) · R. Cavalcante · R. M. Sitler Clínica Adriana Vilarinho, São Paulo, SP, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_65

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65.2 Methods and Techniques Preparation: For all patients, frontal and lateral pictures are taken of the gluteal region. Lidocaine 4–10% cream is applied 30  min before the procedure. Anti-sepsis: Initially, an antibacterial product such as chlorhexidine is used to hygienize the whole area to be treated. Design: Then, design the treatment technique with a marker- or pencil-based drawing with the patient standing on his feet. There are different techniques of drawing to insert the threads. In this point, the number of threads necessary for each case is stablished. Techniques: The insertion points can be at the superior gluteal area, as an inverted U-form, three threads in each side of the buttocks. Other technique is the straight technique, inserting in the middle of the buttock, pulling one side of the thread up and other down. Anesthesia: After that, local anesthesia, such as 1–2% solution of lidocaine with epinephrine (1/200,000), is injected at the insertion area. Insertion: All versions of the thread-lift rely on a similar basic technique, which involves subcutaneous placement of cogged threads along a planned trajectory. Initially, with a needle, an incision is made for the entrance of the threads. To place an individual thread, the dermatologist guides the straight needle through the incision and into the subcutaneous plane. Movement of the needle and suture through the subcutis is generally well tolerated by patients. If the straight needle moves superficially to this plane, it is immediately apparent as linear dimpling of the overlying skin. If it is deeper than the ideal plan, the patient will feel pain or discomfort [3]. Withdrawal of the threads: The straight needle exits the skin at the end of the drawing. It is trimmed from the thread after pulling the attached suture through the skin. Ensure that the threads are cut at the insertion point and the cog ends are submerged underneath the skin; otherwise protrusion may occur. Pull the thread lightly to achieve the desired skin lift and then trim the excess thread.

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Finalization: Clean the area and put dressings on the insertion points and tapes holding tight the buttocks. Topical antibiotic cream is prescribed to apply in these sites for the next few days. Incisions used for insertion of the straight needle and anchoring heal rapidly by secondary intention [3].

65.2.1 Inverted U technique

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65.2.2 Straight technique

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65.3 Clinical Follow-Up The patient must stay with the dressings for 3 days and is oriented to avoid physical exercises or big impacts in the area for 4 weeks. If possible, keep tapes for 1 week. There is no need for massages in the treated area. The patient returns to the medical office in 1  month for new pictures and medical evaluation.

65.4 B  efore and After (Figs. 65.1 and 65.2)

Fig. 65.1  Before (left) and after three months after treatment (right) with poly-I- lactic acid (6 threads total – 3 each side)

Fig. 65.2  Before (left) and after two months after treatment (right) with poly-I- lactic acid (6 threads total – 3 each side)

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65.5 S  ide Effects, Complications, and Their Management The most common side effects are ecchymosis, erythema, and edema. Mild complications such as swelling, bruising, and subjective feelings of “tightness” usually resolve within 1–3 weeks. These can also happen: thread breakage and extrusion, skin dimpling, superficial hemorrhages, and persistent pain. Positive results depend on the process of patient selection (good candidates) as well as

Tip Box

• Choose ideal patients, without voluminous buttocks. • Explain to the patient that the improvement will be due to the collagen stimulation and also because of the traction. • Maintain tapes making suspension of the gluteal region for 1 week. • Avoid impact exercises for 1 month.

selection of the most appropriate technique for the patient [3, 4].

References 1. Horne DF, Kaminer MS. Reduction of face and neck laxity with anchored, barbed polypropylene sutures (contour threads™). Skin Ther Lett. 2006;11(1):5–7. 2. Khawaja HA, Hernandez-Perez E.  Transcutaneous face-lift. Dermatol Surg. 2005;31(4):453–8. 3. Yongtrakul P, Sirithanabadeekul P, Siriphan P. Thread lift: classification, technique, and how to approach the patient. Int J Med Health Sci. 2016;10(12). 4. de Benito J, Pizzamiglio R.  Suspension of the gluteal region with silhouette suture. Aesthet Surg J. 2013;33(3 Suppl):82S–9S.

Part V Chemical Substances for Injectable Cosmetic Neocollagenesis

Introduction: Chemical Substances for Injectable Cosmetic Neocollagenesis

66

Elisangela Samartin Pegas, Felipe Borba Calixto dos Santos, and Beatrice Martinez Zugaib Abdalla

66.1 History [1] The increase in life expectancy has led humanity to seek ways to delay and correct the signs of aging. Most skin changes such as blemishes, ridges, and furrows can be resolved or attenuated through surgical procedures, peelings, and lasers, but these treatments do not provide the improvement of volume loss. It has been described for more than 100 years, and several attempts have also been made to restore facial volume with the use of injectable substances. In 1893, Neuber published the first autologous fat graft on depressive scars. In 1911, Frederick reported the first paraffin fill. The earliest work using non-biological fillers, such as paraffin and petroleum jelly, dates from the late nineteenth

E. S. Pegas (*) Leprosy, Phototerapy and Bullous Diseases Outpatient Clinic at PUC Campinas, Campinas, Brazil F. B. C. dos Santos Department of Dermatology at PUC Campinas, Campinas, Brazil B. M. Z. Abdalla ABC School of Medicine, Santo André, SP, Brazil 2nd Year Resident of Internal Medicine at FMABC, Santo André, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_66

century to the early twentieth century. In the 1960s and 1970s, the use of liquid silicone arose, having been widely used; however, the concern that this substance could migrate and generate granulomas and severe unaesthetic changes caused the abandonment of this procedure in several countries. In 1977, Knaap made the first application of bovine collagen, and in 1981 a major breakthrough was made with this product (Zyderm, Zyplast, Inamed Corp., Santa Barbara, CA), and it was the first FDA (Food and Drug Administration)-approved injectable filler for cosmetic use. The temporary nature of bovine collagen, associated with allergenicity, the need for refrigeration, and two skin test readings (type I and IV hypersensitivity reaction), stimulated the development of new fillers in Europe and Asia. Hyaluronic acid (HA), which is a biocompatible synthetic, emerged in the 1990s as a promising material. The filling technique has evolved rapidly because it can be easily performed and does not require the patient to delay their daily activities or work. Neocollagenesis induction techniques have been sought through injectable substances such as hyaluronic acid, calcium hydroxyapatite, glycol polyethylene, polymethylmethacrylate, fat graft, autologous fibroblasts, and platelet-rich plasma. 467

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66.2 Classification

66.3 Materials Available

There are many products in the market; and with a wide variety, dermatologists must know what are the ideal characteristics and substances that are safe and that have positive results (Table 66.1) [1–3]. Fillers can be classified as permanent and nonpermanent. However, when a filler is a permanent product, it does not confer permanent patient satisfaction, since aging is progressive and structural alterations will not be accompanied by the product, generating unaesthetic effects (Table 66.2) [1–3]. The fillers have different origins and characteristics, with its own peculiarities and indications (Table 66.3) [1–3].

66.3.1 Hyaluronic Acid (HA) [4–7] (Figs. 66.1 and 66.2)

Table 66.1  Features of an ideal cutaneous filler Material characteristics

Performance

Application technique Other

Biocompatible Non-antigenic Non-toxic Non-carcinogenic Non-teratogenic Sterile Chemically inert Not modified by liquid or organic tissues Reproducible Durable Safe No migration Ability to withstand mechanical stress Simple technique Easy application Approved by health authorities Stable formula, for easy transport and storage Good cost/benefit Reversible

Table 66.2  Permanent and nonpermanent fillers Permanent fillers Polymethylmethacrylate (PMMA) Polymer hydrogels

Nonpermanent fillers L-Polylactic acid Calcium hydroxyapatite Autologous fat Collagen Hyaluronic acid

Hyaluronic acid exists naturally in the skin, making up a significant portion of the extracellular matrix (ECM); which is involved in repairing tissues, stabilization of intercellular structures, proliferation and cell migration. When injected, it binds to endogenous HA and attracts and binds to water, adding volume. However, recent research suggests that HA induces neocollagenesis through changes in the structure and function of the ECM. Research has (^) raised the hypothesis that fibroblasts from naturally aged skin could be stimulated through injectable materials that could enhance structural support to the ECM.  The fibroblasts surrounding the injection sites presented an elongated appearance, and immunohistology revealed high levels of procollagen type I (the precursor of mature type I collagen). In these studies, increased collagen production was observed 1 month after injection and remained elevated for up to 3 months. The authors concluded that the injection of HA mechanically induces a stretch of the dermis, which in turn stimulates dermal fibroblasts to produce collagen. Laser capture microscopy of elongated fibroblasts demonstrated an increase by 12-fold of the induction of type I procollagen gene expression and positive regulation of the TGF-­beta pathway, which is influenced by mechanical force, fundamental for fibroblast function in producing collagen. Other papers have demonstrated and theorized that there are collagen fibers that are stretched by the injection of hyaluronic acid, which imposes a mechanical tension around the fibroblasts and, thus, would stimulate the increase in the production of collagen types I and III.  A statistically significant increase was also found in procollagen, tissue inhibitors of metalloproteinase I (TIMP-I), and expression gene of procollagens I and III after a month from the injection.

HA injection stimulates dermal fibroblasts to produce collagen.

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66  Introduction: Chemical Substances for Injectable Cosmetic Neocollagenesis Table 66.3  Filler classification Fillers Nonpermanent (biodegradable)

Autogenic

Allogenic

Heterogenic

Synthetic

Semipermanent

Without culture With culture Cadaver graft Non-­ cadaver graft

Origin Fat Dermis Culture of autologous fibroblasts Acellular dermal graft

Characteristics Non-immunogenic Needs donor area Non-immunogenic Needs donor area Immunogenic

Collagen extracted from dermal tissue fibroblasts culture

Non-immunogenic No test required

Bovine collagen

Antigenic Testing required Contraindicated to individuals with a history of bird allergy Low immunogenicity No test required

Hyaluronic acid Animal Origin (Gallus crest) Hyaluronic acid NASHA technology Bacteria fermentation (with or without lidocaine) Hyaluronic acid + dextranomer

Low immunogenicity No test required Hyaluronic acid + mannitol Low immunogenicity No test required Low immunogenicity Calcium hydroxyapatite Calcium microparticles suspended No test required in carboxymethyl cellulose aqueous gel Low immunogenicity L-Polylactic acid No test required Synthetic polymers Previous reconstitution (24 h Carboxymethyl cellulose + before) mannitol

Fig. 66.1  Patient images before and after use of hyaluronic acid

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Fig. 66.2  Patient images before and after use of hyaluronic acid

66.3.2 Calcium Hydroxyapatite [8, 9]

hydroxy acid family. Injection into the skin results in an immediate, but temporary, response Calcium hydroxyapatite is a biocompatible, non-­ lasting about a week. The latter and progressive antigenic, biodegradable, and opaque material. effect promotes volumization, in which the Initially used as an implant for bone replacement, remaining crystals stimulate neocollagenesis. calcium hydroxyapatite is a substance normally This inflammatory response triggers the producpresent in our body, which is why it rarely causes tion and formation of fibrous connective tissue immunological inflammatory reactions and does around the filler, causing fibroplasia and a gradnot require a skin pre-test. Although it has calcium ual increase in the dermal volume that can take as its component, it does not become hardened after from 3 to 6  months and last for more than application, but is radiopaque and can interfere with 2 years. radiological exams. The calcium hydroxyapatite microspheres (CaHA) contain soft particles suspended in an aqueous solution, carried on by a carInjection of L-polylactic acid produces a boxymethyl cellulose gel which is eventually foreign body type reaction with a gradual absorbed. The microspheres induce histiocyte and increase in collagen production. fibroblast responses, acting as a support to form new tissue around the implant, leading to dermal thickening. Calcium hydroxyapatite lasts about a year, before the particles are degraded as calcium and phosphate and eliminated through the renal sys- 66.3.4 Polymethylmethacrylate (PMMA) [12] tem; however the filler effect can last for 2–5 years.

Calcium hydroxyapatite microspheres induce histiocyte and fibroblast responses, leading to dermal thickening.

66.3.3 L-Polylactic Acid [10, 11] L-Polylactic acid is a synthetic, biocompatible, and biodegradable polymer of the alpha-

The polymethylmethacrylate (PMMA) filler has excellent tissue compatibility, easy handling, resistance and radiolucency, and low thermal and electrical conductance and is lightweight, chemically inert, easily accessible, and hypoallergenic. It is widely used in patients with HIV on antiretroviral therapy, which causes metabolic alterations, such as lipodystrophic syndrome of HIV, characterized by increased cholesterol and triglycerides, insulin resistance, and changes in body fat distribution.

66  Introduction: Chemical Substances for Injectable Cosmetic Neocollagenesis

After PMMA application, the formation of giant cells and neocollagenesis around the microspheres occur.

66.3.5 Polyethylene Glycol [13, 14] Polyethylene glycol (PEG) is a synthetic polymer composed of several units of ethylene glycol, obtained from the polymerization reaction of ­ ethylene oxide, having various molecular weights, with numerous purposes in the pharmaceutical industry, medicine, and biotechnology. It is used in the composition of cosmetic creams, injectable solutions (cutaneous fillers and cartilage regenerators), laxatives, and protein-coupled drug delivery systems. The crosslinking of the PEG with the bis-­ acrylate forms PEG diacrylate, a homogeneous, non-cytotoxic, slow-degradation synthetic biocompatible synthetic gel widely used as a cutaneous filler. It is indicated mainly in facial volumization and can be very useful in the correction of deep wrinkles, furrows, and scars. PEG is an amphiphilic polymer, i.e., soluble in water and most organic solvents.

66.3.6 Autologous Fibroblasts [15–18] The dermis is composed mainly of extracellular matrix and fibroblasts, which produce elastic fibers and collagen (types I and III). The main signs of skin aging are thinning of the epidermis, decrease in the number of dermal cells, collagen fiber breakdown, collagen type I and III reduction, fibroblast number depletion, and hyperplasia of elastic fibers. The dermis is responsible for skin tone, elasticity, and firmness, with the highest concentration of fibroblasts and collagen fibers in its upper portion. Studies have demonstrated that the injection of autologous fibroblasts for correction of dermal defects has provided an increase in the amount of collagen fibers in the patients’ dermis, which can be observed by increasing the number of young fibers in polarized image microphotography.

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66.3.7 Fat Graft [19] (Figs. 66.3 and 66.4) Lipo-enxertia is a surgical technique that consists of injecting the individual’s own fat under the skin. It aims to improve the contours and fill the furrows and depressions of some regions of the body and face. However, the unpredictability of the results, due to the possibility of absorption and consequent loss of the desired volume, is still a limiting factor of fat grafts. Injected fat is partly absorbed by the body in the approximate period of 4–6 months. Several researchers have attempted to circumvent this problem by adding fat additives such as insulin, beta-blockers, fibroblast culture, and, recently, stem cells to improve graft grip.

66.3.8 Platelet-Rich Plasma (PRP) [20–26] Platelet-rich plasma (PRP) is a plasma suspension obtained from blood prepared to contain platelet concentrations higher than those normally found in circulating blood. PRP has received attention recently for its attribution in tissue repair and rejuvenation, being used in the treatment of scars, wrinkles, and alopecias, for example. Platelet degranulation releases growth factors such as platelet-derived growth factor, TGF-beta, fibroblast growth factor-2, vascular endothelial growth factor, epidermal growth factor, cytokines, adhesion molecules, integrins, and coagulation proteins. PRP has been studied for its effects on extracellular matrix remodeling, a process that requires activation of dermal fibroblasts, which are essential for the rejuvenation of aged skin. PRP increases the expression of type I collagen and mRNA in human dermal fibroblasts. Some studies have shown improvement in superficial and deep wrinkles and cutaneous texture of the face, after monthly injections of PRP.

PRP increases the expression of type I collagen and mRNA in human dermal fibroblasts.

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Fig. 66.3  Patient images before and after lipo-enxertia. (Images are a courtesy of Dr. Bogdana Victoria Kadunc)

Fig. 66.4  Patient images before and after lipo-enxertia. (Images are a courtesy of Dr. Bogdana Victoria Kadunc)

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66.4 Collateral Effects, Complications, and Management [27] The side effects from the application of fillers can be early or late (Table 66.4) [27].

Table 66.4  Collateral effects Early-­ onset collateral effects Erythema and edema

Usually immediate and observed in most cases. Occur through local inflammation. It can be aggravated by multiple injections, compact material, and incorrect application technique Bruising/ Occurs by hematoma perforation of small vessels at the application site or by compression and secondary vessel rupture Necrosis Rare complication, caused by local compression (overcorrection or intense inflammation) or accidental intraarterial injection (with vascular embolization)

Infection Nodules

Bacterial or viral etiology Observed as short- and mediumterm effect and manifests itself as whitish or normochromic papules or nodules

Management Place ice for 5–10 min. Edema can be avoided or minimized with fewer applications on the skin

Immediate local compression

Local hygiene, warm compresses, local massage to dissolve the embolus, nitroglycerin paste, and in the case of HA filler, use the injection of hyaluronidase as early as possible. In case of embolization, full heparinization of the patient can be performed Treatment according to etiology Local massage. In extreme cases oral corticoid is indicated. In severe cases surgical removal of the material can be performed. Most cases have spontaneous resolution

Late-onset collateral effects Granulomas

Allergic reaction

Non-painful palpable nodules in the path of filler applications

Management Application of hyaluronidase may be performed in the case of HA filling or intralesional corticosteroid infiltration and even surgical removal of the granuloma Oral or intralesional corticoid

Edema and erythema in the filler application path, which can occur after 1 to 6 months from the application Hypertrophic In puncture sites Occlusive corticoid scar

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References 1. Sandoval MHL, Sandoval DL. In: Steiner D, Addor, editors. Envelhecimento Cutâneo. 2014. p. 250–255. 2. Steiner D, Marçon CR. Terapêutica do Envelhecimento Cutâneo. In: Kadunc B, Palermo E, Addor F, Metsavaht L, Rabello L, Mattos R, Martins S, editors. Tratado de Cirurgia Dermatológica, Cosmiatria e Laser da Sociedade Brasileira de Dermatologia; 2012. p. 259–71. 3. Almeida ART.  Técnicas de Preenchimento. In: Kadunc B, Palermo E, Addor F, Metsavaht L, Rabello L, Mattos R, Martins S, editors. Tratado de Cirurgia Dermatológica: Cosmiatria e Laser da Sociedade Brasileira de Dermatologia; 2012. p. 351–5. 4. Mehta-Ambalal SR.  Neocollagenesis and Neoelastinogenesis: from the laboratory to the clinic. J Cutan Aesthet Surg. 2016;9(3):145–51. https://doi. org/10.4103/0974-2077.191645. 5. Carruthers JD, Carruthers JA, Humphrey S. Fillers and neocollagenesis. Dermatol Surg. 2014;40(Suppl12):S134–6. https://doi.org/10.1097/ DSS.0000000000000227. 6. Wang F, Garza LA, Kang S Varani J, Orringer JS, Fisher GJ, Voorhees JJ. In vivo stimulation of de novo collagen production cause by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol. 2007;143:155–63. 7. Parada MB, Afonso JPJM. Ácido Hialurônico. In: Steiner D, Addor, editors. Envelhecimento Cutâneo; 2014. p. p239–45. 8. Shono MM, Niwa ABM, Osorio NES.  Tratamento para rejuvenescimento das mãos com hidroxiapatita de cálcio. Surg Cosmet Dermatol. 2012;4(2):186–8. 9. Andrade R.  Hidroxiapatita de Cálcio. In: Steiner D, Addor, editors. Envelhecimento Cutâneo; 2014. p. p246–50. 10. Coimbra DDA, Amorim AGF. Ácido Poli-L-Lactico na região medial dos braços. Surg Cosmet Dermatol. 2012;4(2):182–5. 11. Machado Filho CDAS, Santos TC, Rodrigues APLJ, da Cunha MG. Ácido Poli-l-Lactico: um agente bioestimulador. Surg Cosmet Dermatol. 2013;5(4):345–50. 12. Antonio CR, Antonio JR, Oliveira GB, Alves FT.  Preenchimento com PMMA em membros inferiores em paciente com lipodistrofia por antirretrovirais. Surg Cosmet Dermatol. 2014;6(4):373–5. 13. Patel PN, Smith CK, Patrick CW Jr. Rheological and recovery properties of poly(ethylene glycol) diacrylate hydrogels and human adipose tissue. J Biomed Mater Res. 2005;73:313–9. 14. Yarak S, Ruiz R.  Polietilenoglicol. In: Sandoval MHL, Ayres EL, editors. Preenchedores: guia pratico de tecnicas e produtos; 2013. p. 104–7. 15. Monteiro MR, Tersario ILS, Lucena SV, Moura GEDD, Steiner D. Cultura de Fibroblastos dérmicos humanos na presença de ácido hialurônico e polietilenoglicol: efeitos na proliferação celular, produção

E. S. Pegas et al. de colágeno e enzimas relacionadas à remodelação da matriz extracelular. Surg Cosmet Dermatol. 2013;5(3):222–5. 16. Munavalli GS, Smith S, Maslowski JM, Weiss RA. Successful Treatment of Depressed, Distensible Acne Scars Using Autologous Fibroblasts: a multisite, prospective, double blind, placebo-controlled clinical trial. Dermatol Surg. 2013;39(8):1226–36. https://doi.org/10.1111/dsu.12204. 17. Eça LP, Pinto DG, de Pinho AM, Mazzeti MP, Odo ME.  Autologous fibroblast culture in the repair of aging skin. Dermatol Surg. 2012;38(2):180–4. https:// doi.org/10.1111/j.1524-4725.2011.02192.x.Epub201 1oct10. 18. Weiss RA.  Autologous cell therapy: will it replace dermal fillers? Facial Plast Surg Clin North Am. 2013;21(2):299–304. https://doi.org/10.1016/j. fsc.2013.02.008. 19. Benemond TMH, Yokomizo VMF.  Lipoenxertia. In: Kadunc B, Palermo E, Addor F, Metsavaht L, Rabello L, Mattos R, Martins S, editors. Tratado de Cirurgia Dermatológica: Cosmiatria e Laser da Sociedade Brasileira de Dermatologia; 2012. p. 381–90. 20. Pinto JMN, Pizani NS.  Aplicabilidade em derma tologia do plasma rico em plaquetas. Surg Cosmet Dermatol. 2015;7(1):61–4. 21. Faghihi G, Keyvan S, Asilian A, Nouraei S, Behfar S, Nilforoushzadeh MA. Efficacy of autologous plateletrich plasma combined with fractional ablative carbon dioxide resurfacing laser in treatment of facial atrophic acne scars: a split-face randomized clinical trial. Indian J Dermatol. 2016;82:162–8. https://doi. org/10.4103/0378-6323.174378. 22. Leo MS, Kumar AS, Kirit R, Konathan R, Sivamani RK.  Systematic review of the use of platelet-rich plasma in aesthetic dermatology. J Cosmet Dermatol. 2015;14(4):315–23. https://doi.org/10.1111/jocd.12167. 23. Kakudo N, Minakata R, Mitsui T, Kushida S, Notodihardjo FZ, Kusumoto K.  Proliferationpromoting effect of platelet-rich plasma on human adipose-derived stem cells and human dermal fibroblasts. Plast Reconstr Surg. 2008;122(5):1352–60. https://doi.org/10.1097/PRS.0b013e3181882046. 24. Kim DH, Je YJ, Kim CD, Lee YH, Seo YJ, Lee JH, Lee Y.  Can platelet-rich plasma be used for skin rejuvenation? Evaluation of effects of platelet-rich plasma on human dermal fibroblast. Ann Dermatol. 2011;23(4):424–31. https://doi.org/10.5021/ ad.2011.23.4.424. 25. Redaelli A, Romano D, Marcianó A.  Face and neck revitalization with platelet-rich plasma (PRP): clinical outcome in a series of 23 consecutively treated patients. J Drugs Dermatol. 2010;9(5):466–72. 26. Monteiro MR. Plasma Rico em Plaquetas em dermatologia. Surg Cosmet Dermatol. 2013;5(2):155–9. 27. Crocco EI, Alves RO, Alessi C. Eventos Adversos do ácido hialurônico injetável. Surg Cosmet Dermatol. 2012;4(3):259–63.

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67

Maria da Glória Martin Sasseron, Renan Lage, Larissa Mondadori Mercadante, and Luiza de Castro Fernandes

67.1 History/Background Different techniques and materials have been described and developed in order to improve wound healing. Sutures date from about 3000 BC, and, from the first reports until the middle AD 1800s, they were only classified according to their origin (animal/insect, plant or metal). With the appearance of modern sutures, classification included other aspects, such as physical characteristics and composition [1]. Wound dressings made of honey, linen thread, and grease were reported in Egyptian manuscripts dating from 3000  BC and are the oldest descriptions of coverings used to optimize wound healing. In the nineteenth century, several dressings made of linen cloth were developed, including cotton balls created by Gamgee in 1860 [2]. Since then until the Second World War, the concept that a dry environment was essential for adequate healing was considered in the develop-

M. da Glória Martin Sasseron (*) Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil R. Lage Cosmiatric Department, Department of Dermatology of the Pontifical Catholic University of Campinas PUC Campinas, Campinas, SP, Brazil L. M. Mercadante · L. de Castro Fernandes Medical Resident in Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_67

ment of dressings. In 1945, Bloom reported good results following the use of a transparent film in patients with burns; in 1960, Schilling improved this film by the addition of a polyvinyl frame, thus introducing the basis for the development of future resources [2]. In 1962, Winter and Roove observed a 50% increase in the epithelization rate in moist, occluded environments (associated to a reduction in crust formation) when compared to air-exposed lesions, modifying research directions on wound dressings [2, 3]. In 1982, the trade of hydrocolloid dressings to treat partial-thickness wounds began, while hydropolymers were developed in the subsequent decade. The indiscriminate use of antiseptics and antimicrobials in the 1990s later proved to be useful and necessary only in specific cases [2].

67.2 Genesis The process of wound healing is dynamic and formed of distinct phases (Table 67.1): • Phase 1: coagulation, depending on the activity of platelets and the coagulation cascade, through the alignment of wound margins and the cross-linking of fibronectin, providing a temporary matrix [2]. • Phase 2: inflammation, associated to inflammatory cells and their mediators. The main 475

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476 Table 67.1  Phases of Wound Healing Phases Coagulation

Inflammation Proliferation Margin contraction Remodeling

•

•

•

•

•

Main Alterations Depends on the activity of platelets and the coagulation cascade. Margin alignment and cross-linking of fibronectin, providing a temporary matrix Participation and migration of inflammatory cells and their mediators Reepithelization, fibroplasia and angiogenesis Centripetal movement of margins Decrease in scar size and erythema, increase in tension forces

inflammatory cell in this phase is the macrophage. Other participating cells are polymorphonuclear leukocytes and lymphocytes [2]. Phase 3: proliferation, subdivided into three different stages – reepithelization, fibroplasia, and angiogenesis. Reepithelization results from keratinocyte migration from lesion margins (as well as from the cutaneous annexes, when partial-thickness wounds are considered). Fibroplasia is important for the formation of the granulation tissue, while angiogenesis allows the supply of oxygen and nutrients [2]. The granulation tissue is formed of inflammatory cells, fibroblasts, collagen, glycosaminoglycans, and fibronectin, with fibroblasts being the main component in this process [2]. It is also important to highlight that growth factors and the water content in the wound bed are very important for keratinocyte migration [2]. Phase 4: wound contraction, only present in total-thickness cases, consisting of the centripetal movement of margins and the reduction of wound size [2]. Phase 5: remodeling, in which a decrease on scar size and erythema and an increase on tension forces take place. Alterations on collagen content and on the matrix are also seen [2].

An important event during remodeling is the replacement of type III-collagen by type I-collagen in mature wounds, as well as biochemical signaling, including the release of TGF-beta,

matrix metalloproteinases, tissue inhibitors of metalloproteinases, and the stimulation of hyaluronic acid activity [4]. Other participants of the process include PDGF, IGF-1, VEGF, FGF, TNF-­ alfa, IL-1, and IFN-gama [3]. The different phases and mediators taking part in this process are interdependent and interconnected, establishing an active and dynamic relationship [5]. Comorbidities such as diabetes, obesity, malnutrition, and smoking habits negatively impact the process. Drugs such as isotretinoin, anticoagulants, antiaggregants, and oral and topical corticoids also slow down and impair the healing process [2, 6]. Tissue repair may be improved by the use of several materials for synthesis and as dressings. For wound synthesis, adhesives, clamps, and suture threads may be used. Threads are characterized according to their physical properties, such as composition, covering, color and the ability of being absorbed. To choose the best suture type, it is necessary to observe the required tension, the will to invert or reverse margins, wound location, type of repair, hemostasis need, and the integrity of local skin [7]. It is important to respect tension lines and cosmetic units, as well as the need to perform subcutaneous sutures. The parsimonious use of the electrocautery is also a useful practice [2]. Different types of dressings may be used to help restoring tissues. Their adequate choice depends on the procedure performed. Coverings must be able to protect, absorb, and drain, creating an optimal healing environment in the wound bed and optimizing tissue repair [3]. The ideal dressing must fulfill the following requirements: maintenance of local moist conditions, comfort, reduction of pain, easy removal and application, adaptability to different body parts, decrease infection and colonization, and good cost/benefit ratio [3, 8]. Good local moist conditions are indispensable to prevent inadequate healing and to promote satisfying tissue repair in the shortest period of time [5]. Wound coverings may also act on the different phases of the process: hygiene, debridement, reduction of bacterial populations, exudate control, granulation tissue stimulation, and protection during reepithelization [3].

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67.3 Classification/Types Wound healing may be classified as follows: closure by primary intention (Fig.  67.1), by the approximation of wound edges; by secondary intention, when margins are not coapted, requiring granulation tissue formation and epithelization (Fig. 67.2); and by tertiary intention, when topical (or advanced) treatments are needed, with subsequent coaptation of margins [6]. Many classifications, for both wounds and dressings, have been proposed. Wound categorization makes it possible to choose the ideal dressing. • According to their characteristics [3]: –– Simple wounds: close spontaneously, following the physiological stages of wound healing. –– Complex wounds: affect wider or deeper areas and require special resources to close, a

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showing altered development and recurrence. • According to time [3]: –– Acute wounds: complete healing within 3 weeks. –– Chronic wounds: require more than 3 weeks for healing. Chronic wounds may also be classified according to the type of tissue seen on the wound bed: necrotic, sloughy, granulation tissue, and epithelization tissue [9]. Postoperative wounds are considered acute and usually heal by primary intention, except when dehiscence occurs or their development is chronic [6]. Dressings or coverings are therapeutic tools including the cleaning of wounds and the application of materials, aiming on improving the environment of the wound bed and supporting its closure [3].

b

c

Fig. 67.1 (a) Squamous cell carcinoma of the inferior lip. (b) Immediate postoperative of wedge excision, primary closure. (c) Tenth postoperative day

a

Fig. 67.2 (a, b) Closure by second intention in 30 days

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a

b

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Fig. 67.3 (a) Primary closure. Arrow indicating area of higher tension. (b, c) Vaseline use followed by impregnated gauze. (d, e) Seventh postoperative day before and after removal of the suture, with excellent healing

• According to their location, dressings and coverings are [9]: –– Primary: placed directly on wounds and the adjacent skin. –– Secondary: applied over the primary dressing (Fig. 67.3). • According to their action [3]: –– Passive dressings: inert; they protect and maintain the moist environment of wounds. –– Dressings with active principles: contain active substances in their composition, acting on enzymatic debridement and controlling bacterial populations. –– Intelligent dressings: mostly used on chronic wounds; they are able to alter the wound microenvironment, stimulating cytokines responsible for tissue repair. –– Biological dressings: autogenous grafts. Some authors also include in this group allogenous or heterogenous tissues that temporarily replace human skin in lesions such as burns, trauma, and chronic ulcers. –– Composite dressings: use two or more types of dressings. Information on the available dressings, as well as on their composition, mechanism of action, indications, warnings, mode of application, and frequency of change, are important for the adequate healing of wounds [9]. For a precise diagnosis of the type of wound and the stage of the healing process, factors such as the location of

the wound (bony projections, skinfolds), its extent and depth, and the presence and characteristics of exudates should be considered in the selection of a dressing capable of optimizing the process for a particular lesion [2]. It is important to highlight that coverings may and should be replaced according to wound development and tissue alterations on the wound bed. It is highly recommended to use dressings until the complete closure of the lesion [9].

67.4 Available Materials The goal of taking care of wounds is to restore the function, mobility, and integrity of the skin in the shortest time possible, minimizing the risk of infection and the pain caused by the rupture of the skin barrier. Patients also expect perfect, “invisible” scars. Their perception on the formed scar influences their opinion on the quality of the service performed by the surgeon and postoperative complaints. Therefore, physicians search trustworthy treatments capable of producing such results [5]. For tissue repair and the optimization of the healing process, the first step – the suture – must be performed following some principles. The “TAFT” concept is proposed, and it focuses on the following results: deep tension relief, subcutaneous or surface apposition enhancement, and surface finishing touches. The relief of deep ­tensions

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should be performed in specific cases, such as in extensive or deep defects, and in areas with high tensions, being obtained by the insertion of deep points to decrease dead spaces. Improvements in stich positioning include the use of traditional subepidermal or trans-­epidermal stiches. Finally, final touches on the surface include procedures that impact the cosmetic result. Therefore, the suture is presented as the main factor to obtain an aesthetically pleasant effect. Ideally, it should minimize tension, approximate and evert margins, as well as support healing and homeostasis. The ideal technique varies according to the location and characteristics of the defect [1, 7]. In addition to technique, the choice of suture materials also maximize wound healing. Absorbable threads lose most of their tension force 60 days following implantation; if a greater period of time is needed, they are considered nonabsorbable. Traditionally, nonabsorbable threads are used for epidermal closure, while absorbable ones are employed in intradermal procedures. The ideal suture material must be easy to handle, form safe knots with high tension force, show some elasticity to accommodate edema and wound retraction, and minimize the risk of infection (many contain triclosan, a biocompatible, topical antibiotic). Threads may be manufactured with synthetic or natural materials, with the latter being more common: silk (nonabsorbable) and gut (absorbable, composed of degradable proteins). Natural materials lead to greater tissue inflammation when compared to synthetic materials, once synthetic products tend to distribute the force within the suture more evenly. In dermatology, the most used sutures are the simple interrupted and simple continuous sutures, while the most used threads are polyglactin 910 (39.3%), nylon (26.5%), polypropylene (19.5%), polyglecaprone 25 (8.1%) and polydioxanone (United States, 2012). The use of atraumatic needles also improve postoperative healing, with the triangular needle being the most common in dermatological procedures [1, 7]. The ideal time for stich removal depends on location and varies from 5 to 7 days for faces and from 10 to 14 days for the scalp, dorsum, superior, and inferior limbs [1, 7].

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Tissue adhesives are alternatives to sutures. Adhesive liquids are applied directly on the margins of the surgical defect, forming a “glue” that seals the margins instantaneously, thus conferring protection against bacterial invasion. This adhesive is of easy application, dries rapidly, and unglues spontaneously in 7–14 days, for example, octyl cyanoacrylate (Dermabond), butylcyanoacrylate (LiquiBand), and N-butyl-2-cyanoacrylate (GluSeal). There are few reports on contact dermatitis because of the use of adhesives, but there are disadvantages mainly related to their cosmetic result, once they are not capable of everting margins or uniting wounds with greater margin tensions, resulting in wider scars. To minimize such an effect, they may be associated to subcutaneous suturing techniques. Surgical tapes may also be used during a 1-week period, following the pre-application of the surgical glue (example: Mastisol) [1, 7]. There is no “golden standard” technique for wound closure. The dermatological surgeon must consider all the previously explained factors while planning repair procedures that optimize scars aesthetically [1, 7]. An understanding of the dynamic structure of the skin and the biological healing process is also needed in order to obtain an adequate maturation of scars. Humectation, for example, is a crucial element to optimize tissue repair. The formation of a hydrophobic barrier by the use of dressings is capable of preventing the loss of trans-­ epidermal water, thus providing a proper environment for the growth of keratinocytes [ 5]. Several materials may be used at the different stages of postoperative wound care: hygiene, debridement, decrease of bacterial populations, exudate control, granulation tissue formation, and protection during reepithelization [3]. • Gauze dressings: variations include types of cloth, number of threads, and impregnation by substances. Dry gauzes should not be used directly on lesions because of adherence and because of the release of threads and fibers, which could act as foreign bodies. Impregnated gauzes, in turn, avoid adherence and thus do not injure neo-formed tissues. They allow the

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a

b

c

Fig. 67.4 (a) Immediate postoperative of BCC excision on the nasal dorsum with flap. (b) Use of impregnated gauze in the immediate postoperative period. (c) Seventh postoperative day

maintenance of a moist environment, also showing the ability to absorb possible exudates (Fig.  67.4). Indications: superficial burns, bloody areas, after trauma or surgical resection, graft donor or recipient sites, and wounds with granulation tissue formation. Examples include cellulose acetate gauze impregnated with petrolatum (Adaptic®), 10% PVPI solution (Inadine®), non-­adherent gauze made of hydrophobic polyester and impregnated with essential fatty acids (Atrauman®), and gauze impregnated with aloe vera (CarresynGauze®). Non-adherent, nonimpregnated gauzes include Telfa® and Melolin® [8]. • Silicone gel: biocompatible, transparent, and inodorous; it may be used in the pediatric population. The gel forms a semi-occlusive layer to water but permeable to gas exchange. Its presentation includes silicone tapes, cohesive gels, and quick-drying liquid gels. Other substances may be applied over the silicone gel, such as sunscreens and makeup products. The quick-drying liquid gel may be used in exposed areas such as the face, without the need of adherent tapes to keep the product in contact with the skin. The use of silicone gel is recommended after the removal of sutures. It should not be applied on open wounds neither in patients with a history of allergy to its components. Ideally, the product should be let in contact with the scar 24 h/day, requiring the application once or twice a day for 3  months; the time of application may be extended [10, 11]. • Hydrocolloids: materials composed of an external layer of polyurethane foam and a triple

internal layer formed of gelatin, pectin, and carboxymethylcellulose. Hydrocolloids are impermeable to gases and water vapor. They make autolytic debridement easier and liquefy necrotic tissue, consequently increasing granulation. Their function is to make wounds waterproof and to maintain a local moist environment. They are indicated for the prevention and treatment of open, uninfected wounds, venous and decubitus ulcers, burns, partial-thickness ulcers, and the prevention of blisters in athletes and diabetics. They may be also used in refractory, inflammatory diseases, such as psoriasis plaques, and in blistering disorders such as dystrophic epidermolysis bullosa. Dressings may be changed every 3–7  days, depending on exudation. They may be also trimmed. Examples include Duoderm®, Hydrocoll®, Tegasorb®, Restore®, Replicare®, Comfeel®, and Askina Biofilm® [9, 12]. • Calcium alginate: composed of fibers derived from marine seaweed; this material is capable of absorbing wound exudates, providing a moist, adequate environment for healing. It has been used for its hemostatic properties, becoming a gel when in contact with wound exudates (Fig.  67.5). It is indicated for the treatment of highly exudative, open wounds, with or without infection. It may be changed every 24–72  h and should be covered with a secondary dressing. Indications include postoperative wounds (to maintain homeostasis), chronic and recalcitrant decubitus ulcers, as well as exudative ulcers. Examples include Algoderm®, Acquacell®, Curasorb®, Kaltostat®, Melgisorb®, Seasorb®, Sorbsan®, Sorbalgon®, Sorbalgon Plus®, Suprasorb®, Restore Calcicare®, and Tegagen® [9, 12].

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Fig. 67.5 (a, b) Immediate postoperative of nail surgery using calcium alginate. (c) Fifth postoperative day

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f

Fig. 67.6 (a, d) Basal cell carcinoma (BCC). (b, e) Immediate postoperative of BCC excision. (c, f) Use of transparent film in the immediate postoperative period

• Activated charcoal with silver: activated charcoal dressings with silver show an exclusive absorbing function: they absorb odors, but not exudates. Changes depend on their degree of saturation and may not be needed before 72 h. If granulation tissue is formed, they must be replaced by another type of dressing. Indications include infected and non-infected lesions, surgical wound dehiscence, venous and pressure ulcers, and ulcers draining moderate-­ to-abundant amounts of exudate and/or with odor. They are contraindicated for dry, necrotic wounds. Examples include Actisorb Plus 25®, Carbo Flex®, Vliwaktiv®, and Acticoat® [12]. • Semipermeable films: consisting of transparent polyurethane, these materials are adhesive, sterile, comfortable, and highly elastic (Fig. 67.6).

