Cosmetic Chemical Peel Flashcards
A patient with facial hyperkinesia comes to the office for treatment with botulinum toxin type A for temporary improvement in the appearance of moderate to severe glabellar facial lines. How many units of botulinum toxin type A should be administered to this patient, according to the Food and Drug Administration?
A) 1 B) 10 C) 20 D) 50 E) 100
The correct response is Option C.
Two phase 3 randomized, multi-center, double-blind, placebo-controlled studies of identical design were conducted to evaluate botulinum toxin type A prior to FDA approval. The injection volume was 0.1 mL/injection site, for a dose/injection site in the active treatment groups of 4 units. Subjects were injected intramuscularly in five sites—1 in the procerus muscle and 2 in each corrugator supercilii muscle—for a total dose in the active treatment groups of 20 units.
Botulinum toxin type A blocks neuomuscular transmission by binding to acceptor sites on motor nerve terminals, entering the nerve terminals, and inhibiting the release of acetylcholine. One unit corresponds to the calculated median intraperitoneal lethal dose (LD50) in mice. Each vial of botulinum toxin type A contains either 100 units of Clostridium botulinum type A neurotoxin complex, 0.5 mg of albumin (human), and 0.9 mg of sodium chloride, or 50 units of C. botulinum type A neurotoxin complex, 0.25 mg of albumin (human), and 0.45 mg of sodium chloride in a sterile, vacuum-dried form without a preservative.
2017
A 52-year-old woman comes to the office to receive botulinum toxin type A injections to the corrugator and procerus. She returns to the office 1 week later because she is upset that her eyelids on both sides are droopy. Physical examination shows bilateral ptosis. Which of the following is the most appropriate treatment to improve this patient’s condition until the effects of the botulinum toxin type A subside?
A) Apraclonidine
B) Artificial tears
C) Botulinum toxin type A to the lateral orbicularis oculi
D) Ophthalmic tobramycin and dexamethasone
E) Tetracaine
The correct response is Option A.
This patient has developed true eyelid ptosis from her botulinum toxin type A treatments coming into contact and affecting the levator palpebrae superioris muscle within the eyelid. Although the effects of botulinum toxin type A on any muscle are irreversible with medications, attempts to lessen the severity of the ptosis have been made with the use of eyedrops to stimulate the Müller muscle, which is located deep to the levator.
Apraclonidine is an alpha-adrenergic agonist and as such stimulates the Müller muscle to contract. This contraction may elevate the eyelid 1 to 3 mm and lessen the amount of ptosis to varying degrees in order to make the overall appearance of the eyelids more tolerable to the patient until the effects of botulinum toxin type A wear off on their own and levator function naturally returns. The most common dose of apraclonidine is 1 to 2 drops three times daily until ptosis resolves.
Tetracaine is a commonly used numbing agent for the corneal surface that enhances the comfort of using corneal protectors for periorbital surgery.
Tobradex eyedrops are a combination of tobramycin and dexamethasone used for treatment of infection and/or its anti-inflammatory effect in the periorbital region. It has no effect on eyelid ptosis.
Artificial tears are lubricating drops and have no effect on muscular action.
2017
Accidental injection of hyaluronic acid filler into which of the following areas is most likely to cause blindness by retrograde occlusion of the central retinal artery?
A) Cheek B) Geniomandibular groove C) Lateral lip commissure D) Nasal dorsum E) Nasolabial fold
The correct response is Option D.
The dorsal nasal artery is a distal continuation of the ophthalmic artery from the internal carotid artery. During nasal dorsum augmentation, accidental injection of filler into this artery under pressure can push the filler retrograde into the ophthalmic artery. When the pressure is returned to normal, the filler then can flow distally occluding the retinal artery and causing blindness.
Intravascular injection of fillers into the angular artery of the nasolabial line can also cause blindness, although this would more commonly result in skin mottling and necrosis of the nasal tip skin.
The cheek area overlying the malar bone, with few deep vessels, is a relatively safe place for injectables.
Intravascular injection of the geniomandibular groove and lateral lip commissure is more commonly associated with vascular compromise of the lips and chin.
2017
A 50-year-old woman receives an injection of 0.5 mL of hyaluronic acid filler into each nasolabial fold. She returns to the office 30 minutes later because of pain and mottled skin discoloration of the nasal tip and right ala nasi. Which of the following is the most appropriate next step in management?
A) Doppler ultrasonography B) Hyaluronidase injection C) Lidocaine injection D) Massage E) Prostaglandin E1 injection
The correct response is Option B.
This patient presents with signs and symptoms consistent with an intra-arterial injection of hyaluronic acid (HA), which requires emergency treatment to restore circulation.
