Esthétique 1 (Fillers, Botox, Peels) Flashcards
Name some technical ways to decrease pain during filler injection?
- Small injection needle
- Slow fluid injection
- Cooling preparation
- Injection perpendicular to skin
- Vibration or flick movement
- Letting skin fall onto the needle
What are the main characteristics of HA?
- Stiffness (G1)
- Cohesivity
- Cross-linkage
- Viscosity
- Longevity
- Absorption
What are some signs of forehead aging?
- Concavity of lower third of forehead
- Increased forehead lines
- Flattening of the brow
- Flattening of the glabella
What are the characteristics of an attractive female brow?
- Starts medially at the orbital rim
- In line with medial canthus
- Slants upwards by 10-20 degrees
- Eyebrow peak = same distance from the head of the brow as the intercanthal distance
What is the safe placement of of filler in the temporal region
- Supraperiostrlal on bone using needle
- Subcutaenous using microcannula
What is the Tyndall effect?
“blue-ish” hue and skin irregularities (ie. Nodules) caused by too much injection of filler in the subdermal plane or in the superficial dermis
How do you manage Tyndall effect?
- Massages
- Hyaluronidase injection
What is the safest place to inject in the area of the nose?
Exactly midline and on periosteum/perichondrium
What causes jowling
Caused by descent of of fat and skin relative to the fixed pre-jowl sulcus.
Also partly cause by tissue deflation of adjacent zones such as prejowls sulcus, marionette sone and lateral oral commissure
Describe the features of a balanced lip
Distance between philtral coloms = height of lower lip
What are some acute complications of filler injection?
- Oedema
- Pain
- Ecchymosis
- Nerve damage
- Venous compromise
- Skin necrosis
- Blindness (retinal artery through the ophthalmic artery)
- Ophthalmoplegia
Which areas are most at risk for blindness?
- Nasal dorsum
- Glabella
What is the mechanism of action of hyaluronidase
Dissolves hyaluronic acid into small compound sugar molecules and water
What adjunct treatments to hyaluronidase can be used in the context of filler complications?
- Aspirin
- Warm compresses
- Light massage
- Hyperbaric oxygen
- Sildenafyl
- Nitropaste
What are the 3 different injection techniques for fillers
- Fanning (multiple passes in different direction without withdrawing the needle)
- Linear deposition
- Crosshatching (evenly spaced grip pattern)
What are the FDA approved uses of Botox
- Overactive bladder
- Incontinence
- Headaches in chronic migrane
- Muscle stiffness
- Muscular spasticity
- Cervical dystonia
- Stabismus/blepharospasms in 12yrs +
What are the FDA approved uses of botox for cosmetic uses
- Moderate to severe Glabella and crowfeet rhytid treatment
- Axillary hyperhydrosis if refractory to medical treatments
What is the mechanism of action of botox
- Inhibits the release of acetylcholine at the neuromuscular junction
- Blocks neurostimulation and muscular activity
- Causes muscle paralysis
What is the main difference between myobloc vs botox?
Myobloc has:
- shorter duration and quicker onset
- Greater radius of diffusion
- Higher pain with injection
- Type B toxin
What is the anatomic location of the procerus
Originated at the nasal bone and inserts into dermis of the glabella
What causes horizontal rhytids in the glabella region
contraction of the procerus
What rhytids is the frontalis responsible for
Horizontal rhytids ABOVE the brow
How do you differentiate between levator ptosis and frontalis ptosis?
Resolution of forehead rhytids
What causes vertical rhytids in the glabellar region
- corrugator supra-cilli
- orbucularis occuli
What are some muscle of the face commonly treated with botox
- Procerus
- Frontalis
- Corrugator
- Orbicularis occuli
- Nasalis
What is the FDA approve dose of botox for the glabellar region
20 units
How are botox units measured?
1 unit = calculated the lethal intra-peritoneal lethal dose in mice (LD50 in mice)
What is the safe zone for injection in the masseter
Below the the transverse line from the earlobe to the corner of the mouth
What medications that potentiate the effect of botox
- Penicillamines
- Quinines
- Calcium channel blockers
- Aminoglycosides
In which patients is dysport contraindicated
Patients with lactose allergy
What is the treatment of eyelid ptosis following botox injection
Alpha-adrenergic agonist drops - Phenylephrine (stimulate the muller muscle and improves by 1-3mm)
What are the main uses of HA
- Deep rhytids
- Restore volume
What the optimal depth of injection in the midface
Pre-periosteal
Where should you inject fillers in the tear trough area
Periostal injection (safe and higher longevity)
How can you reduce your risk of intravascular injection of fillers
- Large bore cannulas
- Less than 0.1cc per site
- Avoid high pressure injection
- Anesthesia with epi (constricts vessels)
- Good knowledge of anatomy
What are the treatment options for nodule formation following calcium hydroxyapatite injection
- Direct excision
- Observation
- Needle disruption
* Does not respond to steroids
What would be your filler of choice for HIV replated lipoatrophy
Poly-L-lactic acid
What is tretinoin
Vitamin A derivative
What are the main indications for using tretinoin and the recommended dose
- Improves rhytids (only superficial)
- Corrects dyschromia
- 0.05-0.01%
What are the effects of Vitamin A derivatives?
