OfficeBased Cosmetic Treatments

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Office-Based Cosmetic Treatments

• Kelly Douglas Burchett, D.O.
• Advanced Surgical Arts
• Kirksville, Missouri

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History of Cosmetic Surgery

• World War I
• Increased surgical interest in the treatment of
  facial trauma
• 1921group of 6 surgeons are instrumental in
  forming the American Association of Plastic
  Surgery (AAPS)
• Sir Harold Delf Gillies Sir Arbuthnot Lane
  Varaztad Kazanjian Vilray Blair
  John Staige Davis
  Jerome Pierce Webster

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History of Cosmetic Surgery

• 1921 Year Book of the American College of
  Surgeons
• Listed specialties of early members of the AAPS
  include oral surgery, laryngology,
  rhinology-laryngology, rhino-oto-laryngology, and
  surgery

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History of Cosmetic Surgery

• Facial deformities were associated with socially
  unacceptable diseases
• SYPHILIS, lupus, scrofula, abscess, etc.
• These past associations continue to influence
  modern prejudices

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History of Cosmetic Surgery

• After World War I
• Shift in concept of beauty from
  
  
• Protestant Victorianism
• to
• Classical Physical Beauty

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History of Cosmetic Surgery

• I.E. Syphilis frequently caused a saddle-nose
• New York surgeon Joseph Safian, M.D. in a 1926
  radio address
• Many persons with a saddle nose
• are suspected of having inherited disease
  and are greatly handicapped, both
  in their social and business relations.

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• Cosmetic Surgery
• Plastic Surgery
• Reconstructive Surgery

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The Aging Process

• Youthful skin
• Aged skin

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Collagen Elastin Fibers
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The Aging Process

• Extrinsic Aging 90
• UV radiation, smoking, dry skin
• Intrinsic Aging 10
• Thinning dermis
• ? collagen, ? elasticity

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The Aging Process

• The combined effect of gravity, internal tissue
  changes, and external exposure over time

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Office-based Cosmetic Procedures

• Aesthetician-provided procedures
• Botox injection
• Injectable fillers
• Mesotherapy
• Laser applications
• Intense pulsed light/Photodynamic Therapy
• Chemical peels
• Dermabrasion
• Microdermabrasion

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Aesthetic Treatments

• Certified Esthetician
• Skin Care/Cosmeceuticals
• Medical Facial Treatments
• Non-ablative skin rejuvenation/ lunch-time
  lasers

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An ounce of prevention

• Skin care
• UV protection (SPF 30, hats, sunglasses, etc.)
• Moisturizers
• Nutritionantioxidants/multivitamins
• Prescription retinoids
• Stop Smoking
• Botox

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Cosmeceuticals
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The Medical Facial

• Cleansing of the skin and dermaplaning/microdermab
  rasion
• Glycolic (alpha hydroxy)/Jessners applied evenly
• Tingling and slight discomfort for 1-3 minutes
• Skin is gently rinsed
• Improves clarity, tone, and color
• May repeat every 2-4 weeks or as needed

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Injections Fillers

• Botox
• Excellent for dynamic wrinkles and
  hyperhidrosis (sweating)
• Injected into specific muscles
• Injected into axillae or palms
• Causes temporary weakness
• Helps to prevent static wrinkle formation
• Lasts 3-6 months
• The national scare was caused by research grade
  nondilute toxin (not Botox)

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Facial Injections Fillers

• Restylane
• Hyaluronic Acid
• No test patch required
• Enhancement lasting 4 to 6 months
• Used for lips, wrinkles, and folds

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Restylane
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Injections Fillers

• Fat Transfer
• Small amount harvested from body
• Injected beneath the dermis
• Used for enhancement and contour irregularities
• Contains stem cells that can become muscle, fat,
  connective tissue
• Improvement in technique has improved long term
  results 40-60 of original volume persists
  beyond one year

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Mesotherapy

• Phosphatidylcholine 100 mg/ml 4cc
• Collagenase 1000 u/ml 1-2
• Hyaluronidase 150 u/ml 1-2
• L-Carnitine 500 mg/ml 1-2
• Lidocaine 2 without epinephrine 1-2

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Lasers

• Light Amplification by Stimulated Emission of
  Radiation
• Coherent
• photons in phase temporally/spatially
• Collimated
• tight beam, parallel paths
• Monochromatic
• one wavelength

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Selective Photothermolysis
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Laseremission types

• Continuous
• Uninterrupted beam
• Relatively constant power
• Pulsed/Superpulsed (microsec)
• Higher energy/shorter duration pulses
• Q-switched (nanosec)
• Extremely high energy/short pulse duration

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• Laser Wavelength (nm) Application
• ErYAG 294 Skin resurfacing
• Argon 488/514 Vascular lesions
• KTPYAG 532 Vascular lesions
• Copper vapor 578 Vascular lesions
• FLPPD 585 Vascular lesions
• Long pulse 595-600 Leg veins
• Ruby, Q-switched 694 Tattoo removal
• Long pulse 694 Hair removal
• Q-switched Alexandrite 755 Tattoo removal
• NdYAG 1064 Deep vascular
• Q-switched YAG 1064 Tattoo removal
• CO2 10600 Cut/coag/resurf