Accidental intra-arterial injection of fillers leading to arterial compromise is a rare occurrence. When it occurs, devastating outcomes include blindness, stroke, skin necrosis, and permanent scarring. The presenting signs and symptoms may include pain, skin blanching, mottled skin discoloration, and slow capillary refill. The mainstay of treatment for intra-arterial injection of HA products is local injection of hyaluronidase into the site of injection and the local area of skin mottling. Hyaluronidase is an enzyme that catalyzes HA hydrolysis.
Other treatments include massaging the area in order to promote distribution of hyaluronidase, topical nitropaste, aspirin, and warm compresses. Secondary treatments that can be considered after hyaluronidase injection include hyperbaric oxygen, papavarin, prostaglandin E1, heparin, and lidocaine. Radiologic evaluation with Magnetic resonance angiogram (MRA) or Doppler ultrasound would only delay treatment. Massage alone will not benefit this patient.
Recommendations for risk reduction include the following: using large-bore blunt cannulas (27 gauge and larger), injecting less than 0.1-mL bolus in any single injection site, avoiding high-pressure injections, awareness of likely position of named vessels in the treatment area, using local anesthesia with epinephrine, and caution with deep injections around the radix, lateral nasal wall, and periorbital area.
2017
Which of the following is the most common histologic effect of skin treatment with tretinoin?
A) Decrease in angiogenesis B) Decrease in mucin C) Increase in collagen D) Increase in melanin E) Thinning of the epidermis
The correct response is Option C.
Retinoids pass through the cell wall via nonreceptor-mediated endocytosis, are carried to the nucleus on cellular retinoic acid-binding proteins (CRABP, CRABP-II), and exert their effect through binding to retinoic acid receptors and retinoid X receptors. The retinoid-receptor complex binds to the promoter gene in the region of the retinoid response elements, resulting in production of proteins responsible for effects we see histologically and grossly.
In sun-damaged skin, the major findings histologically are reduced collagen quantity and dermal collagen disorder. Retinoids have come to be a mainstay in the treatment of photodamaged skin due to their ability to repair this damage. The effects noted histologically of retinoids on photodamaged skin include increased quantity of collagen (types I, III, and VII), greater organization of the collagen within the dermis, improved organization of elastic tissue, epidermal hyperplasia, increased mucin deposition (epidermal and dermal), and decreased melanin, among others. These histologic changes translate into improvement in rhytides, smoother skin, and correction of dyschromia.
Thinning of the epidermis is incorrect because retinoids result in epidermal hyperplasia.
Decrease in mucin deposition is incorrect because retinoids result in increased mucin deposition.
Decrease in angiogenesis is incorrect because retinoids result in increased angiogenesis in the skin.
Increase in melanin is incorrect because retinoids result in a decrease in melanin content of the skin.
2017
A 45-year-old woman comes to the office because of deep rhytides caused by photoaging. Topical application of 35% trichloroacetic acid in combination with Jessner solution is planned. Which of the following best describes the clinical endpoint during application of this chemical peel?
A) Dark firm eschar B) Grey hue C) Hypopigmentation D) Transparent frost with a pink background E) Uniform deep white frost
The correct response is Option E.
The deep white frost indicates the endpoint for the depth of skin penetration with a deep rhytid chemical peel such as the combination Jessner/35% trichloroacetic acid solution. This indicates that the peel has penetrated into the upper reticular dermis. There is no pink hue because at this level there is vasospasm of the capillaries in the papillary dermis. This depth of penetration is for moderate and deep rhytides. This is a transient phenomenon. Capillary refill should return within 20 to 40 minutes.
A transparent frost with a pink background is the endpoint for a superficial peel, such as that done with a trichloroacetic solution (<30%) alone. This frost is due to the coagulation of proteins in the dermis and epidermis. The pink hue emanates from blood vessels that remain intact in the papillary dermis.
A grey hue indicates a deeper penetration with destruction to the dermis. This level of penetration could lead to abnormal healing, scarring, pigmentation, and texturing changes. Hypopigmentation and superficial epidermolysis are potential complications of a chemical peel and not clinical endpoints to determine depth of penetration.
2017
Which of the following best describes the mechanism of inhibition of muscle contraction by botulinum toxin type A?
A) Binds to acetylcholine in presynaptic nerves, degrading acetylcholine
B) Binds to acetylcholine in postsynaptic nerves, degrading acetylcholine
C) Binds to acetylcholine in postsynaptic nerves, preventing acetylcholine interaction with nicotinic receptors
D) Binds to nicotinic receptor sites on the neuromuscular junction, blocking acetylcholine stimulation
E) Binds to receptor sites in presynaptic nerve terminals, blocking acetycholine release
The correct response is Option E.
Botulinum toxin type A works by binding to receptor sites in presynaptic nerves to prevent the release of acetylcholine into the synapse of neuromuscular junctions.
2017
A 52-year-old woman seeks treatment for signs of facial aging. She reports diffuse fine rhytides caused by a long history of sun exposure and smoking. Which of the following is most likely to result in the greatest long-term increase in dermal collagen content?