- Increase quantity of collagen I, III and VII
- Greater organization of collagen within the dermis
- Improved organization of elastic tissue
- Epidermal hyperplasia
- Increased mucin deposition
- Decreased melanin
- Decreased thickness of stratus corneum
What is the mechanism of retinoic acid in reducing acne
- Inhibition of AP1 transcription factors
- Reduces cornesa adhesions in the stratum corneum => reduced follicular occlusion and comedone formation
- Reduction of protease activity
What is the mechanism of action of systemic isotretinoin (acutane)
Atrophy of sebaceous glands throughout the body and attenuation of secretion of sebum
What are some clinical findings associated with what is salicylic acid toxicity
- Rapid breathing
- Tinitus
- Hearing loss
- Dizziness
- Abdominal cramps
- Central nervous system reactions
What is the mechanism for neutralization of TCA peels
Coagulates and denatures proteins as it penetrates the skin. Can be neutralized with saline. Metabolized in the body in the superficial dermis (can not go systemically)
What is the mechanism of action of Phenol croton oil
Protoplasmic toxin that disrupts cell walls and denatures protein
What are critical steps that must be taken when preforming phenol treatments
Cardiac monitoring
Resp monitoring
List the types of chemical peels (selon leur profondaeut)
Superficial
○ Alpha-hydroxy acid (glycolic and lactic acid)
○ Beta hydroxy (salacylic acid)
○ Jessner solution
Medium
○ TCA 20-35%
Deep
○ Jessner with TCA
○ Phenol
○ TCA over 35%
○ Phenol and croton oil
Décrire la technique générale d’un peel
- Dégraisser la peau 3-5min (acétone, alcohol isopropyl)
- Appliquer le produit (coton-tige, compresse)
- Onguent occlusif (aug profondeur d’action, prévient dessication)
contre-indications aux peel (absolues 4, relative 5)
Absolues
* isotretinoin dans les 6-12 derniers mois
* infection active
* plaie ouverte
* absence d’unités pilosébacée intacte sur le visage
Relatives
* Fitzpatrick 4-5-6
* Dermatite rétinoide active
* Chx visage récente (facelift++)
* Procédure de resurface dans les 3 derniers mois
* atcd de maladie cutanée (vitiligo, rosacée, psoriasis)
Describe the Fitzpatrick classification
I: white: always burns, never tans
II: white: usually burns, hard to tan
III: light brown: sometimes burns, tans average
IV: brown: rarely burns, tans easily
V: dark brown: almost never burns, tans very easily
VI: black: never burns, tans very easily
Describe the Glogau classification for photoaging
I: mild: 28-35: minimal wrinkles, no keratosis, no acne scarring (little makeup)
II: moderate: 35-50: early keratosis, early wrinkling, mild scaring (some makeup)
III: advanced: 50-65: actinic keratosis, telangiectasia, wrinkling at rest, moderate scaring (always makeup)
IV: severe: 60-70: actinic keratosis, skin cancers, severe wrinkling (makeup cakes on)
Describe the Obagi Grades of Frosting
1: atteinte derme papillaire, pink-white frost
2: derme réticulaire superficiel, dense white frost
3: derme mid-réticulaire, gray-white frost
What are some common complications of chemical peels
(acute and chronique)
Aigu
- Herpetic lesion outbreaks
- Brûlure
Chronique
- Hyperpigmentation
- Hypopigmentation (ne se résout pas après 6 mois)
- Cicatrice hypertrophique
4 éléments de safety concernant les peels
- vérifier la concentration des produit
- porter attention à tout ce qui touche le produit
- matériel prêt pour eye washing prn
- jamais passer le contenant par-dessus patient
What is the mechanism of action of ablative laser
- Complete ablation of epidermis and superficial papillary dermis
- Thermal injury and coagulation through papillary dermis
What are some common transient side effects of ablative laser therapy
- Oedema
- Exudation
- Crusting
- Redness
** these are not complications**
Name 2 fillers other than HA approved in Canada
- Poly-L-lactic acid (PLLA)
- Calcium-hydroxy-apatite
- Polymethylmetacrylate (PMMA)
Name 2 functional complications of injecting botox around the eye
Ptosis
Diplopia
Ectropion
10 Indications fonctionnelles du botox
- Migraines
- Blepharospasme
- Strabisme
- Spasme hemi-facial
- Bruxisme
- Tinnitus
- Dystonie cervicale
- Hyperhidrose
- Spasmes vessie, HBP
- Frey’s
- Rhinite allergique
6 complications des neuromodulateurs
-Réaction au site d’injection, ecchymose, douleur
-Céphalée
-Ptose des sourcil, asymétrie
-Acné
-Infection des voies respi
-dysphagie
3 antidotes pour les neuromodulateurs
- Apraclonidine
- Phenylephrine
- Pyridostigmine
*mais pas de vrai antidote?