They may be used as primary or secondary dressings, which may be applied on several non-adherent primary dressings. They maintain the natural moist and pH conditions of the skin, acting as barriers to wound contamination. They are also impermeable to water and permeable to oxygen. Because they are transparent, semipermeable films allow wound visualization, including surgical wounds with little bleeding, graft donor sites, burns, trauma excoriations, and skin lacerations (post-laser and dermabrasion wounds). They do not require secondary coverings or daily changes. Examples include Opsite®, Bioclusive®, Hydrofilm®, Tegaderm®, Aquagard®, Blisterfilm®, Hydrofilm®, Mefilm®, and Poliskin® [5, 12]. • Biological collagen: this group of dressings includes hydrophilic collagen particles of

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bovine origin, as well as compounds made of collagen and alginate (9:1). It is believed that the addition of collagen to the wound bed accelerates reepithelization by the promotion of cell migration. Collagen stimulates granulation and epithelization, in addition to exerting a chemotactic effect on macrophages and fibroblasts, and are indicated for non-infected wounds with little to moderate exudation. The use of an absorbing secondary dressing is recommended. This dressing is contraindicated for people with hypersensitivity to bovine derivatives. Examples include Hy Cure®, Fibracol Plus®, and Promogran® [12]. • Hydropolymers: pads usually composed of three superposed parts  – a central hydropolymer layer (which expands as it absorbs the exudate) and two external non-tissue layers (easily removed because of their non-adherent properties)  – indicated for exudative wounds during the granulation phase. Hydropolymer dressings maintain an ideal moist environment, support the autolytic debridement process, and remove exudates. They do not require secondary coverings and should be changed every 48  h. Examples include Allevyn®, Allevyn Cavity®, Biatain®, Curafoam®, Elasto-Gel®, Elasto-Gel ToeAid®, Hydrafoam®, Lyofoam®, Mepilex®, Oprasorb®, Polymen®, PolyWic®, Tielle®, Tielle Plus®, and Askina Transorbent® [2]. • Hydrogel: dressings are available as transparent gels or plaques. Some are associated to alginate, which increases its absorbing power. Mainly composed of water (20–96% depending on the manufacturer), hydrogels show an enormous ability to absorb high amounts of fluid, without significant increases in volume. Such dressings are very effective in ­decreasing pain and cause a sense of freshness, once they show a high water content that avoids the dehydration of nerve endings. In moist environments, autolysis can occur, thus improving the removal of the devitalized tissue; in wounds with granulation formation, they provide an ideal environment for tissue repair. Indicated for wounds with necrotic, devitalized tis-

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sues, allowing the removal of crusts and dry lesions. When associated to alginate, they may be used in wounds with low exudation, favoring angiogenesis. They require the use of secondary dressings and changes every 12–72  h. Examples include Intrasite gel®, Dermagran®, Duoderm gel®, Hydrosorb®, Hydrosorb Plus®, Hypligel®, Nu-Gel®, and Elasto-gel®, Purilon® [12]. A recent study showed good results following the use of hydrogel dressings associated with pectin and honey in the healing process of rat wounds [13]. • Proteolytic enzymes: mainly used to support debridement procedures. Collagenase (Iruxol Mono®, Kollagenase®, Santyl®), fibrinolysin (Fibrase®), and papain are widely deployed. They should not be used in the healing of wounds by first intention. Change is recommended every 24  h. Hypersensitivity can be observed. Papain may be compounded; commercially available forms include associations with urea (Accuzyme®) and with urea and chlorophyll (Panafil®  – Chlorofilium Copper Complex). Usual concentrations and indications include 2% (presence of granulation tissue), 4–6% (purulent exudates), and 10% (necrotic tissue). A combination of two proteolytic enzymes (Elase®) – fibrinolysin and desoxyribonuclease (of bovine origin)  – is indicated for exudative or infected wounds, with or without necrosis. Application must be careful and limited to three times a day; this product should be kept on the wound bed for 3 h and then removed; other dressings should be used between applications [8]. Silver sulfadiazine, both in the isolated form (Dermazine®, Pratazine®) and associated with cerium nitrate (Dermacerium®, Pratacerium®), is a hydrophilic, bactericide cream indicated for burns and infected or necrotic lesions. It is a low-cost product and must be applied after cleaning the wound and removing the devitalized tissue; moistened gauze should then cover the lesion. Changes are recommended every 12 h [8]. • Cellulose acetate: a semitransparent, vapor semipermeable compound, capable of maintaining a moist wound environment, indicated

67  Tip Chapter: Improving Healing in Cosmetic Procedures

for burns and graft donor sites. It is a low-cost product but may rupture at joints. It should not be used in highly exudative wounds. Example includes Biofill® [8]. • Vapor-permeable membranes: made of nonadhesive polyurethane; such membranes sometimes present openings that allow drainage and coaptation, favoring the maintenance of moist conditions, as well as the selective permeability of the dressing, indicated for burns, graft donor sites, and superficial wounds. Example include Omniderm® [8]. • Cell growth factor: although consisting of a promising biologically active group of substances, these high-cost products require more studies on their clinical applications. They include the platelet-derived growth factor (PDGF), the transformer factor (TFG-beta), the fibroblast growth factor (FGF), the insulin-­ like growth factor (IGF), and the epidermal growth factor (EGF). Example includes Regranex® [8]. • New technologies/tissue engineering: include skin implants of dermal regeneration ­templates, composed of collagen and glycosaminoglycans. An external silicone layer acts as a mechanical barrier. They promote cell growth and collagen synthesis and are indicated for clean wounds and burns. Examples include Apligraf®, Dermagraft®, Integra®. Biopolymers derived of natural rubber latex are a promising technology developed in Brazil and focuses on the ability of latex to stimulate angiogenesis. Snail secretion (Elicina®), a product formed of mineral oil, propylene glycol, acetylic acid, lauryl sodium phosphate, urea, and parabens, also shows healing properties, once it maintains the moist conditions of the wound bed and enhances neo-­angiogenesis and granulation tissue formation. Its use on superficial wounds has shown to be successful, accelerating the healing process [8]. Topical skin treatments should not be used indiscriminately [6]. Antiseptic and degerming agents commonly used for hygiene, wound cleaning, and the protection of peripheral regions should

483

Table 67.2  Healing – postoperative care in simple dermatological procedures Cleaning of wound beds

0.9% PS. Antiseptics and degermants should not be used indiscriminately Suture “TAFT” concept Dressings Dry gauzes should not be use directly and coverings on lesions Impregnated gauzes maintain the local moist environment and avoid injuries on the neo-formed tissues Antibiotics should not be used indiscriminately

not be applied on the wound bed. For cleaning, sprays of 0.9% PS are recommended. The use of topical antibiotics are also contraindicated, since they can be cytotoxic to keratinocytes even in adequate concentrations; they can also result in bacterial resistance and sensitization when very low concentrations are used [8] (Table 67.2). Although the current variety of dressings is increasing, there is no ideal product to treat all wounds. Large therapeutic arsenals increase the possibilities for tissue repair. Health professionals are responsible for making the best choice and should always rely on scientific evidence [3].

67.5 Side Effects and Complications Several factors may impair wound healing: deficient vascular supply, insufficient moisture, nutritional deficiencies, foreign bodies, hematomas, hypoalbuminemia, preexisting comorbidities (such as diabetes), the use of topical or systemic medication, immune status, and the growth of biofilms and microorganisms on the wound bed [2, 3, 14]. Microorganisms that produce biofilms secrete an extracellular matrix, capable of inducing chronic inflammatory responses, as well as impairing the healing process and its chronicity [14]. These complications require the use of oral antibiotics. To accelerate wound healing, biofilms should be removed with procedures such as curettage [6]. Insufficient moisture within a wound may delay the healing process, once it results in tissue

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dehydration (with cell death), inadequate angiogenesis, reduction in growth factors, and more extensive necrosis. Other outcomes include increased pain and sensitivity, translated into worse cosmetic results. Coverings that allow the maintenance of appropriate moisture conditions create a balanced environment [6]. Surgical wounds are usually covered with gauze to protect the lesion and the perilesional skin, offering a physical barrier. Care should be taken while changing gauzes so that the excess drainage and the withdrawal of materials do not favor bacterial infection or injure the wound [6]. Complications, such as allergic contact dermatitis (type IV hypersensitivity reactions), may result from the use of topical antibiotics (especially neomycin), which also increase bacterial resistance and impair the debridement of necrotic tissue. It is recommended to suspend medication when hypersensitivity is observed [6, 15]. Some dressings, such as calcium alginate and hydropolymers, should not be used in dry, exudate-­free wounds, once they cause adherence and maceration of the adjacent skin. Hydrogels and hydrocolloids may also promote this type of tissue maceration [8]. The use of other types of dressings may cause hypersensitivity reactions as well, especially EFAs, compression dressings, semipermeable films, proteolytic enzymes, and biological collagen [8].

67.6 Conclusions/Findings Wound healing is a dynamic process, influenced by several local and general factors. Many different techniques and materials may be used to close wounds. Adequate knowledge guides dermatologists in the selection of the most adequate combinations and in the production of the best possible aesthetic results [7]. Several benefits result from the use of occlusive dressings to treat postoperative wounds, including a reduction in pain and increased convenience for the patient, once they allow longer intervals between changes (compared to conventional dressings), as well as faster, more aesthetic results.

Tip box

• There are two types of surgical wounds: total-thickness and partial-thickness wounds. • Healing is a dynamic process, consisting of a cascade of events, involving five phases: coagulation, inflammation, proliferation, wound contraction, and remodeling. • Several local and general factors may influence the healing process. • Different techniques and materials have been described and developed to accelerate and improve healing. • The first sutures and dressings date from approximately 3000 BC. • In 1962, it was shown that epithelization rates were 50% faster in moist, occluded environments when compared to wounds exposed to air. • Different types of materials for wound synthesis may be used, from adhesives and clamps to suture threads. • Different dressings may be used to promote tissue repair and should be adequately chosen, depending on the procedure in use. • Ideal dressing: maintains local moist conditions, comfort, easily removed and applied, adaptable, decreases infection and colonization, and shows good cost/ benefit ratio. • Wound closure defines healing by primary, secondary, or tertiary intention. • Wounds may be simple or complex and acute or chronic. • Postoperative wounds are considered acute and usually show healing by first intention. • Dressings may be primary or secondary and passive, with active principles, intelligent, biological or composite. • The main dressings used in postoperative procedures are silicone gel and gauze dressings.

67  Tip Chapter: Improving Healing in Cosmetic Procedures

• Silicone gel is recommended after removal of sutures. • Dry gauzes should not be used directly on lesions while impregnated gauzes avoid adherence, maintain local moisture, and avoid injuries in neo-formed tissues. • 0.9% PS is recommended to clean the wound bed. Degermant and antiseptic agents should not be used indiscriminately. • The use of topical antibiotics is also contraindicated because of increases in microbial resistance and sensitization to the product. • Main complications in wound healing include infection, hypersensitivity, bacterial resistance and allergic contact dermatitis, dehiscence, and chronification.

References 1. Yag-Howard C.  Sutures, needles, and tissue adhesives: a review for dermatologic surgery. Dermatol Surg. 2014;40(Suppl 9):S3–S15. 2. Mandelbaum SH, Di Santis EP, Mandelbaum MHS. Cicatrização: conceitos atuais e recursos auxiliares - Parte I. An Bras Dermatol. 2003;78(4):393–408. 3. Smaniotto PHS, Ferreira MC, Isaac C, Galli R. Sistematização de curativos para o tratamento clínico das feridas. Rev Bras Cir Plást. 2012;27(4):623–6. 4. Kerwin LY, El Tal AK, Stiff MA, Fakhouri TM. Scar prevention and remodeling: a review of the medical, surgical, topical and light treatment approaches. Int J Dermatol. 2014;53(8):922–36.

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5. Marini L, Odendaal D, Smirnyi S. Importance of scar prevention and treatment-an approach from wound care principles. Dermatol Surg. 2017;43(Suppl 1): S85–90. 6. Delmore B, Cohen JM, O'Neill D, Chu A, Pham V, Chiu E.  Reducing postsurgical wound complications: a critical review. Adv Skin Wound Care. 2017;30(6):272–86. 7. Regula CG, Yag-Howard C. Suture products and techniques: what to use, where, and why. Dermatol Surg. 2015;41(Suppl 10):S187–200. 8. Mandelbaum SH, Di Santis EP, Mandelbaum MHS. Cicatrização: conceitos atuais e recursos auxiliares  - Parte II.  An Bras Dermatol. 2003;78(5): 521–2. 9. Tayar G, Peterlini MAS, Pedreira MLG. Proposta de um algorítmo para seleção de coberturas, segundo o tipo de lesão aberta em crianças. Acta Paul Enferm. 2007;20(3):284–90. 10. Radwanski HN, Correa WEM, Refosco TJ, Farrapeira Junior A, Pitanguy I.  Silicone gel em cicatrizes de cirurgia plástica: estudo clínico prospectivo. Rev Bras Cir Plást. 2010;25(3):428–33. 11. Weissman O, Tessone A, Liran A, Stavrou D, Farber N, Orenstein A, Haik J, Winkler E.  Silicone Nipple Shields: An Innovative Postoperative Dressing Technique After Nipple Reconstruction. Aesthet Plast Surg. 2010;34(1):48–51. 12. Sasseron MGM.  Atualidades em curativos oclusivos e semi-oclusivos. In: Malagutti W, Kakihara CT, editors. Curativos, estomias e dermatologia: uma abordagem multiprofissional. São Paulo: Martinari; 2014. p. 129–43. 13. Giusto, et  al. A new, easy-to-make pectin-honey hydrogel enhances wound healing in rats. BMC Complement Altern Med. 2017;17:266. 14. Percival SL. Importance of biofilm formation in surgical infection. Br J Surg. 2017;104(2):e85–94. 15. Gehrig KA, Warshaw EM. Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management. J Am Acad Dermatol. 2008;58(1):1–21.

Calcium Hydroxyapatite for Face

68

Eliandre Costa Palermo and Alessandra Anzai

68.1 Materials 68.1.1 Product Description • • Radiesse® injectable implant should be stored at a controlled room temperature between 15°C and 32°C (59°F and 90°F). • Radiesse is FDA approved in volumes of 0.3 cc, 0.8 cc, 1 cc, 1.3 cc, 1.5 cc, and 3.0 cc. • • Radiesse is a sterile, biodegradable and reabsorbed, non-pyrogenic, semi-solid, cohesive implant. • • It is composed of 30% synthetic CaHA microspheres (diameter of 25–45 μm) suspended in 70% viscous gel carrier of sterile water for injection, glycerin, and sodium carboxymethylcellulose. • CaHA is a natural substance found in bones • and teeth, so it is inert and nonantigenic. No allergy test is required prior to use. • It is not derived from human or animal tissue, which minimizes the risk of contamination with pathogens. • CaHA is generally injected with a 30-mm-­

long 27 gauge or 19-mm-long 28 gauge inner diameter needle or a 25 or 27 gauge variable length microcannula. CaHA has a high viscosity that prevents migration of the product. It is elastic, with high resistance to deformation under pressure and its high cohesivity permits a high lifting capacity [1]. CaHA has good safety, efficacy and tolerability profiles that are comparable to those of hyaluronic acid (HA) fillers [2, 3]. The longevity of results of CaHA is a consequence of its dual mechanism of action. Immediately after injection there is a gradual and uniform dissipation of the CaHA microspheres that provides volume. Later, neocolagenesis is induced by fibroblast activation [4]. In some countries, CaHa is available mixed with lidocaine 0.3% (Radiesse® (+) Lidocaine). Other countries use a protocol that adds lidocaine solution to CaHA right before the application. The association reduces patient’s discomfort without relevant changes in the product rheology [1].

E. C. Palermo (*) Faculty of Medicine of the ABC Foundation, Dermatology, São Paulo, SP, Brazil A. Anzai Hospital das Clínicas of University of São Paulo Medical School, Dermatology, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_68

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68.1.2 Dilution • Homogenization, volume of lidocaine for reconstitution.

• The FDA has approved a protocol for mixing Radiesse with lidocaine. The dilution varies according to the application site and clinical indication (Table 68.1).

Table 68.1  Dilution table for products with 0.8 and 1.5 ml

Dilution Radiesse® 0.8 ml Radiesse® 1.5 ml Dilution off-label

a

Support Thick skin 20% 0.15 ml Lidocaine 0.3 ml Lidocaine

Fine skin 40%a 0.3 ml Lidocaine 0.6 ml Lidocaine

Biostimulation Face 100%a or more 0.8 ml Lidocaine / SF 0.9% 1.5 ml Lidocaine / SF 0.9%

68  Calcium Hydroxyapatite for Face

68.2 Methods and  Techniques 68.2.1 Indications • The high elasticity and viscosity, combined with its ability to induce long-term collagen formation, provide a great versatility for CaHA [2, 5–7]. • CaHA is indicated for lifting, volumizing, and improving of the facial contour and correction of moderate-to-deep lines. • Diverse facial regions can be injected: nasolabial folds, perioral region, marionette lines, oral commissures, subdermal support of the brows, temples, malar and buccal fat pads, and chin, as well as saucerized acne scars. • It is also intended for restoration and/or correction of the signs of facial fat loss like a lipoatrophy (HIV +). • Undiluted CaHA may be injected at a deep level just above the periosteum to replenish volume loss and for a lifting effect.

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• A slightly diluted CaHA may be used to restore contours and proportions at the subcutaneous level. • Injecting a hyperdiluted solution into the dermis and subdermis improves the skin laxity due to neocollagenesis and elastogenesis with minimum immediate volumizing effect [8].

68.2.2 Techniques • Mark the treatment site and prepare it with a suitable antiseptic. • Anesthesia can be local or topical (apply 20 min before injection). • For Radiesse without lidocaine, homogenize the product before application. • For injection, use needle (27G) or a blunt cannula (25 G; 50 mm). • The technique varies according to the area and the plan of treatment.

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• For multipoint small boluses use preferably needle and for bolus technique either needle or cannula. • Retrograde linear technique can be performed with needle or cannula, and lines can be disposed in a parallel, fan-like, or crossed fashion. • Place CaHA in deep dermis or subdermal layer (depth of 2–3 mm) for greater stimulation of collagen or in the supraperiosteal

layer to support areas with underlying bone structure. • After injection the area should be vigorously massaged. • The amount injected will vary depending on the site and extent of the restoration or augmentation desired, when considering the undiluted product the correction ratio of Radiesse is approximately 1:1 [2]. • The volume of product injected produces similar soft tissue increase in the long term.

Treatment of nasolabial folds, marionette lines, prejowl with cannula 26G

68.2.3 Injection Techniques for Radiesse® • • • • • •

Linear threading Tower technique Bolus technique Parallel lines Fanning Cross-hatching

Linear threading technique LATERAL VIEW

Fanning technique LATERAL VIEW

TOP VIEW

68  Calcium Hydroxyapatite for Face

491

Tower technique*

Bolus technique*

LATERAL VIEW

LATERAL VIEW intrademal injection

Parallel lines technique LATERAL VIEW

Cross-hatching technique

TOP VIEW

LATERAL VIEW

68.2.3.1 Lifting Treatment Injection Techniques • Dilution 20% • Small supraperiosteal boluses, with 27G needle or 22–25G cannula • Estimated quantity per point, starting from 1 syringe (1.5 ml) • Total volume dependent on patient’s need Areas of Application • Posterior portion of arch – 0.15 ml • Average portion of arch – 0.15 ml

LATERAL VIEW supraperiosteal injection

the

zygomatic

the

zygomatic

TOP VIEW

• Zygomatic eminence/anterior malar – 0.25 ml • Pre-jowl groove – 0.15 ml • Angle of the jaw – 0.2 ml

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68.2.3.2 T  reatment of the Contour of the Mandible

68.2.3.3 T  reatment of the Nasolabial Folds

Injection Techniques • Dilution 20–40% • Retroinjection in the subdermal plane with 27G needle or 22–25G cannula • Estimated amount per area, from 1 syringe (1.5 ml) • Total volume dependent on patient’s need

Injection Techniques • Dilution 20–40% • Linear threading and fanning with needle size: 27G needle • Deep point in the piriform fossa with 25G or 27G cannula • May depend on the degree of correction needed • Estimated amount per area, from 0.6 ml of the syringe (1.5 ml) • Total volume dependent on patient’s need

Areas of Application • Central insertion point in jowl –– Toward the pre-jowl groove – 0.3 ml –– Toward the angle of the mandible – 0.3 ml • Point of insertion at the angle of the mandible –– In the direction of the mandible branch – 0.3 ml

Injection Plane • Injections should be given in the subdermal plane with cannula • Injections could be made in the supraperiosteal plane with 27G needle

68  Calcium Hydroxyapatite for Face

493

68.2.3.4 Prejowl Sulcus and Chin Injection Techniques • Dilution 20–40% • Retroinjection in the subcutaneous tissue with 22–25G cannula (1) • Supraperiosteal plane with 27G needle (2) • Estimated amount per area, from 0.6 ml of the syringe (1.5 ml) • Total volume dependent on patient’s need

68.2.3.5

Injection Plane • Insertion point in marionette line –– Injections should be given in the subdermal plane with cannula. (a) and (b) • Central insertion point in chins –– Injections can be made in the supraperiosteal plane with 27G needle

Areas of Application • Central insertion point in jowl following to: –– Angle of the jaw –– Submalar region –– Pre-jowl groove/marionette line • Point in the submalar region following to: –– Zygomatic region –– Previous malar region –– Nasolabial sulcus

• • • •

Biostimulation Face Treatment Injection Techniques Dilution 100% Retroinjection in the subdermal plane with 27G needle or 25G cannula 0.25  ml in each area considering 1 syringe 1.5 ml per session Do not apply in jowl

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history or presence of multiple severe allergies and patients with bleeding disorders. • Radiesse should not be used in patients with known hypersensitivity to any of the components.

68.3 Clinical Follow-Up

68.2.4 Contraindications • Radiesse should not be injected in hypermobile areas with thin skin like lips, perioral and periorbital region [3, 5]. • Radiesse should not be injected in the glabellar area and in the nose due to the vascular compromise risk. • Contraindicated for patients with severe allergies manifested by a history of anaphylaxis or

• Recent studies show that the biostimulation properties of CaHA remain constant over a period of 12–18 months on average and can remain for up to 24 months in some cases [9]. • Immunohistochemical analysis of biopsy tissue demonstrated significant increases in ­collagen I and III, elastin, and angiogenesis expression compared with baseline [8]. • CaHA is radiopaque. CT can easily detect the product but radiographs are not consistent and reliable. In only 0.6% the CaHA depots blocked the view of underlying structures in CT [10]. • CaHA microspheres are gradually broken down into calcium and phosphate ions and eliminated by enzymatic breakdown [2]. • So far, there is no report of osteogenesis or calcification secondary to CaHA implant [2]. • Improvements in skin elasticity and pliability were demonstrated recently, by cutometry, and increases in dermal thickness by ultrasound, with the use of the product diluted up to 600% [8].

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68.4 B  efore and After (Figs. 68.1, 68.2, 68.3, and 68.4)

Fig. 68.1  Before and after treatment of nasolabial folds, marionette lines, mental crease, chin and contouring the jawline. Volume injected: average 0.8 ml per side and 0.5 ml in the chin. Dilution 20%

Fig. 68.2  Before and after treatment for enhancement of chin, prejowl, jawline and mandibular angle

Fig. 68.3  Before and after treatment of nasolabial folds, folds, malar, mario- nette lines, mental crease, chin and contouring the jawline. Volume injected: average 0.8 ml per side and 0.5 ml in the chin. Dilution 20%

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Fig. 68.4  Before and after treatment of nasolabial folds, marionette lines, prejowl, submalar cheek hollows and contouring the jawline. Volume injected: average 1.2 ml per side. Dilution 20% and 100%

68.5 S  ide Effects, Complications, and Their Management •

• •

•

•

•

•

•

Allergic Reaction • Hypersensitivity reactions to CaHA have never been recorded. Radiesse can be considered an effective soft-­ • Urticaria and angioedema are very rare and tissue filler for overall longevity, biocompatiare related to CaHA carrier or lidoicaine. bility, and low rate of side effects [3, 6]. • Symptoms are itchiness and severe swelling Some side effects are intrinsic to the proceincluding face and tongue. dure, not related to the product. • Treatment consists in anti-histamines and steTemporary local reactions as redness, swellroids. Some cases can require hospitalization. ing, pain, bruising, pruritus, and hematoma last about a week and do not require specific Nodules treatment. • It is the most common reported side effect Dermal implants can cause ischemia, necro[3]. sis, and scarring if they occlude blood • Labial mucosa, perioral, and periorbital vessels. areas, including the tear trough, should not As Radiesse cannot be dissolved as hyaluronic be injected. These areas have frequent musacid with hyaluronidase, high-risk areas for cle movements and little subcutaneous fat occlusion as glabella and nose should be so CaHA particles can cluster and avoided [5]. accumulate. Ischemia is manifested by pain and blanching • The overall nodule formation rate is less than of the skin at the time of injection followed by 1%, when injections are avoided in hypermostinging or tingling and bruising, redness, and bile areas. swelling. • If not visible or small, CaHA nodules resolve Treatment consists in a combination of aspirin without intervention. and other anti-inflammatories or steroids, anti- • Visible nodules could be successfully treated biotics and warm compresses, and nitroglycusing massage, injection of saline, needle erin ointment/vasodilators. punction, or excision. Infection is very rare. Some patients may pres- • For persistent nodules, series of three injecent intermittent edema or persistent edema tions of 5-FU, triamcinolone and lidocaine, or related to a reoccurring systemic infection. 5-FU and lidocaine may be considered.

68  Calcium Hydroxyapatite for Face

Granulomas • Granulomas or Inflammatory nodules are rare and typically occur after 2  weeks of injection. • Granulomas can be related to secondary infection and biofilm formation. • Some reports show that the granuloma rate with Radiesse is smaller than with poly-l-­ lactic acid and even with hyaluronic acid. • Treatment is based on antibiotics and steroids (oral or intralesional). Tip box

• CaHA is a biostimulatory filler with good safety, efficacy, and tolerability profiles [2]. • The safety profile of Radiesse® is similar to that of hyaluronic acid fillers [3]. • It provides immediate soft tissue augmentation and also stimulates collagen production, contributing to a long-­ lasting result. • CaHA has a high viscosity that prevents migration of the product. It is elastic, with high resistance to deformation under pressure and its high cohesivity permits a high lifting capacity. • It is versatile and can be placed into the deep dermis, the subcutaneous tissue, supraperiosteally depending on the area and the plan of treatment. • In some countries, CaHa is available mixed with lidocaine 0.3% ® (RADIESSE LIDOCAINE). Other countries use a protocol that adds lidocaine solution to CaHA right before the application. The association of them reduces patient discomfort without relevant changes in the product rheology. • According to some new studies, the production of type I collagen, an important and fundamental step for the formation of structure and mechanical stability of the skin, is more intense with Radiesse® than with hyaluronic acid (HA) fillers.

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References 1. Sundaram H, Voigts B, Beer K, Meland M. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Surg. 2010;36:1859–65. 2. Loghem JV, Yutskovskaya YA, Werschler P, Calcium Hydroxylapatite W.  Over a Decade of Clinical Experience. J Clin Aesth Dermatol. 2015;8(1):38–49. 3. Kadouch JA. Calcium hydroxylapatite: a review on safety and complications. J Cosmet Dermatol. 2017;00:1–10. 4. Courderot-Masuyer C, Robin S, Tauzin H, Humbert P. Evaluation of lifting and antiwrinkle effects of calcium hydroxylapatite filler. In vitro quantification of contractile forces of human wrinkle and normal aged fibroblasts treated with calcium hydroxylapatite. J Cosmet Dermatol. 2016;15:260–8. 5. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidencebased review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345–54. 6. Jacovella PF. Use of calcium hydroxylapatite (Radiesse®) for facial augmentation. Clin Interv Aging. 2008;3(1):161–74. 7. Graivier MH, Bass LS, Busso M, Jasin ME, Narins RS, Tzikas T. Calcium Hydroxylapatite (Radiesse) for correction of the mid-and lower face: consensus recommendations. Plast Reconstr Surg. 2007;120(6 Suppl):55S–66S. 8. Yutskovskaya YA, Kogan EA. Improved neocollagenesis and skin mechanical properties after injection of diluted calcium hydroxylapatite in the neck and décolletage: a pilot study. J Drugs Dermatol. 2017;16(1):68–74. 9. Pavicic T. Complete biodegradable nature of calcium hydroxylapatite after injection for malar enhancement: an MRI study. Clin Cosmet Investig Dermatol. 2015;8:19. 10. Carruthers A, et al. Radiographic and computed tomographic studies of calcium hidroxylapatite for treatment HIV-associated facial lipoatrophy and corretion of nasolabial folds. Dermatol Surg. 2008;34:S78–84.

Calcium Hydroxylapatite for Hands

69

Tatiana Basso Biasi and Vinicius Pollo Pires

69.1 Materials

because it diminishes pain during and after injection and also turns the product more 69.1.1 Calcium Hydroxylapatite spreadable and moldable [2]. The recommended amount of lidocaine for dilution is • Calcium hydroxylapatite is a synthetic non-­ variable between authors, it starts from 0.2 ml permanent filler compound of 30% CaHA to 1.5  ml lidocaine 1% or 2% for a 1.5  ml microspheres (25–45 μm) and 70% gel carrier CaHA syringe. It can also be used as a mixture consisting of water, glycerin, and of lidocaine and saline [1, 3, 4]. carboxymethylcellulose [1, 2]. It is composed • There are many different techniques for the of minerals that are present in teeth and bone, application of calcium hydroxylapatite. They which turns it inert, biocompatible, and vary according to physician’s preference and non-­ ­ antigenic. Skin testing is not required experience. Some use needles and others preprior to treatment [2]. It does not stimulate fer blunt cannulas. It can also be applied in calcification or foreign body reaction [1]. bolus or multi-puncture technique. At the • After application, the carrier gel is gradually entry points, the skin is tented up to enable absorbed during 2–3 months. The size of the access to the right plane of application [1]. particles does not allow them to be phagocy- • Good correction is described with 1–3  mL tosed by macrophages, which explains the of CaHA per hand in most of the patients CaHA durability. They remain stimulating [1]. Because the safety and effectiveness fibroblast proliferation and collagen synthesis has not been established for injection vol[1]. It promotes an immediate volume umes over 3 mL per hand in one treatment replacement of up to 12  months and has session [3]. demonstrated a longevity of up to 30 months • The Merz Hand Grading Scale (MHGS) is a in the nasolabial folds [2]. five-point photonumeric scale used to grade • The syringe should be diluted prior to using. the appearance of the back of the hands and Lidocaine is FDA approved for dilution has been validated for both photographic and live assessment [3]. A onepoint improvement in the MHGS rating after CaHA treatment is considered a clinically and aesthetically sigT. B. Biasi (*) · V. P. Pires nificant improvement in hand appearance. It is Brazilian Society of Dermatology, useful in daily practice to facilitate the physiFlorianópolis, SC, Brazil cian evaluation during physical examination, e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_69

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500

Fig. 69.1  Merz Hand Grading Scale. 0 or no loss of fatty tissue, 1. Mild loss of fatty tissue and slight visibility of veins. 2. Moderate loss of fatty tissue and mild visibility of veins and tendons. 3. Severe loss of fatty tissue and

moderate visibility of veins and tendons. 4. Very severe loss of fatty tissue and marked visibility of veins and tendons

Fig. 69.2  Materials for the procedure

as well to explain the patient about what is expected from the treatment and after the procedure to evaluate treatment results. The scale can be also helpful to initiate a discussion about the possibility of hand treatment, which some patients may not even know exists [4] (Fig. 69.1). • The CaHA particles are radiopaque and visible on computed tomography (CT) scans. They may also be visible in plain radiography, positron emission tomography (PET), and magnetic resonance imaging (MRI) [2].

69.1.2 The Procedure • In this chapter, we have used: Radiesse® (Merz Aesthetics) 1.5 cc syringe and added the same amount of lidocaine 2% as a diluent. • Figure 69.2 illustrate the materials required for the procedure:Lidocaine cream 40 mg/g –– White pencil marker –– Procedure gloves –– Chlorhexidine 2% aqueous solution –– Lidocaine 2% solution –– Gauze

69  Calcium Hydroxylapatite for Hands

–– Radiesse® (Merz Aesthetics) 1.5 cc syringe. –– Needle 23G for dilution –– Syringe 5 cc for dilution –– Luerlock connector • Needles 27G for application ––

69.2 Methods and Techniques • Before the procedure patient should carefully wash the hands. After this, antisepsis with gauze and topical solution of 2% aqueous chlorhexidine is done. • Draw the visible blood vessels on the back of the hands using appropriate marker pencils. This will help prevent accidental intravascular injection (Fig. 69.3). • A topical anesthetic (lidocaine 4%) is applied to the patient’s hands, 20  min before injection. • Meanwhile, the 1.5  ml content of calcium hydroxyapatite syringe (Radiesse®) is mixed with 1.5 ml of 2% lidocaine without vasoconstrictor to create a homogeneous solution through a Luerlok connector (Baxa, Englewood, NJ). (Fig. 69.4a). • The mixture is passed from one syringe to another around 20 times for homogenization. Half of this volume should be kept in the original syringe for injections with a 27G needle in one hand. The other half is reserved for the other hand (Fig. 69.4b). a

501

• The skin is pinched between two fingers, raised above the vessels like a tent, applying the CaHA in small bolus, in the subdermal plane, above the dorsal superficial fascia (Fig. 69.5). The tents are done in the areas of atrophy, avoiding the previously marked vessels (Fig. 69.6). • The amount of product injected will vary according to the intensity of the atrophy. We advise the use of approximately 0.05  ml at each point. Depending on the atrophy level, further injections may be necessary. • After the procedure, massage with moisturizing cream should be performed in order to evenly spread the product (Fig. 69.7).

Fig. 69.3  Veins marked with white pencil before the procedure

b

Fig. 69.4 (a) Calcium hydroxyapatite syringe connected with lidocaine 2% syringe through a Luerlok connector. (b) Homogenization of CaAH and lidocaine 2%

T. B. Biasi and V. P. Pires

502 Fig. 69.5 Topographic anatomy of the dorsum of the hand. The needle is introduced in the dorsal superficial lamina

8

1 2 3

4

5

7

6

10 9

1 - Dorsal superficial lamina 2 - Dorsal superficial fascia 3 - Dorsal intermediate lamina 4 - Dorsal intermediate fascia 5 - Dorsal deep lamina 6 - Dorsal deep fascia 7 - Extensor tendon 8 - Vein 9 - Bone 10 - Interosseous muscle

Reproducao: Arte Clovis Medeiros

Fig. 69.6  One hand makes the tent while the other makes the injection

Fig. 69.7  Massage to spread the injected product

69.3 Follow-Up • The patient should be advised on the initial nodular aspect of the procedure and on the possibility of hematoma and edema (Fig. 69.8).

Fig. 69.8  Nodular aspect and hematoma after the injection of CaHA, prior to the massage

• Local massage 2 times a day for approximately 7 days can be performed by the patient in order to better spread the product and undo the nodules. • The patient may be instructed to sit on the hands after the procedure. This will help to spread the product and avoid hematomas. • Application of ice compresses for approximately 24  h and sun avoidance are recommended after the procedure. • Oral corticosteroids may be administered for a short period of time in patients with severe edema.

69  Calcium Hydroxylapatite for Hands

503

69.4 Before and After (Figs. 69.9 and 69.10) a

a

b

b

Fig. 69.9  A 65-year-old female patient, (a) before and (b) 20 days after 1.5 ml CaHA at the back of the hands

69.5 S  ide Effects, Complications, and Their Management The adverse effects and complications can be divided in frequent and transient post-injection and occasional. The frequently seen include edema, erythema, ecchymosis, and pruritus [1, 3]. With calcium hydroxylapatite more swelling and bruising are reported than with hyaluronic acid fillers [1]. Pruritus can be treated with topical steroids [3]. Swelling is seen at some degree in most of the patients, and for some authors it is related to the amount of product injected. In most cases it occurs right after the procedure and resolves spontaneously in a few days. It can also happen days to weeks after the injection. When it lasts more than 2 weeks, it can be treated with a short course of oral methylprednisolone [1, 3, 4]. A simple

Fig. 69.10  A 50 year-old female patient (a) before and (b) immediately after 1.5  ml CaHA at the back of the hands

measure to avoid and treat swelling is to elevate and to compress the hands after the procedure and a low salt diet [1, 5]. Figure 69.11 illustrates a case of delayed swelling after CaHA injection that was treated successfully with oral corticosteroid. Nodules are an occasional AE reported after CaHA application. Immediately after the injection, many nodules are visible and can be distributed to the desired area with firm massage because the product is moldable. The more diluted is the product, the easier it is to shape to the desired appearance [1]. Sometimes the nodule persists because of a granuloma formation [1]. For CaHA granulomas the initial approach can be antibiotic therapy and intralesional steroids. If not successful, surgical excision is the recommended therapy [6]. Difficulty with hand movement is rarely seen, and it is preventable by avoiding injection of too much product at one time [1, 3].

T. B. Biasi and V. P. Pires

504

• After the procedure, the patient should be advised to (a) elevate the hands, (b) sit on the hands whenever possible, (c) massage periodically treated area, (d) avoid intense work with hands, (e) avoid sun exposure, and (f) avoid salty food [1, 4, 6, 7]. • Avoid over-injection to prevent limitations in hand motion. Instead of injecting too much product in one session, it is preferable to do additional treatments. Once injected, it is not easy to remove the filler [1].

References

Fig. 69.11  Swelling a week after CaHA application treated successfully with oral corticosteroid

Tip Box

• A simple measure to avoid complications is to ask the patient to wash their hands before the procedure. It will turn easier cleaning the treatment areas [4]. • To make the vessel marks with the marker pencil, put the patient hands below the level of the heart to make the veins more turgit and easily seen [7]. • To make the injections, put the patient hands above the level of the heart to collapse the veins and reduce the chance of bleeding and intravascular insertion [7].

1. Rivkin AZ. Volume correction in the aging hand: role of dermal fillers. Clin Cosmet Investig Dermatol. 2016;9:225–32. 2. Emer J, Sundaram H.  Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-­ based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol. 2013;12(12):1345–54. 3. Fathi R, Cohen JL.  Challenges, considerations and strategies in hand rejuvenation. J Drugs Dermatol. 2016;15(7):809–17. 4. Bertucci V, Solish N, Wong M, Howell M. Evaluation of the Merz hand grading scale after calcium hydroxylapatite hand treatment. Dermatol Surg. 2015;41:S389–96. 5. Marmur ES, Al Quran H, De Sa Earp AP, Yoo JY. A five-patient satisfaction pilot study of calcium hydroxylapatite injection for treatment of aging hands. Dermatol Surg. 2009;35(12):1978–84. 6. Park TH, Yeo KK, Seo SW, Kim J, Lee JH, Park JH, Rah DR, Chang CH. Clinical experience with complications of hand rejuvenation. J Plast Reconstr Aesthet Surg. 2012;65:1627–33. 7. Lefevbre-Vilardebo M, Trevidic P, Moradi A, Busso M, Sutton AB, Bucay VW.  Hand: clinical anatomy and regional approaches with injectables fillers. Plast Reconstr Surg. 2015;136:258S–75S.