A) Deep-plane rhytidectomy B) Fat grafting C) Hyaluronic acid filler injection D) Tretinoin therapy E) Trichloroacetic acid peel
The correct response is Option D.
While all of the listed treatments are effective and employed commonly for facial aging, only tretinoin (Retin-A) has been found to have effectiveness in long-term collagen production. Retinoids are vitamin A derivatives that have profound effects on the skin. Both increases in dermal collagen production and decreases in degradation are seen over 6 to 12 months of treatment. The active form is tretinoin, a metabolite of vitamin A. Within 3 months of starting treatment, improvements in skin softness, texture, and reductions in fine rhytides and dyschromia are apparent. Treatment is typically a 0.05 to 0.01% topical cream applied nightly. Peeling and redness are common, but treatment tolerance improves with time. Early treatment reactions can be treated with decreased product concentration, longer treatment intervals, and topical hydrocortisones.
Fat grafting is a very effective volume replacement and deeper rhytides treatment. While there are some suggestions of increased vascularity and health of overlying skin, effects are secondary and not as profound as tretinoin.
Rhytidectomy (facelifting) results in physical skin tightening by removal, along with deeper tissue (SMAS) repositioning. Skin texture and collagen effects are relatively minor.
Hyaluronic acid fillers are also effective rhytide and volume treatments, but have little or no effect on collagen.
TCA peels effectively treat the epidermis and superficial dermis and have minor collagen stimulation effects through the natural wound-healing process. While surface appearance effects can be dramatic, the amount of collagen stimulation is far less than tretinoin.
Laser resurfacing can result in more dermal injury and resultant collagen production than chemical peels, although hypopigmentation and prolonged recovery are disadvantages. Pre-treatment with tretinoin prior to peels and laser resurfacing can increase the depth of treatment and, some hypothesize, improvements in healing and recovery time.
2016
A 38-year-old woman seeks cosmetic enhancement of the nasolabial area to decrease deep folds. She has had good results from injection of hyaluronic acid–based soft-tissue fillers in the past but now desires a longer lasting result. Calcium hydroxylapatite is chosen based on this request. On follow-up examination 2 weeks later, white nodules are noted along the nasolabial folds. Which of the following is the LEAST effective treatment option to address the white nodules?
A) Direct excision of the filler
B) Injection of a corticosteroid
C) Massage of the folds
D) Needle disruption and unroofing of the lumps
The correct response is Option B.
Calcium hydroxylapatite is a semipermanent material that can be injected as a soft-tissue filler and lasts 1 to 2 years, which is longer than the 4 to 12 months that hyaluronic acid-based fillers last. Safe injection of this material includes prevention of overcorrection, prevention of clumping of filler due to bolus injections, injection in a subdermal plane, and postinjection massage. If nodules form (which usually occur in areas of thin soft-tissue coverage such as the eyelids, lips, and nasolabial region), there are multiple described effective treatments, which include direct excision, observation to allow for the product to resorb, and needle disruption and unroofing. However, whereas lumps caused by poly-L-lactic acid or polymethyl methacrylate respond well to intralesional steroids, these are not as effective in treating lumps caused by calcium hydroxylapatite.
2016
A 23-year-old man is evaluated 1 day after undergoing a chemical peel to the face, entire back, arms, forearms, and hands, in a nonmedical setting. The patient reports nausea, disorientation, and ringing of the ears. Which of the following chemical peels was most likely used on this patient?
A) Glycolic acid B) Resorcinol C) Salicylic acid D) Solid carbon dioxide slush E) Trichloroacetic acid
The correct response is Option C.
This patient is presenting with symptoms of salicylism or salicylic acid toxicity, a rare side effect of salicylic acid peels. Symptoms can include: rapid breathing, tinnitus, hearing loss, dizziness, abdominal cramps and central nervous system reactions. It is more likely to occur when large surface areas are peeled. It has been reported with 20% salicylic acid applied to 50% of the body surface, and lesser areas when stronger concentrations are used. Therefore, care should be taken when treating skin conditions that cover large surface areas, such as acne or psoriasis, with this peel. In general, however, salicylic acid peels are safe when used in more modestly sized areas (less than 20% TBSA) and have minimal complications. They can be used in darker skin types (IV-VI) successfully.
Salicylism has also been reported when large areas are peeled with Jessner’s solution.
The other listed peels do not exhibit this type of toxic reaction.
2016
An otherwise healthy 46-year-old woman undergoes botulinum toxin type A (Botox) treatment for severe glabellar lines. Twelve units of Botox is administered into each corrugator muscle. Eight days later, the patient comes to the office because of ptosis of the right eyelid. Which of the following muscles is most likely inadvertently affected in this patient?
A) Frontalis B) Levator palpebrae superioris C) Müller muscle D) Orbicular muscle of the eye E) Procerus
The correct response is Option B.
