Cosmetic

Question 1

Cosmetic Fillers

Answer 1

• Cosmetic Fillers - Uptodate 2021
  
  • Indications
    
    • HIV associated lipoatrophy
    • Scarring
      
      • Pitted atrophic scars
    • Facial asymmetry
      
      • Congenital
      • Developmenta
      • Acquired
    • Defects
      
      • Temporal hollowing
      • Surgical defects
        
        • Chest wall defect - Post Pec Major flap
  • Contraindications
    
    • Absolute
      
      • Allergic
      • Active infection
    • Relative
      
      • Pregnancy
      • Anticoagulants and Bleeding disorders
      • Immunosuppression
      • Multiple prior cosmetic procedures
  • Complications
    
    • Early (0 - 14 days)
      
      • PBBSI
      • Tyndall effect - Intraepithelial injection
      • Vascular compromise
        
        • Ischaemic necrosis
        • Blindness
          
          • Retrograde flow of filler causing embolism of Retinal artery
    • Late (14 days - 1 year)
      
      • Chronic infection
      • Inflammatory reaction
      • Nodules
      • Filler migration
    • Delayed (>1 year)
      
      • Granuloma
      • Filler migration
        ​
  • Surgical Technique
    
    • Pre-op
      
      • Anticoagulation
        
        • Cease for 1 week if possible
      • Prophylactic antivirals - Uptodate
        
        • Can reactivate latent HZV infection
        • Valacyclovir 1g peri-op
          500mg for 10 days post-op
    • Injection Techniques
      
      • 28 - 30G Needle
        Aspirate prior to injecting
        Aspiration in smaller needles are unreliable
      • Linear Threading
        
        • Needle is inserted and filler is injected upon withdraw
      • Fanning
        
        • Similar to Linear Threading but multiple passes of redirection with retrograde injections
      • Depot/Serial Puncture
        
        • Bolus of filler deposited at needle puncture site
      • Cross-hatching
        
        • Series of parallel linjear injections are performed followed by another series of linear injections perpendicular to the first set of injections
      • Permanant Filler Technique
        
        • Undercorrection is the goal to each treatment
        • Multiple treatments should be planned with subsequent treatments seperated by no less than 1 month
        • Optimal collagen formation is attained by approximately 12 weeks
    • Depth of injection
      
      • Deposition placed too superficially may result in palpable filler
        Deposition placed too deep may not provide the desired effect
      • Mid Dermis
        
        • Fine wrinkles
      • Sub Dermis
        
        • Deep wrinkles
      • Subcutaneous Layer
        
        • Deep wrinkles
      • Supra-periosteum

Question 2

Cosmetic Filler - Permanent Filler Agents

Answer 2

• Advantages v Disadvantages of Temp vs Permanant
  
  • Hyaluronic acid (Temp agent) - if placed incorrectly can be reversed with Hyaluronidase
    
    • Ischaemic compromise
    • Embolism - Retinal artery
  • Misplacement of permanant fillers surgical intervention that is difficult to impossible to remove
  • Permanant fillers - reduced cost of repeat procedures​
• Permanant Fillers
  
  • Technique
    
    • Undercorrection is the goal to each treatment
    • Multiple treatments should be planned with subsequent treatments seperated by no less than 1 month
    • Optimal collagen formation is attained by approximately 12 weeks
  • Autologous Fat
    
    • Main benefit is the lack of risk for hypersensitivity or foreign body reactions
    • PRF may be added to the mixture
    • Risks
      
      • Fat embolism is the most common out of permanant fillers
      • Heterocalcification of fat
  • PMMA - Polymethylmethacrylate microspheres
    
    • 30 - 50 micrometer microspheres
    • Typical mixture contains:
      
      • Bovine collagen
      • Lignocaine
    • Mechanism of action
      
      • Microspheres stimulate local inflammatory reaction
      • Deposition of granulation tissue in the first few weeks
      • New collagen slowly gets laid and surrounds the PMMA microspheres
    • Side effects
      
      • Not recommended for thin skin - Eyelids and lips
        Can cause lumpiness post injections
      • Must be tested for bovine collagen hypersensitivity prior
  • Hydrogels
    
    • Synthetic, Non-biodegradable, Hydrophilic gel with high degree of elasticity
    • Used for deep wrinkles - Not to be placed intra-dermally
    • Used most commonly for HIV associated lipoatrophy
    • Mechanism of action
      
      • Hydrogel induces a lcoal inflammation leading to fibrosis
      • Hyrodgel becomes encapsulated by a rim of collagen isolating it from host tissue
  • Silicone
    
    • Purified polydimethylsiloxane
    • Only filler approved for intraocular use
    • Mechanism of action
      
      • Silicone is similar to Hydrogels
      • Augmenting effect is due to its own volume and its role as a collagen inducer

Question 3

Cosmetic Filler - Temporary Filler Agent

Answer 3

• Advantages v Disadvantages of Temp vs Permanant
  
  • Hyaluronic acid (Temp agent) - if placed incorrectly can be reversed with Hyaluronidase
  • Ischaemic compromise
  • Embolism - Retinal artery
  • Misplacement of permanant fillers surgical intervention that is difficult to impossible to remove
  • Permanant fillers - reduced cost of repeat procedures​
    ​
• Hyaluronic Acid
  