Calcium Hydroxyapatite For Unusual Body Areas

70

Gabriela Casabona

70.1 Materials: (Fig. 70.1)

70.2.2 Technique

• • • • • • • • •

• Needle 23G should be used, as aspiration is recommended before each injection to avoid intravascular injection [2]. • Cannula 25–22G, 48  mm or bigger should be used

1 calcium hydroxylapatite syringe 1.5 ml no lido 1 BD 3 ml syringe 1 two-way or triple-way connector 1 sterile gauze Alcoholic chlorhexidine 2% 1 25–22G blunt cannula 48 mm or 23 G needle Sterile field Sterile gloves Lidocaine 2% with epinephrine

70.3 Clinical Follow-Up 70.3.1 Stretch Marks (Fig. 70.2)

70.2 Methods and  Techniques 70.2.1 Dilution

• Day 1  – bruising, edema seen in the stretch marks, and erythema • Day 7  – bruising improved, no edema or erythema

• Unusual body indications will require CaHA as biostimulator • According to recent studies, it can be diluted 1:1 (which gives you faster conversion of collagen types III–I) or higher like 1:2 and 1:4 [1] • It should be mixed with Lido2%wEpi (max 6  ml total for a 70  kg individual) or 0.9% saline for the use in a subdermal or dermal plane

G. Casabona (*) Beauty Beyond Skin Clinic, Dermatology and Dermatologic Surgery, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_70

Fig. 70.1  Materials used to perform calcium hydroxyapatite for corporal body areas

505

G. Casabona

506 Fig. 70.2  Stretch marks injections follow-up

injection

Immediately after

1 Day

• Day 30  – mild erythema (due to biostimulation), improvement in color, and atrophy • Day 90 – improvement in color and atrophy

• Day 90  – significant improvement in skin color and quality, atrophy, dimples, contour, and laxity

70.3.2 All Other Indications

70.4 B  efore and After (Figs. 70.3a, b; 70.4a, b; 70.5a, b)

• Day 1 – bruising and edema • Day 7  – bruising improved, no edema or erythema • Day 30  – mild improvement in skin appearance, dimples, and contour

• Stretch marks (Fig. 70.3a, b) • Laxity of inner thigh (Fig. 70.4a, b) • Laxity and dimples in buttock and back thigh (Fig. 70.5a, b)

70  Calcium Hydroxyapatite For Unusual Body Areas Fig. 70.3 Female stretch marks (a) after pregnancy and cortisone use in thighs treated with CaHA injection diluted 1:1 with needle 1 syringe per side and microneeding and (b) after 90 days (gaby)

Fig. 70.4 (a) female laxity on inner thigh injected with CaHA 1 syringe per side diluted 1:1 and (b) after 90 days (camila)

a

a

b

507

b

G. Casabona

508

a

b

Fig. 70.5  Patient (a) 3 days after CaHA injection to the butt for laxity treatment and (b) after 15 days

70.5 S  ide Effects, Complications, and Their Management • CaHA implant is safe, with no evidence of systemic adverse effects or immunologic responses. Adverse events like bruising are temporary [3] • One of the most common complications described is nodule formation, and normally it is due to superficial injection in hyperkinetic areas (lips) [4] • The majority of all adverse events reported are due to improper technique and not to

the injected material, such as abscess (Fig. 70.6)

70.5.1 Early Complications (15 days) (Table 70.1)

509

70  Calcium Hydroxyapatite For Unusual Body Areas

a

b

Fig. 70.6  Patient (a) 5 days after CaHA injection in the neck with cannula with an abcess and fluctuation area and (b) 15 days after drainage and oral antibiotics

Table 70.1  Early and delayed adverse events, clinical appearance, pathophysiology, how to avoid, and treatmenta [5, 6] Early complications/ adverse events 15 days Nodules Palpable induration with or without inflammation

Sometimes is due to local edema or product accummulation

Avoid big bolus technique

Accumulation of filler product when used in areas like lips and around eyes

Evenly spread under the skin Never inject bolus bigger than 0.2 per site Do not use in areas with muscle movement such as lips and periorbital Avoid intramuscular injection and intradermal

Saline and massage Surgical excision (if inflammation) Triamcinolone 10 mg/ml intralesional and hyaluronidase 20–50 U per nodule (resistant nodules) 5-FU may be considered (continued)

511

70  Calcium Hydroxyapatite For Unusual Body Areas Table 70.1 (continued) Granulomas* (2–3 months after injection)

Migration

Infection

Skin color change (1–3 months)

Presence of filler particles surrounded by immune cells and fibrous tissue (differential diagnosis for nodule through biopsy and histology) Macrophages can Presence of filler in an area phagocyte particles and migrate to not injected other areas Contamination of Induration, erythema, fever, subcutaneous and sometimes during injection fluctuation

Unwanted tissue response with proliferation of connective tissue and immunoreactive cells.

Yellowish look área (xanthelasma look)

Appearance of the product when injected superficial because of the scattering of the visible light

Granuloma formation is stil unknown, but to avoid remember to take previous history of autoimmune disease Avoid intramuscular injection Prefer small bolus (max 0.2 ml) injection

Oral steroids Triamcinolone 10 mg/ml intralesional and hialuronidase 20–50 U per nodule (resistant nodules) 5-FU may be considered Surgical excision

–

–

Always clean not only in the area of injection but also the surrounding areas with alcoholic chlorhexidine 2% Do not use CaHA as superficial as dermal plane (exception is stretch marks when you want the adverse event to look yellowish as the final result)

Ciprofloxacin 500 mg 12/12 for 15 days or Clarithromycin 500 mg 12/12 h for 15 days 2 monthly fractionated deep ablative laser and lowdensity treatments

*Since 2004, there have been only five reported, confirmed cases of granuloma in over 5 million syringes shipped (0.0005 %). In 2009, a retrospective meta-analysis of studies dating from 1985 until 2005 showed lower granuloma rates with CaHA than with HAs or poly-L-lactic acids: 0.001 % CaHA, 0.04–0.4 % HAs, and 0.2–1 % PLLAs *In two of the largest studies performed with CaHA (Radiesse®) so far, neither granuloma formation nor severe infections were observed over a total study period of 39 months or 52 months, respectively [7, 8] a All complications of late onset described are on face and hand injections; no body complications were described till the moment

Tip Box

• Before injecting CaHA, the patient should be screened and given written informed consent • CaHA needs to be placed into the deep or subdermal tissue layer (except in the case of stretch marks when it can be injected in all layers) • Recommended injection techniques for the use of CaHA in unusual areas of the body include linear threading, fanning, microdrops, and cross-hatching • Unusual body indications: stretch marks (buttocks, knees, inner thigh, lateral thigh, abdomen, arms), laxity (arms, abdomen, buttocks, knees, inner thighs, lateral thighs, back thighs, neck, chest),

•

•

•

•

and atrophic scars (any area from face to body). As with all filler substances, use of CaHA may be associated with a risk of adverse events; however, the majority of reported adverse events are due to technique and are temporary Proper injection technique, choice of injection site, and choice of filler and dilution can limit the risk of adverse events CaHA has been extensively studied and all studies confirmed the high safety profile In two of the largest studies performed with CaHA so far, neither granuloma formation nor severe infections were observed

512

References 1. Casabona G, Pereira G.  Microfocused ultrasound with visualization and calcium hydroxylapatite for improving skin laxity and cellulite appearance. Plast Reconstr Surg Glob Open. 2017;5(7):e1388. 2. Casabona G.  Blood Aspiration Test for Cosmetic Fillers to Prevent Accidental Intravascular Injection in the Face. Dermatol Surg. 2015;41(7):841–7. 3. Sadick NS. A 52-week study of safety and efficacy of calcium hydroxylapatite for rejuvenation of the aging hand. J Drugs Dermatol. 2011;10(1):47–51. (Sadick 2011) 4. Jansen D, Graivier M.  Evaluation of a calcium hydroxylapatite–based implant (Radiesse) for facial

G. Casabona soft-tissue augmentation plast. Reconstr Surg. 2006;118(Suppl):22S. 5. Jacovella PF, Peiretti CB, Cunille DR, et  al. Long lasting results with hydroxylapatite facial filler. Plast Reconstr Surg. 118; 2006. 6. Voigts R, Devore DP, Grazer JM. Dispersion of calcium hydroxylapatite accumulations in the skin: animal studies and clinical practices. Dermatol Surg. 2010;36(Supplement s1):798–803. 7. Tzikas TL. A 52-month summary of results using calcium hydroxylapatite for facial soft tissue augmentation. Dermatol Surg. 2008;34(Suppl 1):9–15. 8. Sadick NS, Katz BE, multicenter RDA. 47-month study of safety and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face. Dermatol Surg. 2007; 33(Suppl 2):S122–6. discussion S126–127.

Platelet-Enriched Plasma

71

Abraham Benzaquén-Barchillón and Eduardo de Frutos-Pachón

71.1 Materials (Figs. 71.1, 71.2, and 71.3) • Tourniquet • Blood draw tools

• • • •

Centrifuge Calcium chloride Injection material From 3 to 6 tubes with anticoagulant

Fig. 71.1 The essentials to obtain PRP and its subsequent injection for aesthetic purposes: tourniquet and blood draw tools, centrifuge, calcium chloride, and injection material

A. Benzaquén-Barchillón (*) Clínica Benzaquén, Málaga, Spain e-mail: [email protected] E. de Frutos-Pachón Clínica Kalos, Fundación Tejerina, Talavera, Spain e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_71

Fig. 71.2  3–6 tubes with anticoagulant are used to obtain 13–27 mL of whole blood before each treatment session 513

A. Benzaquén-Barchillón and E. de Frutos-Pachón

514

Fig. 71.4  Patients position to obtain the blood

Fig. 71.3  Angular centrifuge with a head for six tubes and electronic speed control Fig. 71.5  Obtaining the peripheral blood

71.2

Methods and Techniques [1–8]

• Once the patient has signed his informed consent and photos have been taken, he should sit comfortably and remain calm while we draw his blood ­sample (Fig. 71.4). • Peripheral blood is obtained from the tail vein or other appropriate blood vessel (Fig. 71.5). • 3 Tubes with anticoagulant, containing a total amount of 13.5 mL of blood, are enough for the treatment of stretch marks in both arms (Fig. 71.6). • Entering the tubes in the centrifuge so that their distribution is homogeneous and there are no imbalances during the centrifugation process (Fig. 71.7). • Total time of centrifugation, 8 minutes. • Spin speed, 2500 rpm. Depending on the size of the centrifuge, we can get the same centrifugal force in a bigger centrifuge and with less speed.

Fig. 71.6  Tubes with obtained blood

• Once the centrifugation process is completed, tubes are removed. We can see the different phases of blood. PRP is the fraction of plasma closest to the red phase of blood (Fig. 71.8).

71  Platelet-Enriched Plasma

Fig. 71.7  Tubes are entering into the centrifuge wells

515

Fig. 71.10  The PRP fraction added to 1.0 mL of ­calcium chloride

Fig. 71.8  Tube appearance after spinning is completed Fig. 71.11  Preparing the skin with chlorhexidine

Fig. 71.9  Obtaining PRP fraction from the tubes, usinge a 21G syringe

• Obtaining PRP fraction through a 21G needle. The manipulation of the plasma must be done using a closed system or in a clean chamber with laminar flow (Fig. 71.9). • Up to 1.5  mL of PRP can be obtained from each of the tubes. Add 0.1  mL of calcium chloride in order to activate growth factors (Fig. 71.10).

• Skin cleansing with chlorhexidine. A slight erythema is due to the vaporization of the ethyl chloride to the skin. This anesthetic causes a cooling and insensibility of the peripheral nerves (Fig. 71.11). • Small amounts of PRP can be applied in intralesional deposits, using a 30G needle, just as a mesotherapy in the area affected by stretch marks (Fig. 71.12). • The most experienced doctors can apply this therapy drawing back each stretch marks, injecting into the dermal plane (Fig. 71.13). • Just finished the treatment, the appearance of the skin is good, although there may be some nodules during the first minutes and a slight erythema may also be seen during the first hours (Fig. 71.14). • In our experience, androgenetic alopecia is the most frequent indication for PRP growth factor therapy, both men and women.

516

Fig. 71.12  Application technique into the dermis

A. Benzaquén-Barchillón and E. de Frutos-Pachón

Fig. 71.15  Perpenticular position of the needle when applied into the scalp dermis

Fig. 71.13  Stretch marks injection technique Fig. 71.16  Combination of the PRP technique with PDO threads

• The application of PRP growth factors to the scalp should be done in a deep plane, following the natural lines of hair separation in the longitudinal axis. • A treatment with PRP growth factors has just been done, immediately before a treatment with smooth PDO threads to improve sagging in the skin of abdomen (Fig. 71.16).

Fig. 71.14  Immediate aspect of the skin after injection of PRP

• Since the application of anesthetic is more difficult in this area, we are using a large amount of cold chlorhexidine to reduce the pain of the punctures (Fig. 71.15).

71.3 Clinical Follow-Up [1–8] Erythema: The day after the treatment, this patient still had erythema in the area where the ethyl chloride anesthetic was applied.

71  Platelet-Enriched Plasma

71.4 Before and After (Figs. 71.17, 71.18, 71.19, 71.20, and 71.21)

Fig. 71.17  Before (on the left) and after (right) treatment of stretch marks of the arms with PRP

Fig. 71.18  Before (on the left) and after (right) treatment of stretch marks of the flanks with PRP

Fig. 71.19  Before (on the left) and after (right) treatment of face wrinkles with PRP

517

518

A. Benzaquén-Barchillón and E. de Frutos-Pachón

Fig. 71.20  Before (on the left) and after (right) treatment of male androgenic alopecia with PRP

Fig. 71.21  Before (on the left) and after (right) treatment of sagging skin alopecia with PRP

71.5 S  ide Effects, Complications, and Their Management [1–8] Erythema: PRP growth factor is an autologous and well-tolerated product. Complications may arise more from the technique, as a slight erythema for some hours (Fig. 71.22). Hematomas in the neck: The skin of the neck is very sensitive and it is easy to appear hematomas the day after doing this treatment. Of course, PRP complications only deserve symptomatic treatment (Fig. 71.23).

Fig. 71.22 Erythema post immediate treatment of injected PRP

71  Platelet-Enriched Plasma

Fig. 71.23  Hematoma in the neck post treatment of injected PRP

Tip Box

• To assure the proper aseptic environmental conditions to avoid infections. • To use only origin-tracked materials to assure safety and efficacy of the procedure per se.

References 1. Alcaraz-Rubio J, Oliver-Iguacel A, Sánchez-López JM.  Plasma rico en factores de crecimiento plaquetario. Una nueva puerta a la Medicina regenera-

519 tiva (Platelet-rich plasma in growth factors. A new door to regenerative Medicine). Rev Hematol Mex. 2015;16:128–42. 2. Cabrera-Ramírez JO, Puebla-Mora AG, González-­Ojeda A, García-Martínez D, Cortés-Lares JA, MárquezValdés AR, Contreras-Hernández GI, BracamontesBlanco J, Saucedo Ortiz JA, Fuentes-­ Orozco C. Platelet-rich plasma for the treatment of Photodamage of the skin of the hands. Actas Dermosifiliogr. 2017;108:746 pii: S0001-­7310(17)30208–9. https://doi. org/10.1016/j.ad.2017.04.006. 3. Sánchez AR, Sheridan PJ, Kupp LI.  Is platelet-­ rich plasma the perfect enhancement factor? a current review. Int J Oral Maxillofac Implants. 2003;18(1):93–103. 4. Beca T, Hernández G, Morante S, Bascones A. Plasma rico en plaquetas. Una revisión bibliográfica. Av Periodon Implantol. 2007;19:39–52. 5. Gentile P, Cole JP, Cole MA, Garcovich S, Bielli A, Scioli MG, Orlandi A, Insalaco C, Cervelli V.  Evaluation of not-activated and activated PRP in hair loss treatment: role of growth factor and cytokine concentrations obtained by different collection systems. Int J Mol Sci. 2017;18(2). pii: E408. https://doi. org/10.3390/ijms18020408. 6. Ferneini EM, Beauvais D, Castiglione C, Ferneini MV.  Platelet-rich plasma in androgenic alopecia: indications, technique, and potential benefits. J Oral Maxillofac Surg. 2017;75(4):788–95. https://doi. org/10.1016/j.joms.2016.10.040. 7. Gkini MA, Kouskoukis AE, Tripsianis G, Rigopoulos D, Kouskoukis K. Study of platelet-rich plasma injections in the treatment of androgenetic alopecia through an one-year period. J Cutan Aesthet Surg. 2014;7:213– 9. https://doi.org/10.4103/0974-2077.150743. 8. Anitua E, Pino A, Martinez N, Orive G, Berridi D. The effect of plasma rich in growth factors on pattern hair loss: a pilot study. Dermatol Surg. 2017;43(5):658–70. https://doi.org/10.1097/DSS.0000000000001049.

Poly-L-Lactic Acid for the Face

72

Carla Albuquerque, Kenia Calil, and Viviane Reis

72.1 Materials: (Fig. 72.1) • Antiseptic solution such as isopropyl alcohol or chlorhexidine. • Anesthetic cream. • 10  ml syringe and 21G needle to dilute the product • 3-ml syringe (4) • Lidocaine with epinephrine or phenylephrine (as local anesthesia) and lidocaine without epinephrine (to add to the reconstituted ­product immediately before it is injected). • Distilled water to dilute the product ­(poly-l-­lactic acid – Sculptra®). • 1-ml syringe and 30G × ½” 0.30 × 13  mm needle for local anesthesia • 21G or 22G microcannulas for subcutaneous injections • 25G needle for the subdermal injections and 24G needle for the supraperiosteal injections • Marking pencils.

C. Albuquerque (*) Carla Albuquerque Clinic of Dermatology, São Paulo, SP, Brazil K. Calil Kenia Calil Clinic of Dermatology, Marília, SP, Brazil

Fig. 72.1  Materials needed to perform poly-Llactic acid injections in the face

72.2 Methods and Techniques 72.2.1 Pre-op Evaluation • Patients eligible for PLLA are those with volume loss, bone reabsorption, and signs of skin atrophy. • Expectations should be realistic. • Contraindications: immune system diseases and patients who are allergic to any product ingredient and have a history of keloid formation or hypertrophic scarring and active inflammation. Safety has not been established for pregnant, lactating, breastfeeding, or under 18-year-old patients.

V. Reis Viviane Reis Clinic of Dermatology, Bauru, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_72

521

522

C. Albuquerque et al.

72.2.2 Preparation and Anesthesia • Photographic documentation is very important as results of the procedure are gradual over the months. We suggest taking pictures before, after each session and 6 months after the first session. • Photographic documentation in 5-positions: front, 45 degrees (right and left), 90 degrees (right and left). • Application of anesthetic cream at least 30 min before injections. • Antisepsis with 2% chlorhexidine alcohol. • Marking of treatment plans.

72.2.3 Reconstitution and Hydration • Reconstitute the vial content in 8 ml of sterile water for injection. • Inject sterile water into the vial slowly (do not shake it). • After reconstitution, allow the product to stand for 24–72 h before injecting it. • Store it at room temperature up to 30  °C or under 8 °C. • Add 2 ml of 2% lidocaine to the reconstituted product and then shake the vial in a circular motion for homogenization.

Fig. 72.2 Supraperiosteal Injection  – Needle. 0.1– 0.2 ml/point (x)

injection sites are the temporal, maxillary, zygomatic, piriform fossa, and mandible and mentum areas (Fig. 72.2) [1, 3–6].

72.2.4.1 Bone Support • In volume loss areas, PLLA is preferably injected with a 21G or 22G cannula, with a prior insertion with a larger gauge needle in the subcutaneous plane and in retroinjection with a fan pattern (about 0.2 ml/cm2 per injection) (Figs. 72.3 and 72.4) [1, 7–9].

72.2.4 Injection Techniques • Make treatment markings after the patient is thoroughly examined statically and dynamically while sitting upright and the head slightly tilted forward to better evaluate the degree of sagging and volume loss. To evaluate bone reabsorption areas, we suggest palpating the temporal region, zygomatic arch, piriform fossa, and mandible and mentum angle and branch [1, 2]. • In bone reabsorption areas, PLLA is injected in the supraperiosteal plane in small boluses with 1- or 3-ml syringes and 24-g 3/4 or 25-g needles, 0.1–0.3 ml per point, and the needle is inserted into the skin at a 90° angle. Always aspirate before injecting. Supraperiosteal

Fig. 72.3  Subcutaneous Injection; Cannula; Fan Pattern. 0.2 ml/cm2 or 0.2 ml per retroinjection

72  Poly-L-Lactic Acid for the Face

523

72.2.4.3 Skin Sagging PLLA should not be injected in hyperdynamic musculature areas such as the forehead and perioral and periocular areas [3, 10].

72.3 Clinical Follow-Up

Fig. 72.4  Subdermal Injection – Needle 0.02 ml/point

72.2.4.2 Fat Compartment Replacement • In skin atrophy areas, we recommend using 1-ml syringes and 25G or 26G ½ needles in linear retroinjection in the subdermal plane, making several 0.02–0.05-ml parallel lines (Fig. 72.4) [1, 5, 7, 9].

• Post-procedure massage is essential 2 times a day for 7 days. • An average of 1–2 vials per session is used and about three sessions are made with 4–6-­ week intervals between them [1]. • Correction degree and response time depend on factors such as age, sex, genetics, lifestyle, eating habits, and skin phototype. Smokers do not tend to respond equally well. • Maintenance sessions may be recommended 12 months from the end of the initial treatment [1, 7].

524

C. Albuquerque et al.

72.4 Before and After (Figs. 72.5, 72.6, and 72.7)

Fig. 72.5  A 60-years patient: A total of three vials were used (one vial per session, with monthly intervals. Before: Photo on the above row; After: Photo on the below row, 6 months later)

72  Poly-L-Lactic Acid for the Face

525

Fig. 72.6  A 44-year patient: Three vials were used (one vial per session, with monthly intervals. Before: Photo on the above row; After: Photo on the below row, 6 months later)

526

C. Albuquerque et al.

Fig. 72.7  A 41-year patient: Two vials were used (one vial per session, with monthly intervals. Before: Photo on the above row; After: Photo on the below row, 6 months later)

72.5 S  ide Effects, Complications, and How They May Be Managed • Complications are generally rare and easy to manage when the proper technique is used by an experienced professional and recommendations are followed by patients. • Bruising, ecchymosis, edema, and some local sensitivity are expected after this procedure and usually regress spontaneously. • Although relatively high rates of nodule and

papule formation were reported during early use of injectable PLLA, updated methods have led to better safety and efficacy, including patient selection, preparation, and instruction; product preparation; timing of injections and avoidance of overcorrection; an updated understanding of the anatomy of the aging face; and site-specific injection techniques [11]. • Treatment of complications, despite being rare when current techniques are used, is listed in Fig.72.8.

72  Poly-L-Lactic Acid for the Face

527 Complications Late

Early

• Incorrect reconstitution • Irregular distribution • Superficial injection (Intradermal) • Injection in contraindicated areas

• edema, pain, ecchymosis and erythema • easy resolution and recede spontaneously within 10 days

Nodule Inflammatory

Non-inflammatory Solid Massage

Floating

Biopsy + Culture (Bacteria / Fungus / Microbacteria)

Aspiration / Antibiogram and Culture

No improvement

Suspicion of Biofilm Improvement

Follow-up

Infiltration with distilled H O or 2 Saline Solution Improvement

Follow-up

No improvement Biopsy

Treatment in compliance

Yes

No

Antibiotic therapy Macrolide (clarithromycin) 500 mg 12/12 hr for 21 days

Quinolone (Moxifloxacin/Avalox) 1x day 400mg for 21 days)

• Intralesional corticoid (5,1,0 mg 6° mg with or without fluoracil • Oral corticoid: 0.5–1.0 mg kg if necessary • Oral minocycline – anti-inflammatory, immunomodulatory and anti-granuloma activities.

At least 2 associated antibiotics

Intralesional corticoid

Fig. 72.8  Algorithm to treat complications of poly-L-lactic acid injections

Tip Box

• Patients eligible for PLLA injections are those with facial sagging, volume loss, signs of bone reabsorption, and skin atrophy [12, 13]. • Photographic documentation should be made before the first session and 6  months after the beginning of the treatment. • The patient should be sitting while being assessed and the markings made. • Adequate time for reconstitution: 24–72 h. • Greater dilution: 10  ml per vial (final volume, 8 ml of distilled water and 2 ml of lidocaine without vasoconstrictor). • Technique: In bone reabsorption areas, PLLA injection plane is supraperiosteal in small boluses with 1- or 3-ml syringes and 24G 3/4 or 25G needles, 0.1–0.3 ml per point, and the needle is inserted into

•

•

•

•

th

Quinolone (Avalox) 4 generation 400 mg / d for 6 weeks + Macrolide (clarithromycin) 500 mg 12/12 hr for 6 weeks

the skin at a 90-degree angle. Always aspirate before injecting. Supraperiosteal injection sites are the temporal, maxillary, zygomatic, piriform fossa, and mandible and mentum areas. In volume loss areas, PLLA is preferably injected with a 21G or 22G cannula with a prior insertion of a larger gauge needle in the subcutaneous plane and in retroinjection with a fan pattern (about 0.2 ml/cm2 per injection). In skin atrophy areas, we recommend the use of 1-ml syringes and 25G or 26G ½ needles in linear retroinjection in the subdermal plane, making several 0.02– 0.05-ml parallel lines. PLLA should not be injected in hyperdynamic musculature areas such as the forehead and perioral and periocular areas.

528

• Do not overfill or overcorrect. • Allow 4 or more weeks between sessions. • Massaging the treated area is very important for the final result as it contributes to an even product distribution and a better result. The treated area should be massaged immediately after the procedure by the doctor himself/herself, and the patient should maintain the massage for at least 7 days, two times a day for 5 min at home.

References 1. Fitzgerald R, Vleggaar D.  Facial volume restoration of the aging face with poly-l-lactic acid. Dermatol Ther. 2011;24(1):2–27. 2. Lowe NJ, Maxwell CA, Lowe P, Shah A, Patnaik R. Injectable poly-l-lactic acid: 3 years of aesthetic experience. Dermatol Surg. 2009;35(Suppl 1): 344–9. 3. Goldman MP. Cosmetic use of poly-L-lactic acid: my technique for success and minimizing complications. Dermatol Surg. 2011;37(5):688–93.

C. Albuquerque et al. 4. Palm M, Chayavichitsilp P. The “skinny” on Sculptra: a practical primer to volumization with poly-L-lactic acid. J Drugs Dermatol. 2012;11(9):1046–52. 5. Thioly-Bensoussan D.  A new option for volumetric restoration: poly-L-lactic acid. J Eur Acad Dermatol Venereol. 2006;20(Suppl 1):12–6. 6. Beer K. Dermal fillers and combinations of fillers for facial rejuvenation. Dermatol Clin. 2009;27(4):427–32. 7. Lam SM, Azizzadeh B, Graivier M. Injectable poly-L-­ lactic acid (Sculptra): technical considerations in soft-­ tissue contouring. Plast Reconstr Surg. 2006;118(3 Suppl):55S–63S. 8. Lowe NJ. Optimizing poly-L-lactic acid use. J Cosmet Laser Ther. 2008;10(1):43–6. 9. Lacombe V. Sculptra: a stimulatory filler. Facial Plast Surg. 2009;25(2):95–9. 10. Apikian M, Roberts S, Goodman GJ.  Adverse reactions to polylactic acid injections in the periorbital area. J Cosmet Dermatol. 2007;6(2):95–101. 11. Vochelle D. The use of poly-L-lactic acid in the management of soft-tissue augmentation: a five-year experience. Semin Cutan Med Surg. 2004;23(4):223–6. 12. Vleggaar D, Fitzgerald R, Paul Lorenc Z.  The need for consensus recommendations on the use of injectable Poly-L-Lactic Acid for facial and nonfacial volumization. J Drugs Dermatol. 2014;13(4/ Suplements 28):s44. 13. Salles AG, Lotierzo PH, Gimenez R, Camargo CP, Ferreira MC.  Evaluation of the poly-L-lactic acid implant for treatment of the nasolabial fold: 3-year follow-up evaluation. Aesthet Plast Surg. 2008;32(5):753–6.

Poly-L-Lactic Acid for the Neck

73

Renata Indelicato Zac and Adilson Da Costa

73.1 Materials • • • • • • • • • • • • • •

1 vial of PLLA 2 vials of 10 ml sterile water for injection 1 10 ml syringe 2 18G needle 1 pair of gloves 4% lidocaine cream Ice Chlorhexidine digluconate 2% Sterile gauze 1 pair of sterile gloves 1 vial of lidocaine 2% 4 Luer lock 1 ml syringe 4 26G needle 1 Skin marker (Fig. 73.1)

73.2

Fig. 73.1 Materials

Methods and Techniques [1–6]

• Each vial of PLLA was diluted in 8 ml sterile water for injection, 24–48  h before use. The vial was kept on ambient temperature (less than 30 °C) (Fig. 73.2). Fig. 73.2 Dilution R. I. Zac (*) Dermatology Department, Minas Gerais Military Hospital, Belo Horizonte, MG, Brazil A. Da Costa Instituto de Assistência Médica ao Servidor Público Estadual, Tenured International Professor and Mentor for PhD and MSc Programs, São Paulo, SP, Brazil

© Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_73

• 30–60 min before starting the procedure, mark the area to be treated and apply topical anesthesia (4% lidocaine cream). • Apply ice immediately before the injections.

529

R. I. Zac and A. Da Costa

530

• Clean the skin up with chlorhexidine digluconate 2% or other solution that the patient is not allergic. • Add 2 ml of lidocaine 2% to previously diluted PLLA suspension and stir gently (Fig. 73.3). • In each Luer lock 1 ml syringe with an 18G needle, put 0.5  ml of the suspension and 0.5 ml of sterile water for injection. • Substitute this needle with a short 26G needle. • Pinch the skin between the index finger and the thumb in equidistant 1.0 cm points in the previously demarcated area (Fig. 73.4).

• The level of the injection should be the transition between the deep dermis and subcutaneous tissue. • The injections must be made with the needle inserted at an angle of 60° and the bevel facing down. • Aspiration before injection is recommended. • The volume injected at each point was 0.1 ml of the diluted product. • Each patient received about 12  ml total volume. • After finishing the injection, the treated area was manually massaged for 2 min.

73.3 Clinical Follow-Up [1–6] • All patients were asked to vigorously massage the entire area for 5  min, 5 times a day, for 5 days (Fig. 73.5). • Patients were asked to return to doctor’s office after 1 week and monthly or bimonthly after that. • One session is recommended for patients with slight texture alterations and flaccidity, while 2–4 sessions for at least 4–8 weeks apart are suitable for those with greater challenges. Fig. 73.3 Preparation

Fig. 73.4 Pinching

Fig. 73.5 Massage

73  Poly-L-Lactic Acid for the Neck

531

73.4 Before and After (Figs. 73.6 and 73.7)

Fig. 73.6 Before (Courtesy: Dr. Cristiana César Evangelista, Porto Alegre, RS, Brazil)

Fig. 73.7 After (Courtesy: Dr. Cristiana Evangelista, Porto Alegre, RS, Brazil)

César

73.5 S  ide Effects, Complications, and Their Management [1–6] • The most commonly seen adverse effect was the appearance of hematomas and ecchymosis in the treated areas, which regressed spontaneously after 7–10 days. • Erythema, itching, and edema can occur after injection (Fig. 73.8). • Patients tolerated pain well. • Palpable nodules were treated with an injection of sterile water and vigorous massage. The remaining nodules were treated with intralesional triamcinolone (Fig. 73.9).

Fig. 73.8  Side Effects (Courtesy: Dr. Cristiana César Evangelista, Porto Alegre, RS, Brazil)

R. I. Zac and A. Da Costa

532

• The level of the injection should be the transition between the deep dermis and subcutaneous tissue. • The injections must be made with the needle inserted at an angle of 60° and the bevel facing down. • Aspiration before injection is recommended. • The volume injected at each point was 0.1 ml of the diluted product. Fig. 73.9  Nodules (Courtesy: Dr. Doris Hexsel, Porto Alegre, RS, Brazil)

References • Very rarely, hypersensitivity reactions, angioedema, and sarcoidosis may occur. • Infections at the site of injection are also rare if you follow sterile injection technique.

Tip Box

• Dilute PLLA in 10 ml sterile water for injection. • Add 2 ml of lidocaine 2% to previously diluted PLLA suspension and stir gently. • In each Luer lock 1 ml syringe with an 18G needle, put 0.5 ml of the suspension and 0.5 ml of sterile water for injection. • Substitute this needle with a short 26G needle. • Pinch the skin between the index finger and the thumb in equidistant 1.0  cm points in the previously demarcated area.

1. Hart DR, Fabi SG et al. Current Concepts in the Use of PLLA: Clinical Synergy Noted with Combined Use of Microfocused Ultrasound and Poly-l-Lactic Acid on the Face, Neck, and Décolletage. Plast Reconstr Surg. 2015;136(5 Suppl):180S–187S. 2. Lourenc Z P. Techniques for the Optimization of Facial and Nonfacial Volumization with Injectable Poly-L-lactic Acid. Aesth Plast Surg. 2012;36:1222–9. 3. Mazzuco R, Hexsel D. Poly-L-Lactic Acid for Neck and Chest Rejuvenation. Dermatol Surg. 2009;35:1228–37. 4. Redaelli A, Forte R. Cosmetic use of polylactic acid: report of 568 patients. J Cosmet Dermatol. 2009;8:239–48. 5. Vleggaar D. Facial enhancement and the European experience with Sculptra. J Drugs Dermatol. 2004;3(5):542–7. 6. Vleggaar D. Facial volumetric correction with injectablepoly-l-Lactic acid. Dermatol Surg. 2005;31(Suppl. 4):1511–8.

Poly-L-Lactic Acid for Arms

74

Daniel Dal’Asta Coimbra and Betina Stefanello

74.1 Materials • For reconstitution of the product: 24–36  h before with 8  cc of distilled water and preserved without shaking at room temperature. • For final dilution: 8 cc of distilled water and 4 cc of 2% lidocaine without epinephrine. The final dilution bottle used is 20 cc. • For application: white pencil to divide and demarcate areas, 20 Luer-lock syringes of 1 cc, gauze, chlorhexidine, and mixing 0.4 cc of the product and 0.6 cc of solution.

74.2 Methods and Techniques 74.2.1 Methods • The PLLA should not be used directly in wrinkles or lines and does not provide an immediate effect. The end result will be a reflection of the quality of the neocollagenesis of the selected patient, proper planning for its use, and the proper preparation and product injection [1–3].

D. D. Coimbra · B. Stefanello (*) Les Peaux Clinic of Dermatology, Rio de Janeiro, RJ, Brazil Rubem David Azulay Institute of Dermatology, Santa Casa of Mercy of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

© Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_74

• It is important to recognize that the use of PLLA requires careful reconstitution of the product in accordance with the procedure described in the prescribing information.

74.2.2 Techniques • It is important to recognize that the use of PLLA requires careful reconstitution of the product in accordance with the procedure described in the prescribing information. • According to the label, reconstitution involves adding 5  cc of distilled water followed by standing material at least 2 h to allow hydration [3]. In clinical practice, many physicians include lidocaine during the reconstitution step and using a higher reconstitution volume (i.e., add >5  mL of sterile water) and longer times of hydration, although these variations are not described on the label (Figs. 74.1 and 74.2) [4–12]. • In our experience, the use of PLLA technique for medial and anterior arms: the PLLA is reconstituted on the previous day (24–36  h before) with 8  cc of distilled water and preserved without shaking at room temperature. Immediately before use, the bottle must be shaken vigorously until homogeneity of the product. Simultaneously prepare 12  cc solution using 8 cc of distilled water and 4 cc of

533

D. D. Coimbra and B. Stefanello

534

Fig. 74.1  Reconstituted PLLA with 5 cc of destilled water with or without lidocaine

Fig. 74.3  The linear retrograde technique of application of PLLA

•

•

Fig. 74.2  Depositing parallel cylinders of PLLA into the arm’s dermis

2% lidocaine without epinephrine. The final dilution bottle used is 20 cc [13–15]. • No refrigeration is required and should be stored at temperatures between 5 and 30 °C; it is recommended that the solution should be used within 72 h. • The arm region to be treated is divided and demarcated into four areas. Using Luer-lock syringes of 1 cc, mixing 0.4 cc of the product and 0.6 cc of solution [15]. • The application technique is linear retrograde, depositing parallel cylinders approximately 0.05 cc of the final solution in deep dermis. In each quadrant approximately 1.25  cc of the product is used for a total of 5  cc per arm.

•

•

After application, 10 min of vigorous massage is performed on the treated area, and the patient is instructed to perform the same at home, twice daily for 10  days (Fig. 74.3) [13–15]. Each session requires only 10 cc of the product for both arms. The number of sessions varies from two to four, at intervals of about 4–6 weeks to prevent overcorrection. Four weeks after the first application, it is already possible to notice improvement in the skin texture in the treated area, reduced sagging and appearance reminiscent of cellulite in place, and the results are more evident from the second application [15]. In some cases the improvement is evident 4 months after the first application. The result can last more than 24 months. Patients who have a greater sagging region can be treated with 10 cc of solution in each arm, making the application around the circumference [15].

74.3 Clinical Follow-Up • The PLLA is a filler with long duration that produces effects through the induction of cellular response resulting in the collagen formation. The microparticles of PLLA are biocompatible and biodegradable synthetic polymers [3].

74  Poly-L-Lactic Acid for Arms

• When we choose the treatment with PLLA in rejuvenating both the face and body, we should consider that the results vary from patient to patient and are also directly related to the amount of product applied, implementation of depth, and dilutions and volume injected into each point [16]. • To avoid small late nodules (after 12 months), we suggest diluting 20 cc with application in the deep dermis in small volumes and vigorous massage on-site treated immediately after application and in subsequent days, to reduce the chance of product buildup. • The depth of the application interferes with results obtained by the treatment. The most appropriate body application is in the deep dermis or subcutaneous, thereby decreasing the formation of nodules, while maintaining the product in contact with fibroblasts, which probably leads to increased collagen production and better results [17]. • There is no consensus in the literature on the quantity of product per application. The injected volume of 5 cc per arm every application was estimated and maintained due to the good results obtained, requiring studies to assess and quantify volume of the product by extension of the treated skin area. • To treat other body areas, also use this dilution of 20 cc per vial. The dose is usually a bottle for application in the abdomen, a bottle in the buttocks, and a bottle on thighs when we treat anterior and medial [18, 19]. • The application of PLLA for rejuvenation of body areas is a minimally invasive procedure, durable and low frequency of complications [20, 21]. • We should avoid large volumes, low dilution, and short break between sessions [1, 20, 21]. • The results are promising and have a positive impact on quality of life of patients with a high level of safety and long-lasting results [20, 21].

535

74.4 Before and After (Fig. 74.4, 74.5, 74.6, and 74.7)

Fig. 74.4  Before (on the left) and after (on the right) 1 year of injecting PLLA: 4 applications of 5 mL each per arm

Fig. 74.5  Before (on the left) and after (on the right) 6 months of injecting PLLA: 2 applications of 5 mL each per arm

Fig. 74.6  Before (on the left) and after (on the right) 1 year of injecting PLLA: 2 applications of 5 mL each per arm

D. D. Coimbra and B. Stefanello

536

Tip Box

Fig. 74.7  Before (on the left) and after (on the right) 1 month of injecting PLLA: 4 applications of 5 mL each per arm

74.5 S  ide Effects, Complications, and Their Management • Side effects described are generally self-­ limited and include pain application, erythema, local edema, transient bruising, and papules or nodules. • The incidence of nodules or papules is reduced with greater dilution of the product, the subcutaneous injection (avoiding superficial injections), after application and massage house and administration by trained professionals. • Most nodes have spontaneous resolution in a few months or years [1, 22–24]. • The occurrence of inflammatory granulomas is very rare and the pathophysiology is not known. There is no standard treatment, but in general there is a good response with the use of oral minocycline associated with oral and intralesional corticosteroid therapy. • There are reports of the use of intravenous 5-fluoracil in the treatment of inflammatory nodules related to application of PLLA [22–24].

• PLLA stimulates neocollagenesis and provides a natural look. • With a correct dilution, it can be used in body areas such as the neck, chest, back of the hands, lower breast region, thoraco-­ axillary fold, buttocks, arms, and medial thighs with good results. • It is good to keep in mind that when using PLLA we have to consider the following sentence: treat to repair, wait to restore, and evaluate to refine. • Treatment sessions should be spaced with 4–6  weeks of interval to avoid overcorrection. • When treating arms, PPLA reconstitution on the previous day (24–36 h before) with 8 cc of distilled water and preserved without shaking at room temperature. • Immediately before use, the bottle must be shaken vigorously until homogeneity of the product. Simultaneously prepare 12  cc solution using 8  cc of distilled water and 4 cc of 2% lidocaine without epinephrine. • The application technique is linear retrograde, depositing parallel cylinders approximately 0.05 cc of the final solution in deep dermis. • At the end of the session, it is essential to massage the treated area vigorously until homogeneity. • In clinical practice, many physicians include lidocaine during the reconstitution step, after hydration and just before the procedure. • The end result will depend on the patient’s ability to induce neocollagenesis and on the correct way of dilution and technique of application.