Ptosis following botulinum toxin type A (Botox) treatment to the glabellar area is most commonly associated with inadvertent exposure of the levator palpebrae superioris muscle to Botox. This muscle is the primary upper eyelid elevator and is innervated by the third cranial nerve. The muscle portion arises from the greater wing of the sphenoid and is typically 40 mm long. The tendinous distal portion is 14 to 20 mm long and is termed the levator aponeurosis. The transition from the muscular to the tendinous portion occurs in the region of Whitnall’s ligament, a condensation of the superior sheath of the levator muscle.
Ptosis from Botox treatments most commonly occurs when the Botox spreads outside the intended target muscle. This is most commonly a technical error on the part of the injector by not staying high enough within the corrugator muscle and above the orbital rim. Ptosis from Botox injections cannot be reversed; however, the condition does completely resolve when the Botox effect wears off after several (3 to 4) months. Interval treatment to help improve, but not definitively treat, the ptosis consists of alpha-adrenergic eyedrops such as Iodipine or phenylephrine ophthalmic preparations, which cause stimulation of Müller’s muscle to help improve the condition somewhat, but do not adequately resolve the ptosis. Müller’s muscle is an accessory eyelid elevator and lies deep to the levator. It is innervated by the sympathetic nervous system. Contraction of this muscle (such as with pharmacologic stimulation) contributes about 2 mm to lid retraction.
2016
An otherwise healthy 54-year-old woman with Fitzpatrick Type II skin undergoes full-face carbon dioxide laser resurfacing. She received acyclovir for 3 days before the procedure. She is treated with a closed dressing regimen. On postoperative day 2, the patient has onset of facial pain and pruritus. Physical examination shows marked diffuse erythema and edema. Which of the following is the most likely diagnosis?
A) Allergic reaction B) Bacterial infection C) Fungal infection D) Herpes simplex virus E) Normal healing
The correct response is Option E.
Resurfacing causes complete ablation of the epidermis and superficial papillary dermis with thermal injury and coagulation through the papillary dermis. Wound healing occurs by re-epithelialization from the dermal appendages (hair follicles and sebaceous glands) and is complete within 7 to 10 days. The thermally damaged dermal layers are repaired by the stimulation of fibroblasts. This coagulated tissue is replaced by new bundles of tight collagen, a process that continues for up to 6 months. Thus, the result tends to improve over time.
During the initial period of healing and during the re-epithelialization, there is considerable edema and exudation of proteinaceous material, resulting in redness and crusting. Erythema is most intense during the first month after treatment but may persist for 6 months or more.
In addition to intense erythema, other expected adverse effects occurring in virtually all patients during the first postoperative week include marked edema, pain, and pruritus.
Allergic reactions, or contact dermatitis, occur most often in open postoperative dressing regimens where the patient has used topical products that contain irritants. Signs and symptoms suggestive of an allergic contact dermatitis include diffuse and intense facial erythema and/or pruritus.
Bacterial and fungal infections are often the result of prolonged (greater than 48 hours) wound occlusion in the postoperative period. Although the risk of bacterial infection is increased in the closed technique compared with the open, in this case, the dressing was changed at day 1 and it is therefore unlikely. Additional findings on examination suggestive of infection include lesions with skin invasion, focal areas of increased erythema, discoloration, purulent rather than serous discharge, and ulceration. The patient described did not exhibit any of these findings. The most common bacterial pathogen is Staphylococcus aureus, and the most common fungal pathogen is Candida.
Despite adequate antiviral prophylaxis, 2 to 7% of laser-treated patients have been shown to develop herpes simplex virus reactivation. An outbreak on laser-treated skin may have symptoms such as superficial erosions and irregular redness. These findings are not present in this case.
2016
A 15-year-old boy is evaluated for clusters of open and closed comedones on his forehead, cheeks, and chin. Physical examination shows similar lesions on the upper chest and back. Which of the following is the mechanism of retinoic acid in the treatment of pustular acne?
A) Atrophy of pilosebaceous glands
B) Decreased cohesiveness of keratinocytes
C) Disruption of cell walls and denaturation of proteins
D) Interference with DNA synthesis
E) Suppression of metabolic processes of melanocytes
Please note: Upon further review, this item was not scored as part of the examination.
The correct response is Option B.
In addition to treatment of acne and associated skin conditions, topical retinoids are also commonly used as a method of nonsurgical facial rejuvenation. Topical retinoids act by decreasing corneocyte adhesion in the stratum corneum, resulting in reduced follicular occlusion and comedone formation. In addition to acne treatments, topical retinoids also improve fine rhytides, correct mild hyperpigmentation changes, and create smoother skin.
Phenol chemical peels are used to improve rhytides and pigment changes in the aging face. They penetrate to the upper layer of reticular dermis and act by disrupting cell walls and denaturing proteins.