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Light Based Modalities

• Telangiectasias in order of preference/effectiven
  ess
• Diode laser (variable-pulsed-width 532nm)-as
  effective as pulsed-dye without puerperal
• pulsed-dye laser (puerperal results)
• IPL
• Hemangiomas
• pulsed-dye laser (585nm wavelength)
• 2-10 treatments spaced 6-8 weeks apart
• Port-wine stains
• Pulsed-dye laser (585nm)
• 2-12 treatments spaced 6-8 weeks apart
• superficial lesions, red lesions, younger than
  10, head and neck lesions respond better

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Light Based Modalities

• Superficial lesions (generally shorter-wave-length
  systems)
• Freckles
• Q-switched 532nm NdYAG laser
• recur frequently
• Café-au-lait lesions
• Q-switched NdYAG lasers
• difficult to treat, recur often
• Lentigos
• Q-switched NdYAG lasers
• CO2, Erbium, KTP
• recurrence uncommon
• Peels, topicals

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Light Based Modalities

• Nevi
• biopsy if suspicious
• Q-switched NdYAG 532, 694, 755nm lasers
• respond within 1-3 treatments
• Melasma
• Q-switched NdYAG laser
• hormonal control
• bleaching agents
• sun avoidance
• tend to recur
• Rosacea
• topicals (antibiotics, tretinoin)
• oral abx
• IPL
• KTP laser

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Light Based Modalities

• Deep lesions-deeper, therefore treated better
  with longer wavelength (goes deeper) can use
  ruby, alexandrite, and NdYAG
• blue nevi
• 1064 nm NdYAG laser
• nevus of ota and ito
• Q-switched 1064nm NdYAG laser
• multiple treatments
• recurrence is unusual

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Aesthetic Treatments

• Intense Pulse Light (IPL)Not a laser
• Noncoherentpolychromatic (500-1200 nm) using
  filters to select wavelength
• Applications include fine wrinkles, mild acne
  scarring, hair removal, pigmented/vascular
  lesions
• No down time
• Performed by certified technologist or physician

Quantum SR by Lumenis
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Aesthetic Treatments
Quantum SR
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Levulan Photodynamic Therapy (PDT)

• Aminolevulinic Acid (ALA)
• Used as a photosensitizer
• FDA approved for AKs
• Also used in acne, sebaceous disorders, skin
  cancers, and cosmetics.
• Used in conjunction with a light based modality

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Skin Resurfacing

• Multiple methods (dermabrasion, chemical peel CO2
  laser)
• Used to smooth wrinkles, scars, and blemishes
• Excellent results, but longer down time
• Avoid sun exposure for 2-4 weeks afterwards
• May wear make-up after 2 weeks

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Peels

• Chemical cutaneous injury to specific level
• Limitations of facial peeling
• Cannot reduce pore size, eliminate
  telangiectasias, eliminate deep scars, efface
  deep wrinkles
• Can improve appearance of sun-damaged skin,
  flatten mild scarring, smooth out rhytids,
  destroy epidermal lesions, help with acne, remove
  pigmented lesions, blend other interventions
• Lower preoperative Fitzpatricks type translates
  into lower risk of pigmentation problems
• Inquire about history of Accutane therapy in last
  6 months, XRT, previous facial cosmetic surgery,
  abnormal scar formation, rosacea, seborrheic
  dermatitis, atopic dermatitis, psoriasis

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Peels

• Superficial
• Very light
• Injure stratum corneum
• 10-20 TCA
• Jessners
• Tretinoin
• Salicylic acid
• Light
• Injure entire epidermis
• 70 glycolic acid (must be rinsed)
• 25-35 TCA
• Solid CO2 slush
• Medium
• 35 TCA Jessners vs. 70 glycolic acid vs. CO2
  
• Risk of scarring with 50 TCA
• Deep
• Baker-Gordon solution
• Phenol, water, septisol, croton oil
• Phenol cardiac toxicity precautions

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Peels

• Superficial peel
• No intervention necessary
• Medium/Deep peel
• Antiviral agent (continued x 10d-2wk)
• Weak tretinoin solution 1-2 wks before
• 4-8 hydroquinone gel for patients with
  Fitzpatrick skin types III or higher
• Evaluate for cardiac status, kidney disease

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Dermabrasion

• Time-honored method of skin resurfacing
• Abrasive brushes and friezes to mechanically
  remove superficial layers of the skin
• Results similar to laser/chemical peels
• Requires experience to perform wellfelt to have
  increased incidence of scarring and
  hypopigmentation
• Still the best application for deep scarring,
  deep rhytids, acne-related pits/scars
• Requires sedation, assistant, protection from
  bodily fluids
• Learning points
• Hand dermabrasion of thin-skinned areas
• Carry dermabrasion across vermillion border
• Rotation of brush/frieze should be toward nearby
  vital structures to avoid tearing of tissues

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Dermabrasion
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Microdermabrasion

• Aluminum oxide crystals pumped at high speeds
  toward skin surface. Suction applied to remove
  crystals and debris.
• Less operator-dependant than dermabrasion
• Consistent depth of tissue loss (adjustable)
• Less blood exposure than dermabrasion
• Usually two passes to remove epidermis (pinpoint
  bleeding)
• Results not as dramatic, may need several
  treatments
• Erythema resolves after 24 hours
• Risks of hyper/hypopigmentation and scarring low
• Indicated for minor degrees of sun damage,
  wrinkling, acne scarring, blending of treatment
  boundaries

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Microdermabrasion
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Kelly Douglas Burchett, D.O.Advanced Surgical
Arts
Office-based Cosmetic Treatments