74  Poly-L-Lactic Acid for Arms

References

537

12. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid for the treatment of HIV-associated facial lipoatrophy. J Am Acad 1. Murad A, Hayes G, Edward MK, Jack PMJ, Keyvan Dermatol. 2005;52:233–9. N, Isaac MN, et al. ASDS guidelines of care: inject13. Radaelli A.  Cosmetic use of polylactic acid for able fillers. Dermatol Surg. 2008;34(Suppl 1): hand rejuvenation: report on 27 patients. J Cosmet 115–48. Dermatol. 2006;5(3):233–8. 2. Distante F, Pagani V, Bonfigli A. Stabilized hyaluronic 14. Radaelli A, Forte R.  Cosmetic use of polylactic acid of non-animal origin for rejuvenating the skin acid: report of 568 patients. J Cosmet Dermatol. of the upper arm. Dermatol Surg. 2009;35(Suppl 1): 2009;8(4):239–48. 389–93. 15. Coimbra D, Amorim AGF. Ácido Poli-L-láctico 3. Sculptra [prescribing information], Bridgewater, NJ: na região medial dos braços. Surg Cosm Dermatol. Dermik Laboratories; a business of sanofi-aventis 2012;4(2):182–5. U.S. LLC. 2006. 16. Fitzgerald R, Vleggaar D.  Facial volume restoration 4. Vleggaar D, Bauer U.  Facial enhancement and the of the aging face with poly-l-lactic acid. Dermatol European experience with Sculptra (poly-l-lactic Ther. 2011;24:2–27. acid). J Drugs Dermatol. 2004;3:542–7. 17. Lowe NJ, Maxwell CA, Lowe P, Shah A, Patnaik 5. Sherman RN.  Sculptra: the new three-dimensional R. Injectable poly-l-lactic acid: 3 years of aesthetic filler. Clin Plast Surg. 2006;33:539–50. experience. Dermatol Surg. 2009;35(Suppl 1): 6. Lam SM, Azizzadeh B, Graivier M. Injectable poly-­ 344–9. L-­ lactic acid (Sculptra): technical considerations 18. Peterson JD, Goldman MP. Rejuvenation of the aging in soft- tissue contouring. Plast Reconstr Surg. chest: a review and our experience. Dermatol Surg. 2006;118:55S–63S. 2011;37(5):555–71. 7. Vleggaar D. Facial volumetric correction with injectable 19. Teimourian B, Malekzadeh S.  Rejuvenation of the poly-L-lactic acid. Dermatol Surg. 2005;31:1511–7. upper arm. Plast Reconstr Surg. 1998;102(2):545–51; 8. Valantin MA, Aubron-Olivier C, Ghosn J, et  al. discussion 552–3. Polylactic acid implants (New-Fill) to correct facial 20. Mazzuco R, Sadick NS.  The use of poly-L lipoatrophy in HIV-infected patients: results of the lactic acid in the gluteal area. Dermatol Surg. open-label study VEGA. AIDS. 2003;17:2471–7. 2016;42(3):441–3. 9. Mandy SH. Fillers that work by fibroplasia: poly-L-­ 21. Sadick NS, Arruda S. The use of poly-L-lactic acid in lactic acid. In: Carruthers J, Carruthers A, editors. the abdominal area. Dermatol Surg. 2017;43(2):313–5. Soft tissue augmentation. 2nd ed: Saunders; 2007. 22. Duffy DM.  Complications of fillers: overview. p. 101–4. Dermatol Surg. 2005;31:1626–33. 10. Mandy SH. Satisfying patient expectations with soft-­ 23. Lowe NJ, Maxwell CA, Lowe P, Shah A, Patnaik tissue augmentation. Dermatol Online J. 15(7):1. R.  Adverse reactions to dermal fillers: review. 11. Duracinsky M, Leclercq P, Herrmann S, Christen MO, Dermatol Surg. 2005;31(11 pt 2):1616–25. Dolivo M, Goujard C, et  al. Safety of poly-L-lactic 24. Gladstone HB, Cohen JL.  Adverse effects when ® acid (New-Fill ) in the treatment of facial lipoatroinjecting facial fillers. Semin Cutan Med Surg. phy: a large observational study among HIVpositive 2007;26:34–9. patients. BMC Infect Dis. 2014;14:474.

Poly-L-Lactic Acid for Hands

75

Francisco Marcos Perez Atamoros and Alberto Avila Lozano

75.1 Materials PLLA • PLLA is created through corn dextrose fermentation, prepared as micronized and lipophilic, with an average particle size of 40–63 μm. • These particles are large enough to escape phagocytosis and directly incite a subclinical locally controlled inflammatory response that results in encapsulation and fibroplasia. • Although encapsulated PLLA may degrade by 9 months, subsequent fibroblast induction and neocollagenesis can increase dermal thickness and volume for more than 2 years. • In addition to the face, PLLA has also been used in the hands, neck, chest, and buttocks and in atrophic scars. • To reconstitute injectable PLLA with 3–5 ml of sterile water for injection (SWFI). • There are many reports of different dilutions of it that goes from 5 to 24 ml that also may minimize adverse effects [1, 2]. • The vial should be allowed to stand for at least 2  h at room temperature (and up to a maxi-

• •

•

• •

mum of 72 h) and agitated just prior to injection to obtain a uniform suspension. PLLA should not be refrigerated or frozen. The amount of product injected depends on the area to be injected and the amount of atrophy present. Dilution volume can vary depending on treatment area. Author recommendation is to reconstitute lyophilized powder using higher dilution volumes (7 ml or more), specially for extracranial uses, at least 24 h. Give a massage immediately following implantation and during a designated follow-­up period. We also add, prior to application, 4 ml of lidocaine without epinephrine for a total volume of 17 ml in the chest area and 2 ml to the hand area for a total volume of 7 ml.

75.2 Methods and Techniques • The material should be injected into the upper subcutis, using a threading technique so we can distribute PLLA uniformly.

F. M. P. Atamoros (*) · A. A. Lozano Centro Dermatologico Tennyson, Mexico City, DF, Mexico e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_75

539

540

• Volume should be limited to 0.1–0.2  ml, spaced at distance 0.5–1 cm. • To agitate PLLA in the syringe many times during application. • An even cross-hatched threading injection pattern can be used in the treatment area using a 1- to 1.5-inch needle to deposit the product as the needle is withdrawn. • Depending on the area we are going to treat, we use different dilutions. • After the injection, the material should be massaged firmly to allow a better distribution; some authors also recommend to use a moisturizing cream. • Massage must be done during the treatment session, immediately posttreatment, and afterward twice a day for 5 min by the patient for 1–2 weeks. • Massage is also going to decrease the incidence of post-injection papules and nodules [2].

Chest • In the technique for the décolletage, we have to dilute the PLLA in 17 ml (13 ml of SWFI and 4 ml of lidocaine) [3]. • Place the injections with a 1-in. 25G needle starting with rhytids centrally between the breasts then proceeding laterally and superiorly in the plane of the subcutaneous fat [4]. • Using a retrograde linear threading technique, apply 0.3 ml/cm per injection. • The boundaries of the treatment area are the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally.

Hands • PLLA can be used in the hands with very good results, but we must use a different dilute preparation to avoid the formation of nodules [5].

F. M. P. Atamoros and A. A. Lozano

• We use a preparation with 10  ml of diluent per PLLA vial (07 ml of SWFI and 3 ml of lidocaine) with a 1-in. 25G needle or cannula. • Due to the proximity of the dermis to the tendon sheath, precise delivery into the loose areolar space is critical to minimize nodule formation [5, 6].

• Since the effect of injectable PLLA is doseand not volume-dependent, a high reconstitution volume in this unique anatomic area assures uniform dispersion and accurate deposition of the product • It is vital to give a massage to the hand during the treatment and advice the patient to continue massaging for 30 days at least two times a day. • Many treatments may be required to have a good result; in contrast to other products, a waiting period is necessary to determine whether full correction is needed. • In a case series from Sadick and colsCols, they treated 26 patients with PLLA for hand rejuvenation [6]. • They reconstituted the vial on the night before the procedure to a volume of 10 ml using 6 ml of sterile water for injection and 1% lidocaine. • One half vial was injected per hand, with five 1-ml syringes on each side in a subdermal plane.

75  Poly-L-Lactic Acid for Hands

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• Patients were advised to massage for 5 min at 75.4 a time, 5 times/day for 5 days and then once a day for a month. They need an average of 2.38 treatments, with an average of 3.06 vials per patient [6]. • Another retrospective review of patients treated with PLLA in the hands concluded a high degree of satisfaction with the results, with only minor and short-term injection-­ related AE.

Buttocks • PLLA in this area can be used to obtain tissue augmentation or to correct postsurgical irregularities [7]. • The patients going to have a better outcome are those who have normal or low BMI. • For these areas we use a dilution of 17 ml of the product (10 ml SWFI and 7 ml lidocaine HCl 1%) administered using a 1.5-in. 25G needle or cannula. • A tunneling technique in the subcutaneous plane should be utilized. The patient is then reevaluated at 8 weeks, at which time the decision for further augmentation is made.

75.3 Clinical Follow-Up • It is important to advice the patient that the results are not immediate. A second or third treatment will be necessary to achieve the results. Set a patient appointment after 4–8 weeks to repeat treatment. • Because of the mechanism of action of the product, we recommend to follow the patient initially every month for 2–3 months to look for adverse effects. • Then in a year, we recommend to evaluate the results and to do, if it is necessary, another application.

 efore and After B (Figs. 75.1 and 75.2)

Fig. 75.1  Before and after 8-week treatment with polyL-lactic acid on dorm of the hands

Fig. 75.2  Before and after 12-week treatment with polyL-lactic acid on dorm of the hands

75.5 S  ide Effects, Complications, and Their Management • The adverse effects can be related to the product or injection. • The ones related to the injection are temporary side effects, as with any other medication that are injected, including bruising, swelling, edema, and pain in application area. • They are relatively frequent (90% of treatments) with soft tissue augmentation products and are generally short term in duration and resolve spontaneously.

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• One of the most frequent adverse effects is the subcutaneous nodules or papules of 5 mm or less. • Although these lesions resolve spontaneously in many patients, some authors use precautions, such as to inject a very dilute solution (16  ml or more), longer intervals between injection sessions (8 weeks), and vigorous massage regularly for 1 or more weeks. • Very dilute solutions (16 ml or more), longer intervals between injection sessions (8  weeks), and vigorous massage regularly for 1 or more weeks in the case of hand rejuvenation. • The incidence of these papules varies from 5% to 44%. • To treat these papules, we can use methods that include excision, intralesional corticosteroid injections, desiccation, and breaking up the nodule with a needle followed by saline injection [8]. • Delayed hypersensitivity has been reported; this reaction can occur with cosmetic devices and may arise several months or years after injection. • This can be manifested as itching, edema, and erythema, in addition to the formation of late granulomas (which are diagnosed histologically, depending on the filler used). • Granulomas resulting from a foreign body mass are unpredictable and should be differentiated from papules and nodules. • The occurrence of granulomas with PLLA is rare. • In the unlikely event of granuloma formation following injection of PLLA, steroid administration, intralesional, intramuscular or oral, with or without immune-modulating medications, over several weeks or months, has been noted as the mainstay of therapy [8]. • Allergic reactions are rare.

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• Always after the injection, a firm massage improves product distribution and is reported to decrease the incidence of postinjection papules and nodules [2]. • The success and durability of PLLA depends to a great extent on its appropriate use. • Dilution in SWFI in proper manner according to the area to be treated. • Reconstituting the product 24–48  h prior to injection. • The use of cross-hatching injections into the upper subcutis rather than superficial injection is going to result in a better outcome, and we are going to avoid the presence of nodules.

References 1. Jagdeo J, Ho D, Lo A, Carruthers A.  A systematic review of filler agents for aesthetic treatment of HIV facial lipoatrophy (FLA). J Am Acad Dermatol. 2015;73(6):1040–54. 2. Reszko AE, Sadick NS, Magro CM, et al. Late-onset subcutaneous nodules after poly-L-lactic acid injection. Dermatol Surg. 2009;35(Suppl 1):380–4. 3. Goldman MP. Cosmetic use of poly-L-lactic acid: my technique for success and minimizing complications. Dermatol Surg. 2011;37:688–93. 4. Vanaman M, Fabi SG.  Regional approaches with injectablellers: décolletage. Plast Reconstr Surg. 2015;136(5 Suppl):276S–81S. 5. Butterwick K, Sadick N.  Hand rejuvenation using a combination approach. Dermatol Surg. 2016;42:S108–18. 6. Sadick NS, Anderson D, Werschler WP.  Addressing volume loss in hand rejuvenation: a report of clinical experience. J Cosmet Laser Ther. 2008;10:237–41. 7. Lorenc ZP. Techniques for the optimization of facial and nonfacial volumization with injectable poly-L-­ lactic acid. Aesthetic Plast Surg. 2012;36:1222–9. 8. Narins RS.  Minimizing adverse events associated with poly-L-lactic acid injection. Dermatol Surg. 2008;34(Suppl 1):S100–4.

Poly-L-Lactic Acid for the Gluteal Area

76

Maria Helena Lesqueves Sandoval

76.1 Materials [1–10] According to my daily practice, the recommendations for the materials and tools used to apply PLLA (Sculptra®) are as follows (Fig. 76.1): • 1 vial of Sculptra® • 10 cc syringe for the dilution • 7–8 ml of sterile water for injection (SWFI) or bacteriostatic water • 1 cc or 3 cc syringes for the procedure • Lidocaine 2% with or without epinephrine • Sterile connector (Luer-lock to Luer-lock) • Needle: Terumo 26G × 1.5 inch 0.45 × 12 mm or 27G 1-inch needle. • Cannula 22G  ×  50  mm (experienced practitioners)

76.2 Methods and Techniques [1–10] To obtain successful results with this product, the application technique used will depend on the objectives and needs of the individual patient. The following guidelines describe application techniques for the use of Sculptra® M. H. L. Sandoval (*) Department of Dermatology, Aesthetic Dermatology Unit, Cassiano Antonio Moraes Hospital, Vitoria, ES, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_76

to improve gluteal volume and contouring, correct symmetry, and irregularities in the skin’s surface as well as decrease the appearance of cellulite. The biggest challenge in the treatment of sagging skin in body areas is the wide range of factors that need to be considered according to each individual patient. The main indications for this treatment are loss of gluteal fat secondary to aging or weight loss as well as genetic predisposition.

76.2.1 Preparing the Patient The use of topical anesthetic depends on the preference of the patient, but it is rarely requested for the gluteal area. The patient should come to the appointment having previously showered, and then just prior to the procedure, the skin is cleaned using chlorhexidine 1% solution. Photos are taken and injection marks are drawn with the patient in the supine position.

76.2.2 Preparing the Product • The product is hydrated with 8 ml of SWFI or bacteriostatic water at least 24  h prior to injection. • The vial must be kept at a temperature between 5  °C and 30  °C (4  °F to 85  °F) and not be shaken during hydration 543

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Fig. 76.1  Materials and tools do apply PLLA

Fig. 76.2  3 ml syringes for further dilution with a sterile connector Luer-lock to Luer lock

• 2 ml of lidocaine 2%, with or without epinephrine, is added to the solution immediately prior to the procedure to obtain a ratio of 1:10 ml. • The solution is then diluted further with SWFI or bacteriostatic water using 2 × 3 ml syringes and a connector Luer-Lock to Luer Lock (Fig. 76.2). • The volume of the final injection for gluteal treatment is 1:20 ml. • The decision of how much to use in each side of the gluteal area depends on the patient’s needs.

Fig. 76.3  Markings show injection points for the parallel bar technique

76.2.3 Techniques • With the patient lying down, PLLA is injected in a retrograde manner, reaching the subcutaneous tissue at the level of the deep dermis. • 0.2 ml is used per injection with a parallel bar or crossing technique, as illustrated in Figs. 76.3 and 76.4.

Fig. 76.4  Markings for the crossing technique

• A cannula may also be used with a fan technique, depending on the level of experience of the practitioner.

76  Poly-L-Lactic Acid for the Gluteal Area

76.3 Clinical Follow-Up • Usually we plan 2–3 sessions, with 30–45 days apart. • Patients are asked to massage the treated area twice a day for 5 min over 10 days. • Any moisturizing lotion can be used for the massage.

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• Follow-up pictures can be taken 3 and 6 months after the last application to make an assessment of the results.

76.4 Before and After (Figs. 76.5, 76.6, and 76.7)

Fig. 76.5  Before and after: 35-year-old patient, 3 months after the second session of PLLA on the gluteal area

Fig. 76.6  Before and after: 36-year-old patient after 2 sessions of PLLA on the gluteal area for irregularities of the skin (left side)

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Fig. 76.7  Before and after: 36-year-old patient after 2 sessions of PLLA (right side)

76.5 S  ide Effects, Complications, and Their Management [1–10] • Treatments are usually very well tolerated in all patients. No serious adverse effects have been documented to date. • It is common for bruising to appear at the injection sites and these will disappear spontaneously after a few days (Fig. 76.8). • Despite the discomfort that the bruised areas may cause, it is important for the patient to continue their daily post-procedure massage to prevent the formation of nodules. Fig. 76.8  Bruising in the treated area

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Plast Surg. 2011;19(3):e22–7. 2. Coimbra DD, Amorim AGF. Poly-L-lactic acid in the rejuvenation of the medial and anterior arms. Surg • Avoid taking aspirin, vitamin E, ginkgo Cosmet Dermatol. 2012;4(2):182–5. biloba, or any anticoagulant medication 3. Cunha MG, Daza F, Rezende FC, Machado Filho CDS.  Poly-L-lactic acid for injections in sagging in the week prior to the procedure. body skin. Surg Cosmet Dermatol. 2016;8(4):322–7. • Always advise patients that the results 4. Fitzgerald R, Vleggaar D.  Facial volume restoration of this procedure will only appear after of the aging face with poly-l-lactic acid. Dermatol some months. Ther. 2011;24(1):2–27. 5. Lacombe V. Sculptra: a stimulatory filler. Facial Plast • Avoid sun exposure until the skin has Surg. 2009;25(2):95–9. completely recovered from bruising. 6. Lowe NJ.  Dispelling the mith: appropriate use of • Ensure that patients understand the poly-l-lactic acid and clinical consideratiins. J Eur importance of post-procedure massage Acad Dermatol Venereol. 2006;20(Suppl 1):s2–6. 7. Mazzuco R, Sadick NS. The use of poly-L-lactic acid in the treated area. in the gluteal area. Dermatol Surg. 2016;42(3):441–3. • A patient will obtain optimal results by 8. Machado Filho CDS, Santos TC, Rodrigues APLIR, using this treatment in conjunction with Cunha MG. Ácido poli-L-láctico: um agente bioeenergy-based skin tightening treatments stimulador. Surg Cosmet Dermatol. 2013;5(4): 345–50. such as radiofrequency or micro 9. Varani J, Dame MK, Rittie L, Fligiel SE, Kang S, focused ultrasound, and continue the Fisher GJ, Voorhees JJ. Decreased collagen production regularity of exercises. in chronologically aged skin: roles of age-dependent alteration in fibroblast function and defective mechanical stimulation. Am J Pathol. 2006;168(6):1861–8. 10. Vleggaar D, Fitzgerald R, Lorenc ZP, Andrews TJ, Butterwick K, Comstock J, Hanke CW, O’Daniel References G, Palm MD, Roberts WE, Sadick N, Teller CF. Consensus recommendations on use of injectable 1. Bauer U, Graivier MH.  Optimizing injectable poly-­ poly-l-lactic acid for facial and nonfacial volumizaL-­lactic acid administration for soft tissue augmentation. J Drugs Dermatol. 2014;13(Suppl 4):s44–51. tion: the rationale for three treatment sessions. Can J

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Polyacrylamide for the Face

77

Natacha Quezada Gaón, Cristián Vera-Kellet, and Ximena Wortsman

77.1 Materials • • • • •

1–12 ml of polyacrylamide [1] 27-25-21-18G cannula 27-25-21-18G needle Local anesthesia with lidocaine Insulin syringe with 30G needle to apply anesthesia • Chlorhexidine • Sterile gauze (Fig. 77.1)

77.2 Methods and Techniques • Perform a complete medical history, considering personal pathological history, allergies, previous herpes history, etc. • Adequate conversation with the patient, equating their reason for consultation and explaining realistically what can be improved. • Take informed consent to explain in detail the procedure and its complications. • Take standard photographs before and after the procedure. • Asepsis and antisepsis.

• Make the patient’s cosmetic diagnosis considering the anatomy, aesthetic planes, and age. • asegurar la cánula a la jeringa de poliacrilamida, depositando el producto en p­ untos, bolos o en retroinyección lineal, abanico, según necesidad. • Delimit the working area (Fig. 77.2). • Apply a small anesthetic point. • Insert the needle of the size of the cannula to be used, 30° of inclination traversing the epidermis and dermis, until reaching the subcutaneous tissue (deep plane) [2]. • Secure the cannula to the polyacrylamide syringe, depositing the product in points, boluses, linear retroinjection, or fan-shape mode, as needed. • Consider that the application technique is similar to that of high-bulk density hyaluronic acid (Fig. 77.3) [3, 4].

N. Quezada Gaón (*) · C. Vera-Kellet Department of Dermatology, Pontifical Catholic University of Chile, Santiago de Chile, Chile X. Wortsman Department of Dermatology at University of Chile, Santiago del Chile, Chile © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_77

Fig. 77.1 Materials 549

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a

b

c

Fig. 77.2 (a) Before, (b) zone marking according to Braz for malar correction, and (c) immediate post-procedure

77.3 Clinical Follow-up • Further sessions must be planned with 30–45 days apart.

• Patients are asked to massage the treated area several times a day, for 2 weeks, using any moisturizing lotion. • Follow-up pictures must be taken every 3 months to realized the outcomes obtained.

77  Polyacrylamide for the Face

a

551

b

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Fig. 77.3 (a) Before, (b) marking of the area according to Mateus for nasogenian groove lift associated with malar correction, and (c) immediate post-procedure

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77.4 Before and After (Figs. 77.4, 77.5, and 77.6) a

b

Fig. 77.4  Before (a) and after 4 ml filler (b), in malar region

a

b

Fig. 77.5  Before (a) and after 2 ml filler (b) in the mental region

77  Polyacrylamide for the Face

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b

Fig. 77.6  Before (a) and after rhino modeling 1 ml of filler (b)

77.5 S  ide Effects, Complications, and Their Management • Early side effects reported include pain, edema, permanent burning of the lips, and infections. • Within months, some effects seen include biofilms, nodules, and Tyndall effect (Fig. 77.7). • Foreign body reaction may be minimal and transient, with demonstrated fibrosis in a vascularized network of connective tissue. But even in months it can form granulomas. • Delayed complications include gel migration and lupus panniculitis [5]. • Problems of technique and intravascular application may produce necrosis, which is difficult to handle. • Always in case of complications remember that the ultrasound is an excellent ally (Fig. 77.8) [6].

Fig. 77.7  51-year-old male, HIV positive, with history of lipoatrophy treated with polyacrylamide shows a palpable bump (arrow) in the medial part of the right cheek, close to the nasofold line

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• If there is a facial granuloma, the gel can be drained with a needle [7]. • Do not forget that it is a filler that degrades within months; however 2.5% is not absorbed and can be potentially riskier than hyaluronic acid.

References Fig. 77.8 Ultrasound (transverse view; right cheek) demonstrates two oval-shaped, anechoic deposits measuring 6.0 and 7.7 mm (major axes) in the superficial part of the hypodermis that corresponds to polyacrylamide (between markers)

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• Remember that the best indication for this gel is HIV patients because of the risk of granulomas. • Working with cannula avoids traumatizing the tissues, hematomas, and application in deep planes more efficiently. • As every filler remember the anatomically risk zones.

1. Pallua N, Wolter TP.  A 5-year assessment of safety and aesthetic results after facial soft-tissue augmentation with polyacrylamide hydrogel (Aquamid): a prospective multicenter study of 251 patients. Plast Reconstr Surg. 2010;125(6):1797–804. 2. Yamauchi P. Emerging permanent filler technologies: focus on Aquamid. Clin Cosmet Investig Dermatol. 2014;7:261–6. 3. Lesqueves Sandoval MH, Leis Ayres E. Rellenos Guía práctica de técnicas y productos. Sao Paulo. Ed. AC Farmacéutica. 2014;9.1:221–236. 4. Mateus A, Palermo E. Cosmiatria e laser. Sao Paulo Ed AC Farmacéutica 2012;26:254–258. 5. Gupta K, Bhari N, Verma KK, Gupta S.  Permanent injectable polyacrylamide hydrogel dermal filler for a large subcutaneous defect secondary to lupus panniculitis. Dermatol Surg. 2017;43(1):152–4. 6. Wortsman X, Wortsman J.  Polyacrylamide fillers on skin ultrasound. J Eur Acad Dermatol Venereol. 2012;26:660–1. 7. Kavoussi H, Ebrahimi A. Delayed gel indurations as an adverse effect of polyacrylamide filler and its easy treatment. Dermatol Res Pract. 2012;2012:539153.

Polycaprolactone for the Face

78

Pierre Nicolau

78.1 Materials • • • •

Ellansé® Sterile gauze Syringes with lidocaine with epinephrine Needle 27-25-21-18G and/or cannula 27-25-21-18

78.2 Methods and Techniques • Ellansé consists of PCL microspheres 25–50 μm in diameter (30% by volume) suspended in phosphate-buffered saline, glycerin, and carboxymethyl cellulose carrier gel (CMC) 70% by volume [1]. • The gel is absorbed within 4–5 weeks, allowing for a complete encapsulation of each microsphere independently, thus preventing cluster formation and minimizing risks of nodules [1]. • The CMC gel has a viscosity of approximately 1000 Pa, a G’ much higher than that of hyaluronic acid fillers, preventing the product to be displaced and thus maintaining its precise location within the tissues [2].

• The CMC gel is not cross-linked, and even with this high viscosity, it is easily injectable through a 27G needle or cannula [3]. • PCL microspheres are formed by esterification of the hydroxy-caproic acid molecules, so the chemical composition consists only of carbon, oxygen, and hydrogen molecules. • PCL microspheres are gradually absorbed through hydrolysis from within, maintaining their spherical shape and volume, and releasing only CO2 and water, without any persisting by-products. • As the rate of degradation of PCL is known, it has been possible to design a range of four products depending on the persistence of the microspheres within the tissues, that is, 1, 2, 3, or 4 years [4, 5]. • There are no differences between each presentation: same volume, same number of molecules and microspheres, and same v­ iscosity, as it is only the time needed to hydrolyze the PCL that is different. • Each product comes in a box containing two syringes of 1 ml, with four sterile 27G, 37 mm needles. • The duration of the microspheres is indicated by the letters on the box, S for 1 year, M for 2 years, L for 3 years, and E for 4 years (Fig. 78.1). • The encapsulation process seen with any filler leads to permanent production of fibrotic,

P. Nicolau (*) Pierre Nicolau Clinic of Plastic Surgery, Figueras (Girona), Spain © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_78

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p­ rotective type III collagen, due to changes in the shape and volume of the particles, maintaining the original inflammatory process. • Ellansé is the only filler with proven production of more collagen type I than collagen type III, resulting in a biological rejuvenation of the skin and not only its scar like thickening (Fig. 78.2) [6].

78.2.1 Product’s injection • First cleaning up the skin with a cleansing micellar solution. • Marking the areas and point of injections with an easily removable marking pen. Fig. 78.1  Micropsheres of Ellansé

a

b

c

d

Fig. 78.2 (a, b) Ellansé microspheres totally encapsulated in mainly collagen type I fibers (yellow and red staining), after primary encapsulation in collagen type III (green fibers), at 9  months. (From Nicolau and

Marijnissen-Hofsté [6]). (c, d) PLLA particles showing 98 times increase of collagen type III (green staining) at 6  months, Fig.  78.1d, when compared to baseline Fig. 78.1c. (From Goldberg et al. [7])

78  Polycaprolactone for the Face

• Disinfection with chlorhexidine solution using sterile 10 × 10 sterile gauze swabs. • Deep epi-periosteal bolus injection technique: a 27G needle is recommended (Fig. 78.3a, b). –– At a 90° angle to the surface of the bone, introduce the 27G needle down to the periosteal plane. –– Lift the needle for approximately 1 mm to avoid damaging the periosteum. –– Inject slowly boluses of 0.1 ml to not more than 0.2–0.3 ml. –– Retrieve the needle slowly. • A light pressure can be applied in case of bleeding, but no massage is needed, as the a

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volumizing effect looked for is immediate, and there is no need to spread the product. • Superficial, subdermal injection technique with 27G needle. –– As described in step 4.1, introduce the needle at a 90° angle to shorten the intradermal path, and then turn the needle parallel to the surface of the skin, not deeper than 5 mm. –– Inject slowly in a retrograde manner straight or fanlike lines, of between 0.05 and 0.2 ml each • Superficial or deep injections with cannulas (Figs. 78.3a, b and 78.4a, b).

b

Fig. 78.3 (a) Marking the points of deep pre-periosteal injections and (b) deep pre-periosteal bolus injection technique with a 27G needle

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b

Fig. 78.4 (a, b) Deep epi-periosteal bolus injection technique with a 25G cannula. (a) Entry point with a 25G needle after local anesthesia (b) 25G cannula pushed to the pre-periosteal plane

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a

b

Fig. 78.5 (a, b) Superficial subdermal linear/fanning injection technique with a 25G cannula: nasolabial folds, marionette lines (a) 25G cannula in the subdermal plane

for Marionette line. (b) 25G cannula in the subdermal plane for nasolabial fold

• For patient’s comfort, it is possible to anesthetize the entry point with 0.2–0.3  ml of lidocaine. –– For deep, pre-periosteal injections (Fig. 78.4a, b) ◦◦ Create the entry point with the needle of required gauge, 23G for a 25G cannula and 25G for a 27G cannula. ◦◦ Follow steps 4.1 to 4.4. ◦◦ For linear injections, inject slowly in a retrograde manner lines of 0.05  ml to 0.2–0.3 ml at maximum. –– For subdermal injections (Fig. 78.5a, b), ◦◦ Follow step 6.1.1. ◦◦ Follow steps 5.1 to 5.2. • Mixing with an anesthetic solution: the product is not painful if injected slowly. –– For very sensitive patients, it can be mixed with xylocaine or lidocaine with or without adrenalin (epinephrine) with a maximum volume of 0.2 ml, that is, 20% of the volume of the syringe. –– Aspirate the anesthetic solution in a 2.5 or 3 ml Luer-Lock syringe, connect the syringe

to a dual female Luer-Lock connector, and mix with 20–30 strokes, sending the product alternatively in each syringe. • Immediate result should be just under the optimal effect looked for, as the final volume seen at the end of the third month is usually between 20% and 30% more than the volume injected, due to the thick elastic fibers of collagen type I, especially in younger patients. • Postinjection massages are recommended solely after superficial, subdermal biostimulation or volume, like in hands. Molding might be necessary for the nose, chin, or jawline and is easily achieved.

78.3 Clinical Follow-Up • Immediately postinjections, some swelling, bruising, and tenderness, due to the trauma of the injection, might be seen. • At the end of the first month, patients might feel a diminution in the apparent result of

78  Polycaprolactone for the Face

20–40%. This is due to the disappearance of the carrier gel and will be gradually compensated by the collagen type I formation. • For volume compensation, final result is seen at the third month. • For biostimulation of collagen type I, the improvement of the quality of the skin is obvious at the third month, but may continue to

a

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improve up to 1  year. Injections can be repeated after 3  months when production of collagen type I is obtained.

78.4 Before and After (Figs. 78.6, 78.7, 78.8, 78.9, and 78.10)

b

Fig. 78.6 (a, b) Correction of a notch in the alar rim (a) Before injection of 0.1 ml (b) 1-year postinjection

P. Nicolau

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b

c

d

Fig. 78.7 (a, b) Ellansé for fat loss compensation: (a) Before malar groove correction with 0.6  ml per side of Ellansé M, deep pre-periosteal boluses of 0.1–0.2  ml. Needle 27  G and nasolabial fold correction with 0.1  ml subdermal injection of Ellansé S., needle 27 G (b) After

injection. (c) Before malar groove correction with 1 ml per side of Ellansé M deep pre-periosteal boluses of 0.2  ml, needle 27 G. Marionette line correction with 0, 3 ml per side of Ellansé S, subdermal lines of 0.05 ml each, fanning technique, 25G cannula (d) 1 year, after injection

78  Polycaprolactone for the Face

a

c

Fig. 78.8 (a–d) Ellansé for bone compensation. (a) Before chin correction, Ellansé M deep pre-periosteal, 1.2  ml, boluses of 0.3  ml, needle 27G (b) Immediately after injection. (c) Before nose correction. Anterior Nasal

561

b

d

Spine 0.5  ml Ellansé M, single bolus injection, Needle 27G, Dorsum: 0.8  ml Ellansé M, Retrograde linear Injection, deep pre-periosteal needle 27G 40  mm. (d) immediately after correction

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a

c

b

d

Fig. 78.9 (a–d) Ellansé as a skin booster: biostimulation of collagen without volume augmentation. (a, c) Before. (b, d) After 11 months. 1 ml in 20 Lines of 0.05 ml per side, Fanning technique, 25 G cannula

a

b

Fig. 78.10 (a, b) Ellansé S for hands (a) Before injection: 1.5 ml per hand, cannula 25G, superficial, supra-venous upper layer of dorsum. (b) Immediately after injection

78  Polycaprolactone for the Face

78.5 S  ide Effects, Complications, and Their Management • In our experience, the immediate adverse effects observed are similar to those encountered with other fillers: edemas, ecchymosis, hematomas, and discomfort are related to the injection traumatism (Fig. 78.11). • Nodules are reported at low rates and are essentially due to deficient injection technique and overcorrection as they might be a ­consequence of an excess of tension within the tissues. • To date, in excess of 300,000 patients have been treated since 2009 using the PCL-based

a

563

stimulator, and no reports of granuloma have been documented. • Some localized inflammations have been reported, each time associated with a deficient injection technique: either too superficial (intradermal) or with too much volume (Fig. 78.12). • Treatment of nodules and inflammations is best achieved with intralesional injections of prednisolone 40 mg diluted in 1 ml of saline, 0.5  ml of lidocaine, and 0.5  ml of 50 UI of hyaluronidase. • Prednisolone will treat the cellular and vascular reaction, and lidocaine, being acidic, and hyaluronidase will both modify the local metabolisms.

b

Fig. 78.11 (a, b) Ecchymosis following deep venous puncture without intravascular injection (a) day 3 (b) day 7

a

b

Fig. 78.12  Nodules due to too superficial injections of Ellansé M. (a) Before treatment (b) Total disappearance at 6 months

P. Nicolau

564

Tip Box

• PCL microspheres have a known full absorption time, allowing for choice of duration of the injected product without any degradation of by-products. • PCL microsphere filler is an excellent volumizing product; its fast encapsulation prevents its displacement and gives maximum result per volume injected. • PCL microsphere is the only material to date not maintaining a production of collagen fibrotic type III for all duration of presence of the filler in the tissues, allowing for mainly normal skin type I collagen production. • Final result, due to the size of type I collagen fibers (10–20  times thicker than type III), is greater than the initial volume, thus allowing for less product to be needed. No need for overcorrection or “touch-up.” • PCL microsphere filler inducing more normal skin type I collagen than type III can be used with as little volume as possible to be injected as a pure biostimulator without distorting the normal superficial anatomy. • Injections can be done either superficially, in the subdermal plane, or deep, at the supra-periosteal level, for volume loss compensation or pure collagen type I stimulation. • As it is easy to inject, it can be used with needles or cannulas, 27 or 25G,

whichever duration is needed, without the need for special needles, syringes, or cannulas. • PCL microsphere filler is to date the only product whose clinical results last for at least 6–12 months longer than the presence of the product in the tissues, thanks to the production of collagen type I large fibers.

References 1. Nicolau PJ.  Long lasting and permanent fillers: biomaterial influence over host tissue response. Plast Reconstr Surg. 2007;119(7):2271–86. 2. Stocks D, Sundaram H, Michaels J, Durrani MJ, Wortzman MS, Nelson DB. Rheological evaluation of the physical properties of hyaluronic acid dermal fillers. J Drugs Dermatol. 2011;10:974–80. 3. De Melo F, Marijnissen-Hofsté JM.  Investigation of physical properties of a polycaprolactone dermal filler when mixed with lidocaine and lidocaine/epinephrine. Dermatol Ther. 2012;2(1):13–23. 4. Pitt CG. Poly (e-caprolactone) and its copolymers. In: Chassin M, Langer R, editors. Biodegradable polymers as drug delivery systems. New  York: Dekker; 1990. p. 71–119. 5. Sun H, Mei L, Song C, Cui X, Wang P. The in vivo degradation, absorption and excretion of PCL-based implant. Biomaterials. 2006;27:1735–40. 6. Nicolau PJ, Marijnissen-Hofsté JM.  Neocollagenesis after injection of a polycaprolactone based dermal filler in a rabbit. Eur J Aesthetic Med Dermatol. 2013;3:19–26. 7. Goldberg DJ, Guana A, Volk A, Daro-Kaftan E. Singlearm study for the characterization of human tissue response to injectable ply-L-lactic acid. Dermatol Surg. 2013;39(6):1–8.

Polycaprolactone for Extrafacial Areas

79

Natacha Quezada Gaón, Ximena Wortsman, and Patricia Apt

79.1 Materials • • • • • • • •

2 syringes of polycaprolactone Sterile gauze Lidocaine with epinephrine 2 ml Syringe of insulin (for anesthesia) Inject more than 3 ml (for the mixture) Key of two routes Needle 27-25-21-18G Cannula 27-25-21-18G (Fig. 79.1).

79.2 Methods and Techniques • To realize a clinical complete history, consider the pathological personal precedents, allergies, history of herpes, autoimmune pathologies, etc. • To consider as relative contraindication if the patient is in use of any anticoagulative m ­ edication (such as heparin, aspirin, vitamin E). The case must be evaluated carefully.

N. Quezada Gaón (*) Department of Dermatology, Pontifical Catholic University of Chile, Santiago de Chile, Chile X. Wortsman Department of Dermatology at University of Chile, Santiago de Chile, Chile P. Apt Las condes Clinic, Santiago de Chile, Chile

© Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_79

Fig. 79.1  Polycaprolactone materials

• Adquate conversation with the patient equating his motive of consultation and explaining realistically what is possible to improve. • An informed consent that explains the procedure, complications, and risks should be signed before. • Standard photography registry, authorized by the patient • Clean the area with chlorhexidine 2%. • Make the cosmetic diagnosis of the patient considering the anatomy, the cosmetic planes, and the age • Being considered a filler with biostimulatory effect, it is interesting to use it in hands and neck zones that have a loss of volume due to a poor quality of skin [1].

565

N. Quezada Gaón et al.

566

a

b

Fig. 79.2 (a) Polycaprolatone without mixing. (b) Homogeneous mixing after a few minutes of constant movement

• Mix 1 ml of polycaprolactone and 1 ml of lidocaine using the two-way tap; mix until a homogeneous liquid is obtained (Fig. 79.2). • Delimit the area to work well; in case of the hands, draw the veins, and in case of the neck, draw the areas of loss of volume and more wrinkles (Fig. 79.3) [2]. • Apply a small anesthetic point. • Insert the needle of the size of the cannula to be used, 30° of inclination traversing the epidermis and dermis, until reaching the subcutaneous cellular tissue (deep plane). • Secure the cannula to the syringe with polycaprolactone in points, boluses, linear retroinjection, or fan, according to necessity [3]. • Consider that the application technique is similar to that of high-density hyaluronic acid (Fig. 79.5) [4]. • It is essential to vigorously massage the worked area for 5–10 min (Fig. 79.4).

Fig. 79.3  The anatomy of the hand allows the veins and tendons to be clearly seen, facilitating the area to be demarcated

79  Polycaprolactone for Extrafacial Areas

a

567

b

c

Fig. 79.4 (a) Anesthetic point. (b) Introduction of the cannula and previous entry with a needle. (c) Massage

N. Quezada Gaón et al.

568

a

b

Fig. 79.5 (a) Marcation every 1.5 cm in the neck with needle 25, in subcutaneous cellular tissue with 0.2 ml per point with 1 ml of polycaprolactone diluted with 1 ml of anesthesia (b) Post 6 weeks

79.3 Clinical Follow-up • Further sessions must be planned with 30–45 days apart. • Patients are asked to massage the treated area several times a day, for 2 weeks, using any moisturizing lotion. • Follow-up pictures must be taken every 3 months to realized the outcomes obtained.

79  Polycaprolactone for Extrafacial Areas

569

79.4 Before and After (Figs. 79.6, 79.7, 79.8, 79.9, 79.10, and 79.11) a

b

Fig. 79.6  Before (a) and immediate (b) post of 1 ml polycaprolactone

Fig. 79.7  Before (a) and after 1 month (b) of 1 ml of polycaprolactone

N. Quezada Gaón et al.

570

a

b

Fig. 79.8  Before (a) and after 4 weeks (b) of 1 ml of polycaprolactone in the neck

a

b

Fig. 79.9  Before (a) and after 8 weeks (b) of 1 ml of polycaprolactone in the neck

79  Polycaprolactone for Extrafacial Areas

a

571

b

Fig. 79.10  Before (a) and after 6 weeks (b) of 1 ml of polycaprolactone in the neck

a

b

Fig. 79.11  Before (a) and 6 weeks (b) after administration of 2 ml of polycaprolactone in the neck

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572

79.5 S  ide Effects, Complications, and Their Management • The early side effects are pain, swelling, burning, and infections (Fig. 79.12). • As medium-term effects have been reported within the months, biofilms, nodules, persistent erythema, and foreign body reaction may be minimal and transient. • The late side effects may be granulomas whose severity depends on the anatomical

zone treated, and some cases have been reported like xanthelasma-like reaction [5]. • Due to technical problems, if applied superficially, granulomas will surely be made, and if the application is intravascular, necrosis can be produced with difficult handling [6]. • In complications, it is important to note that ultrasound is an excellent ally (Figs. 79.13 and 79.14) [7].