Hydroquinone causes reversible depigmentation of the skin and is also used in nonsurgical facial rejuvenation. It works by suppressing metabolic processes of the melanocyte, specifically the inhibition of the oxidation of tyrosine to 3,4-dihydroxyphenylalanine (DOPA). The depigmentation effect is reversible; if a patient stops using hydroquinone, the pigmentation changes will return.
5-Fluorouracil acts by interfering with DNA synthesis by blocking the methylation of deoxyuridylic acid. It is used in the treatment of cutaneous malignancy and is not used in the treatment of pustular acne.
Systemic isotretinoin remains the most effective and aggressive drug for severe cystic acne. It functions by causing atrophy of the pilosebaceous gland and attenuating the secretion of sebum. Isotretinoin is not used for cosmetic purposes. In fact, the reduced activity of the sebaceous glands predisposes patients to hypertrophic scarring, and any skin resurfacing procedure (chemical peel, carbon dioxide laser) is contraindicated in patients who have been on systemic retinoid therapy within 6 months to 1 year.
2016
A 38-year-old woman receives an injection of hyaluronic acid gel fillers to improve the appearance of her nasolabial folds. The evening after she received the injection, the patient calls the answering service and reports to the surgeon that, several hours after the injection, she developed skin “irritation” on the left side of the nose with skin discoloration, swelling, and numbness. Which of the following is the most appropriate next step in management?
A) Evaluate the patient in person
B) Initiate treatment with an oral antihistamine
C) Initiate treatment with an oral benzodiazepine
D) Tell the patient to immediately apply ice
E) Reassurance
The correct response is Option A.
The most severe and feared early occurring complication of soft-tissue filler agents is tissue necrosis, caused by interruption of the vascular supply to the area by either direct injury of the vessel, compression of the area around the vessel, or obstruction of the vessel by the filler material. It is a rare event, and although more commonly reported in the glabellar region, it has been reported following injection of the nasolabial fold area with hyaluronic acid gel and calcium hydroxylapatite (Radiesse) filler products, causing alar necrosis.
Treatment options for impending necrosis are based on those recommended for the treatment of the glabella and remain anecdotal. Typically, if noted immediately, injections are halted, warm compresses are applied, and nitroglycerin paste is used for local vasodilatation. Immediate use of hyaluronidase to the injection site is also recommended. The use of hyperbaric oxygen is controversial.
Recognition of the possible problem is essential, so that early intervention can minimize tissue necrosis and subsequent deformity. Ice would potentially worsen the already compromised blood flow to the area and is not recommended. Benzodiazepines and antihistamines do not treat the underlying problem, which is tissue ischemia.
2015
A 36-year-old woman with Fitzpatrick Type II skin is evaluated because of melasma that is refractory to hydroquinone therapy. A biopsy is performed, and examination of the specimen confirms the diagnosis of mixed melasma extending to the upper reticular dermis. Administration of which of the following is most appropriate to treat this area?
A) Glycolic acid 50 to 70% B) Jessner solution C) Salicylic acid 20 to 30% D) Tretinoin E) Trichloroacetic acid 35 to 50%
The correct response is Option E.
Chemical peeling causes controlled destruction of parts of the epidermis and/or dermis, followed by regeneration of new dermal and epidermal tissues. In a controlled manner, a chemical peel induces injury at a specific depth of the skin. Peels are categorized as superficial, medium depth, or deep, depending on the level of injury. Superficial peels cause necrosis of the epidermis only. Medium-depth peels create a wound through the epidermis into the level of the upper reticular dermis. Deep peels penetrate to the mid reticular dermis.
Salicylic acid 20 to 30% would cause injury to the stratum corneum and possibly the stratum granulosum with exfoliation. The depth is less than 100 µm, which is classified as superficial-very light. Both glycolic acid 50 to 70% and the Jessner solution penetrate to a depth of 100 µm, which is considered superficial-light. These agents cause necrosis of the entire epidermis down to the basal layer and stimulate regeneration of new epithelium. A medium-depth peel extends 200 µm, penetrates through the epidermis and papillary dermis to the upper reticular dermis, and results in increased collagen production. Trichloroacetic acid solution 35 to 50% would penetrate to medium-depth. A deep peel penetrates to deeper than 400 µm and causes necrosis to part or all of the mid reticular dermis.
Careful preprocedure evaluation is imperative in choosing the appropriate peel for each patient. Fitzpatrick skin type must be assessed to determine the risk of post-peel complications. If a patient has had a recent medium or deep peel within the past 3 months, facial surgery with extensive undermining or isotretinoin therapy within the past 6 months, or a history of keloid scarring, then care must be taken when selecting medium-depth or deep peels because the risk of hyperpigmentation and/or permanent scarring is increased.
Patients with mixed and dermal melasma are often difficult to treat because of the deeper pigment. A test spot is helpful in determining the patient’s tolerance for the peel when there is concern about the potential adverse effects.