  • Chemically altered through cross-linking to resist degradation in vivo.
    Uncrossed hyaluronic acid degrades within a few days
  • Typically lasts 6 - 12 months
  • Reversed by Hyaluronidase
  • Mechanism of action
    
    • Space filling is attributed to water molecules bound to Hyaluronic acid
      ​
• Collagen
  
  • Shorter effects compared to Hyaluronic acid
  • Allergy testing required pre-op
    
    • Bovine collagen
  • Collagen fillers are less common now with the advent of Hyaluronic acid
    ​
• Hydroxylapatite
  
  • Smooth hydroxylapatite
  • Mechanism of action
    
    • Carrier gel is gradually resorbed and remaining hydroxylapatite microspheres stimulate the local production of endogenous collagen

Question 4

Skin Peel - Chemical Peels

Indications and Classifications

Answer 4

• Chemical peel is a procedure using medication to induced controlled keratocoagulation and denaturation of the proteins within the epidermis and dermis
• Indications
  
  • ​Pre-malignant epidermal neoplasms
  • Acne and acneiform eruptions and scarring
  • Dyspigmentation
  • Rejuvenation of chronic photoageing
    ​
• Classification
  Laser peels have supplanted deep chemical peels because of thier improved control of ablative depth
  
  • ​Depth of Chemical Peel
    
    • Superficial / Exfoliation
      
      • Confined to the epidermis
    • Medium Depth / Light Peel
      
      • Into the papillary dermis
    • Deep Peel
      
      • Can be subdivided into
        
        • Upper reticular dermis / Medium Peel
        • Mid-reticular dermis / Deep Peel
      • Should be carried out in a surgical setting with at least sedation
  • Glogau Classification of Photoageing
    
    • I - Mild
      
      • 28 - 35 yrs old
      • No wrinkles
        Mild pigment changes
        ​No keratosis
    • II - Moderate
      
      • 35 - 50 yrs old
      • Wrinkles in motion
        Early brown spots
        Keratosis palpable but not visible
        Parallel smile lines begin to appear
    • III - Advanced
      
      • 50 - 65 yrs old
      • Wrinkles at rest
        Obvious discolourations
        Visible keratosis
    • IV - Severe
      
      • 60 - 75 yrs old
      • Only wrinkles
        Yellow-grey skin
        Skin malignancies present
        Wrinkles throughout
        ​
  • Frosting
    
    • Chemical peels leads to protein denaturation of keratin and collagen leading to a “white frost”
      This is an important clinical marker used to judge the depth of the chemical peel
    • Frosting clinical indicates penetration into the papillary dermis
    • Frost Level I
      
      • Erythema
      • Stringy or patchy light frosting
    • Frost Level II
      
      • Frosting appear uniform
      • White coated frosting with underlying erythema showing through
    • Frost Level III
      
      • Solid white enamel frosting with little to no background erythema

Question 5

Skin Peel - Chemical Peels - Technique and Complications

Answer 5

• Surgical Technique
  
  • Pre-op
    
    • Antibiotic Perioperatively
      
      • Bacterial superinfection increases with deeper peels
      • Mupirocin ointment is used for Medium and Deep peels post operatively
        
        • Deep peels - 14 days for epithelialization
    • Antiviral Prophylaxis
      
      • HSV reactivation
      • Antiretrovirals should be given if there is a history of HSV
      • Commenced 2 days pre-operatively
    • Antifungal
      
      • Candida superinfection - Associated with Deep peels
      • Not routinely prescribed but should be monitored and prescribed if there are any indications
    • Retinoic Acid (Tretinoin)
      
      • Topical Vit A metabolite cream
      • Decreases epidermal adhesions and thus thins the skin
        Allows deeper penetration of skin peels
  • Superficial Peels
    
    • Treat conditions confined to the epidermis
    • Minimal downtime and risk of complications as peel does not breach beyond epidermis
  • Medium Peels
    
    • Fine Rhytides
    • Chronic actinic photodamage
    • Superficial hyperpigmentary disorders - Melasma
    • Superficial acne scars
    • Actinic premalignant changes
  • Deep Peels
    
    • Fallen out of favour due to improvements in lasers
    • Associated with systemic toxicities of chemical agents
      ​
• Complications
  
  • PBBS
  • Infection
    
    • Reactivation of latent HSV
    • Bacterial superinfection - risk increased with deeper peels
    • Candida superinfection - risk increased with deeper peels
  • Systemic toxicity
    
    • Phenols - Arrhythmias
      
      • Requires cardiac monitoring
      • Used for deep peels
  • Scarring
    
    • Hypertrophic and Keloid
    • Ectropion
  • Hyperpigmentation

Question 6

Skin Peel - Laser Resurfacing

Answer 6

• Ablative Non-fractionated
• Ablative fractionated
• Non-ablative Non-fractionated
• Non-ablative fractionated
• Radiofrequency