Tip Box

• Working with cannula avoids traumatized tissues and prevents hematomas. • Apply in deep subcutaneous cellular tissue or supraperiosteal. • Like all fillers, the areas of anatomical risk should be remembered. • In case of nodules one can try to dilute with physiological serum. • If there are granulomas, they can be infiltrated with corticoids, hyaluronidase, or 5-fluorouracil or surgically removed from the area.

Fig. 79.12  Swelling and pain in the left hand 3  weeks after application of polycaprolactone in both hands

a

Fig. 79.13 (a) Polycaprolactone. 28-year-old female with history of erythema and swelling of the tip of the nose and upper lip (arrow) after a nonsurgical rhinoplasty with polycaprolactone. (b) Color Doppler ultrasound (transverse view) shows hypodermal deposits (*) with

b

hyperechoic spots that show mini-comet tail artifact within a hypoechoic matrix, in the most cephalic part of the upper lip that was compatible with polycaprolactone. Notice the hypervascularity (colors) in the periphery of the deposits due to inflammation

79  Polycaprolactone for Extrafacial Areas

a

Fig. 79.14 (a) Polycaprolactone. 60-year-old female with history of a palpable lump in the tail of the left eyebrow after injection with polycaprolactone. (b) Color Doppler ultrasound (transverse view; lateral part of the left eyebrow) shows hypodermal deposit (*) with hypoechoic matrix that contains tiny hyperechoic spots

573

b

with mini-comet tail artifact compatible with polycaprolactone. There is increased vascularity (in colors) in the periphery of the deposits due to inflammation. Notice the linear structures (arrow) in the surface that correspond to hair tracts located in the tail of the left eyebrow

4. Galadari H, van Abel D, Al Nuami K, Al Faresi F, Galadari I. A randomized, prospective, blinded, split-­ face, single-center study comparing polycaprolactone to hyaluronic acid for treatment of nasolabial folds. J 1. Bae B, Lee G, Oh S, Hong K. Safety and long-­term effiCosmet Dermatol. 2013;12:73–7. cacy of forehead contouring with a polycaprolactone-­ 5. Eviatar JA, Massry GG, Bernardini FP, Hartstein based dermal filler. Dermatol Surg. 2016;42:1256–60. ME.  Xanthelasma-like reaction to filler injection. 2. Lefebvre-Vilardebo M, Trevidic P, Moradi A, Busso Ophthal Plast Reconstr Surg. 2017;33(4):244–7. M, Sutton AB, Bucay VW.  Hand: clinical anatomy 6. Wortsman X.  Identification and complications of and regional approaches with injectable fillers. Plast cosmetic fillers: sonography first. J Ultrasound Med. Reconstr Surg. 2015;136:258s–75s. 2015;34:1163–72. 3. Figueiredo VM. A five-patient prospective pilot study 7. Wortsman X, Quezada N.  Ultrasound morpholof a polycaprolactone based dermal filler for hand ogy of Polycaprolactone filler. J Ultrasound Med. rejuvenation. J Cosmet Dermatol. 2013;12:73–7. 2017;36:2611.

References

Polyethylene Glycol for the Hands and Face

80

Samira Yarak and Luis Henrique Barbizan de Moura

80.1 Materials • • • • •

REMAKE® Antiseptic solution. 18G1⁄2 cannulas. 18G1/2 needles. 2% lidocaine-epinephrine.

80.2 Methods and Techniques 80.2.1 Facial Treatment • Pretreat the anesthetic injection sites with topical anesthetic 30 min prior to treatment. • Position the patient in a 45° reclined position. • Clean the area to be treated with alcohol or chlorhexidine solution. • Inject 2% lidocaine-epinephrine solution at the needle/cannula entry point. The injections are placed subcutaneously. Care should be taken to inject the smallest possible anesthetic volume because local infiltration causes edema and may result in tissue distortion.

• A 18G½ needle is used to create an entry point for the cannula. • The technique used for injection depends upon the area being treated: retrograde linear threading (melolabial folds), fanning, or cross-hatching (for cheek augmentation) (Fig. 80.1). • The plane of injection is the superficial-to-mid subcutaneous layer (Fig. 80.2). • PEG product is not intended to be placed intradermally nor supraperiostally. • After injection, the product is massaged until smooth. • Patients are instructed to massage hands several times daily for the first 48 h.

80.2.2 Soft Tissue Augmentation of the Hands The aging process of the hands is a complex event. Multiple factors contribute to the aging of the hands, such as ultraviolet radiation, temperature variations, and friction forces. These factors result in dyschromias, excessive skin

S. Yarak (*) · L. H. B. de Moura Dermatology – UNIFESP EPM, Hospital São Paulo, São Paulo, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_80

575

576

S. Yarak and L. H. B. de Moura

Fig. 80.2  Recommended injection depth of PEG filler. Note that the product is injected subdermally

ble to persist despite repeated movement and pressure.

Fig. 80.1  Injection technique for soft tissue augmentation of the face with PEG. (a) Bolus injection and linear threading. (b) Cannula entry points and injection using the fanning technique

laxity, and loss of subcutaneous tissue, leading to a marked visualization of the underlying veins, bones, and tendons on the dorsal side of the hands, as well as the presence of solar melanose, keratoses, telangiectasias, and eventually malignant tumors [1]. Multiple therapies are proposed for the treatment of the dyschromias and textural alterations such as chemical cauterization, cryotherapy, chemical peels, and laser resurfacing [2–4]. However, they do not address the loss of volume. Volume restoration with dermal fillers or fat has become a standard of care for this purpose. PEG is an option for the volume replacement of the dorsal hand, with promising results. The advantage of PEG over other biosynthetic hydrogels is due to its slow degradation time. The ideal filler for soft tissue augmentation of the hands must be moldable to provide enough volume and dura-

• Pretreat the anesthetic injection sites with topical anesthetic 30 min prior to treatment. • Clean the area to be treated with alcohol or chlorhexidine solution. • Inject 2% lidocaine-epinephrine solution at the cannula entry point. The injections are placed subcutaneously. • A 18G½ needle is used to create an entry point for the cannula. The authors recommend one proximal entry point at the dorsal wrist (Fig. 80.3). An alternative approach is two distal entry points between metacarpals (Fig. 80.4). • The use of flexible microcannula reduces the risk of perforation of the deep and thin layer of the dorsal fascia, reducing the risk of bruising, ecchymosis and inadvertent intravascular injection. • The injections are made interdigitally and the plane of injection is the subcutaneous layer, between the two dorsal fascia of the hands, which is a safe and avascular plane. PEG product is not intended to be placed intradermally. A useful tip to facilitate the access to this plane is by tenting the skin of the central dorsal hand with fingers. • The technique used for PEG injection into the dorsal hands is the retrograde linear threading. • After injection, the product is massaged until smooth. • Patients are instructed to massage hands several times daily for the first 48 h. The results are seen 1 week later.

80  Polyethylene Glycol for the Hands and Face

a

577

b

c

d

Fig. 80.3 (a) Injection technique using cannula and a single proximal entry point at the wrist. (b) Inject 2% lidocaine-epinephrine solution at the cannula entry point. (c) A 18G½ needle is used to create an entry point for the

e

cannula. (d) Introducing the microcannula. (e) The injections are made interdigitally and the plane of injection is the subcutaneous layer, between the two dorsal fascia of the hands

578

80.3 Clinical Follow-Up PEG hydrogel is a synthetic temporary filler with aesthetic effects lasting up to 1 year. Its durability in up to 1 year after application is demonstrated because no significant reduction in the volume deposited in the procedure location was observed [5]. Also, the same study [5] concluded by ultrasound assessment that the product remains prac-

S. Yarak and L. H. B. de Moura

tically unchanged at the location after 120 and 360  days. PEG hydrogel is made of a material with high biocompatibility and slow degradation and viscoelasticity.

80.4 B  efore and After (Figs. 80.5, 80.6, 80.7, 80.8, 80.9, and 80.10)

Fig. 80.5  Subject before the injection of PEG filler for cheek augmentation and volume replacement of the melolabial fold. Note the volume loss in lid-cheek junction and melolabial fold

Fig. 80.4  Alternative injection technique using two distal entry points between metacarpals

Fig. 80.6  Subject immediately after the injection of PEG filler for cheek augmentation and volume replacement of the melolabial fold. Note the improvement in lid-­cheek junction and melolabial fold

80  Polyethylene Glycol for the Hands and Face

Fig. 80.7  Subject before the injection of PEG filler for cheek augmentation and volume replacement of the melolabial fold

579

Fig. 80.10  Subject’s hands immediately after soft tissue augmentation with PEG filler. Note the improvement in the dorsal hands volume and reduction of the visualization of the vessels and tendons

80.5 S  ide Effects, Complications, and Their Management

Fig. 80.8  Subject immediately after the injection of PEG filler for cheek augmentation and volume replacement of the melolabial fold

Fig. 80.9  Subject’s hands before soft tissue augmentation with PEG filler

• Although regarded as safe, the widespread use of dermal fillers has led to an increase in the incidence of complications. However, the true incidence of complications is difficult to establish because of the reporting system [6]. • When compared to the hyaluronic acid fillers, there are few studies in the medical literature with PEG, making it even more difficult to determine the frequency of complications. • Study with 40 female volunteers with loss of malar volume were treated with PEG injection and then evaluated for 12 months. No patient reported any adverse effect during the study period. The presence of lumps was observed in three patients, which fully receded with hand massage. In addition, the ultrasound assessment did not detect nodules or granulomas or any undesirable effect sign on the filler region, which confirms the high biocompatibility of PEG [5]. • There are complications that can occur with any dermal fillers, such as erythema, ecchymosis, edema, infections, nodule formation, granulomatous reactions, and vascular compromise. As these complications have not been specifically reported with the injection of

S. Yarak and L. H. B. de Moura

580

PEG filler, their pathophysiology and treatment are beyond the scope of this chapter. The reader is referred to an article that approaches the subject in depth [6].

Tip Box

• PEG is a synthetic biomaterial that can be used as synthetic dermal filler due to its high biocompatibility, slow degradation time and viscoelasticity. • Blunt-tip cannula has been shown to produce less erythema and is safer when avoiding intravascular injection. • Adverse reactions and patient satisfaction are closely related to the physicochemical, technical, and local filler properties as well as the host’s biological response.

References 1. Shamban AT. Combination hand rejuvenation procedures. Aesthet Surg J. 2009;29(5):409–13. 2. Goldman MP, Fabi SG.  Hand rejuvenation: a review and our experience. Dermatol Surg. 2012;38(7):1112–27. 3. Sadick NS, Anderson D, Werschler WP.  Addressing volume loss in hand rejuvenation: a report of clinical experience. J Cosmet Laser Ther. 2008;10(4):2237–41. 4. Lacarubba F, Tedeschi A, Nardone B, Micali G. Mesotherapy for skin rejuvenation: assessment of the subepidermal low-echogenic band by ultrasound evaluation with cross-sectional B-mode scanning. Dermatol Ther. 2008;21 Suppl 3:S1–5. 5. Addor FAS, Guerra Neri SRN. Injectable polyethylene glycol gel as dermal filler: 01 year clinical and ultrasound follow-up. J Clin Exp Dermatol Res. 2016;7:331. 6. Chiang YZ, Pierone G, Al-Niaimi F.  Dermal fillers: pathophysiology, prevention and treatment of complications. J Eur Acad Dermatol Venereol [Internet]. Wiley-Blackwell. 2016;31(3):405–13.

Polymethylmethacrylate Microsphere Injections in the Face

81

Gottfried Lemperle

a

81.1 Materials • • • • •

Artecoll®, Bellafill®, or Permanique®. Antiseptic solution 25G cannulas. 18G1/2 needles for anesthesia 2% lidocaine-epinephrine

b

81.2 Methods and Techniques Blunt 25G cannulas are preferred over pointed 26G needles to avoid intravascular injection. • The standard injection technique beneath a nasolabial fold consists of subdermal tunneling and delivering a strand of PMMA at the dermal-subdermal junction (Fig. 81.1a, b) [1]. • This strand beneath a fold acts as support structure that protects against further folding and allows the diminished thickness of the dermis to recover to its original thickness. • Most fillers are injected too deeply—a waste of material. The thickness of the facial dermis is 1.0  mm, and the diameter of a 25G cannula is 0.5  mm; therefore, the correct plane for injection is only 2× the diameter of

G. Lemperle (*) Division of Plastic Surgery, University of California, San Diego, La Jolla, CA, USA © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_81

Fig. 81.1 (a) Beneath a wrinkle or fold, the correct injection depth is the dermal-subdermal plane. (b) The channel is filled with PMMA during withdrawal of the needle or cannula

•

•

•

•

a cannula or needle beneath the skin surface (Fig. 81.2a). Push the cannula forward under pressure on the plunger, so that the extruding filler may push small vessels aside and thereby prevent hematomas. Filling the created channel as the cannula is being withdrawn (Fig. 81.2b). Injection of any filler into facial muscles may cause lumps and filler dislocation due to muscle movement. Anchoring a “solid implant” either in the dermal-­subdermal plane (Fig. 81.2b) or on the periosteum of the underlying bone is therefore important. Palpating and gentle pressure to the injected volume rather than excessive massaging of the 581

G. Lemperle

582 Fig. 81.2 (a) The filler has to be “anchored” in the network of the dermal-subdermal plane. (b) At least two strands of PMMA will level the fold. A third strand 4 weeks later will improve the result

a

b

injected site is needed in order to prevent dissipation and bruising. • Flattening irregularities from injection with a fingernail during the first week after treatment, if necessary.

•

•

81.2.1 Indications • Forehead and temples—Chinese women, for example, prefer rounded foreheads and dislike temple depressions. 0.5–2  ml PMMA are injected epiperiosteally or epifascially through cannulas in a fanlike manner. • Horizontal frontal folds—Injection of forehead lines must be deep enough that the gray of the cannula does not shine through the skin, since intradermal delivery of PMMA microspheres may result in a chain of tiny white granules (Fig. 81.3). • Glabellar frown lines—To avoid injections into the supratrochlear artery (risk of blind-

•

•

•

ness), the PMMA should be “anchored” in a strict superficial subdermal plane. Tear troughs—The thin skin in this area lacks subcutaneous fat and is fixed to the dark and thin orbicularis muscle (Fig. 81.4a, b). After a strictly epiperiosteal injection [2], the tip of the needle is scratched over the lower orbital rim, above the infraorbital nerve, and beneath the orbicularis muscle. This shall prevent the subdermal appearance of a chain of small white nodules, compressed through muscle movement. Nasal bridge—For correction of underdeveloped or uneven nasal bone, a 1-inch 23G cannula is inserted through a nostril, parallel to the nasal bone; the space of the missing bridge is filled during withdrawal (Fig. 81.5a, b). The implant is then molded with slight pressure, and the patient is advised to continue molding for another week, if indicated.

81  Polymethylmethacrylate Microsphere Injections in the Face

a

a

b

b

Fig. 81.3 (a) Deep frontal folds need a very viscous filler like PMMA to be leveled. (b) The result after 3 months

• For saddle noses, a “step-by-step” augmentation is recommended to allow patients to get accustomed to their new look. • The nasal tip can be elevated using bulk injections between alar cartilages and skin—and below the columella above the nasal spine (Fig. 81.6a). • Indented cheeks and facial dystrophy— Indented cheeks are often caused by atrophy of Bichat’s fat pad. Facial dystrophy is a side effect of anti-HIV therapy. • PMMA injections can either be “anchored” at the lower rim of the malar bones or may be performed perpendicularly through the cheek with a finger placed on the inner cheek mucosa (“tower technique” of Bartus 2011, Fig. 81.6b). • Malar augmentation—After the patient points out her need for augmentation in front of a mirror, one syringe and a perpendicular directed needle are delivered with one stroke onto the bone.

583

Fig. 81.4 (a) Shadowed lower eyelids can be filled by a strand of PMMA along the lower orbital rim. (b) The result 10  years after the injection of 2  ×  0.8  ml Artefill epiperiosteally, that is, beneath the orbicularis muscle to avoid lumps

• The overlying muscles will smoothen and eventually flatten the implant. A second injection may be required after 1–3 months. • Receding chin—The same technique of epiperiosteal bulking may be used in chin augmentation. Fanlike injections and massage will flatten the implant and diminish projection. • One to two milliliters in one perpendicular epiperiosteal injection can be delivered to the middle of the chin. • Massaging is not recommended since the overlying muscles contribute to a natural smoothening. • Nasolabial folds—Deep nasolabial folds are best supported by two or three strands of high viscosity PMMA, implanted through a cannula parallel and precisely medial to the nasolabial fold (Fig. 81.7a, b). • To prevent intra-arterial injection, the facial artery should be palpated beneath the

G. Lemperle

584 Fig. 81.5 (a) A small curved nose in a relative large Brazilian face should not be surgically reduced. (b) After PMMA injections into the nasal bridge and elevation of the nasal tip (Fig. 81.7a) it fits the bigger nose to the face

a

a

b

Fig. 81.6 (a) The elevation of the nasal tip needs two bulks of fillers: one above the crura and one into the columellar base, that is, on top of the nasal spine. (b) Augmentation of an indented cheek with a permanent filler can best be done using the “tower technique” of Bartus (2011)

­ asolabial fold just above the mucosa of n the lips. • In patients with thin skin, care must be taken that the implant is deep enough; or the implant site could appear erythematous for several months.

b

• To prevent the implant from becoming visible in the form of little granules, the dermis is scratched from beneath during injection using a blunt 23G cannula. • During the first 3  days, PMMA has a pasty consistency and may be shifted laterally through facial muscle movement. • Therefore, the area should be kept quiet with a transparent tape for 3 days. • If the subnasal triangle is indented, a fanlike strictly subdermal injection is indicated to avoid any epiperiosteal injection at this site since the underlying quadratus labii superior muscle may move the implant upward. • A second injection is often necessary, especially in the lower nasolabial fold adjacent to the corners of the mouth. • Lip Augmentation should be discussed very carefully (Fig. 81.8a). • The accentuation of the upper and lower vermilion border (“white roll”) is no problem and eliminates 5  mm of the radial lip lines (Fig. 81.9a, b). • The “empty space” between vermilion and muscle must be targeted with the needle from the side—and the space is filled with a strand of PMMA through pressure on the plunger. • Additional PMMA should never be injected into the muscle but in form of microdroplets

81  Polymethylmethacrylate Microsphere Injections in the Face Fig. 81.7 (a) Deep nasolabial folds in a patient with thick sebaceous skin—an ideal indication for viscous PMMA. (b) Eight months after two sessions with 2 × 1.7 ml Artecoll

a

a

585

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b

Fig. 81.8 (a) The vermilion border can easily be augmented by hitting the empty pocket beneath it. (b) PMMA must be injected into the “white roll” and as microdroplets in the “dry-wet border” intraorally

between the mucous glands along the drywet border of the inner vermilion (Fig. 81.8b). • Negative mouth corners—Horizontal augmentation of the lower vermilion border 10  mm from the corner everts the lip and lifts the drooping corner. • Marionette lines—The vertical elongation of a negative mouth corner should be filled with

cross-hatching horizontal and vertical PMMA strands. • Since there is little fat between skin and orbicularis oris muscle, the cannula must be guided very superficially (Fig. 81.1a, b) above the muscle to avoid lumping. • Acne scars: Flat scars can be approached with the needle tip from 1 cm distance [3].

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• “Boxcar scars” should be filled perpendicularly— best by using 1:1 diluted PMMA injected with the help of a Dermojet®.

81.3 Clinical Follow-Up • PMMA is a permanent filler with long-lasting aesthetic effects, especially when injected in motionless areas, such as the temples, cheeks, nose, or chin. • High viscosity fillers like Artecoll are ideal for soft tissue and bone augmentation [1], whereas low viscosity fillers, like hyaluronic acids, are superior for the augmentation of fine wrinkles and lips. • Earlier studies have shown that a small percentage of patients were dissatisfied with “non-visible effects.” • Since PMMA is not absorbed, a “non-visible effect” may be caused by an inadequate amount of volume injected or by PMMA injected too deeply into the subdermal fatty tissue [4]. • Since strict epiperiosteal use has been recommended, no foreign body granulomas have been reported so far in China [5].

81.4 Before and After See Figs. 81.3, 81.4, 81.5, 81.7, and 81.9. Fig. 81.9 (a) Radial lip lines are rather difficult to inject. (b) The lower half disappears after the accentuation of the vermilion border (Fig. 81.9a)

a

81.5 S  ide Effects and Complications , and Their Management 81.5.1 Nodules • The most commonly reported side effects are nodules (Fig. 81.10a, b) and unevenness due to inadequate technical skills of the injectors. • Nodules may occur when PMMA is implanted too deeply and close to a facial muscle, causing small palpable or visible lumps to form [6]. • If PMMA was implanted beneath a muscle (as in submuscular tear trough or chin augmentation), the constant muscle movement leveled the implant within the first 3 weeks.

81.5.2 Foreign Body Granulomas • Foreign body granulomas may occur from 6 months to years after intradermal injection of PMMA (Fig. 81.11a, b) at a rate of roughly 1:1000 patients, similar to most other dermal fillers [7]. • The treatment of choice is the immediate intralesional injection of high doses of triamcinolone (40 mg/ml) or betamethasone (5 mg/ml) [8]. • If the effect is not obvious after 4 weeks, steroid doses must be doubled. b

81  Polymethylmethacrylate Microsphere Injections in the Face

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Fig. 81.10 (a) Two intradermal ridges after too superficial injection of hyaluronic acid. (b) Two Artecoll nodules in the lip caused by smoking just after the injection

a

• There is no risk of over-treatment: A Chinese woman received 4  ×  240  mg triamcinolone without signs of skin atrophy after granuloma treatment 5 years following facial injections of 67 ml Artecoll. Tip Box

b

Fig. 81.11 (a) Foreign body granulomas developing 1  year after Arteplast injections. (b) Total regression 4  weeks after intralesional injections of 2  ×  40  mg triamcinolone

• PMMA injections are safe and permanent if applied epiperiosteally in the face or “anchored” subdermally in nasolabial and glabellar folds. • The meticulous knowledge of the anatomy of the face and a three-dimensional imagination of its muscles and vessels are prerequisite for effectiveness and satisfaction. • To avoid intra-arterial injection and possible skin necrosis or even blindness, a blunt 23G-cannula is recommended— or to move the pointed needle back and forth during injection! • To date, granulomas have occurred only in patients following intradermal injections—the dermis is the organ with the most severe immunological reactions.

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References 1. Lemperle G, Knapp TR, Sadick NS, Lemperle SM.  ArteFill® permanent injectable for soft tissue augmentation: 1. Mechanism of action and injection techniques. Aesthetic Plast Surg. 2010;34:264–72. 2. Mani N, McLeod J, Sauder DN, Bothwell MR. Novel use of polymethylmethacrylate (PMMA) microspheres in the treatment of infraorbital rhytids. J Cosmet Dermatol. 2013;12:275–80. 3. Karnik J, Baumann L, Bruce S, et al. A double-blind, random- ized, multicenter, controlled trial of suspended polymethylmeth-acrylate microspheres for the correction of atrophic facial acne scars. J Am Acad Dermatol. 2014;71:77–83. 4. Lemperle G, Sadick NS, Knapp TR, Lemperle SM.  ArteFill® permanent injectable for soft tis-

G. Lemperle sue augmentation: 2. Indications and applications. Aesthetic Plast Surg. 2010;34:273–86. 5. Li D, Luo SK, Wang YC, Lemperle G.  Facial volume restauration with permanent dermal filler (Artecoll-4) in Chinese women. Facial Plast Surg. 2017;33:537–44. 6. Lemperle G, Gauthier-Hazan N, Wolters M, Eisemann-Klein M, Zimmermann U, Duffy D. Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes. Plast Reconstr Surg. 2009;23:1842–63. 7. Medeiros CC, Cherubini K, Salum FG, de Figueiredo MA.  Complications after polymethylmethacrylate (PMMA) injections in the face: a literature review. Gerodontology. 2014;31:245–50. 8. Lemperle G, Gauthier-Hazan N. Foreign body granulomas after all injectable dermal fillers: part 2. Treatment options. Plast Reconstr Surg. 2009;123:1864–76.

Polymethyl Methacrylate for the Body

82

Marcio Soares Serra

82.1 Material

82.2 Methods and Techniques

PMMA comes as a colloidal solution containing methylcellulose with PMMA microspheres, ranging from 30 to 50 μm. It comes in syringes and vials presenting three different concentrations: 2%, 10%, and 30% (Fig. 82.1) [1, 2].

Patients are examined and marked in a standing position, and secondary marks for anesthesia buttons are made (Figs. 82.2 and 82.3). A 0.2 ml of an anesthetic solution of 2% lidocaine with epinephrine diluted half and half with saline solu-

Fig. 82.1  PMMA comes in syringes containing 1.5– 3.0 ml presenting 3 different concentrations: 2%, 10% and 30%

M. S. Serra (*) Marcio Serra Clinic of Dermatology, Rio de Janeiro, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_82

Fig. 82.2  Lipoatrophy areas are marked, preferable, with patients in standing positions 589

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tion was injected on each anesthesia button marked. As for the face, the distance between the anesthesia buttons depended on the length of the needle used, for the body mostly used 22G needles. Most of the body areas were treated with a 30% colloidal solution of PMMA, but depending on the quality of the skin (thinner skin) and superficial area, PMMA 10% can be used [2]. Treatment consisted of net-crossed retrograde injections in the subcutaneous layer in all areas. For the buttock we started from the perianal area to the lateral part of the hips and then toward the sacral area; on the other body areas we usually start at the most atrophic area [2]. Although some professionals apply PMMA intramusculary to volumize calves and buttocks, there are no studies about this technique. We, in particular, consider that the best indication of PMMA for large areas such as buttocks is to improve the shape and contour more than to give volume. Non-steroids anti-inflammatory and antibiotics, mostly azithromycin, are prescribed after the procedure for 3–5 days. After buttocks treatment, patients are advised to avoid sitting on the day of the procedure and for all body areas, including buttocks, avoid training with resistance exercises for 7 days after treatment [2, 3].

ment and on follow-up consultations (Figs. 82.4, 82.5, 82.6, 82.7, 82.8, and 82.9) [2, 3].

82.4 Before and After (Figs. 82.4, 82.5, 82.6, 82.7, 82.8, and 82.9)

Fig. 82.4  Buttock - before

82.3 Clinical Follow-Up New sessions were performed with a minimum of 90 days interval for the other body treatments. All patients are photographed before and after treatFig. 82.5  Buttock - after 1 sessions

Fig. 82.3  Secondary marks (circles in black) are made for anesthesic buttons

Fig. 82.6  Chest - before

82  Polymethyl Methacrylate for the Body

Fig. 82.7  Chest - after 2 sessions

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Fig. 82.10  Side effects: bruising

82.5 S  ide Effects, Complications, and Their Management

Fig. 82.8  Upper legs - before

• Major side effects were mild pain on the day of the procedure, edema, redness, and bruising on treated areas (Fig.  82.10), which disappeared within 3–7  days with just local treatment, such as cold compress. Patients that referred moderate pain usually were after leg treatment that improved with oral analgesic and anti-­ inflammatory drugs. No infection was observed or formation of late immune granulloma [2–5].

Tip Box

Fig. 82.9  Upper legs - after 2 sessions

• To inject the product into the correct skin depth: Epiperiosteal or subdermal, depending on the area to be treated. • To avoid skin ischemia and necrosis using a large cannula, such as 22G or 23G. • To avoid granulomas, it is necessary not to inject the product into dermis. • The correct evaluation of the patients is necessary to prepare them in relation to the cost of the procedures and number of syringes.

592

References 1. Carvalho Costa IM, Salaro CP, Costa MC. Polymethylmethacrylate facial implant: a successful personal experience in Brazil for more than 9 years. Dermatol Surg. 2009;35:1221–7. 2. Serra MS, Gonçalves LZ, Ramos-e-Silva M. Soft tissue augmentation with PMMA-microspheres for the treatment of HIV-associated buttock lipodystrophy. Int J STD AIDS. 2015;26:279–84. 3. Serra M, Gonçalves LZ, Gontijo SG.  Treatment of HIV-related facial and body lipodystrophy with polymethylmethacrylate (PMMA); 10 years expe-

M. S. Serra rience. 10th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. London, UK, Nov 2008 [Abstract P-72]. Antivir Ther. 2008;13(Suppl 4):A75. 4. Serra M.  Facial implants with polymethylmethacrylate for lipodystrophy correction: 30 months followup. 3rd International Workshop on Adverse Drug ­ Reactions and Lipodystrophy in HIV.  Athens, Oct 2001 [Abstract P114]. Antivir Ther. 2001;6(Suppl 4):75. 5. Lemperle G, Gauthien-Hazn N, Wolters M, Eisemann_ Klein M, Zimmermann U, Duffy DM. Foreign body granuloma after all injectable dermal fillers: part 1. Plast Reconstr Surg. 2009;123:1.

Part VI Micro-aesthetic Surgery and Others

Introduction: Dressings to Improve Healing in Cosmetic Procedures

83

Maria da Glória Martin Sasseron, Renan Lage, Larissa Mondadori Mercadante, and Luiza de Castro Fernandes

83.1 History/Background Dressings made of linen, oil, and honey were known since 1500  BC by ancient Egyptians, who observed that closed wounds healed more rapidly than open ones. The concepts of absorption, barrier, and antimicrobial effect are still used in the manufacturing of current dressings [1]. In turn, the opening and draining of acute and chronic wounds was encouraged in Hypocrites time, since the presence of exudates was almost always related to infection [2]. In the 1950s, the concepts of occlusion and moisture returned with the studies of Oscar Gielje, who showed better healing results in the occluded half of ulcers, when compared to open halves. In 1962, George Winter published a milestone study, comparing the effects of occlusion and air on epithelization in pigs, with occlusion improving results by 30%. In 1972, this benefit was finally established with the publication of

M. da Glória Martin Sasseron (*) Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil R. Lage Cosmiatric Department, Department of Dermatology of the Pontifical Catholic University of Campinas PUC Campinas, Campinas, SP, Brazil L. M. Mercadante · L. de Castro Fernandes Medical Resident in Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_83

“Epidermal Wound Healing” by Rovee, although information on bacterial proliferation in closed environments was questionable (but elucidated in the 1980s) [2].

83.2 Genesis Healing is a dynamic process, consisting three main phases: inflammatory, proliferative (cellular increase and matrix deposition), and remodeling. Adequate healing takes place when the three phases occur efficiently [3]. The maintenance of a local moist environment is one of the most important conditions for satisfactory wound healing, thus being one of the main goals of using dressings. A dry wound bed increases the time needed for healing (once it impairs the migration of keratinocytes) as well as crust formation, in addition to causing tissue dehydration (with cell death), reducing growth and angiogenesis factors, and increasing the formation of necrotic tissue. Dressings capable of maintaining local moisture and providing adequate protection accelerate and balance the healing process [4]. Other important characteristics of dressings include their ability to absorb exudates, impermeability to bacteria and external water, pain relief, decreased damage during dressing removal, comfort, absence of particle contamination, frequency of dressing change, and their effect on the formation of unaesthetic scars [5, 6] (Table 83.1). 595

596 Table 83.1  Characteristics of wound dressings Maintenance of local moisture Pain relief Decreased damage

Absorption of exudates Comfort Easy application and removal Impermeability to external Less frequent dressing water and microorganisms changes Good cost-benefit ratio Absence of debris (reduced contamination of the wound bed)

83.3 Classification/Types Wound dressings may be basic (cotton gauzes), advanced (hydrogels, hydrocolloids and films), and antimicrobial [5]. They may also be divided into two groups: open and closed methods [7]. Open dressings consist of the application of creams and ointments. If coverings (associated or not with topical substances) are used, they are called closed dressings [7]. Both the open and closed types are primary dressings, while those used to immobilize primary dressings to the patient’s skin are called secondary dressings [1]. Occlusion may be achieved both through the open and closed methods and depends on patient endorsement, effort to get better, and local wound care. Closed dressings were developed to increase comfort and provide adequate occlusion during the acute recovery phase [7]. The occlusion technique offers several advantages: the formation of a moist environment, protection against microorganisms, pain relief, exudate control, and the stimulation of reepithelization, promoting the formation of more aesthetically pleasing scars, with reduced fibrosis [1, 8] (Table 83.2) Studies have shown that the use of occlusive dressings for 48–72  h after dermatological procedures reduces crusts, discomfort, and ­ edema and favors reepithelization; they may be used for 2–7 days, improving patients’ self-care [7–9]. For some authors, though, this type of

M. da Glória Martin Sasseron et al. Table 83.2  Mechanisms of action of occlusive dressings [2] Maintenance of a moist environment, favoring the migration of epithelial cells More active, available growth factors Greater availability of matrix elements Maintenance of an electrical gradient

dressings may predispose wounds to fungal and bacterial growth, an assumption that has not been corroborated. On the contrary, occlusive dressings act as barriers to the growth of microorganisms and absorb exudates, especially in highly exudative wounds following resurfacing procedures [10]. Open techniques, in turn, are less likely to cause infection; however, they may be more inconvenient and painful for patients, since patients themselves are responsible for taking care of dressings, increasing the time for complete reepithelization. Care includes cleansing with physiological serum every 3  h in the first 48 h, followed by gentle drying, and the application of emollient creams for barrier repair. The frequency of cream application should decrease with healing progress, being replaced by the use of a moisturizing sunscreen [7, 9]. Closed dressings usually create semiocclusive environments and present four main layers: the first is in contact with the wound bed; the second is composed of vaseline or an impregnated gauze, promoting the required hydration and reducing the growth of microorganisms; the third favors absorption by gauze; and the fourth is responsible for fixation with tapes, cotton masks, or surgical nets (Fig. 83.1) [8]. Occlusive dressings may be classified into films, foams, gels, hydrogels, hydrocolloids, alginates, and special coverings. Cost and availability may impair the use of such materials. Other disadvantages that limit their use in postoperative wounds include handling difficulties, the inability to visualize the wound bed, and lack of compression [2].

83  Introduction: Dressings to Improve Healing in Cosmetic Procedures

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Fig. 83.1 (a) Medium peeling. (b) Perioral dermabrasion. (c, d) Perioral dressing with impregnated gauze

83.4 Available Materials 83.4.1 Impregnated Gauzes Trade names: Adaptic®, Jelonet®, Curity®, Lomatuell H®, Inadine®, Bactigras®, Xeroform®, and Mesalt®.

The use of dry gauzes in direct contact with the wound bed should be avoided; it does not promote adequate moisture, allows the entrance of bacteria, causes adherence, and releases threads (that favor inflammation and impair healing), in addition to presenting a low ability of absorbing exudates [1, 4, 6]. Nonadherent gauzes are preferred. Impregnated materials are widely used, espe-

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cially acetate cellulose gauzes impregnated with petrolatum. They do not adhere to the wound, are easy to remove, and reduce pain during changes, decreasing local damage and maceration and not interfering with the regeneration tissue [1, 6, 11]. Impregnated gauzes may be used after surgical resection, in graft donor or recipient sites, superficial wounds, and wounds with granulation tissue formation (Fig. 83.2) [6, 11].

oxygen. They also allow the visualization of the wound, adapt to different body parts, and do not require daily changes. There is a possibility of causing hypersensitivity. These dressings may be used in superficial wounds with little exudation, such as laser wounds, dermabrasion, burns, and surgical wounds with little bleeding (Fig. 83.3). Disadvantages include their low absorbing properties and difficulties during application [1, 6].

83.4.2 Semipermeable Films

83.4.3 Hydrogels

Trade names: Bioclusive®, Opsite Post Op®, Opsite IV3000®, Opsite Flexigrid®, Opsite Flexifix®, Polyskin II®, Tegaderm®, Askina Derm®, Suprasorb F®, Suprasorb M®, Melfilm®, Mefix®, and Mepore Pro®. Semipermeable films are composed of transparent, adhesive, sterile, semipermeable polyurethane, capable of maintaining wound moisture. They form an impermeable barrier to water and external agents, but permeable to water vapor and

Trade names: Nu-Gel®, Nu-gel®, Purilon gel®, Duoderm Gel®, Saf-Gel®, Intrasite gel®, Aquafio®, Solosite®, Curafil®, Suprasorb G gel®, Normigel®, and Hypergel®. Hydrogels are formed of a tridimensional net of hydrophilic polymers that are nondegradable and insoluble in water. They absorb large amounts of fluids, are semitransparent, and are available in gels or plaques. Indicated for dry lesions, wounds with little exudation or with partial or deep tissue

a

b

c

d

Fig. 83.2 (a) Preoperative of correction of earlobe. (b) Primary dressing with impregnated gauze. (c) Occlusion with regular gauze. (d) 14th postoperative day

83  Introduction: Dressings to Improve Healing in Cosmetic Procedures

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Fig. 83.3 (a) Immediate postoperative of electrocoagulation of seborrheic keratosis (QS). (b) Use of transparent film

loss, first- and second-degree burns, dermabrasion, and skin donor sites [1, 6, 12]. Disadvantages include maceration of the wound or the adjacent skin and difficulties during dressing immobilization (materials are slippery) [1]. The use of hydrogels with high glycerin contents (65%) was reported in after laser resurfacing procedures, resulting in increased reepithelization of tissues [12]. • Tulle fabric dressings: Tulle is a synthetic fabric composed of polyamide fibers, traded in different sizes and in sterile conditions. It may be applied directly on the bed of the surgical wound, and, although forming a nonadherent layer, this material shows some permeability. Vaseline and antibiotic creams complement this dressing, providing adherence because of their association to a gauze covering [8]. Because of its impregnation with exudates, this gauze should be removed after 24  h, while the tulle may be maintained from one to several days, depending on the depth of the wound. Daily hygiene requires the application of physiological serum over the tulle. Possible applications include procedures following dermabrasion, laser resurfacing, nail surgeries, and graft donor or recipient sites. This low-cost method allows a good visualization of the wound bed and reduces pain and the mechanical rupture associated with dressing change [8]. • Silicone gel: This dressing is indicated for the prevention of hypertrophic scars and keloids,

especially in patients with a positive personal history. It is believed that its mechanism of action is predominantly associated with occlusion, which maintains local moisture; decreases capillary permeability, hyperemia, the synthesis of collagen, and inflammatory mediators; and stimulates keratinocytes to produce growth factors, regulating fibroblasts [13, 14]. Formulations include liquid gels, cohesive gels, and tapes. They are transparent and biocompatible and allow gas exchange and have characteristics of semiocclusive dressings [13]. The use of silicone gel can begin after suture threads are removed. Changes are recommended twice a day, for a 3-month period. Use can be extended for three additional months if needed [13]. • Topical antibiotics: These substances affect the healing process both through their antimicrobial effect and also because they act as ointments. Such antimicrobial effect is still unclear; their indiscriminate use may cause irritation in exposed skins (Fig. 83.4) [10, 15]. • Other dressings: To treat wounds following laser resurfacing, some factors such as speed of reepithelization; reduction in crust formation, erythema, and pruritus; and the comfort of patients have all been considered in the development of dressings. Materials include polymer nets (N-terface®, Mepitel®), hydrogels (2nd skin®), polymer films (Silon-­ TSR®), and ® composite foams (Flexzan , Revitaderm®). One of the main advantages of occlusion

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Fig. 83.4 (a) Keloid in the left ear. (b) Immediate postoperative of keloid shaving. (c) Use of topical antibiotic in the immediate postoperative period

obtained through an open technique is patient comfort. In such cases, patients are required to maintain wound moisture through the application of creams or ointments every 3–4 h (including the hours of sleep). Dressings are usually changed every 48 h, for 4–5 days following the procedure; after this period, this technique is replaced by the open method [7, 16].

83.5 Complications in Aesthetic Procedures and the Use of Wound Dressings • Burns: Caused by epidermal thermal damage, burns can occur as the result of the use of any apparatus, especially ablative lasers. The postoperative management of burns in aesthetic procedures includes occlusion and the maintenance of moist conditions, as well as the application of topical medications for barrier repair

and semipermeable films (Fig.  83.5). The products must be hypoallergenic, including the mild antiseptics used for cleansing, thus reducing the risk of contact dermatitis [17–19]. • Bacterial infections: The rate of infection in resurfacing procedures tends to be low (less than 5% of the cases), mostly when performed in the whole face. The most prevalent microorganisms are Pseudomonas aeruginosa, Staphylococcus aureus, and S. epidermidis, with polymicrobial infections being common. A higher incidence of polymicrombial infections has been reported in wounds where occlusive dressings were maintained for more than 48 h; however, the use of occlusive dressings is controversial, once it clearly results in better healing, indicating the need of further studies on this subject. Symptoms of bacterial infection develop between the second and tenth postoperative day. In such cases, the use of mupirocin nasal ointments and gentamicin

83  Introduction: Dressings to Improve Healing in Cosmetic Procedures

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Fig. 83.5 (a) Burn as a complication after pulsed intense light. (b) Use of transparent film. (c) Complete recovery

otologic solutions has been reported in preand postoperative procedures, reducing the risk of infection (such applications have not been corroborated by scientific evidence). Frequent dressing changes should be performed, in addition to the use of compresses with water-diluted acetic acid solutions, to reduce bacterial colonization. Systemic antibiotics should also be introduced if any evidence of infection is detected [17–19]. • Delayed healing and scar formation: The use of ablative lasers is the most frequent cause of delayed healing. However, some situations, such as collagen diseases, smoking habits, and the occurrence of infection, may predispose patients to this condition. The available treatments for these complications

include infiltration of corticosteroids in hypertrophic lesions and the use of topical silicone gel [17–19].