Tretinoin 0.01% causes increased turnover of follicular epithelial cells and helps prevent collagen loss. It is not indicated for melasma.
2015
Treatment with poly-L-lactic acid (Sculptra) is most likely to correct the soft-tissue facial deformity associated with which of the following conditions?
A) Discoid lupus
B) Progressive hemifacial atrophy
C) Scleroderma
D) Secondary effects of HIV treatment
The correct response is Option D.
Poly-L-lactic acid, marketed as Sculptra, has been utilized for the treatment of HIV retroviral drug–related lipoatrophy since 1999. The images shown illustrate such a patient.
Since its initial use, the indications for utilization have broadened and include most etiologies of lipoatrophy with its second most common use for age-related changes. In patients with age-related facial changes, it has been useful for mid face rejuvenation and temporal hollowing. Similar to age-related changes is weight loss that, when mild, will also respond to poly-L-lactic acid but when severe, will require a rhytidectomy. Lipoatrophy secondary to discoid lupus has been reported to respond best to fat grafting. The least likely to respond to poly-L-lactic acid is progressive hemifacial atrophy due to the severity of the soft-tissue deformity and will usually require soft-tissue augmentation with a free flap in severe cases and fat grafting in mild cases.
2014
A 67-year-old woman with Fitzpatrick Type I skin comes to the office because of deep rhytides and signs of photoaging. Which of the following chemical peels will penetrate to the reticular dermis?
A) Alpha-hydroxy acid B) Beta-hydroxy acid C) Jessner solution D) Phenol-croton oil E) 20% Trichloroacetic acid
The correct response is Option D.
Croton oil is mixed with phenol to create a deeper peel. These are part of the ingredients in the Baker-Gordon and Hetter solutions. Hetter’s studies demonstrated that it was the croton oil that controlled the depth of the peel. The deeper the chemical peel, the greater the risk of scarring and hyperpigmentation. Because of this increased risk of hyperpigmentation, deep chemical peels are best suited for patients that have Fitzpatrick Type I skin.
Chemical peels vary in their depth of penetration into the dermis. Superficial peels penetrate to the epidermis. Alpha-hydroxyl acids (glycolic and lactic acid) and beta-hydroxy acid peels (salicylic acid) are superficial peeling agents. Jessner solution (14 g resorcinol, 14 g salicylic acid, 14 mL of lactic acid, and 100 mL of 95% ethanol) is also a superficial peel that can be used in conjunction with a trichloroacetic acid peel to achieve a deeper and more uniform peel. Superficial peels affect the epidermis and dermal-epidermal interface. Twenty percent trichloroacetic acid is a medium-depth peel that penetrates into the papillary dermis.
2014
Which of the following is the only cosmetic indication for which onabotulinumtoxinA (Botox Cosmetic) and abobotulinumtoxinA (Dysport) have been approved by the US Food and Drug Administration?
A) Cervical dystonia
B) Forehead lines
C) Glabellar lines
D) Vertical lip creases
The correct response is Option C.
The only FDA-approved cosmetic indication for the use of onabotulinumtoxinA and abobotulinumtoxinA is to temporarily improve the appearance of moderate to severe glabellar lines. Although these products are widely used to treat other cosmetic concerns, these are all considered off-label uses. To this point, there have been no definitive adverse event reports of distant spread of botulinum toxin products when used at appropriate doses for dermatologic indications. There have been reports of adverse events in doses used for dystonia, especially in children.
RimabotulinumtoxinB is only approved for treating cervical dystonia. On November 22, 2011, the FDA released a report renaming botulinum toxin type A and botulinum toxin type B to ensure their safe use (see table). Some of the reasons were to emphasize the differences in dosing and indications, and that these products are not interchangeable. The FDA recently approved application of Botox Cosmetic for smile lines related to activity of the lateral orbicularis oculi.
Summary of FDA-Approved Botulinum Toxin Products
Trade Name / Drug Name / Indication:
- Botox / OnabotulinumtoxinA / Botulinum
toxin type A / Cervical dystonia, Severe primary axillary hyperhidrosis, Strabismus,
Blepharospasm
- Botox Cosmetic / OnabotulinumtoxinA / Botulinum toxin type A / Temporary improvement in the appearance of moderate to severe glabellar lines
- Dysport / AbobotulinumtoxinA / Botulinum
toxin type A / Cervical dystonia, Temporary
improvement in the appearance of
moderate to severe glabellar lines
- Myobloc / RimabotulinumtoxinB / Botulinum
toxin type B / Cervical dystonia
- The marketed trade names and the product formulations have not changed.
2014
A 51-year-old woman comes to the office because of unilateral swelling of the breast 1 year after subglandular silicone augmentation mammaplasty. The patient says she has not had any recent trauma, fever, or myalgia. Physical examination shows a periprosthetic fluid collection. No erythema or edema is noted. Which of the following is the most appropriate next step in management?
A) Needle aspiration, Gram staining, and culture
B) Oral administration of antibiotics and complete blood count
C) Reduction of activity and use of a support brassiere
D) Ultrasound-directed aspiration and cytology
The correct response is Option D.
The most important diagnosis that needs to be ruled out is anaplastic large T-cell lymphoma (ALCL). This is a rare (one per million) non-Hodgkin lymphoma that has been reported in women with and without breast implants. However, increasing case reports suggest an association with breast implants, although direct causation has not been established. In ALCL associated with breast implants, malignant cells infiltrate the periprosthetic capsule or the periprosthetic fluid collection. The criteria for diagnosis include malignant cytology, strong CD30 expression, and cytokeratin negativity. Therefore, ultrasound-directed aspiration and cytology is most appropriate.
Reduction of activity, wearing a support brassiere, and follow-up in 2 weeks would be appropriate for perioperative tissue edema but is not appropriate treatment for late seromas.
Needle aspiration with Gram staining and culture risks injury to the implant and would not give the cytology necessary to determine if ALCL were present.
Oral administration of antibiotics and complete blood count would not be warranted in this situation where infection is unlikely by history and physical examination.
Ultrasound-directed aspiration and drain placement alone would not give the cytology necessary to determine if ALCL were present.
2014
A 40-year-old woman comes to the office because of fine rhytides and skin discoloration caused by photoaging. Topical application of 0.025% tretinoin is planned. Which of the following best describes the mechanism of action of topical retinoid therapy?
A) Decreased activation of skin appendages resulting in thinning of the stratum corneum
B) Decreased corneocyte cohesion resulting in increased desquamation
C) Increased free radical scavenging activity and synthesis of Types I and III collagen
D) Inhibition of AP-1 transcription factor binding to DNA resulting in diminished protease activity
E) Inhibition of tyrosinase resulting in diminished conversion of dopamine to melanin
The correct response is Option D.
Tretinoin (all-trans-retinoic acid; Retin-A) is one of the best long-term topical therapies available for chronically photoaged skin. The mechanism of action of retinoids is regulated through specific nuclear receptors. Ultraviolet (UV) radiation activates a series of phosphokinases that stimulate c-Fos and c-Jun proto-oncogenes and thereby activate AP-1 transcription factor. AP-1 causes activation of metalloproteases such as collagenase, gelatinase, and stromelysin, which then break down collagen. Tretinoin results in a 70% inhibition of AP-1 transcription factor binding to DNA and a significant reduction in protease activity.
Long-term use of tretinoin is associated with improved skin texture, decreased sallowness, a reduction in fine rhytides and actinic keratosis, fading of pigmented macules, and an overall improvement in skin appearance. Histologic effects of tretinoin include increased epidermal and granular layer thickness; elimination of dysplasia, atypia, and microscopic actinic keratoses; uniform dispersion of melanin granules; increased collagen and glycosaminoglycan deposition in the papillary dermis; and diminished dermal elastosis, angiogenesis, and compaction/thinning of the stratum corneum.
Tretinoin side effects include erythema, photosensitivity, and desquamation. Patients are initially started on a low dose with nightly application until tolerance is achieved. Because tretinoin is a photosensitizer, sunscreen use is absolutely imperative. Topical retinoids should be used for a minimum of 3 to 4 months, with the greatest improvement after 1 year of use. Patients who use alpha-hydroxy acids concomitantly with topical retinoids will see a synergistic effect, and this combination is tolerated well in most patients.
Isotretinoin (13-cis retinoic acid; Accutane) impairs sebaceous gland activity, impairs epithelialization, and thins the stratum corneum. Alpha-hydroxy acids cause desquamation as a result of diminished corneocyte cohesion just above the granular cell layer. Dermal effects of these acids include increased collagen and glycosaminoglycan production. UV radiation-stimulated oxygen free radicals are the primary mediators of UV skin damage.
Vitamin C has been shown to be the primary water-soluble nonenzymatic antioxidant that helps protect skin cells from UV radiation. Other functions of Vitamin C include increased Types I and III collagen production, decreased pigment synthesis, improved epidermal barrier function, and regeneration of oxidized Vitamin E.
Hydroquinone impairs the conversion of dopamine to melanin. The result is decreased formation of melanin and increased degradation of melanosomes.
2013
A 65-year-old woman comes to the office because of dysphagia and voice changes 3 days after undergoing injection of 50 units botulinum toxin type A because of platysmal banding. This patient’s condition is most likely caused by injection of botulinum toxin type A to which of the following anatomical locations?
A) Central fat pad below the thyroid cartilage
B) Cervicomental junction
C) Inferior border of the mandible at the angle
D) Pars facialis below the mandibular margin
The correct response is Option B.