83.6 Side Effects and Complications, and Their Management • Nonadherent gauzes may be impregnated with antibiotics, which may be toxic to fibroblasts [6]. • Hydrogels should not be used in closed surgical wounds or highly exudative lesions. One of their disadvantages is that they need to be changed every 12–24 h. It is important to highlight that maceration of adjacent tissues may also occur [6].

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• Semipermeable films may detach gradually in already epithelized areas (dressings become loose). They may cause hypersensitivity and should not be used in the first day after surgery because of the high exudate production [6]. • Infection is a major concern when using closed dressings. Adequate practices following laser resurfacing include the change of dressings and the inspection of the wound bed in the first 48 h after the procedure. The use of transparent coverings is also useful. Disadvantages of closed dressings are as follows: they may become loose and dislodge (especially in the perioral region) in the first 48 h after the procedure (because of the high rates of exudate production) and may cause claustrophobic feelings in some patients [7]. • In closed wounds, moist dressings or dressings with indicatives of local infection should be removed. Unusual pain may be related to this complication [4]. • The removal of coverings should be done carefully so that the wound bed and the neo-­ formed tissues are not damaged, especially if adherence has occurred [4].

83.7 Conclusions Wound dressings may be beneficial in surgical and cosmetic dermatology, helping to promote wound healing. Dermatologists should evaluate available procedures, patient’s wishes, and the cost-benefit ratio of materials. There is no individual dressing applicable to all cases. Most studies focus on the treatment of chronic wounds, but there is no consensus on the most adequate dressing to treat acute postoperative wounds [20]. Accelerating the reepithelization process is highly valued so that patients may go back to their normal routine as soon as possible. A careful surveillance during the postoperative period is essential and as important as the technique itself. Thereby, better results are obtained following ablative procedures, affecting the patient perception toward a successful procedure [9].

Tip Box

• Resurfacing: promotes skin repair, increasing collagen synthesis—controlled removal of the epidermis and the dermis. • Pre-procedure: topical tretinoin. • Post-procedure: open or closed occlusion—promotes an adequate environment for keratinocyte growth. • Healing is a dynamic process, consisting of three main phases: inflammatory, proliferative, and remodeling. • The maintenance of local moisture is one the most important characteristics for adequate healing, being one of the main goals of using dressings. • Dressings may be basic, advanced, or antimicrobial; open or closed. • Open dressings consist of cleansing and the application of creams or ointments to repair the skin barrier—better patient engagement and practicality. • Closed dressings include immobile coverings in direct contact with lesions— absorption of exudates, less frequent dressing changes, and faster healing. • Dressing occlusion may be maintained both through the open and closed techniques. • Occlusion offers many advantages: formation of a moist environment, protection against microorganisms, pain relief, exudate control, and stimulation of reepithelization. • Impregnated gauzes do not adhere to wounds, are easily removed, reduce pain during dressing change, and have little interference on the regeneration tissue. • Semipermeable films form barriers, allow wound visualization, adapt to different body parts, and do not require daily changes. • Hydrogels are composed of tridimensional nets of hydrophilic polymers, absorb high amounts of fluid, are semitransparent, and are available in gels or plaques.

83  Introduction: Dressings to Improve Healing in Cosmetic Procedures

• Tulle fabric dressings: low cost, reduce pain and the mechanical rupture associated with dressing change. • Silicone gel: indicated for the prevention of hypertrophic scars and keloids. • Complications: maceration, hyper­ sensitivity reactions, dressings may become loose or dislodged, and infection.

References 1. Sasseron MGM.  Atualidades em curativos oclusivos e semi-oclusivos. In: Malagutti W, Kakihara CT, editors. Curativos, estomias e dermatologia: uma abordagem multiprofissional. São Paulo: Martinari; 2014. p. 129–43. 2. Eaglstein WH.  Moist wound healing with occlusive dressings: a clinical focus. Dermatol Surg. 2001;27(2):175–81. 3. Smaniotto PHS, Ferreira MC, Isaac C, Galli R. Sistematização de curativos para o tratamento clínico das feridas. Rev. Bras. Cir. Plást. 2012;27(4):623–6. 4. Delmore B, Cohen JM, O'Neill D, Chu A, Pham V, Chiu E.  Reducing postsurgical wound complications: a critical review. Adv Skin Wound Care. 2017;30(6):272–86. 5. Dumville JC, Gray TA, Walter CJ, Sharp CA, Page T, Macefield R, Blencowe N, Milne TK, Reeves BC, Blazeby J.  Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev. 2016;12:CD003091. 6. Mandelbaum SH, Di Santis EP, Mandelbaum MHS. Cicatrização: conceitos atuais e recursos auxiliares - Parte II. An Bras Dermatol. 2003;78(5):521–2. 7. Newman JP, Fitzgerald P, Koch RJ. Review of closed dressings after laser resurfacing. Dermatol Surg. 2000;26(6):562–71. 8. Kadunc BV, di Chiacchio N, Trindade Almeida AR. Tulle or veil fabric: a versatile option for dressings. J Am Acad Dermatol. 2002;47(1):129–32.

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9. Khatri KA, Bhawan J, Bhatty RS, Garcia V. Comparison of the open technique with a new wound dressing, H2460, in the healing of an acute wound after laser skin resurfacing. J Cosmet Laser Ther. 2007;9:173–80. 10. Duke D, Grevelink JM.  Care before and after laser skin resurfacing – a survey and review of the literature. J Cosmet Laser Ther. 2007;9:173–80. 11. Terrill PJ, Varughese G.  A comparison of three primary non-adherent dressings applied to hand surgery wounds. J Wound Care. 2000;9(8):359–63. 12. Okan G, Rendon MI.  The effects of a high glycerin content hydrogel premolded mask dressing on post-­ laser resurfacing wounds. J Cosmet Laser Ther. 2011;13(4):162–5. 13. Radwanski HN, Correa WEM, Refosco TJ, Farrapeira Junior A, Pitanguy I.  Silicone gel em cicatrizes de cirurgia plástica: estudo clínico prospectivo. Rev Bras Cir Plást. 2010;25(3):428–33. 14. Kerwin LY, El Tal AK, Stiff MA, Fakhouri TM. Scar prevention and remodeling: a review of the medical, surgical, topical and light treatment approaches. Int J Dermatol. 2014;53(8):922–36. 15. Reis NA, Machado Filho CDS, Timoner FR. Profilaxia em cirurgia dermatológica. Surg Cosmet Dermatol. 2010;2(1):47–53. 16. Newman JP, Koch RJ, Goode RL.  Closed dressings after laser skin resurfacing. Arch Otolaryngol Head Neck Surg. 1998;124(7):751–7. 17. Marini L, Odendaal D, Smirnyi S. Importance of scar prevention and treatment— an approach from wound care principles. Dermatol Surg. 2017;43:S85–90. 18. Costa FB, El Ammar ABPC, Campos VB, Kalil CLPV.  Complications in laser dermatologic surgery. Part II: fractional and non-fractional ablative laser and fractional non-ablative laser. Surg Cosmet Dermatol. 2011;3(2):135–46. 19. El Ammar ABPC, Costa FB, Kalil CLPV, Campos VB. Complications in laser dermatologic surgery Part I: Non-fractional non-ablative lasers. Surg Cosmet Dermatol. 2011;3(1):47–53. 20. Faz A.  Efeito do uso de silicone em spray na Reparação cutânea em procedimentos envolvendo ablação epidérmica: estudo de 20 casos. Surg Cosmet Dermatol. 2011;3(1):41–6.416.

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Leslie Baumann and Erica Monteiro

84.1 Background Familiarity with the skin-type characteristics is critical for successful cosmetic procedure outcome. Aiming this, detailed cutaneous examination, including degree of sebaceous activity (oily or dry skin), photoaging, presence of postinflammatory hyperpigmentation, infection, and preexisting inflammation, will be facilitated using Baumann’s skin-type classification [1–3]. The procedures discussed are as follows: • Skin surgery • Injectables (fillers, toxins, and fat reduction), microneedling, and ablative lasers • Nonablative lasers and light • Chemical peels

84.2 Classification Performing cosmetic procedures in mixed and global skin types can be challenging. There are certain skin types that are at greater risk than othL. Baumann Baumann Cosmetic Dermatology Clinic, Miami, FL, USA E. Monteiro (*) Department of Humanities and Medical Sciences, Federal University of São Paulo (UNIFESP), São Paulo, SP, Brazil e-mail: [email protected] © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_84

ers for development of one or more complications after these treatments. The emerging world phenotype continues to have far-reaching, important implications for patients and those involved in caring for the skin [1, 4–7]. There are several unfavorable reactions that may result in skin of any color that undergoes a cosmetic procedure. The observation that skin of any color has a unique response when under environmental or physical stress dates past antiquity to ancient civilizations, including Egyptian civilization [2–4, 8]. In the dawn of Western medicine, the predominant skin type was light/white in color, and procedures/treatments were geared toward that one phenotype. There was not a perceived need to classify the different types of Caucasian skin because there were little observed differences in clinical behavior among the European skin type of that time [1–3]. Modern-day globalization has had an impact on human phenotype. Mixing of ethnicities has led to the increased emergence of mixed genotypes resulting from interethnic marriages and progeny. This mixing of ethnicities leads to a significant change in the world demographics as we are developing new skin types. We have all experienced the phenotypically blonde-haired, blue-eyed patient who develops scarring after cosmetic surgery and conversely the dark-complexioned patient who has no adverse sequelae from a deep trichloroacetic acid 605

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(TCA) peel. And whereas the skin care product market has undergone rapid innovation and exponential growth, the categories used to describe skin types have changed little over the last century. Identifying and classifying the patient’s skin type can prevent some side effects and ameliorate the final cosmetic results. Skin care pre- and post-procedure can be used to improve the results [1–8]. There are many skin-type classifications. The Fitzpatrick skin phototype classification remains the gold standard. It is simple and user friendly. However, this system fails to accurately predict skin reactions. Baumann’s skin-type classification system is a tool to predict the skin’s response to injury and insult from cosmetic procedures and to identify the propensity of sequelae from inflammatory skin disorders. It can be a predictor of an impending complication, such as hyperpigmentation, which can then be avoided [1–8]. In early 1990, Helena Rubinstein identified four skin types: dry, oily, combination, and sensitive [1–3]. In 2005, Dr. Baumann developed a system of skin typing based on our modern understanding of four basic skin parameters: dry or oily, sensitive or resistant, pigmented or nonpigmented, and wrinkled or unwrinkled (tight) [1–3]. There are four basic dichotomies or parameters introduced in the Baumann Skin Type Indicator (BSTI) that more accurately characterize skin types. Evaluating skin according to these parameters—dry or oily, sensitive or resistant, pigmented or nonpigmented, and wrinkled or unwrinkled—and thus differentiating among the 16 permutations of possible skin types facilitate identifying the most suitable topical treatments for their skin (Tables 84.1 and 84.2). Not only can Baumann’s classification permit classifying the skin type, but we can also plan the patient’s treatment according to the BSTI, and we can predict and anticipate some skin troubles that the patients can experience during the treatment. In other words, we have a dynamic and prognostic classification [1–3]. The four skin-type parameters are as follows. The Baumann Skin Type Indicator (BSTI) is a validated questionnaire [3], which consists of a

3- to 5-min computer-based questionnaire assessing four main parameters of the skin: • • • •

Oily vs. dry Sensitive vs. resistant Pigmented vs. nonpigmented Wrinkle prone vs. tight

Depending on the way the questions are answered, the patient is diagnosed as having a distinct skin phenotype known as the Baumann Skin Type®. There are 16 possible Baumann skin types based on these four parameters. The Baumann Skin Type is designated by four letters (Table 84.1). The Baumann Skin Type (BST) can vary with seasons, hormone fluctuation, lifestyle changes, pregnancy, medications, move to a new geographic location, and other factors. Patients should retake the questionnaire if they have experienced any of these changes so that their skin care regimen can be properly adjusted.

84.3 Procedure Types 84.3.1 Skin Surgery Whether patients are having a biopsy, surgical excision, or Mohs surgery, the outcome will be improved when proper skin care is used before and after the procedure.

84.3.1.1 P  resurgery Skin Care and Supplements (Table 84.3) The goal is to speed healing and minimize infection, scarring, and hyperpigmentation. For 2 weeks prior to surgery, use products that have been shown to speed wound healing by increasing keratinization and/or collagen production. Ingredients that should be used prior to wounding include retinoids such as tretinoin and retinol. Several other studies have convincingly shown that pretreatment with tretinoin speeds wound healing. Kligman evaluated healing after punch biopsy and found that the wounds on arms pretreated with tretinoin cream 0.05–0.1% were significantly smaller by 35–37% on days 1 and 4 and

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Table 84.1  The 16 Baumann skin types [1–3, 9] The four skin-type parameters Skin hydration: dry (D) vs. oily (O)

Characteristics Maintaining sufficient skin hydration is a complex process involving numerous factors, such as lipids in the stratum corneum, natural moisturizing factor (NMF), hyaluronic acid (HA), and sebum production The stratum corneum is surrounded by a watertight lipid bilayer composed primarily of ceramides, fatty acids, and cholesterol. When present in the proper proportion, these constituents form the skin barrier that functions similarly to a brick wall (keratinocytes) surrounded by mortar (lipid bilayer), protecting the skin and keeping it watertight Transepidermal water loss (TEWL) results from defects in the stratum corneum and leads to xerotic or dry skin that is rough in texture and characterized by an elevated number of ridges Barrier disruption can also lead to increased skin sensitivity with an increased incidence of contact dermatitis or eczema. Patients with barrier disruption fall into the category of DS (dry, sensitive) skin types Resistant (R) skin types rarely suffer from inflammation described below and can tolerate a larger variety of products and procedures Sensitive (S) skin can be subdivided into subtypes, characterized by inflammation. The distracted, sensitive skin types are as follows:  acne (pimples)  rosacea (redness)  burning/stinging  allergic Patients often exhibit several types of sensitive skin. For instance, a patient who has frequent rashes to skin care and develops pimples would have the acne, allergic subtypes of sensitive skin

Considerations Educating patients with dry skin to avoid ultraviolet exposure would give them smoother, more hydrated skin and will prevent photoaging and skin cancer Topical skin care products that are aimed at barrier repair focus on delivering the three key components to the stratum corneum: ceramides, fatty acids, and cholesterol. Because fatty acids are delivered from the diet, a healthy diet can also enhance the skin barrier. By the same token, cholesterolreducing drugs can disrupt the barrier The wax esters, triglycerides, and squalene found in sebum help protect the skin from the environment. Lipid films on the skin, formed from sebum-derived fat, also help prevent TEWL. However, no association has been shown between low sebum production and xerosis

It is important to distinguish the types of sensitive skin because they each require different kinds of cosmeceutical ingredients. The BSTI questionnaire identifies which sensitive skin subtypes a patient has by adding a number to the end of the four letters. For example, an oily, sensitive (acne), pigmented, wrinkle-prone patient would be designated OSPW1, while an OSPW type with rosacea would be designated OSPW2. For simplicity, these could also be designated as OSPW Acne Type or OSPW Rosacea Type. In some cases, the patient may have more than one type of sensitivity. For example, an OSPW who exhibits both acne and rosacea would be designated as an OSPW12 or as an OSPW Acne and Rosacea Type Resistant (R) skin types often require stronger products and procedures to see significant results Recommend formulations in order to lessen Skin Plgmentation: This skin parameter refers to the proclivity to pigmented (P) vs. develop undesired dark spots on the face or chest facial dyschromias and minimize Nonplgmented (N) (e.g., melasma, solar lentigos, ephelides) but not postinflammatory hyperpigmentation after cosmetic procedure or surgery to ethnicity. For example, both a red-haired freckled Caucasian and an African American with melasma or unwanted hyperpigmentation would be considered pigmented (P) types Skin resistance: resistant (R) vs. sensitive (S)

(continued)

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Table 84.1 (continued) The four skin-type parameters Characteristics Wrlnkled (W) vs. In the BSTI questionnaire section that determines tight (T) whether a patient is a wrinkled (W) skin type or a tight (T) type, genetic factors are considered in questions about the skin appearance of patients’ ancestors. The questionnaire also asks about smoking history, diet, daily sun exposure, tanning habits, tanning bed use, exposure to pollution, use of retinoids, and ethnicity

Considerations The W/T score that results can be used by the physician to determine a patient’s propensities and behaviors that might warrant modification as well as appropriate treatments. Higher scores are associated with a greater incidence of photoaging. It is logical to assume that higher W scores would also correspond to an increased incidence of skin cancer Given the well-documented relationship between exogenous influences and observable cutaneous effects, it becomes clear that the W/T is the only skin-type parameter within an individual’s control. In other words, a person can alter one’s behavior to reduce the risk of photo-induced extrinsic aging, which results from external factors such as smoking, excessive use of alcohol, poor nutrition, exposure to pollution, and habitual exposure to the sun Of course, behavior modification might not be sufficient if some or significant wrinkling has already begun. In fact, there are several treatments in the dermatologic armamentarium to prevent and to treat wrinkles Many skin care products do not have the capacity to penetrate deeply enough into the lower layers of the skin to reverse or treat wrinkles. Most creams fail into this category, as they cannot penetrate deeply enough into the dermis Retinoic acid is a Food and Drug Administration (FDA)-approved treatment to ameliorate wrinkles and is available by prescription Sun protection is important in all four parameters. For example, a dry, sensitive, pigmented, wrinkled (DSPW) skin type would greatly benefit from sun protection because ultraviolet (UV) damages the skin barrier, making the skin drier and more sensitive, contributes to acne, and worsens dyspigmentation, in addition to causing wrinkles

Characteristics Oily, pigmented, sensitive, and wrinkled skin is characterized by having acne breakouts, facial redness, or flushing or even being susceptible to skin rashes and irritation. Darkening of the skin in certain areas is a result of inflammatory problems. In some cases, dark patches such as melasma and freckles occur. This type has a tendency to wrinkle because of a lifestyle that may include sun exposure and/or cigarette smoking OSPT Oily, sensitive, pigmented, and tight (nonwrinkled) skin is characterized by facial redness and/or flushing, acne breakouts, or frequent skin rashes and irritation. The inflammatory problems associated with this type are often followed by a darkening of the skin areas that were affected by the pimples or skin irritation. Like the OSPW, dark patches such as melasma and freckles occur often. However, this skin type has a lower tendency to wrinkle than other types because of increased skin pigmentation that protects the skin from aging, and if you find you are of this skin type, it will benefit you to lead good lifestyle habits like avoiding sun exposure and smoking cigarettes OSNW Oily, sensitive, nonpigmented, and wrinkled skin often has acne breakouts or facial redness and flushing, as well as frequent skin rashes and irritation. Unfortunately, this skin type has less protective skin pigmentation and, because of that, has a tendency to wrinkle because of current or past lifestyle habits, which may include sun exposure or smoking cigarettes OSNT Oily, sensitive, nonpigmented and tight (nonwrinkled) skin is characterized by acne breakouts or facial redness and flushing or frequent skin rashes and irritation. This skin type will probably get easier as patient gets older if he/she continues to practice good habits. This is a result of the skin type having a lower tendency to wrinkle. Just avoid sun exposure and smoking cigarettes, and it will be sufficient ORPW Oily, resistant, pigmented, and wrinkled skin rarely suffers from sensitivity such as acne breakouts or facial redness or skin rashes. However, dark patches such as melasma and freckles frequently occur. This type tends to wrinkle, so avoid sun exposure or cigarette smoking ORPT Oily, resistant, pigmented, and tight (nonwrinkled) skin rarely suffers from sensitivity such as acne breakouts, facial redness, or skin rashes. However, dark patches such as melasma and freckles frequently occur. This skin type has a lower tendency to wrinkle than other types because of increased skin pigmentation, which is great and helped further by maintaining a healthy lifestyle ORNW Oily, resistant, nonpigmented, and wrinkled skin rarely suffers from sensitivity such as acne breakouts, facial redness, or skin rashes. This skin type has less protective skin pigmentation and tends to wrinkle because of current or past lifestyle habits such as sun exposure or cigarette smoking. This skin has a strong protective barrier, so prescribe products with higher concentrations of active ingredients ORNT Oily, resistant, nonpigmented and tight (nonwrinkled) skin rarely suffers from sensitivity such as acne breakouts or facial redness. This skin type also has a lower tendency to wrinkle if a healthy lifestyle is maintained. This skin type will most likely get easier as patient gets older if he/she continues a healthy lifestyle

Skin type OSPW

No

Yes

No Yes

No

Yes

No

Yes

No

No Yes Yes

No

No

(continued)

Wrinkle easily Yes

Propense to hyperchromia post-procedure Yes

Table 84.2  Using this nomenclature allows physicians to use a standardized methodology that takes into account all four of the skin parameters, each of which contributes to the patient’s skin phenotype and needs. Taking all four of the parameters into consideration when prescribing a skin care regimen will improve outcomes because all of the important variables are taken into account [1–3]

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Skin type DSPW

Propense to hyperchromia post-procedure Characteristics Dry, sensitive, pigmented, and wrinkled skin is characterized by acne breakouts and/or facial redness and flushing. These inflammatory Yes problems are often followed by a darkening of the skin where the pimples or skin irritation occurred. The skin’s protective barrier is weak, and this makes it more susceptible to skin rashes and dehydration, which also means that the patient will be more likely to get dark spots. It’s important to note the tendency to wrinkle DSPT Dry, sensitive, pigmented, and tight (nonwrinkled) skin generally has acne breakouts and frequent skin rashes and irritation. The skin’s Yes protective barrier is unfortunately weak, and the result is that it makes it more susceptible to skin rashes and dehydration. Dark patches may develop on the face from sun exposure. This skin type has a lower tendency to wrinkle than other types because of increased skin pigmentation, which helps to protect the skin No DSNW Dry, sensitive, nonpigmented, and wrinkled skin is characterized by acne breakouts or facial redness and flushing or frequent skin rashes and irritation. The skin’s protective barrier is weak, and this makes it more susceptible to skin rashes and dehydration. This skin type has less protective skin pigmentation and results in wrinkles, especially if you take on a lot of sun exposure DSNT Dry, sensitive, nonpigmented, and tight (nonwrinkled) skin is characterized by acne breakouts or facial redness and flushing or frequent No skin rashes and irritation. The skin’s protective barrier is weak. Beware because this makes it more susceptible to skin rashes and dehydration. However, it does have a lower tendency to wrinkle. YES DRPW Dry, resistant, pigmented, and wrinkled skin rarely suffers from sensitivity such as acne breakouts, facial redness, or skin rashes. However, dark patches such as melasma and freckles often occur. While this skin type has a strong protective barrier, it does have a tendency to wrinkle, so be careful with sun exposure and bad habits Yes DRPT Dry, resistant, pigmented, and tight (nonwrinkled) skin rarely suffers from sensitivity issues such as acne breakouts, facial redness, or skin rashes. Luckily, this skin type has a lower tendency to wrinkle than other types because of increased skin pigmentation and the strong protective barrier No DRNW Dry, resistant, nonpigmented, and wrinkled skin rarely suffers from sensitivity such as acne breakouts, facial redness, or skin rashes. This skin type has less protective skin pigmentation and therefore tends to wrinkle because of current bad habits, so stay clear of excessive sun exposure DRNT Dry, resistant, nonpigmented, and tight (nonwrinkled) skin rarely suffers from sensitivity issues like acne, facial redness, or skin rashes. No This skin has a strong protective barrier, so look for products with higher concentrations of active ingredients

Table 84.2 (continued)

No

Yes

No

YES

No

Yes

No

Wrinkle easily Yes

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47–50% smaller on days 6, 8, and 11 than the untreated arms. Most studies suggest a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7  days of tretinoin application and normalizes after 14 days of continued treatment. That way, the skin will have Table 84.3  Pretreatment skin care for surgeries Presurgery (Speed healing; minimizing infection, scarring, and hyperpigmentation)

Skin care, activities, ingredients, supplements permitted Retinoids (2–6 weeks before) Vitamin C, alpha hydroxy acid (AHA)a

Skin care, activities, ingredients, supplements to avoid Growth factorsb Aspirin, ibuprofen, naproxen, St. John’s wort, vitamin E, omega-3 fatty acid supplements, flaxseed oil, ginseng, salmon, alcohol—at least 10 days prior to the procedure Smoking avoided 4 weeks prior to the procedure

Activities, ingredients, and supplements permitted and avoided [1–8, 10–15] a Wound healing studies have not been done b Although there are no studies evaluating the effects on promoting skin cancer, caution is prudent

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recovered from any retinoid dermatitis prior to surgery. Adapalene should be started 5–6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period. Although wound healing studies have not been done, pretreating skin with topical ascorbic acid and hydroxy acids might help speed wound healing by increasing collagen synthesis.

84.3.1.2 I ngredients and Activities to Avoid Presurgery (Table 84.3) Avoid ingredients that could promote skin tumor growth. Although there are no studies evaluating the effects of growth factors on promoting the growth of skin cancer, caution is prudent. To reduce bruising, patients should avoid aspirin, ibuprofen, naproxen, St. John’s wort, vitamin E, omega-3 fatty acid supplements, flaxseed oil, ginseng, salmon, and alcohol. Most physicians agree that these should be avoided for 10  days prior to the procedure. Smoking should be avoided 4 weeks prior to the procedure. 84.3.1.3 P  ostsurgery Skin Care and Supplements (Tables 84.4, 84.5, and 84.6) Oral vitamin C and zinc supplements were shown to speed wound healing in rats when taken immediately post-procedure. Oral arnica tablets and

Table 84.4  Posttreatment skin care for surgeries Postsurgery (Speed healing; minimizing infection, scarring Skin care, activities, ingredients, and hyperpigmentation) supplements permitted Oral vitamin C and zinca Oral arnica tablets or tincturesb Topical Arnica Montana and Rhododendron tomentosum (Ledum palustre) in a gel pad Topical curcumina Triad of antioxidants in occlusive ointmentb Defensin in a topical formulationb Zinc oxide sunscreen after epithelialization

Skin care, activities, ingredients, supplements to avoid Topical retinoids post skin cancer surgery Benzoic acid, AHA, ascorbic acid—acid products sting wounded skin. Avoid until complete reepithelialization Aspirin, ibuprofen, naproxen, vitamin E Smoking Chemical sunscreen can cause allergic contact dermatitis, avoid at least 4 weeks after the surgery Organic products with essential oils and botanical ingredients may cause allergic contact dermatitis

Activities, ingredients, and supplements permitted and avoided [1–8, 10–15] a Wound healing studies in rats/animals b Few trials

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612 Table 84.5  Pretreatment skin care for surgeries Prefillers, toxin, fat reductor, microneedling, ablative lasers (Speed healing; minimizing bruising, infection, scarring, and hyperpigmentation)

Skin care, activities, ingredients, supplements permitted Retinoids and vitamin C (2–4 weeks before) to increase collagen Arnica supplementsa

Skin care, activities, ingredients, supplements to avoid Aspirin, ibuprofen, naproxen, St. John’s wort, vitamin E, omega-3 fatty acid supplements, ginseng, alcohol—at least 10 days prior to the procedureb Smoking avoided several weeks prior to the procedure

Activities, ingredients, and supplements permitted and avoided [1–8, 10–16]. Few trials. b They can interfere with the blood’s ability to clot, unless otherwise directed by a physician. a

Table 84.6  Posttreatment skin care for surgeries Postfillers, toxin, fat reductor, microneedling, ablative lasers (Speed healing; minimizing bruising, infection, Skin care, activities, ingredients, scarring, and hyperpigmentation) supplements permitted Oral arnica tablets or tinctures for 2 days post-procedure or until bruising and swelling has resolveda Topical arnica pads immediately after injections and leave on for 6 h Wet washcloth to be placed in the freezer for 5–10 min and then applied on the face (optional) Acetaminophen instead of NSAIDS if pain medication is needed Cold compresses or ice packs within the first 24 h after filler injections

Skin care, activities, ingredients, supplements to avoid Topical retinoids post skin cancer surgery Benzoic acid, AHA, ascorbic acid (acid products sting wounded skin. Avoid until complete reepithelialization after microneedling or ablative lasers Aspirin, ibuprofen, naproxen, vitamin E Smoking and alcohol Chemical sunscreen after microneedling or ablative lasers. Avoid until complete reepithelialization Organic products with essential oils and botanical ingredients may cause allergic contact dermatitis Strenuous physical activities and heat such as hot showers for 48 h to prevent bruising

Activities, ingredients, and supplements permitted and avoided [1–8, 10–16] a Few randomized controlled trials

tinctures are often used prior to and after surgery to reduce bruising and inflammation. There is much anecdotal support for the use of arnica but few trials to substantiate its efficacy to prevent bruising and reduce swelling. Topical products used after surgery play an important role in healing. The combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) in a gel pad was shown to reduce postoperative ecchymosis and edema after oculofacial surgery. Topical cur-

cumin speeds wound healing in animals. Another study showed that an occlusive ointment containing a triad of antioxidants sped wound healing. Defensin, a protein important in wound repair, is available in a topical formulation. Defensin has been shown to activate the leucine-rich repeat-­ containing G-protein-coupled receptors 5 and 6 (also known as LGR 5 and LGR 6) stem cells. Defensin speeds wound healing by increasing LGR stem cell migration into wound beds.

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Wounds should be covered to protect from sun exposure until they are reepithelized. Once epithelized, zinc oxide sunscreens can be used. These have been shown to be safe with minimal penetration into the skin.

84.3.1.4 I ngredients to Avoid Postsurgery (Table 84.4) Topical retinoids should not be used post skin cancer surgery until epithelialization is complete. A study by Hung et al. in a porcine model that used 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding demonstrated that use of tretinoin 10 days prior to wounding sped reepithelialization, while use after the procedure slowed wound healing. Acidic products will sting wounded skin. For this reason, benzoic acid, hydroxy acids, and ascorbic acid should be avoided until the skin has completely reepithelialized. Products with preservatives and fragrance should be avoided if possible. Vitamin E derived from oral supplement capsules slowed healing after skin cancer surgery and had a high rate of contact dermatitis. Chemical sunscreens are more likely to cause an allergic contact dermatitis and should be avoided for 4 weeks after skin surgery. Organic products with essential oils and botanical ingredients may present a higher risk of contact dermatitis because of allergen exposure. Although there are no studies evaluating the effects on promoting skin cancer, caution is prudent.

84.3.2 Injectables (Fillers, Toxins, and Fat Reductor), Microneedling, and Ablative Lasers 84.3.2.1 P  retreatment Skin Care and Supplements Prior to any of these procedures, patients can use a high-quality vitamin C serum and retinol for 2–4 weeks to help increase collagen production.

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84.3.2.2 Ingredients and Activities to Avoid Pretreatments With fillers, bruising may be more of a concern than with other cosmetic treatment options. Measures can be taken prior to injections and needling to help reduce the likelihood and severity of bruising once the procedure is over. Temporarily discontinue use of vitamins, supplements, and medications that can interfere with the blood’s ability to clot, unless otherwise directed by a physician. These include aspirin, ibuprofen, naproxen, St. John’s wort, vitamin E, omega-3 fatty acids, ginseng, and others. If pain medication is needed, use acetaminophen instead of nonsteroidal anti-inflammatory drugs (NSAIDS). Avoid drinking alcohol 1–2  days prior to injections. Stop smoking for several weeks before and after treatment to maximize the body’s natural healing process. Take arnica supplements. Although some bruising, swelling, or redness can be expected after each of these treatments, taking a little extra time to prepare can help minimize these common side effects. Standard photography and informed consent should always be obtained before the procedure. 84.3.2.3 Ingredients and Cosmetc Skin Care Post Filler Injections To help alleviate these symptoms and maximize their results, the provider should apply skin-­ soothing products like arnica pads immediately after injections and leave on for 6 h. Oral arnica supplements should be taken for 2  days post-procedure, or until bruising and swelling has resolved. Within the first 24  h after injections, cold compresses or ice packs can be applied to help reduce swelling. Patient can put a wet washcloth in the freezer for 5–10 min. It can then be applied on the face. The washcloth is stiff at first, but then it molds nicely around the face and is not cold enough to burn the skin. Patients should avoid alcohol, strenuous physical activities, and heat such as hot show-

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ers for 48 h after getting dermal fillers to prevent bruising.

84.3.2.4 Ingredients and Cosmetc Skin Care Post Microneedling Granulomatous reactions and/or acne can be seen after having had microneedling. This may be due to what is applied to the skin after the procedure. It is recommended not to use any topical products including sunscreen for 24 h after this treatment until these reactions are better understood. One study showed that the channels stay open for 12–18 h, depending on the length of the needles, and that pore closure can be delayed significantly under occluded conditions [16]. For this reason, avoid placing anything on the skin for 24 h post microneedling.

84.3.3 Nonablative Laser, IPL (Intense Pulsed Light), and Tightening Devices

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Standard photography and informed consent should always be obtained before the procedure. During this time, it is very important to boost collagen production in every way possible. Using a topical vitamin C and high-potency retinol is critical to improve results. Other options such as heparan sulfate and defensin may also help increase cellular response and increase collagen production [7]. Postoperative treatment with ascorbic acid containing serum following laser resurfacing reduced duration of redness post-procedure. Another study showed that an occlusive ointment containing a triad of antioxidants sped wound healing [7].

84.3.4 Chemical Peels Chemical peels have widespread acceptance in the facial cosmetic treatment of aging faces (aging and photoaging), acne (comedones, pustules, and superficial scarring), pigmentary abnormalities, and more. Many chemicals are available for facial peeling, including phenol, trichloroacetic acid (TCA), alpha hydroxy acids, and retinoic acid. All act by varying degrees of cellular destruction of the epidermis and papillary dermis, producing consistent histologic changes.

Intense pulsed light (IPL) and hair removal laser are some of the more commonly performed cosmetic procedures that have produced untoward complications [13–15]. With nonablative lasers and nonsurgical skin-­ Classification of Peels According to the tightening devices like Ultherapy, Thermage, and Histological Depth of Necrosis (Fig. 84.1) IPL, some immediate results may be visible, but most patients see the most results unfold over the A. Very superficial light peels: necrosis up to the next several weeks. level of stratum corneum. Agents used: TCA 10%, glycolic acid (GA) 30–50%, salicylic Fig. 84.1  The goal of a chemical peel is to cause the outer layer of skin to peel and flake, revealing the fresh, smooth layer underneath

Chemical agent

Epidermis

615

84  Tip Chapter: How Might Cosmeuticals Improve Skin Aesthetic Procedures Outcome?

acid 20–30%, Jessner’s solution 1–3 coats, tretinoin 1–5% B. Superficial light peels: necrosis through the entire epidermis up to basal layer. Agents used: TCA 10–30%, GA 50–70%, Jessner’s solution 4–7 coats C. Medium depth peels: necrosis up to upper reticular dermis. Agents used: TCA 35–50%, GA 70% plus TCA 35%, 88% phenol unoccluded, Jessner’s solution plus TCA 35%, solid CO2 plus TCA 35%

D. Deep peels: necrosis up to mid-reticular dermis. Agents used: Baker-Gordon phenol peel

84.3.4.1 P  repeeling Preparation (Table 84.7) For optimal results, preparation of the skin in the weeks before the procedure is very important. Topical retinoic acid preparations used daily for 3–6 weeks prior to the procedure may create better and more even penetration of the peeling solution in sebaceous and hyperkeratotic skins.

Table 84.7  Pre- and post-chemical peel recommendations [5–7, 14, 15]

Considerations Priming

Infections

Acne

Photoaging Photoprotection

Benefits/recomendations Reduce wound healing time, facilitate uniform penetration, detect intolerance to any agent, enforce patient compliance, and reduce the risk of complications Control any active infection or dermatoses. In patients with history of herpes simplex posted for medium depth and deep peels, antiviral therapy with acyclovir or famciclovir is recommended, beginning 2 days prior to the procedure and continued for 7–10 days until complete reepithelialization Benzoyl peroxide, topical retinoids, adapalene topical antibiotic (associated with benzoyl peroxide), alpha hydroxy acids Topical retinoids, hydroquinone, alpha hydroxy acids, vitamin C Broad-spectrum sunscreens and clothes

Moisturization Prevention of hyperpigmentation

Hydroquinone (2–4%) alone or in combination with other agents

Fast healing

Tretinoin 0.025%

Maintenance (agents that are likely to be used in post-­ procedure maintenance)

Tretinoin 0.025%, adapalene 0.1%, glycolic acid 6–12%, kojic acid, azelaic acid, vitamin C

Pre (at least 2–4 weeks prior to the procedure) +

Post (long, after complete Post (immediate) reepithelialization)

+

+

+

+

–

+

+

–

+

+

+

+

+ + In patients prone to + postinflammatory hyperpigmentation + –

+ +

+ (after reepithelialization) + (after reepithelialization)

Tretinoin is known to reduce healing time after resurfacing [5–7]. The choice of the priming agent depends on the individual physician’s preference and individualized patient requirements

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Standard photography and informed consent should always be obtained before the procedure for all types of peelings. In patients with a history of recurrent herpes simplex, it is necessary to prescribe prophylaxis with systemic antivirals from the day before the procedure until full reepithelialization. Generally, it is not necessary to discontinue use of any of the patient’s medications including anticoagulants, aspirin, or nonsteroidal anti-inflammatory or antihypertension drugs. A new consensus statement says it is not necessary to postpone elective skin procedures for patients with concurrent or recent systemic isotretinoin therapy [17]. According to our experience with superficial peeling, smoking does not have any adverse effect on postpeel healing or on the extent of the results.

84.3.4.2 P  ostpeeling Recommendations (Table 84.7) The goal of a chemical peel is to cause the outer layer of skin to peel and flake, revealing the fresh, smooth layer underneath. Patients will experience some level of dryness and flaking for 2–5 days after treatment. During this time of dryness and flaking, their skin is more sensitive (more redness and stinging), and they cannot use vitamin C, retinol, avobenzone, glycolic acid, and lactic acid. In this 2–5-day period, using a soothing gel or mask helps calm and soothe the skin. Other great options to use in this post-procedure time period are heparan sulfate and hyaluronic acid. Patients should be advised to stay out of the sun and to avoid picking at dry, flaking skin. Exfoliating scrubs and other facial brushes and other forms of friction, including microdermabrasion, should be avoided during the healing process. Avoid any products with hydroxy acids and retinol until the skin barrier has been restored. Use calming skin care products with anti-­ inflammatory ingredients such as green tea, argan oil, and chamomile to help alleviate any stinging or redness while the skin recovers.

84.4 Conclusions 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 cosmeceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right treatment to restore and rehabilitate their skin. The aim of this chapter is optimizing outcome from facial surgical and cosmetic procedures and improving the outcomes.

Tip Box

• To ensure the best outcome from surgical treatments, patient education is crucial. • The Baumann skin typing system assigns patients to one of 16 skin types based on their answers to a validated questionnaire [18] known as the Baumann Skin Type Indicator [19, 20]. • Using the Baumann Skin Type nomenclature improves communication between physicians, scientists, researchers, aestheticians, and patients about skin care regimen efficacy and adverse events [10, 18–20]. • Because studies have demonstrated that patients cannot properly self-diagnose their skin type, the Baumann Skin Type should be diagnosed using a validated questionnaire for that purpose [18–20]. • The more that patients know and understand about the ways in which they can prepare for their procedure and treat the skin after the procedure, the better the outcomes will be. • Retinoids should be used 2–3 days prior to procedures to speed healing. • Retinoids should not be used after the procedure until reepithelialization has occurred. • Vitamin C and zinc supplements taken post-procedure might speed wound healing.

84  Tip Chapter: How Might Cosmeuticals Improve Skin Aesthetic Procedures Outcome?

• Standard photography and informed consent should always be obtained before the cosmetic procedures. • A new consensus statement says it is not necessary to postpone elective skin procedures for patients with concurrent or recent systemic isotretinoin therapy [17].

References 1. Baumann L. Understanding and treating various skin types: the Baumann Skin Type Indicator. Dermatol Clin. 2008;26(3):359–73. 2. Baumann LS. The Baumann skin typing system. In: Textbook of aging skin. Berlin Heidelberg: Springer; 2010. p. 929–43. 3. Baumann L. Validation of a questionnaire to diagnose the Baumann skin type in all ethnicities and in various geographic locations. J Cosmet Dermatol Sci Appl. 2016;6(01):34–40. 4. Monteiro EO. Cor da pele e pigmentos. RBM Espec Dermatol. 2010;67:5–10. 5. Nikalji N, Godse K, Sakhiya J, Patil S, Nadkarni N. Complications of medium depth and deep chemical peels. J Cutan Aesthet Surg. 2012;5(4):254–60. 6. Baumann LS.  A pre- and post-procedure skincare guide for your patients. 2016. 7. Baumann LS. The importance of proper pre- and post-­ procedure regimens. 2016. 8. Baumann L. Cosmeceuticals in skin of color. Semin Cutan Med Surg. 2016;35(4):233–7.

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9. Taylor SC. Cosmetic problems in skin of color. Skin Pharmacol Appl Ski Physiol. 1999;12(3):139–43. 10. Baumann L. Skin ageing and its treatment. J Pathol. 2007;211(2):241–51. 11. Monteiro EO, Bauman LS. The science of cosmeceuticals. Exp Rev Dermatol. 2006;1(3):379–89. 12. Stuzin JM.  Discussion. A randomized controlled trial of skin care protocols for facial resurfacing: lessons learned from the Plastic Surgery Educational Foundation’s Skin Products Assessment Research study. Plast Reconstr Surg. 2011;127:1343–5. 13. Roberts WE. Skin type classification systems old and new. Dermatol Clin. 2009;27(4):529–33. 14. Monteiro EO.  Acne e fotoproteção. RBM Rev Bras Med. 2009;66(6):6–9. 15. Monteiro EO.  Filtros solares e fotoproteção. RBM Espec Dermatol Cosmiatria. 2010;67:5–18. 16. Kalluri H, Kolli CS, Banga AK.  Characterization of microchannels created by metal microneedles: formation and closure. AAPS J. 2011;13(3):473–81. 17. Spring LK, Krakowski AC, Alam M, et al. A systematic review with consensus recommendations. JAMA Dermatol. 2017;153(8):802–9. 18. Baumann L, Penfield R, Clarke J, Duque D. A validated questionnaire for quantifying skin oiliness. J Cosmet Dermatol Sci Appl. 2014;4:78–84. 19. Baumann L.  The Baumann skin-type indicator: a novel approach to understanding skin type. In: Barel AO, Paye M, Maibach HI, editors. Handbook of cosmetic science and technology. 3rd ed. New  York: Informa Healthcare; 2009. p. 29–40. 20. Baumann L.  The Baumann skin typing system. In: Farage MA, Miller KW, Maibach HI, editors. Textbook of aging skin. New  York: Springer; 2010. p. 929–44.

Chemical Liposculpture of the Chin

85

Valerie D. Callender and Jessica A. McCarrick

85.1 Materials (Fig. 85.1) • Alcohol pads • ATX-101 10 mg/mL supplied in 2 mL vials, maximum of 5 vials (10  mL) per treatment based on treatment area • Ice or Zimmer cooler [1] • Topical or injectible local anesthesia (lidocaine or lidocaine with epinephrine) • Gauze • 1-cc syringes • 30G or smaller needles • White cosmetic pencil • Ibuprofen

85.2 Methods and Techniques • Prior to procedure: –– Careful patient selection: • Patients should have at least moderate submental fat, stable body weight, and absence of significant tissue laxity. V. D. Callender (*) Callender Dermatology and Cosmetic Center, Glenn Dale, MD, USA Department of Dermatology, Howard University Hospital, Washington, DC, USA e-mail: [email protected] J. A. McCarrick Department of Dermatology, Howard University Hospital, Washington, DC, USA © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_85

–– Past medical history: • History of bleeding disorders, treatment with anticoagulant and antiplatelet medications. • Psychiatric history, expectations. • Screen for signs and symptoms of other causes of submental fullness: –– Thyromegaly –– Cervical lymphadenopathy –– Past surgical and procedural history: • Assess history and dates of prior surgical or aesthetic treatment. –– Review key anatomic landmarks: • Sternocleidomastoid muscle • Antegonial notch (mid-mandible, approximates location where marginal mandible nerve courses superficially) [2] • Thyroid cartilage • Evaluate submental fat –– Assess submental fat: • Pinch and palpate the submental area (Fig. 85.2). • Ideal patients will have at least a moderate amount of submental fat. –– Assess skin laxity: • Ideal patients should not exhibit significant skin laxity. –– Assess preplatysmal fat: • Ask the patient to “grimace,” which tenses the platysmal muscles, and then assess preplatysmal fat [3].

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Fig. 85.1 Materials used for chemical liposculpture of the chin

Fig. 85.2  Evaluate the submental fat

• Only preplatysmal, not postplatysmal, fat should be injected. –– Mark danger zone (no treatment zone): to avoid injury to the marginal mandibular nerve (Fig. 85.3): • Mark/trace the inferior border of the mandible.

Fig. 85.3  Mark the danger or no treatment zone to avoid injury to the marginal mandibular nerve

• Draw a second line 1.0–1.5 cm below the inferior border of the mandible, from the angle of the mandible to the mentum. • Do not inject above this line.

85  Chemical Liposculpture of the Chin

Fig. 85.4  Apply the injection grid

–– Mark treatment area: • Anterior: submental crease • Posterior: hyoid bone posteriorly • Lateral borders: boundaries of submental fat pad per assessment on palpation –– Apply the injection grid (Fig. 85.4): • Use an alcohol pad to wipe away any grid markings outside of the desired treatment area. –– For patient comfort and to minimize postprocedural pain, swelling, and bruising: • Use of ice/cold packs or Zimmer chiller for 15 min prior [1]. • Topical anesthesia and/or injectable local anesthesia (e.g., lidocaine with epinephrine) –– Injection into submental fat in marked treatment area: • Technique: pinch submental/preplatysmal fat between two fingers; inject mid-

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way into subcutaneous fat with needle perpendicular. • Up to 50 injections into grid-marked treatment area. • Each injection dose is 2  mg/cm2 or 0.2 mL. • Maximum dosage of 100 mg (10 mL) • 0.2-mL injections at 1-cm spaced intervals –– Treatment intervals: • 1 month (28 days) apart • Up to six treatments total • Most patients have clinically meaningful response within 2–4 treatments. • Reevaluate submental fat with each treatment to ensure adequate amount to warrant retreatment. • With successive treatments, the amount of submental fat is reduced and less ATX-101 will be required.

85.3 Clinical Follow-Up • Consider postoperative visit at 1  week to assess complications. • Patients may return for treatment at 1 month (28  days) apart for a maximum of six treatments. • Reevaluate submental fat with each treatment to ensure adequate amount to warrant retreatment. Patients typically require less ­ ATX-101 with successive treatments as the amount of submental fat decreases.

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85.4 Before and After (Fig. 85.5)

Fig. 85.5  Before and after treatment

85.5 S  ide Effects, Complications, and Their Management • Anticipated adverse events are common, but typically mild and transient, often include local (treatment area) pain, numbness, erythema, swelling/induration, and bruising. • Pain: –– Oral ibuprofen and/or acetaminophen 1  h before procedure (before arrival), unless contraindicated [4] –– Pre- and postprocedural ice –– Topical and local anesthetic (lidocaine with epinephrine) • Erythema and swelling (Fig. 85.6): –– Typically lasts less than 1 week. –– Cold application prior to procedure. –– Careful injection technique. –– Oral ibuprofen 1 h prior to procedure [4]. –– Advise patients to schedule 2–3 days of rest, free of social obligations, after treatment. –– Advise patients to sleep with head elevated.

Fig. 85.6  Erythema and edema immediately after deoxycholic acid injection

• Bruising: –– When possible, consider discontinuation of anticoagulant/antiplatelet medications 7–10 days prior to procedure [4]. –– Local anesthetic preinjection using lidocaine with epinephrine 15  min before treatment.

85  Chemical Liposculpture of the Chin

–– Evaluate risk/benefit ratio in patients with bleeding abnormalities or receiving ­treatment with antiplatelet or anticoagulant medications. • Marginal mandibular nerve injury: –– Symptoms: asymmetric smile, asymmetric facial weakness –– All reported cases resolved, with median duration of 44 days • Dysphagia: –– Symptoms of pain, swelling, and submental induration. –– Avoid treatment in patients with history of dysphagia, as it may exacerbate [2]. –– Median duration of 3 days. • Rare reported complications include severe neutrophilic dermatoses, submental alopecia, and submental abscess. Tip Box

• Ideal patient will have moderate submental fat, stable weight, and no significant tissue laxity. • Pretreat 1 h before with to oral ibuprofen to minimize pain and swelling. • Lidocaine with epinephrine may aid in patient comfort and minimize bruising. • Unlike other cosmetic injectables, the target location of ATX-101 is subcutaneous fat, not dermis.

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• Repeat treatments at 28 day intervals, up to 6 treatments total. • Less ATX-101 is required with successive treatments as the amount of clinically significant submental fat is reduced. • Most patients will require 2–4 treatments before cosmetically significant results are obtained.

References 1. Shamban AT. Noninvasive submental fat compartment treatment. Plast Reconstr Surg Glob Open. 2016;4(12 Suppl Anatomy and Safety in Cosmetic Medicine: Cosmetic Bootcamp):e1155. 2. Jones DH, Kenkel JM, Fagien S, Glaser DA, Monheit GD, Stauffer K, Sykes JM. Proper technique for administration of ATX-101 (deoxycholic acid injection): insights from an injection practicum and roundtable discussion. Dermatol Surg. 2016;42(Suppl 1):275–81. 3. U.S.  Food and Drug Administration. Kybella full prescribing information. 2015. https:// w w w. a c c e s s d a t a . f d a . g o v / d r u g s a t f d a _ d o c s / label/2015/206333Orig1s000lbl.pdf. Accessed 18 Apr 2017. 4. Fagien S, McChesney P, Subramanian M, Jones DH. Prevention and management of injection-related adverse effects in facial aesthetics: considerations for ATX-101 (deoxycholic acid injection) treatment. Dermatol Surg. 2016;42(Suppl 1):300–4.

Microneedling for Neocollagenesis of the Face

86

Gabriella Fabbrocini, Caterina Mazzella, and Mirella D’Andrea

86.1 Materials • Manual dermaroller: the standard medical dermaroller has a 12-cm-long handle with a 2  ×  2-cm-wide drum-shaped cylinder at one end studded with 8 rows and 24 circular arrays of 192 fine microneedles, usually 0.5–3 mm in length and 0.1–0.25  mm in diameter (Fig. 86.1a). • Automated microneedling device is also now produced. This ergonomic device makes use of disposable needles and guides to adjust a

needle length for fractional mechanical resurfacing. The tip has 9–12 needles arranged in rows. The advantage is that it “is possible regulate the depth of penetration of the needles” (Fig. 86.1b).

86.2 Methods and Techniques • Percutaneous collagen induction therapy works best when combined with a topical product containing alpha and omega hydroxy b

Fig. 86.1  The standard medical dermaroller (a) and the automated microneedling device (b) G. Fabbrocini (*) · C. Mazzella · M. D’Andrea Dermatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_86

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•

•

•

•

acids, omega hydroxy acids for at least 3  weeks (preparation phase) before the skin needling session begins. During each session, the patient is prepared in a similar manner to a surgical procedure: the facial skin is disinfected, and then a topical anesthetic is applied, allowing it to work for 60 min. The treatment is then carried out by rolling the needling tool over the areas affected by aging and photoaging signs four times in four different directions: horizontally, vertically, and diagonally right and left. The microneedles penetrate through the epidermis but do not remove it; the epidermis is only punctured and heals rapidly (Fig.  86.2). The needle seems to separate the cells from each other rather than cut through them. Because the needles are set in a roller, every needle initially penetrates at an angle and then goes deeper as the roller turns. The epidermis, and particularly the stratum corneum, remains intact except for the minute holes. These microinjuries lead to minimal superficial bleeding (Fig. 86.2) and set up a wound-­ healing cascade with the release of various growth factors such as platelet-derived growth factor (PGF), transforming growth factor alpha and beta (TGF-α and TGF-β), connective tissue activating protein, connective tissue growth factor, and fibroblast growth factor (FGF). The needles also break down the old hardened scar strands and allow it to revascularize. Neovascularization and neocollagenesis are initiated by migration and proliferation of fibroblasts and laying down of intercellular matrix.

Fig. 86.2  Sequential representation of microneedling

• A fibronectin matrix forms after 5  days of injury that determines the deposition of collagen resulting in skin tightening persisting for 5–7 years in the form of collagen III. • Histological examination of the skin treated shows up to 400% increase in collagen and elastin deposition at 6  months post operation [1]. • Finally, it is important that for the first 24  h after a treatment, make sure that the patient does not use any skin products that are not noncomedogenic or specifically designed to be used with microneedling such as makeup, sunscreen, sunblock, tanning lotion, facial peel, or any skin care product that contains irritating and toxic ingredients. It is also important to avoid using alcohol-based ­products immediately after the treatment because they can provoke bruising sensation and erythema.

86.3 Clinical Follow-Up • Normally, skin aging program consists of three sessions of needling for each patient a month apart from each other, and the first follow-­up is done after 1  month from the third session, and then 3 months and 6 months after the last session (Figs.  86.3a–d and 86.4a–b). • Patients should be well educated on the use topical therapy with emollients and soothing cream for 48 h after each session. In addition, sun exposure is avoided by using sunscreens with sun protection factor value of 30 or more during the daytime (Fig. 86.4).

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86.4 B  efore and After (Figs. 86.3, and 86.4) a

b

c

d

Fig. 86.3  Before (a), after 1 month from the third session (b), after 3 months from the third session (c), after 6 months from the third session (d)

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a

b

c

d

Fig. 86.4  Before microneedling (a-c) and after microneedling (b-d)

86.5 S  ide Effects, Complications, and Their Management • Immediately after this procedure, the skin is more sensitive to sunlight: it is important to prevent hyperpigmentation and avoid direct sunlight after treatment for 1  week. The patient has to apply SPF 30 or higher sunscreen when going outside.

• The skin will feel tender to touch: do not use facial scrub until the skin has completely recovered. • After treatment, the skin will feel dry: it is important to not use skin toner or apply topical product with irritation ingredients such as glycolic/salicylic/TCA id, etc., and do not use topical product with toxic ingredient such as hydroquinone, etc.

86  Microneedling for Neocollagenesis of the Face

a

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b

c

Fig. 86.5  Side effects and complications. (a) Herpes. (b) Acne. (c) Erythema

• The skin will lose its moisture: avoid invasive treatment (laser/chemical peel/microdermabrasion) until the skin has recovered. • Adverse events are well known: the common ones are erythema and irritation, dry skin, and skin tenderness, which usually lasts within a few days. • Rare complications are post-inflammatory hyperpigmentation, erythema, aggravation of acne and reactivation of herpes (Fig. 86.5a–c), systemic hypersensitivity, allergic granulomatous reactions, and local infections following the use of a nonsterile instrument. • The management of these complications is different for each of them. For herpes, antiviral systemic therapy and preventive measures should be prescribed to patients who are predisposed. In hyperpigmentation, solution of glycolic acid (50%) or hydroquinone creams combined with sunscreen or laser therapy should be used. For infection, antibiotic therapy has to be prescribed, topical therapy with mupirocin 2% ointment, three times daily for

10  days, or alternatively fusidic acid, and in severe cases, systemic therapy with amoxicillin and clavulanic acid, two times daily for 6 days.

Tip Box

• Microneedling is relatively safe, but it should be avoided in subjects with active skin pathologies, patients who tend to form keloid, patients suffering from disorders of coagulation or collagenopathy, and patients on chemo/ radiotherapy. • At the end of the sessions, to limit to a minimum the visible consequences of the microneedling, immediately apply smoothing creams and protect the treated skin with high-protection creams (SPF 50 or 30). • The effects of microneedling for skin aging are enhanced when the procedure

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is combined with topical antiaging vitamin C serum and retinoid derivative application. Microneedling has also been combined with human embryonic stem cell-derived endothelial precursor cell in some experimental studies [2].

References 1. Fabbrocini G, De Vita V, Fardella N, Pastore F, Annunziata MC, Mauriello MC, Monfrecola A, Cameli N.  Skin needling to enhance depigmenting serum penetration in the treatment of melasma. Plast Surg Int. 2011;2011:158241. 2. Fabbrocini G, Fardella N, Monfrecola A, Proietti I, Innocenzi D. Acne scarring treatment using skin needling. Clin Exp Dermatol. 2009;34:874–9.

Acne Scar: Shaving and Electrosurgery

87

Joaquim José Teixeira de Mesquita Filho and Francine Papaiordanou

87.1 Materials • Razor blade (Fig. 87.1) • Bipolar eletrocautery • Eletrocautery tip (Figs. 87.2 and 87.3)

Fig. 87.1  Razor blade Fig. 87.2 Eletrocautery

J. J. T. de Mesquita Filho (*) Dermatologi Surgery Unit, Ruben David Azulay Institute, Santa Casa of Mercy of Rio de Janeiro, Rio de Janeiro, RJ, Brazil

Fig. 87.3  Eletrocautery thin tip

F. Papaiordanou Francine Papaiordanou Clinic of Dermatology, Rio de Janeiro, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_87

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87.2 Methods and Techniques 87.2.1 Shaving • The main indication for shaving in acne scars are the papular type • These distensible elevations, similar to anetodermal lesions, are common in the chin, nose, and trunk. These scars are raised and fibrotic [1, 2]. • They are relatively easy to treat. • Hypertrophic scars can also be improved with shaving and radiofrequency. • It is important to remember that these sometimes bridged scars, reminiscent of a keloid scar, are actually a redundancy of the skin and can be reviewed with shaving or excision with suture [3, 4]. • With the shaving technique, the lesions are lowered to the level of normal skin, using a razor blade curved between the thumb and the forefinger. • Lateralized/pendular movements are performed. • Hemostasis can be done with 40% aluminum chloride or compressive dressings. • Tangential excision with a blade may also be performed on bridged scars [5]. • The shaving technique can also be performed with radioelectrosurgery. In place of the razor blade, the papular scars are shaved with a “loop tip” of the electrocautery (Figs.  87.4, 87.5, and 87.6).

J. J. T. de Mesquita Filho and F. Papaiordanou

87.2.2 “CROSS” (Chemical Recontruction of Skin Scars) Technique, Modified • The “CROSS” technique used to treat “ice pick” scars, primarily described to be performed with 90% thricloroacetic acid, can be modified using the eletrocautery with a thin tip [3]. • The tip should gently touch the base of the scar until a thermal damage is noticed (burn). • Care must be redoubled in order to not promote damage around the scar. • This procedure is well tolerated with topical anesthetics or nerve block and infiltrative anesthesia in less-tolerant patients, with minimum discomfort and performance in ­ 5–15 min (Figs. 87.7 and 87.8).

Fig. 87.5  Scar demarcation

Fig. 87.4  Papular scars on the chin

Fig. 87.6  Razor blade in “pendulum like” movements

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Figs. 87.7 and 87.8  “CROSS” technique in “ice pick” scars

Figs. 87.9 and 87.10  Radiofrequency vaporization in a bridged scar

87.2.3 Electrodissection for Papular Scars • It is suggested to vaporize the lesions with electrosurgery [6, 7]. • During the procedure, the tissue temperature should be maintained at minimum enough levels to achieve the necessary destruction. • Contraction of the epidermis occurs in the area of the scar [5].

87.2.4 Vaporization with Radiofrequency • Radiofrequency vaporization can be performed in the section of “bridge-type” scar

and on the edges of superficial crater scars [6]. • Always avoid big damages to the surrounding tissues [5]. • This technique can also be performed to smooth the edges of the scar after a punch excision technique [7] (Figs.  87.9 and 87.10).

87.3 Clinical Follow-Up • Daily photoprotection with sunscreen SPF 60 or more • Use of whitening formula for at least 30 days before and 30  days after the procedure (Kligman’s or Kligman’s modified formula) [7].

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87.4 Before and After (Figs. 87.11, 87.12, 87.13, 87.14, and 87.15)

Fig. 87.11  Female patient with multiple “ice pick” scars

Fig. 87.14  Radioelectrosurgery shaving technique on a papular scar with a loop tip

Fig. 87.15  1 month after the procedure Fig. 87.12  The same patient, 1 month after the modified “CROSS technique” procedure

87.5 S  ide Effects, Complications, and Their Management

Fig. 87.13  Local anesthesia

• Unrealistic-expectations or uncooperative patients who do not follow treatment regimens are more likely to get complicated. • Adequate counseling, priming the skin, and supportive medical therapy, apart from good intra- and postoperative care, are essential for satisfactory surgical outcomes [2]. • Post-procedural hyperpigmentation. The use of depigmenting formulas, such as Kligman’s (dexamethasone 0.1% in combination with 0.1% tretinoin, and 5% hydroquinone in a cream base), or Kligman’s modified, 30 days

87  Acne Scar: Shaving and Electrosurgery

prior to the procedure and after treatment may prevent this complication [8]. • In more persistent cases of hyperpigmentation, intense pulsed light or 1064  nm q-switched Nd:YAG laser can be useful. • Depressed scars can occur when the shaving of papular scars get deeper than expected (wrong technique) Tip Box

• Tip 1: Electrosurgery and shaving are simple, inexpensive, and, when well performed, are very effective to improve acne scars. • Tip 2: As acne patientes are usually anxious and have a past of previous unsucessful treatments, try to perform the most effective procedure in the first session, so they can notice the best result as possible. • Tip 3: Before any procedure, talk, listen, and understand the patient’s longings and desires. Much dissatisfaction occurs due to lack of communication between the doctor and the patient. • Tip 4: Assemble with your patient a treatment strategy, explaining the techniques and number of sessions needed, so they can understand that it is a treatment plan to be performed.

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References 1. Khunger N, IADVL Task Force. Standard guidelines of care for acne surgery. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S28–36. 2. Kadunc BV, Trinidade de Almeida AR. Surgical treatment of facial acne scars based on morphologic classification: a Brazilian experience. Dermatol Surg. 2003;29(12):1200–9. 3. Bhardwaj D, Khunger N. An assessment of the efficacy and safety of CROSS technique with 100% TCA in the management of ice pick acne scars. J Cutan Aesthet Surg. 2010;3(2):93–6. 4. Jacob CI, Dover JS, Kaminer MS.  Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol. 2001;45(1):109–17. 5. Kadunc BV.  Tratamento das cicatrizes de acne. In: Gadelha AR, Costa IMR, editors. Cirurgia Dermatológica. 3rd ed. São Paulo: Editora Atheneu; 2017. p. 715–22. 6. Goodman GJ.  Treatment of acne scarring. Int J Dermatol. 2011;50(10):1179–94. 7. Batra RS. Surgical techniques for scar revision. Skin Therapy Lett. 2005;10(4):4–7. 8. Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol. 1975;111:40–8.

Acne Scars: 5-Fluorouracil (MMP® Technique)

88

Maria Teresa Pereira Soares, Dirlene Melo Palmeira Roth, and Samir Arbache

88.1 Materials • 5-Fluorouracil (50 mg/mL). The medication is already diluted by the vendor in a vial and must be kept between 22 °C and 25 °C. • Tattoo machine, approved by the Brazilian Health Agency (ANVISA) for medical use and drug delivery, including chemotherapy drugs (Fig. 88.1) • Liner-type cartridge which is most suitable to the shape of the lesion (Fig. 88.2) • Sterile machine drape (Fig. 88.2) • Sterile gloves • Sterile gauze • Chlorhexidine 0.5% alcoholic solution for asepsis • 1  mL syringe with permanent needle and plunger protector (Fig. 88.3). This syringe is used to aspirate the 5-FU, and afterward the plunger protector, which is sterile, is used to hold the medication to be applied • TNT disposable cap, mask, and apron

M. T. P. Soares Maria Teresa Pereira Soares Clinic of Dermatology, São Sebastião do Paraíso, MG, Brazil D. M. P. Roth (*) · S. Arbache Department of Dermatology, University of Mogi das Cruzes, Mogi das Cruzes, SP, Brazil e-mail: [email protected]; samir@ dermocentro.com.br © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_88

Fig. 88.1  Presentation of the machine with its sterile drape (the unprotected part can be autoclaved), sterile field, and another option to place the medication (dappen dish, used by dentists and autoclavable)

88.2 Methods and Techniques [1-10] • At least 15 days before treatment, prepare the skin with SPF 30 during the day and tretinoin (0.025–0.05%) at night, before lying down. Suspend 48 h prior to the procedure. • Consent form. • Photographic documentation. • Lidocaine- and tetracaine-based topical anesthesia can be used 30  min prior to the procedure. 637

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• Vigorously and repeatedly remove the topical anesthesia from the skin prior to MMP® in order to prevent it from accidentally being infused during the procedure. • Microinfusion of Medication into the Skin is a surgical procedure, and therefore strict asepsia and antisepsis principles must always be followed. • Facial asepsis using 0.5% alcohol chlorhexidine. • Needling frequency setting, 60 rpm. • Aspirate 5-FU using the 1 mL syringe with a permanent needle and place it in the plunger protector.

• Fit the liner cartridge, and only after doing so should you turn on the machine. • Once the machine is on, position the needle inside the plunger protector. The cartridge will be loaded by capillarity (Fig. 88.4). • Puncture the lesion by trying to cover the entire area of the scar (Fig. 88.5). • The endpoint is the formation of pinpoint bleeding, which indicates that the medication has reached the papillary dermis (Fig. 88.6). • Occlude using sterile plastic dressing or leave it open, but do not wash for at least 6  h (Fig. 88.6).

Fig. 88.2  Cartridge model for small and circular lesions

Fig. 88.4 Medication capillarity

Fig. 88.3 Legend— syringe with permanent needle to aspirate and the plunger protector used as a recipient for the 5-fluorouracil

entering

the

cartridge

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88.3 Clinical Follow-Up [1-10]

Fig. 88.5  Demonstration of application on patient

• Perilesional erythema and hematic crusts in lesions are immediately expected (Fig. 88.5). The erythema disappears on the following day, while the crusts persist for 5–7 days. • On the following day, already start using SPF 30, and once the crusts come off, resume tretinoin use. • After 4 weeks, reassess. Perform a new photographic registry and a new treatment session. • The number of sessions varies according to lesion depth, size, and degree of fibrosis, but usually 2–3 are sufficient. • This treatment can be combined with other techniques, such as fractionated CO2 or skin needling.

88.4 Before and After (Figs. 88.7, 88.8, 88.9, and 88.10)

Fig. 88.6 Desired endpoint and occlusive plastic dressing

Fig. 88.7  Before and after two sessions

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Fig. 88.8  Before and after one session

Fig. 88.9  Before and after one session (close up)

88.5 S  ide Effects, Complications, and Their Management [1-10] • Drug toxicity effects have not been reported even when applied to several lesions on upper and lower limbs of the patient in a single treatment session.

• Discreet hyperpigmentation seldom occurs, which is transitory and disappears in 4 weeks, • As with all potentially teratogenic drugs, 5-fluorouracil handling by pregnant physicians and treatment on pregnant patients must be avoided at all costs (Fig. 88.11).

88  Acne Scars: 5-Fluorouracil (MMP® Technique)

Fig. 88.10  Before and after one session

Fig. 88.11  Discreet hyperpigmentation around the lesions. The circle highlights scar improvement

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Tip Box

• Both the machine and medication present excellent cost/benefit. • Store 5-fluorouracil below 25 °C. • Do not store in a refrigerator or freezer in order to avoid precipitation. • In case precipitation occurs, heat to 60 °C to dissolve and agitate vigorously. • Protect from light exposure. • Do not apply excessive force in case pinpoint bleeding does not form immediately. It may take 20 s to appear due to fibrosis: treat all scars first, then only reapply on those without pinpoint bleeding.

References 1. Arbache S, Roth D, Arbache ST, Hirata SH. Original Method to Repigment Achromic Laser Tattoo Removal Scars. Case Rep Dermatol. 2019;11(2):140–44. 2. Arbache S, Mattos EDC, Diniz MF, Paiva PYA, Roth D, Arbache ST, Oliveira ELT, Michalany NS, Hirata SH. How much medication is delivered in a novel drug delivery technique that uses a tattoo machine? Int J Dermatol. 2019;58(6):750–5. 3. Arbache S, Michalany NS, Hirata SH. Reply to: “Comment on ‘Activation of melanocytes in idiopathic guttate hypomelanosis after 5-fluorouracil infusion using a tattoo machine: Preliminary analysis of a randomized, split-body, single blinded, placebo controlled clinical trial’”. J Am Acad Dermatol. 2018;79(4):e81–e82.

M. T. P. Soares et al. 4. Arbache S, Roth D, Steiner D, Breunig J, Michalany NS, Arbache ST, de Souza LG, Hirata SH. Activation of melanocytes in idiopathic guttate hypomelanosis after 5-fluorouracil infusion using a tattoo machine: Preliminary analysis of a randomized, split-body, single blinded, placebo controlled clinical trial. J Am Acad Dermatol. 2018;78(1):212–5. 5. Arbache S, Godoy CE. Microinfusion of drugs into the skin with tattoo equipment. Surg Cosmet Dermatol 2013;5(1):70­4. 6. Artzi O, Koren A, Niv R, Mehrabi JN, Friedman O. The Scar Bane, Without the Pain: A New Approach in the Treatment of Elevated Scars: Thermomechanical Delivery of Topical Triamcinolone Acetonide and 5-Fluorouracil. Dermatol Ther (Heidelb). 2019;9(2):321–6. 7. Çalıskan E, Gamsızkan M, Açıkgöz G, Durmuş M, Toklu S, Doğrul A, Kurt A, Tunca M. Intralesional treatments for hypertrophic scars: comparison among corticosteroid, 5-fluorouracil and botulinum toxin in rabbit ear hypertrophic scar model. Eur Rev Med Pharmacol Sci. 2016;20(8):1603–8. 8. Mao X, Wo Y, He R, Qian Y, Zhang Y, Cui D. Preparation and characterization of different sizes of ethosomes encapsulated with 5-fluorouracil and its experimental study of permeability in hypertrophic scar. J Nanosci Nanotechnol. 2010;10(7):4178–83. 9. Cincik H, Gungor A, Cakmak A, Omeroglu A, Poyrazoglu E, Yildirim S, Cekin E, Candan H. The effects of mitomycin C and 5-fluorouracil/ triamcinolone on fibrosis/scar tissue formation secondary to subglottic trauma (experimental study). Am J Otolaryngol. 2005;26(1):45–50. 10. Eşme A, Yildirim C, Tatlipinar S, Düzcan E, Yaylali V, Ozden S. Effects of intraoperative sponge mitomycin C and 5-fluorouracil on scar formation following strabismus surgery in rabbits. Strabismus. 2004;12(3):141–8.

Acne Scars: Bleomycin Plus Triamcinolone Injection (MMP® Technique)

89

Maria Teresa Pereira Soares, Dirlene Melo Palmeira Roth, and Samir Arbache

89.1 Materials • 1  mL syringe with permanent needle and plunger protector (Fig. 89.1) • Bleomycin sulfate 3 IU/mL (note that the vial contains 15 IU of lyophilized) • Powder must be diluted into 5 mL of 0.9% saline solution or distilled water [1] • Triamcinolone acetonide 10 mg to 40 mg/mL • Liner cartridge (Fig. 89.2)

• Tattoo machine approved by the Brazilian Health Agency (ANVISA) for medical use and drug delivery, including chemotherapy drugs • Sterile machine drape figure [2] • Sterile gloves • Sterile gauze • Chlorhexidine 0.5% alcoholic solution • TNT disposable cap, mask and apron

Fig. 89.1  Syringe with permanent needle and plunger protector

M. T. P. Soares Maria Teresa Pereira Soares Clinic of Dermatology, São Sebastião do Paraíso, MG, Brazil D. M. P. Roth (*) · S. Arbache Department of Dermatology, University of Mogi das Cruzes, Mogi das Cruzes, SP, Brazil e-mail: [email protected]; samir@ dermocentro.com.br © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_89

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Fig. 89.2  Detail of the liner 7 cartridge Fig. 89.3  Machine ready for use

89.2 Methods and Techniques • At least 15  days prior to treatment, prepare the skin with SPF 30 during the day and tretinoin (0.025–0.05%) at night, before lying down. Suspend 48  h prior to the procedures • Consent form. • Photographic documentation. • Lidocaine- and tetracaine-based topical anesthesia can be used. • Certify that the anesthetic has been completely removed from the skin prior to doing MMP® in order to avoid accidental infusion during the procedure. • Perform facial asepsis using 0.5% alcohol chlorhexidine. • Needling frequency setting, 60 rpm. • Aspirate the bleomycin using the 1 mL syringe with a permanent needle and place it in the plunger protector. • Fit the liner 7 cartridge, and only after doing so should you turn the machine on (Fig. 89.3).

Fig. 89.4  Demonstration of how the medication is loaded into the cartridge by capillarity

• Once the machine is on, position the needle inside the plunger protector. The cartridge will be loaded by capillarity (Fig. 89.4).

89  Acne Scars: Bleomycin Plus Triamcinolone Injection (MMP® Technique)

• Puncture the lesion by trying to cover the entire scar. • The endpoint is the formation of pinpoint bleeding (Fig. 89.5). • Occlude using sterile plastic dressing or leave it open, but do not wash for at least 6 h (Fig. 89.5).

89.3 Clinical Follow-Up • Perilesional erythema and hematic crusts in lesions are immediately expected. • The erythema disappears in up to 24 h. • The crusts remain for 5–7 days. • On the following day, already start using SPF 30. • After 4 weeks, reassess. Perform a new photographic registry and a new treatment session. • The number of sessions varies according to lesion depth, size, and degree of fibrosis, but usually 2–3 is sufficient. • This treatment can be combined with other techniques such as fractionated CO2, provided a 4-week interval is observed between procedures.

89.4 Before and After (Figs. 89.6, 89.7, 89.8, 89.9, and 89.10) Fig. 89.5  Desired endpoint

Fig. 89.6  Before and after two sessions

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Fig. 89.7  Before and after one session

Fig. 89.8  Before and after three sessions

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Fig. 89.9  Before and after three sessions

Fig. 89.10  Before and after three sessions

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89.5 S  ide Effects, Complications, and Their Management • Drug toxicity effects have not been reported even when applied to several lesions during a single session. • Hyperpigmentation may occur, which spontaneously disappears in 3–4 months. • The combination of bleomycin and acetonide decreases side effects 7 (this is the reference number; I was unable to superscript it). • As with all potentially teratogenic drugs, 5-fluourouracil handling by pregnant physicians and treatment on pregnant patients must be avoided at all costs.

Tip Box

• Both the machine and medication present excellent cost/benefit. • Insert: store between 2 and 8  °C protected from light until dilution.

• Insert: after dilution, use in 24 h. • If stored at 4 °C after dilution, it may be used for 6–8 weeks [3]. • The authors achieved good results using the following proportion: 5–10  mg of triamcinolone, 1.5–3  IU of bleomycin with 0.3 mL of 40 mg/mL triamcinolone acetonide, depending on the level of fibrosis.

References 1. Payapvipapong K, Niumpradit N, Piriyanand C, Buranaphalin S, Nakakes A.  The treatment of keloids and hypertrophic scars with intralesional bleomycin in skin of color. J Cosmet Dermatol. 2015;14:83–90. 2. Shippee BM, Bates JB, Richards KL.  The role of screening and monitoring for bleomiycin pulmonar toxicity. J Oncol Pharm Pract. 2016;22(2):308–12. 3. Lazo JS, Boland CJ, Schwartz PE. Bleomycin hydrolase activity and cytotoxicity in human tumors. Cancer Res. 1982;42:4026–31.

Acne Scar: CROSS (Chemical Reconstruction of Skin Scar)

90

Vito Abrusci and Valentina Benzecry

90.1 Materials

90.1.1 Brushes

• Good illumination is mandatory. Direct overhead lighting will accentuate the scars, facilitating scar visualization. • Magnifying glasses (1,5 – 2X) are important to optimize visualization of small scars, for the precise application of TCA and to avoid overtreatment. • Cotton swabs should be kept on hand. They may be necessary to dry out the excess of TCA inside the scars. • Nonsterile gloves should be used to protect the operator’s hands from accidental contact with TCA. • Eye goggles are important to avoid damage to the patient’s eyes. • A receptacle with a wide base to contain the TCA. This should be positioned on a flat stable surface to avoid accidental spilling. • Alcohol is used to degrease the patient’s face before treatment. • Cold wet packs are used to minimize the burning sensation. Avoid direct contact of ice with the patient’s skin.

• We prefer tiny brushes rather than wooden applicators. They are more precise and need less dipping in the TCA, thus shortening the treatment time. • Tiny round brushes of two different sizes (00, 01) are used for the TCA application, according to the size of the scar (Fig. 90.1). • One brush normally lasts a procedure for a whole face. Have replacement brushes since TCA ­damages them (hair falls off progressively). • Use natural hair brushes. They allow to treat more scars per treatment, while synthetic ones are rapidly dissolved by the TCA. The brush hair should be cut with scissors to a length of 3–5 mm.

90.1.2 Trichloroacetic Acid (TCA) • 90% TCA solution should always be ordered from the same pharmacy or laboratory, to ensure a consistent composition. • TCA causes precipitation of proteins and coagulative necrosis of epidermal cells and necrosis of collagen in the papillary to upper reticular dermis [1].

V. Abrusci (*) · V. Benzecry Private Practice, Milan, Italy © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_90

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Fig. 90.1  Materials. Note the tiny brushes on the right side

• The TCA damage stimulates dermal collagen remodeling for several months which fill and improve scars’ appearance [2].

90.2 Methods and Techniques 90.2.1 Global Assessment Before the Procedure • Perform an exhaustive medical history, including past history of hypertrophic scarring, postinflammatory hyperpigmentation, and hypopigmentation with other treatments. • Perform an accurate physical examination with the patient in the sitting and lying-down position, assessing the extension, severity, and localization of acne scars. • Determine if the patient is suitable for CROSS. The main indication is the presence of ice pick scars. Small box scars, varicella scars, and enlarged pores may also benefit (Figs. 90.6, 90.7, 90.8, and 90.9).

V. Abrusci and V. Benzecry

• We consider that medium-large (>4 mm) and/ or deep scars such as box scars, rolling scars, or varicella scars may worsen, enlarge, or produce additional scarring (Figs.  90.10 and 90.11). • Avoid patients with active acne lesions. Resolution of acne should be accomplished prior to scar treatment. • Avoid treating patients with active infections. • Hypertrophic scarring or permanent hypo/ hyperpigmentation could suggest an increased risk of scarring but could also be due to inadequate procedures. • Be cautious with patients presenting postacne hypertrophic scars. In this case, it is advisable to perform a therapeutic trial. Treat three scars from 1 to 3 mm. • Patients with oily skin should be advised that they may have prolonged erythema and reepithelization time. • Caution is recommended in dark-­ complexioned patients [3] since they are prone to develop post-inflammatory hyperpigmentation and scarring.

90.2.2 Discuss with the Patient • Carefully assess patient’s expectations about the treatment outcome. • Explain the procedure. Show before, transoperative, and after pictures of CROSS therapy. It will make the patient aware of the postoperative evolution. • Obtain a clear understanding of the patient’s willingness to tolerate burning sensations, edema, erythema, and brownish coloration of the treated areas. • Make clear that at least three sessions are usually needed, even though you might think that tw.e patient that he should avoid sun exposure for up to 3 months after the last treatment session. • Thursday and Friday are the preferred days to perform this procedure since the following 2 days the patient can stay at home, and by Monday treated areas are easily camouflaged with makeup. • If possible, the procedure should be scheduled in winter, for further prevention of sun exposure.

90  Acne Scar: CROSS (Chemical Reconstruction of Skin Scar)

• Avoid retinoids or other topical treatments that could enhance TCA penetration for at least 1 week before the procedure. • The patient should not take oral isotretinoin for at least 3 months prior to the first session. • If the patient has a history of frequent and/or serious episodes of facial herpes, recent or not, prescribe oral valacyclovir (1  g twice daily), from 1 day before to day 7 after surgery.

90.2.3 The Day of the Procedure • If active viral and/or bacterial infections are present, reschedule the treatment session. • Dermatitis could enhance TCA penetration. • The patient must come without makeup. Avoid washing or rubbing the skin surface. Facial erythema or humidity can enhance TCA penetration. • Don’t use any kind of skin markers in order to avoid the TCA from becoming colored and remaining in the skin after the frosting has gone.

90.2.4 Description of the Procedure • Wear nonsterile gloves and magnifying glasses. The patient must wear eye protection goggles or must keep the eyes closed during the procedure. • Advise the patient about the burning sensation he will experience and explain that it will subside in approximately 3 min with the application of cold wet packs. • The patient must be in the supine position and must be instructed, in order to avoid accidents, not to move the face or hands even if feeling a burning sensation. • Cleanse and degrease the patient’s face using alcohol. It does not stain and does not leave remnants on the skin surface. • No topical or local anesthesia is needed. Consider nerve block anesthesia if scars are located in susceptible areas. • The brush should be dipped in the TCA, avoiding excessive soaking. Wipe the brush on the walls of the receptacle in order to eliminate excess TCA.