In patients wishing to avoid platysmaplasty or surgical neck lift, platysmal bands can be softened with neuromodulators. The platysma is a very superficial muscle, and injecting neuromodulators too deeply may affect the strap muscles - causing dysphagia, or the cricothyroid muscle - causing voice changes. While injection into the pars facialis just below the mandibular margin is safe, the cervicomental junction is considered a danger zone because of the potential effect on deeper muscles involved in swallowing. Injection inferior to the thyroid cartilage and centrally would not effectively treat the banding but a superficial injection into the fat is unlikely to cause any muscular disturbance. Injection along the inferior border of the mandible at the angle may affect facial nerve function but would not cause dysphagia or voice change. Injection at the medial margin of the sternocleidomastoid is unlikely in the treatment of platysmal banding.
In a patient who presents with dysphagia or vocal changes after treatment of platysmal banding with neuromodulator, a reversible orally active anticholinesterase agent like pyridostigmine may be useful to counteract some of the effects until the agent wears off. Care must be taken to monitor for adverse side effects of anticholinesterase treatment, such as nausea, vomiting, diarrhea, and increased salivation.
2013
A 45-year-old woman comes to the office for consultation regarding smoothing of furrows between the eyebrows. Which of the following findings is a contraindication to abobotulinum toxin type A (Dysport) treatment in this patient?
A) Diabetes mellitus B) Ehlers-Danlos syndrome C) Gluten intolerance D) Lupus E) Milk allergy
The correct response is Option E.
Since the U.S. Food and Drug Administration approval and introduction of botulinum toxin type A in the 1990s, injectable cosmetic treatments have exponentially outnumbered cosmetic surgical treatments provided by plastic surgeons, and the prevalence of treatment continues to increase. Dysport is a product developed by Medicis (Scottsdale, AZ), which also has botulinum toxin as an active ingredient to reduce glabellar furrows. Dysport is contraindicated for individuals who have an allergy to cow’s milk protein.
2013
A 42-year-old woman comes for follow-up examination 1 day after undergoing injection of 0.8 mL of hyaluronic acid into the glabella. She has had severe pain since the procedure. Physical examination shows marked swelling and violaceous discoloration of the skin overlying the glabella. Massage and warm compresses produce minimal improvement. Which of the following is the most appropriate next step in management?
A) Antibiotic therapy B) Aspiration of injected material C) Conservative operative debridement D) Hyperbaric oxygen therapy E) Injection of hyaluronidase
The correct response is Option E.
Although the use of injectable soft-tissue fillers is relatively simple, it is not completely without risk. Patients should be consulted with respect to the possibility of the potential complications, and surgeons must be familiar with their incidence and treatment.
The patient in the scenario described has atypically severe pain, swelling, and discoloration 1 day after the procedure. While most patients will report some mild discomfort and bruising, these symptoms are usually not severe, and have usually begun to resolve within the first few days of the procedure. Severe persistent pain prompts further evaluation and potentially early intervention. The presence of persistent pain, swelling, and violaceous discoloration can be an indication of vascular compromise, which is most often seen after injection of the glabellar region. Direct arterial injection will result in immediate blanching in the distribution of the artery. Venous compression, on the other hand, results when too large a volume of filler is injected into a small area, resulting in venous congestion of the overlying skin.
Treatment of vascular compromise should be prompt and aggressive. If blanching is noticed on injection and an arterial occlusion is suspected, injection should be stopped and aspiration attempted. Patients with venous compromise usually have symptoms 1 or 2 days after the procedure, and aspiration at this point is rarely feasible. Massage and warm compresses should be initiated to disperse the contained material and vasodilate the compromised dermal vasculature. Nitroglycerin paste may also be helpful. Injection of hyaluronidase will further debulk the filler and is an important tool in the treatment of both early and late filler complications. If skin necrosis seems imminent, more aggressive measures, such as hyperbaric oxygen therapy, may be helpful. Once present, necrosis is treated with topical antibiotics and, potentially, surgical debridement.
Prevention of this complication is more likely to occur if the surgeon uses a smaller needle and the smallest possible volume of filler to correct the problem. Superficial injection should also be avoided. Patients should be informed of the potential complications of this procedure, and surgeons should be swift in the treatment of these problems when they arise.
2012
A hospital would like to run a marketing campaign for the use of botulinum toxin type A in the treatment of facial rhytides on behalf of the plastic surgery department. Which of the following areas of the face is most appropriate to address in this campaign?
A) Chin B) "Crow's feet" C) Forehead D) Glabella E) Jowls
The correct response is Option D.
Botulinum toxin type A is Food and Drug Administration-approved only for use in the glabellar area. While off-label uses of FDA-approved drugs, such as the use of botulinum toxin type A in the treatment of forehead rhytides and brow ptosis, is legal, only FDA-approved uses may be advertised.
2012