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• Treat the entirety of one cosmetic area at a time in order to avoid the resulting edema hiding other surrounding scars. • Smaller scars or enlarged pores must be treated first, followed by medium-sized. Larger scars should be left for the last part of the procedure. • If done otherwise, the resulting edema surrounding larger scars may hide smaller lesions close to them. • Immediately after treating one cosmetic area, an assistant must apply cold wet packs to alleviate the burning sensation, which will last no longer than 3 min. • While applying cold wet packs, treat the contralateral cosmetic area of the face. In this way you can adequately expose each area to be treated and save time. • Proceed to the 90% TCA focal application, “wetting/painting” every scar. • Do not expect to observe the white frosting immediately. It will take a few seconds. If you do not wait, you may overtreat. • The walls, the bottom, and about 1  mm of the borders of each scar should be “wet/painted” and become frosted following the TCA application. • Avoid “filling” the scar with TCA since it may lead to deep penetration of TCA. No remnants of liquid TCA should be left in the scars. If this happens, dry it out using a cotton swab. • Adequate application of TCA will always produce frosting of the scar, and no reapplications are needed (Fig. 90.2).

90.2.5 Immediately After and up to 24 h After the Procedure • At the end of the procedure, even if there is no burning sensation, apply cold wet packs in all the treated areas for approximately 15 min in order to reduce edema and erythema. • Advise the patient that frosting will disappear in less than 1 h (Fig. 90.3), then it will acquire a brownish color after 24  h (Fig. 90.4) and a dark brown color after 48 h (Fig. 90.5). • Inform the patient that the erythema and edema around each treated scar will subside in about 24 h without symptoms.

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b

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Fig. 90.2 (a) Immediately after TCA application. Note frosting and erythema at each treated scar. (b). Immediately after TCA application. Note frosting and surrounding edema in each treated scar

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Fig. 90.3 (a) On the right side, after 30  min of TCA application, frosting has disappeared while edema and erythema persist. On the left side of the face, 15 min after

TCA application, frosting is still visible. (b) After 15 min of TCA application, frosting, edema, and erythema start to subside

• Instruct the patient to apply cold wet packs for 15 min three times a day during the first 24 h to help reduce edema and erythema. • Until reepithelization is achieved, and to avoid crust formation, the patient should apply a very thin layer of Aquaphor® ointment, three times daily for the first 2 days.

• To avoid crust formation, from the second day, instruct the patient to apply a soothing delicate facial cream not less than three times a day and Aquaphor® at night before going to bed. • The patient should be advised not to remove by any means what may seem to be crusts, in

90  Acne Scar: CROSS (Chemical Reconstruction of Skin Scar)

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Fig. 90.4 (a) Two days after CROSS.  Note brownish coloration at each treated scar. (b) Twelve days after CROSS. Brownish coloration has subsided completely

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Fig. 90.5 (a) Five days after CROSS. Note dark brown coloration at each treated scar. (b) Nine days after CROSS. A few treated scars are still brownish, while others look slightly reddish

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order to avoid worsening of preexisting scars or other complications (Figs. 90.10 and 90.11). • If necessary, the patient may use makeup, but not perfumes, the following day based on medical judgment. • Using makeup before reepithelization of large or deep scars may lead to complications (Fig. 90.11). • No oral antibiotics, antivirals, or analgesics are needed.

90.3 Clinical Follow-Up • If possible, follow-up consultations should be performed on days 1 and 7 and at 1 month, 2 months, and 3 months after the procedure. • In order to have a closer follow-up and to obtain photographic documentation, the patient must send you pictures daily during the first week and two times a week until the first month. • Until reepithelization is achieved, the patient should wash his face with shaving foam for sensitive skin. • From the second day, a brownish color appears at each treated scar (Fig. 90.4). Subsequently,

a

• •

•

•

•

•

it becomes dark brown and then progressively disappears between days 8 and 14 (Fig. 90.5). These colorations can be easily camouflaged with makeup. To avoid postinflammatory hyperpigmentation and until reepithelization is achieved, the patient must avoid sunlight exposure by using physical means (hats, umbrella). During these first 6–14  days, application of sunscreen or other creams should be avoided (except for Aquaphor®, the soothing cream and makeup). Once reepithelization is achieved, daily application of a noncomedogenic 50 SPF sunscreen is mandatory during the following 3 months. To shorten postoperative erythema and to avoid hyperpigmentation, we instruct the patient to apply low-potency topical corticosteroids after reepithelization. We prescribe a very thin layer of 0.5% hydrocortisone cream twice a day for the first 10 days, then once a day for 10 days, and finally Monday and Thursday nights for 1 month.

90.4 Before and After (Figs. 90.6, 90.7, 90.8, and 90.9) b

Fig. 90.6 (a) Before. (b) One month after one session of CROSS

90  Acne Scar: CROSS (Chemical Reconstruction of Skin Scar)

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Fig. 90.7 (a) Before. (b) One month after two sessions of CROSS

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Fig. 90.8 (a) Before. (b) Three months after two sessions of CROSS

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Fig. 90.9 (a) Before. (b) Three months after two sessions of CROSS

90.5 S  ide Effects, Complications, and Their Management 90.5.1 Side Effects • Side effects are mainly caused by the excessive application or enhanced penetration of TCA.  Thus, they are preventable in the majority of cases by using an adequate technique. • Excessive application of TCA can be prevented by appropriately dipping the brush, by removing excess TCA, and by not “filling” the scar with TCA. • Avoid repeated applications, and do not overtreat the borders of the scar. • Avoid enhanced penetration of TCA by making sure that the patient is not currently using retinoids. Also, the skin should be evenly dry and degreased before TCA application. • Excessive application and enhanced penetration of TCA can result in more cosmetic discomfort and longer reepithelization time. • During the first week, cosmetic discomfort [4] may be experienced due to the brownish ­coloration of the scars, but it can be minimized by using emollients and makeup as instructed.

90.5.2 Complications • Complications of CROSS are persistent erythema, hyper/hypopigmentation, additional scarring (Figs.  90.10 and 90.11), and keloid formation [5]. • Choosing the right patient, with dilated pores, small and not-too-deep ice pick scars, box scars, and varicella scars helps to avoid complications (Figs. 90.10 and 90.11). • In most cases, an adequate technique and/or postoperative care can prevent complications. • Avoiding crust formation (Fig. 90.10) is crucial to prevent all possible complications listed above. • Postoperative erythema is usually transient and lasts up to 8 weeks. Avoiding sun exposure and daily application of sunscreen as instructed are sufficient in most cases. • Post-inflammatory hyperpigmentation is more frequently observed in darker skins [3], although it can be seen in fair skin phototypes. It may persist for up to 6 months [1]. • Post-inflammatory hyperpigmentation is treated with morning application of 4% hydroquinone cream followed by 50 SPF sunscreen and makeup in female patients.

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Fig. 90.10 (a) Crust formation after treatment of larger and deeper scars and inadequate postoperative care by the patient. (b) Crust removal by the patient without medical consent

b

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Fig. 90.11 (a) Before. (b) After 45 days of CROSS. Note worsening of deep big box scars and additional scarring due to patient’s inadequate postoperative care and crust removal

• At night, for post-inflammatory hyperpigmentation, prescribe variable parts of 0.1% tretinoin cream, 20% azelaic acid cream, and betamethasone dipropionate cream, depending on skin type. • Rarely, if erythema or post-inflammatory hyperpigmentation persists, vascular and pigment-­ specific lasers may be a suitable option. • Transient hypopigmentation can be observed, particularly in darker skin phototypes. It lasts up to 3 months and subsides spontaneously.

Tip Box

• CROSS consists in the focal application of high-concentration TCA, which produces focal necrosis of epidermis and dermis that results in collagen remodeling.

• It maximizes the collagen remodeling while overcoming the risk of scarring, hypopigmentation, and hyperpigmentation. • It is a simple, effective, and safe method to treat atrophic acne scars, especially small deep scars such as ice picks and also enlarged pores and post-varicella scars. • Using two different sizes of tiny brush during CROSS allows the application of a constant quantity of TCA to the scar, precisely, effectively, and safely, independently of the size of the scar. • No anesthesia, antibiotic, or antiviral prophylaxes are necessary. • Downtime is minimal. • Reepithelization of the treated areas generally occurs within 14 days.

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• Avoiding sun exposure is mandatory for 3 months immediately following the procedure. • Daily application of sunscreen is of utmost importance once reepithelization is achieved. • Side effects can be minimized by using an adequate technique and careful postoperative care. • Complications such a persistent erythema, post-inflammatory hyperpigmentation, or hypopigmentation are usually self-limited and subside with adequate medical management. • In summary, CROSS is a simple, lowcost, easy-to-perform, efficient technique for the treatment of small deep acne scars.

References 1. Brody HJ.  Variations and comparisons in medium-­ depth chemical peeling. J Dermatol Surg Oncol. 1989;15:953–63. 2. Cho SB, Park CO, Chung WG, Lee KH, Lee JB, Chung KY.  Histometric and histochemical analysis of the effect of trichloroacetic acid concentration in the chemical reconstruction of skin scars method. Dermatol Surg. 2006;32:1231–6. 3. Khunger N, Bhardwaj D, Khunger M. Evaluation of CROSS technique with 100% TCA in management of ice pick acne scars in darker skin types. J Cosmet Dermatol. 2011;10:51–7. 4. Leheta T, Tawdy AE, Hay RA, Farid S. Percutaneous collagen induction versus full concentration trichloroacetic acid in the treatment of atrophic acne scars. Dermatol Surg. 2011;37:207–16. 5. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment of acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg. 2002;28:1017–21.

Acne Scar: Dermal Graft

91

Sergio Schrader Serpa

91.1 Materials

91.2

• The dermal collector developed by the author consists of a cylindrical surgical instrument, with a cutting edge at the free extremity, from which protrudes a ridge with 3 cm of length, ending at the other extremity in a piece of solid metal that functions as a handle (Fig. 91.1). • Dermographic pen. • Lidocaine, epinephrine, and saline solution. • Scalpel no. 11. • 4.0 and 6.0 mononylon suture. • 16 or 18 gauge needles or Nokor® needle. • Delicate Iris scissors. • Delicate angle forceps.

91.2.1 Donor area

Fig. 91.1  Serpa dermal collector

S. S. Serpa (*) Clínica Dermatológica Sergio Serpa, Rio de Janeiro, RJ, Brazil e-mail: [email protected]

© Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_91

Methods and Techniques [1–7]

• Paravertebral areas from dorsal or lumbar regions are chosen as donor sites because the dermis is thick, there is a lack of coarse hair follicles, and there are no large caliber blood vessels (Fig. 91.2a). • The patient must be positioned in ventral decubitus. • The procedure’s area is demarcated with a dermographic pen. • A tumescent solution consisting of 0.5% lidocaine with epinephrine (1:100.000) is injected (Fig. 91.2b). • A 3 mm incision is made using a no. 11 blade in one of the extremities of the demarcated area, through which the dermal collector was introduced (Fig. 91.2c). • With the skin pinched by the surgeon’s fingers, the dermal collector is progressed by semi-circular movements parallel to the skin, and subjacent to the epidermis, until it reached the other extremity of the demarcated area (Fig. 91.2d). • At that point, another small no. 11 blade incision is made, yielding an already deepithelized cylindrical fragment of dermis (Fig. 91.2e and f). • The dermal collector is pulled back, and the incisions are closed with one or two no. 4.0 mononylon suture knots. 659

S. S. Serpa

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b

c

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e

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Fig. 91.2  Donor area. Obtention of dermal tissue. (a) demarcation of the donor area (b) injection of tumescent solution of anesthesia (c) minimum incision with no.11 blade (d) introducion and progression of the dermal collector (e) incision with no. 11 blade in the other extremity of the demarcated area (f) yield of fragment of dermis

91  Acne Scar: Dermal Graft

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b

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Fig. 91.3  Receptor area. Treatment of acne scars with dermal grafting. (a) demarcation of distensible acne scars (b) subcision with needle (c) production of dermal disks

91.2.2 Receptor area • Choose depressed and distensible acne scars that are suitable for dermal grafts and demarcate them with a dermographic pen (Fig. 91.3a). • The anesthetic solution of 2% lidocaine with epinephrine is injected. • The subcision of the scar is performed using a 16 or 18 gauge needle or a Nokor® needle, producing the space (pocket) where the graft will be positioned (Fig. 91.3b). • The cylindrical fragment of dermal graft is fractionated in the form of disks through delicate Iris scissors (Fig. 91.3c).

• Each space created by the subcision in the scars is filled by a dermal disk through a delicate angled forceps (Fig. 91.4a and b). • The treated scar is closed with 6.0 mononylon suture and left for 7 days.

91.3 Clinical Follow-Up [1–7] • After 3 days, it is possible to verify little bruise in the donor area, as well as in the recipient area (Fig. 91.5). • After 7  days, the suture is removed in the recipient area (Fig. 91.6). • After 12  days, the suture is removed in the donor area (Fig. 91.7).

S. S. Serpa

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a

b

Fig. 91.4  Receptor area. Treatment of acne scars with dermal grafting. (a, b) introdution of dermal discs into spaces created on scars

Fig. 91.5  Clinical follow-up. After 3 days

Fig. 91.7  Clinical follow-up. After 12 days. Removal of the suture in the donor area

Fig. 91.6  Clinical follow-up. After 7 days. Removal of the suture in the recipient area

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91.4 Before and After (Figs. 91.8, 91.9, and 91.10) a

a1

b

Fig. 91.8  Before and after. (a) and (a1) before (b) after 6 months

a

Fig. 91.9  Before and after. (a) before (b) after 4 months

b

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a

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Fig. 91.10  Before and after. (a) before (b) after 10 months

Fig. 91.11  Complications. Scarring not very noticeable in the donor area

91.5 S  ide Effects, Complications, and Their Management [1–7] • Relative difficulty in carrying out the procedure; depends on the surgeon’s skills. • The main side effect is the production of scarring in the donor area. Some patients evolve without obvious scarring (Fig.  91.11), while others have noticeable scarring months after the procedure (Fig. 91.12). • There is possibility of formation of epithelial cysts in the recipient area, but in this technique, the dermal tissue obtained already comes devoid of epidermis, and epithelial cysts were not noticed.

Fig. 91.12  Complications. Scarring more noticeable in the donor area

• Patients complain of mild discomfort in the donor area on the following 2 days, and bleeding is rare.

Tip Box

• The harvesting of autologous dermal grafts through the use of the dermal collector confers considerable speed to the technique, when compared to other methods. • Up to 30 dermal discs to be used in the filling of acne scars can be produced in just a few minutes.

91  Acne Scar: Dermal Graft

• The scar produced at the donor site is acceptable, and the dermal tissue is already obtained with no epidermis, avoiding cyst formation in the receptor area.

References 1. Lexer E.  Free transplantation. Ann Surg. 1914;60:166–94. 2. Leaf N, Zarem HA. Correction of contour defects of the face with dermal and dermal-fat grafts. Arch Surg. 1972;105:715–9.

665 3. Davis RE, Guida RA, Cook TA.  Autologous free dermal fat graft: reconstruction of facial contour defects. Arch Otolaryngol Head Neck Surg. 1995;121:95–100. 4. Swinehart JM.  Dermal grafting. Dermatol Clin. 2001;19:509–22. 5. Gozali MV, Zhou B. Effective treatments of atrophic acne scars. J Clin Aesthet Dermatol. 2015;8(5): 33–40. 6. Shilpa K, Sacchidanand S, Shilpashree P, Leelavathy B, Divya G, Ranjitha R, Lakshmi DV.  Outcome of dermal grafting in the management of atrophic facial scars. J Cutan Aesthet Surg. 2016;9(4):244–8. 7. Serpa SS.  A new method for obtaining autologous dermal graft for tissue filler techniques. Surg Cosmet Dermatol. 2009;1(4):197–8.

92

Acne Scars: Dermabrasion Bogdana Victoria Kadunc

92.1 Materials (Fig. 92.1) 1 . Protection of the medical team, since blood can become aerolized during dermabrasion 2. 4% chlorhexidine solution 3. Topical anesthesia, plain 2% lidocaine with epinephrine for nerve blocks, and a solution containing 2% lidocaine = 15  ml + 10% sodium bicarbonate = 1.5 ml + saline = 30 ml to perform the tumescent anesthesia [1] 4. 35% trichloroacetic acid (TCA) Fig. 92.1 Materials needed for chemabrasion: (1) Plastic mask for protection of the medical team, (2) 4% chlorhexidine solution, (3) anesthesia materials, (4) 35% TCA, (5) electrically powered device equipped with an handheld drill, (6) diamond fraises, wire brush, (7) dressing materials

5

5. Eletrically powered device equipped with a handheld drill (15,000–25,000 rpm) 6. Diamond fraises of various shapes, sizes, and textures and/or wire brushes, which are more aggresive 7. Dressing materials

92.2 Methods and Techniques • Precise dermabrasion indications: superficial nondistensible depressed acne scars and

2

7

4 3 1 6

B. V. Kadunc (*) Department of Dermatology, Pontifical Catholic University of Campinas, Campinas, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_92

667

668

•

•

•

•

medium or deep nondistensible scars superficialized by other methods Contraindications: presence or risk of melasma or koebnerising conditions, prior radiation treatment, extensive undermining in the area or isotretinoin intake up to 6 months prior to the procedure, and immunosuppression Preoperative care: complete medical h­ istory, physical exam, HIV tests, and hepatitis panel Preoperative medications: tretinoin cream for 3  weeks in order to reduce the reepithelialization period and antiherpetic systemic medications for 2 weeks, starting 2 days beforehand Sequence of the technique: A. Asepsis of the skin with 4% chlorhexidine solution B. Anesthetic procedures: (a) Topical anesthesia (b) Supratrochlear, supraorbital, infraor bital, and mental nerve blocks (c) Tumescent intradermal anesthesia in the areas to be abraded (Fig. 92.2) C. Full-face 35% TCA application to obtain a medium chemical peel followed by a motor-driven dermabrasion in the most scarred cosmetic units (chemabrasion) [1]. D. Motor-driven dermabrasion: (a) The body of the hand engine is held with the forefingers, while the thumb holds its neck. (b) In order to stabilize the area to be abraded, the skin must be stretched in three points by the assistant’s hands

Fig. 92.2  Tumescent intradermal anesthesia

B. V. Kadunc

and the nondominant surgeons’s hand. (c) The fraise/brush is passed over the skin perpendicularly to the direction of the rotation throughout the whole cosmetic unit to be treated (Fig. 92.3). (d) As the epidermis is removed, the papillary dermis pinpoint bleeding is observed. A second pass is performed in the most scarred areas. (e) Proceeding further into the dermis, the pinpoints become scarce, giving place to a parallel-band look, which caracterizes the midreticular dermis, the end point of the procedure. E. The dressing sequence consists of a semi-­ occlusive membrane dressing (N-­Terface® or sterilized veil fabric) [2], petrolatum jelly, gauze, and tubular elastic bandages (Fig. 92.4).

Fig. 92.3  The wire brush is passed over the skin

Fig. 92.4  The veil fabric membrane dressing

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92.3 Clinical Follow-Up • From 24 and 48 h afterward, the patient returns to the office to repeat the same dressing sequence, after a careful cleaning of the exsudate, over the membrane (Fig. 92.5). • From the third to the eighth day, the patient, after removing the membrane (Fig.  92.6), cleans his face and reapply ointments at home three times per day in order to hydrate the area, which allows proper reepithelialization. • Complete reepthelialization occurs in 7–10 days.

Fig. 92.5  24 h post-op: cleaning the exsudate over the membrane

92.4 Before and After (Figs. 92.7, 92.8, 92.9, and 92.10) • The results are extremely compensating, not only for the leveling of the skin surface but also for the intense neocolagenesis resulting after 6 months.

Figs. 92.7 and 92.8  Before and after chemabrasion (1 session)

Fig. 92.6  72 h post-op: cleaning after removing the membrane

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B. V. Kadunc

Figs. 92.9 and 92.10  Before and after full-face chemabrasion (1 session)

92.5 S  ide Effects, Complications, and Their Management • Bacterial or fungal infections rarely occur. The highest incidence is of herpes infections if adequate prophylaxis is not done. • Accidental post dermabrasion acne flares are handled with the standard acne treatment. • The post-inflammatory hyperpigmentation can manifest 20–30 days after the procedure, more commonly in photoype III or IV patients, solved within 30  days with tretinoin-­ hydroquinone combined creams (Fig. 92.11). • Delayed epithelialization, which is frequent on jawline or zygomatic arch areas, may develop with erythema and hypertrofic scars. They need to be treated as soon as possible with topical or intralesional corticosteroids (Fig. 92.12). • Cutaneous hypopigmentation without atrophy can improve with intense pulsed light sessions or chemical peels in the surrounding dermabraded areas. • The hypopigmentation with atrophy has no efficient treatment and is due to inadequate Fig. 92.11 Post inflammatory hyperpigmentation 25 deepening. days after the procedure

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• Correcting acne scars is a very challenging situation, and in most cases, it becomes necessary to associate various methods of approach to the treatment [4]. • The chemabrasion process facilitates the mechanical exfoliation and helps to blend dermabraded and nondermabraded regions, reducing demarcation lines [1]. • Punch techniques  – excisions, elevations, and graftings – subcision, fillers, and microneedling [5] frequently complete the ablative processes. Fig. 92.12  Hypertrofic scars 60 days after dermabrasion, due to inadequate deepening

Tip Box

• The success of the procedure depends essentially on correct indication, adequate pre- and postoperatory care, and realistic expectations of the patients. • It is recommended to wait from 6 to 12 months after using oral isotretinoin for dermabrasion of complete cosmetic units reaching the middle reticular dermis [3]. • For an outpatient-setting procedure to be possible, the local anesthesia should be sufficient and comfortable for the patient. • Pain, 5–10  days after dermabrasion, may mean a herpes virus infection. • Retouching can be done in  localized areas 60 days after the initial procedure.

References 1. Meski AP, Cuce LC.  Chemabrasion for the treatment of perioral wrinkles: clinical analysis and epidermal Langerhans cells qualifi cation. Surg Cosmet Dermatol. 2009;1(2):74–9. 2. Kadunc BV, di Chiacchio N, Almeida ART. Tulle or veil fabric: a versatile option for dressings. J Am Acad Dermatol. 2001;47:129–31. 3. Waldman A, Bolotin D, Arndt KA, Dover JS, Geronemus RG, Chapas A, et  al. ASDS Guidelines task force: consensus recommendations regarding the safety of lasers, dermabrasion, chemical peels, energy devices, and skin surgery during and after isotretinoin use. Dermatol Surg. 2017;43:1249–62. 4. Kadunc BV, Almeida ART.  Surgical treatment of facial acne scars based on morphologic classification: a Brazilian experience. Dermatol Surg. 2003;29:1200–9. 5. Domyati M, Barakat M, Awad S, Medhat W, Fakahany H, Farag H.  Microneedling therapy for atrophic acne scars: an objective evaluation. J Clin Aesthet Dermatol. 2015;8:36–42.

Acne Scar: Hyaluronic Acid Filler

93

Ada Regina Trindade de Almeida and Danielle Claudino de Oliveira Costa

93.1 Materials Topical lidocaine ointment, gauze pads, chlorhexidine solution, marker pen or pencil, hyaluronic acid filler (Fig. 93.1, Table 93.1).

Table 93.1  Hyaluronic acid filler options for distensible or rolling acne scars Juvederm Volift ou Volbella Restylane vital, vital light Belotero balance or soft Emervel classic Perfectha Derm, Finelines Teosyal global action

Fig. 93.1 Materials used in the procedure

The original version of this chapter was revised: Text in Tip Box content has been corrected. The correction to this chapter is available at https://doi. org/10.1007/978-3-319-78265-2_114 © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_93

A. R. T. de Almeida (*) · D. C. de Oliveira Costa Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, SP, Brazil 673

A. R. T. de Almeida and D. C. de Oliveira Costa

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93.2 Methods and Techniques

93.2.2 Treatment

93.2.1 Identifying the Correct Acne Scar Type

Topical anesthetic cream is applied to the affected region for 30 min (Fig. 93.3a). The affected area is cleansed with 0.2% chlorhexidine solution (Fig. 93.3b). Identified rolling scars are highlighted using a marking pen or brown pencil (Fig. 93.3c and d).

Distend the skin around the scars and look if they improve or not. If yes, scars can be treated by HA filler injection (Fig. 93.2). Fig. 93.2 Identifying distensible acne scars

a

Fig. 93.3 Skin preparation for procedure

a

b

c

d

b

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93.2.3 Injection Technique

93.3 Clinical Follow-Up

Dose: 0.02–0.04 ml by scar, according to depth and size The needle is positioned perpendicular to the scar, and the skin is punctured through the deep dermis. Small deposits of product are placed under each scar, in a gradual tapering retrograde fashion as the needle is withdrawn (Fig. 93.4). The corrected site is then compressed gently to prevent bruising [1]. If necessary, a mild massage can be performed after the treatment in order to dissolve palpable papules and to better mold the filler [1].

The follow-up visit is scheduled after 14–30 days. At that moment, if necessary, the treatment can be repeated to correct untreated or undertreated areas. The effect is immediate and lasts up to 24 months.

Fig. 93.4 Injection technique

a

b

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93.4 Before and After (Figs. 93.5 and 93.6) Fig. 93.5 Patient showing acne scarring before (a) and 7 days after treatment (b)

Fig. 93.6 Patient showing acne scarring before (a) and 7 days after treatment (b)

a

b

a

93.5 S  ide Effects, Complications, and Their Management Erythema, mild and transient edema, and bruising may occur after the puncture. They can be treated with cold compresses, but often nothing is needed. It resolves within hours and at most within 1–2 days [1, 2]. Nodules/papules are reversed with local massage, hyaluronidase, and/or steroid infiltration [1, 2]. Theoretically, ischemia and impending necrosis of the skin may occur if a blood vessel is occluded by direct intravascular injection or external compression in any place. Since in this technique the filler is placed superficially, the risk is very rare. Careful revision in search of any sign of blanching or purple color of the skin is mandatory at the end of the procedure. If necessary, prompt hyaluronidase injection will clear the blood flow and solve the problem [2].

b

Tip Box

Acne scar treatment with hyaluronic acid fillers offers several advantages, like immediate and reproducible results, better accuracy than other techniques, long-lasting results, and high patient satisfaction.

References 1. Goodman GJ, Van Den Broek A. The modified tower vertical filler technique for the treatment of postacne scarring. Australas J Dermatol. 2016;57(1): 19–23. 2. Crocco EI, Alves RO, Alessi C. Eventos adversos do ácido hialurônico injetável. Surg Cosmet Dermatol. 2012;4(3):259–63.

Acne Scar: Microneedling

94

Flávio Barbosa Luz and Tadeu de Rezende Vergueiro

94.1 Materials

• Miniature versions in stamp form and different needle lengths (0.2–3  mm) can also be • Materials related to asepsis and antisepsis. used for localized scars [3]. • Materials related to topical and injectable • The rolling and stamping instruments are preanesthesia or sedation according to sterilized by gamma irradiation and designed convenience. for a single use [2]. • The rolling standard device comprises a cable • Automated microneedling pen-shaped device with a length of at least 10  cm and a drum-­ with disposable needles can be reusable in difshaped cylinder of 10–20  mm in width and ferent patients, and it is more practical to treat 20 mm in diameter at one end [1]. narrow areas [3]. • The roller head is equipped with microneedles synthesized on silicon or stainless steel and whose sizes range from 0.2 to 3  mm in 94.2 Methods and Techniques length and 0.1–0.25  mm in diameter (Fig. 94.1) [2, 3]. • As always, the success of the procedure begins • For treating acne scar, a needle length of with the correct selection of patients. 1.5 mm or more is usually used. In the case of • Absolute contraindications are active herpes drug delivery, a needle of 0.5–1.5  mm in labialis, any other local infection, any local length is used. suspected or confirmed malignant lesion, and • On areas where greater precision is required, local field cancerization [3, 4]. such as the perioral region, a smaller cylinder • The selection of patients during pregnancy of 10 mm in width should be used [3]. and lactation, on systemic retinoids, on anticoagulant and antiplatelet therapy, with blood dyscrasias, keloidal tendency, unrealistic expectations, or severe chronic diseases, should be judiciously evaluated. F. B. Luz (*) • The patient should be advised about the proceUniversidade Federal Fluminense (UFF), dure, expected results, and side effects. Niterói, RJ, Brazil Surgical risk in case of sedation and written T. de Rezende Vergueiro informed consent should be obtained. Department of Dermatology, University Hospital • The patient should be warned about good Pedro Ernesto, Federal Fluminense University, response in rolling and boxcar scars and poor Niterói, RJ, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_94

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678 Fig. 94.1 Materials used in microneedling for acne scar

•

• •

•

•

•

•

response in ice-pick and other deeper atrophic scars [4, 5]. Besides photoprotection, the patient’s skin can be prepared with topical formulations of retinoids or vitamin C [6]. Patients with history of herpes simplex should receive prophylaxis. The patient should be placed supine with the head in neutral position. In this moment, the vital signs should be measured. Conventional antiseptics, such as ethanol, iodinated compounds, and chlorhexidine, can be used to prepare the site. The use of sterile surgical field is also advised. Topical anesthesia with lidocaine, prilocaine, or tetracaine can be applied; however, it is less effective than local injectable anesthesia and sedation [6]. Neural blockade of the face with local injectable anesthetics is an interesting tool on the management of the microneedling, providing a simple and effective approach. The peripheral branches of the trigeminal nerve that may be blocked are the ­supraorbital,

•

•

•

•

•

supratrochlear, nasociliary, infraorbital, zygomatic, and mental branches. For patient comfort in  local injectable anesthesia, use syringes with delicate needles (25–30G). About 2–3 ml of the anesthetic solution with 2% lidocaine with or without epinephrine (generally at a dilution 1:200,000 to 1:400,000) is sufficient for each neural blockade. Before microneedling, the site should be carefully cleansed with sterile saline solution or other sterile neutral solutions to avoid possible transdermal delivery of such antiseptics and topical anesthetics. The treatment site should be rolled in eight directions (vertically up and down, horizontally to the right and left, and in both diagonal ways), applying light to moderate pressure, depending on the area and effect desired (Fig. 94.2a and b) [7]. The endpoint for any treatment session is the appearance of uniform fine pinpoint bleeding through thousands of micropuncture sites, and a violaceous dotting may be reached [5].

94  Acne Scar: Microneedling

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• The number of rolling passes required is variable for each patient and area and is inversely proportional to the density of the needles on the roller head. • The counting of the rolling passes may assist in the uniformity of treatment. • In deep-seated scarring, the skin should be stretched in a perpendicular direction so that the base of the scar can also be reached by the microneedles [4]. • During and after microneedling, it is prudent to avoid unsafe drugs in the intradermal and subcutaneous routes. • Any bleeding beyond the pinpoint pattern is not expected. However, it can be abbreviated with cotton balls during a few minutes. • After stopping the bleeding points, the formed serous ooze should be removed from the skin surface using sterile saline solution. a

• Post procedure, the patient is advised to follow sun-protective measures and use moisturizer regularly, avoiding skin dryness and crusting.

94.3 Clinical Follow-Up • The microneedling causes thousands of micropuncture injuries, which generally oozes for less than 24 h and heals within 2–3 days with no sequelae (Fig. 94.3a and b). • Treatments can be performed with intervals of 2 or more weeks, and various sittings usually are needed to achieve the desired effect. • Generally, a minimum of three sessions are required for a significant improvement. • The final result cannot be verified promptly because the remodeling phase may last for 6 months or more. b

Fig. 94.2  Way to pass the rolling stand device on the skin face Fig. 94.3  Skin after 7 days of the microneedling session

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94.4 Before and After (Figs. 94.3 and 94.4a–d) Fig. 94.4  Skin (a) before, (b) immediately after, (c) after 5 days, and (d) after 30 days of the microneedling session

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94  Acne Scar: Microneedling

94.5 S  ide Effects, Complications, and Their Management • Side effects are commonly mild and transient, causing minimal downtime. • Slight erythema and edema are the most common effects (Fig. 94.4b) and may last for 1–4 days (mean of 2–3 days). Transient slight pain may also occur [5]. • Microneedling preserves the epidermis and rarely leads to post-inflammatory hyperpigmentation unlike ablative procedures, being safe in all skin types [6]. • Local infections following the use of a nonsterile instrument have been observed. • Systemic hypersensitivity reactions and allergic contact dermatitis may occur due to materials used in the needles, as well as during anesthesia and with drug delivery [8]. • Systemic toxic reactions may be also associated to drug delivery, such as administration of topical anesthetics simultaneously with microneedling. • Foreign body granulomatous reactions have been related with the use of unsafe drugs in the intradermal and subcutaneous routes during microneedling. • Tram-track effect has been reported mainly in microneedling over bony prominences. This can be avoided by using less pressure and smaller needles in these áreas [3]. • Other possible events are aggravation of acne, reactivation of herpes, and transient lymphadenopathy [3, 5]. Tip Box

• Microneedling is an effective, safe, and minimally invasive technique. • Its success stems from promoting regeneration rather than cicatrization. • Needle length of 1.5 mm or more is suitable for treating acne scar. • In general, the procedure produces good response in rolling and boxcar scars and poor response in ice-pick and other deeper atrophic scars.

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• The microneedling is more tolerable for patients with neural blockade of the face and sedation. • Before microneedling, the treatment area should be carefully cleansed with sterile neutral solutions to avoid unintentional drug delivery. • The roller head should be passed in eight directions, applying light to moderate pressure, depending on the treatment area and intended effect. • The endpoint is the appearance of uniform fine pinpoint bleeding, which may result in a violaceous dotting. • Unsafe drugs in the intradermal and subcutaneous routes are not recommended during and after microneedling. • Side effects are mostly mild and transient, causing minimal downtime. • As the procedure preserves the epidermis, it is safe on all skin types.

References 1. Fernandes D.  Percutaneous collagen induction: an alternative to laser resurfacing. Aesthet Surg J. 2002;22(3):307–9. https://doi.org/10.1067/ maj.2002.126195. 2. Doddaballapur S.  Microneedling with dermaroller. J Cutan Aesthet Surg. 2009;2(2):110–1. https://doi. org/10.4103/0974-2077.58529. 3. Singh A, Yadav S. Microneedling: advances and widening horizons. Indian Dermatol Online J. 2016;7(4): 244–54. https://doi.org/10.4103/2229-5178.185468. 4. Majid I.  Microneedling therapy in atrophic facial scars: an objective assessment. J Cutan Aesthet Surg. 2009;2(1):26–30. https://doi. org/10.4103/0974-2077.53096. 5. Garg S, Baveja S.  Combination therapy in the management of atrophic acne scars. J Cutan Aesthet Surg. 2014;7(1):18–23. https://doi. org/10.4103/0974-2077.129964. 6. Aust MC, Reimers K, Vogt PM.  Medical needling: improving the appearance of hypertrophic burn-­ scars. GMS Verbrennungsmedizin. 2009;3:Doc03. http://www.egms.de/static/en/journals/vmed/2009-3/ vmed000007.shtml 7. El-Domyati M, Barakat M, Awad S, Medhat W, El-Fakahany H, Farag H. Microneedling therapy for

682 atrophic acne scars: an objective evaluation. J Clin Aesthet Dermatol. 2015;8(7):36–42. 8. Soltani-Arabshahi R, Wong JW, Duffy KL, Powell DL.  Facial allergic granulomatous reac-

F. B. Luz and T. de Rezende Vergueiro tion and systemic hypersensitivity associated with microneedle therapy for skin rejuvenation. JAMA Dermatol. 2014;150(1):68–72. https://doi. org/10.1001/jamadermatol.2013.6955.

Acne Scar: Punch Elevation

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Caroline Silva Pereira, Beatrice Martinez Zugaib Abdalla, and Fábio Rebucci

95.1 Materials The materials used at the surgical table are shown in Fig. 95.1 and listed below:

• • • •

Sterile mitts Aqueous chlorhexidine Gauze Anesthetic: 2% lidocaine hydrochloride with norepinephrine hemitartrate (1:50.000)

Fig. 95.1 Materials used for the procedure

C. S. Pereira (*) Pontifical Catholic University, São Paulo, SP, Brazil

F. Rebucci ABC School of Medicine, Santo André, SP, Brazil

ABC School of Medicine, Santo André, SP, Brazil B. M. Z. Abdalla ABC School of Medicine, Santo André, SP, Brazil 2nd Year Resident of Internal Medicine at FMABC, Santo André, SP, Brazil © Springer Nature Switzerland AG 2020 A. Da Costa (ed.), Minimally Invasive Aesthetic Procedures, https://doi.org/10.1007/978-3-319-78265-2_95

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• 1, 1.5, and 2.0  mm straight wall disposable punch instruments • Sterile dressing

95.2 Methods and Technique Firstly, it is essential that the scars chosen for this technique have regular edges and the bases of a normal appearance in order to proceed with this technique. Figures  95.2a, b (16-year-old male patient) and 95.3 (45-year-old female patient) show the elevation of the scars after the immediate procedure and Fig. 95.4, the end of the procedure with sterile dressing, which the patients remained with for 7  days without exchanges, to avoid movement and manipulation of the scars. After cleansing the patient’s skin with aqueous chlorhexidine and infiltration of anesthetic into the subcutaneous layer in each selected scar, 10–15  min is expected for adequate anesthesia and vasoconstriction, and then we proceed with the technique:

Fig. 95.2  Image showing the elevation of the scares after the immediate procedure. (Male patient, 16-years-­ old, phototype III)

Fig. 95.3  Image showing the elevation of the scars after the immediate procedure. (Female patient, 45-years-­old, phototype II)

Fig. 95.4  Image showing the end of the procedure with sterile dressing. (Male patient, 16-years-old, phototype III)

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• The punch instrument is first sized to match exactly the inner diameter of the scar, therefore choosing the appropriate punch size. • The cicatricial tissue cylinder is incised to the subcutaneous level. • Careful lifting of the tissue is performed so that it rises higher than the surrounding skin, without fully highlighting the incised tissue. • Place sterile dressing at the procedure site, so that the scar does not move. In some articles, a small drop of 2-octyl-cyanoacrylate glue had been placed on the surface of the tissue, or even the suture of the raised scar has been performed.

95.3 Clinical Follow-Up

Fig. 95.5  Image showing clinical follow-up on the 7th day after the procedure. (Male patient, 16-years-old, phototype III)

Fig. 95.6  Image showing clinical follow-up on the 15th day after the procedure. (Male patient, 16-years-old, phototype III)

The degree of clinical improvement was based on the photo comparison of the treated scar in relation to the preoperative scar, as well as the satisfaction and well-being of the patient. The photographs, for clinical follow-up, were performed preoperatively and postoperatively at subsequent visits at D7, D15, and D30. The clinical follow-up of the 16-year-old male patient is shown in Figs. 95.5 and 95.6a–c, showing D7 and D15, respectively. And the clinical follow-up of the 45-year-old female patient is shown in Figs.  95.7a, b and 95.8a–c, as D7 and D15, respectively. During the follow-up visits, no infections, inflammations, or any type of incidents associated with the treatment described were observed.

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95.4 Before and After (Figs. 95.9, 95.10, 95.11, and 95.12)

Fig. 95.7  Image showing clinical follow-up on the 7th day after the procedure. (Female patient, 45-years-old, phototype II) Fig. 95.9  Image of the patient in preoperative state. (Male, 16-years-old, phototype III)

Fig. 95.10  Image showing clinical follow-up on the 30th day after the procedure. (Male patient, 16-years-old, phototype III)

Fig. 95.8  Image showing clinical follow-up on the 15th day after the procedure. (Female patient, 45-years-­old, phototype II)

95  Acne Scar: Punch Elevation

Fig. 95.11  Image showing clinical follow-up on the 30th day after the procedure. (Female patient, 45-years-­old, phototype II)

95.5 S  ide Effects, Complications, and Their Management Some complications may occur with this procedure [1], such as depression or unevenness from raising the scar at its junction with the adjacent skin, thus leaving a gap and preventing the adequate result, demonstrated in Fig.  95.12, performed on the 45-year-old female patient. Compliance with postoperative care is unpleasant and must be discussed with patients. This type of therapy, although often being challenging, presents a satisfactory results [1].

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Fig. 95.12  Image showing a complication of the procedure as unevenness with the adjacent skin when raising a scar. (Female patient, 45-years-old, phototype II)

Tip Box

• The treatment modality presented encompasses some indications for specific scars, providing a satisfactory aesthetic result, including deep-based ice-pick atrophic scars, narrow (