3 causes de la non réponse au botox type A
génétiques
anticorps pré-formés
dose sous-thérapeutique
*essayer autre marque si jamais
Contre-indication au neuromodulateurs
-infection active
-allergie à un ingrédient (albumine pour les 3, lactose pour dysport)
-grossesse
Relatives : Maladie de la jonction neuromusculaire, médicaments qui diminue la transmission neuromusculaire (Succinylcholine, PNC, BCC, aminoglycosides, quinines)
9 caractéristiques d’un injectable idéal?
○ Sécuritaire et non toxique
○ Non allergène
○ Réversible
○ Disponible
○ Prédictible
○ Vieillis avec le patient
○ Downtime minimal
○ Non palpable
Facile à utiliser
4 avantages d’un filler synthétique
Pas de transmission
pas de donneur
disponible
permanence possible
4 inconvénient d’un filler synthétique
Risque de granulome
infections
migration du produit
déformations
nommer 2 fillers biodégradable
graisse (??)
HA
nommer 2 fillers semi-permanent
hydroxiapatithe de calcium
Acide poly-L-lactique (PLLA)
nommer 2 fillers permanent
PMMA
silicone
est-ce que l’hydroxiapatite de calcium et le PLLA forment une capsule?
HC: non
PLLA: oui
3 façons de réduire la formation de nodules avec le PLLA ?
injectant en profondeur
reconstituer avec plus de volume (>5ml)
reconstituer overnight (>2h)
5 éléments de prise en charge d’une occlusion artérielle
hyaluronisade
massage
nitropaste
aspirine
hyperbare
sildenafil, prostaglandines
quoi faire pour prévenir injection intra-artérielle
Cannules
petits bolus
injecter à basse pression
retirer avant d’injecter
connaitre son anatomie
occlure à leur origine
prise en charge d’un nodule suite à fillers
chaleur
massage
hyaluronidase (si HA)
excision chirurgicale
injection de cortico
Sclérothérapie
Différence entre une injection intra-artérielle et intra-veineux?
Artérielle : Blancheur, froideur, immediat
Veineux : Bluish hue, légèrement delayed
What is the pathophysiology of blindness?
Occlusion de l’artère ophtalmique qui occlue artère rétienne central
quel est le endpoint de la dermabrasion
saignement paprika
6 indications de microdermabrasion
photodamage
hyperpigmentation
rides superficielles
strech marks
cicatrice acnée
pores élargis
quelle couche de peau la microdermabrasion affecte?
stratum corneum
décrire les 3 éléments du pre conditionning pour un peel
Tretinoin (0.1%)
Acide glycolique (exfoliation)
Hydroquinone (bleeching)
faire 6-8 semaines avant
3 bénéfices de faire du pre conditionning pour un peel
- augmente l’effet du peeling
- diminue risque d’hyperpigmentation post traitement (hydroquinone)
- diminue l’inflmmation, accélère la guérison (tretinoid)
décrire la composition du Jessner’s peel
14g resorcinol
14g acide salicylique
14cc acide lactique
100cc ethanol 95%
nommer des indications de peel chimique
- élastose solaire
- rides superficielles
- Dyschromie
- Lentigo solaire
- KA
- Acnée rosacée
- mélasma
comment évaluer la dyschromie d’un patient
mettre pièce dans le noir
tenir Wood lamp à 8-12 pouces du visage
Plus la dyschromie est superficielle, pire sera l’alllure du patient sous la lampe de wood
Effets des peels chimiques sur l’épiderme et le derme?
Épiderme :
* augmente les mélanocytes
* reforme les rete ridge
* uniformise les cellules
Derme :
* organise le collagène
* augmente les fibroblasts
* augmente l’épaisseur du derme
décrire l’épaisseur de ‘‘l’atteinte’’ des différent peels
light: stratum corneum
medium: derme papillaire
profond: derme réticulaire
prophylaxie anti-herpétique pour medium et profond
2 avantages des peel profonds vs le TCA?
Moins d’hyperpigmentation
Moins de cicatrices hypertrophiques
compositions du Baker-Gordon peel
i. Savon
ii. H2O
iii. Huile de croton
iv. Phenol
complications des peel
-Hyper/hypopigmentation
-Brulures
-Erythème persistant
-Acné, milia
-Cicatrices hypertrophiques
-Infections : HSV
-Céphalées
-Systémique: artyhmie (Baker), rein (Baker), oedème laryngé (peel profond), hypothyroidie (Jessnes)
qu’est-ce que la cohésivité d’un filler
Cohésivité d’un filler HA est la force les liens qui tiennent une unité d’acide hyaluronique ensemble
quel est le endpoint de la dermabrasion
saignement paprika
quel est le endpoint de la microdermabrasion
début de l’érythème
dermabrasion: 5 éléments qui font varier la profondeur
pression utilisée
embout utilisé
temps de traitement
type de peau
vitesse de la machine
6 indications pour microdermabrasion
pores élargis
hyperpigmentation
strech marks
cicatrices d’acnées
rides superficielles
photodamage
downtime
saignement
profondeur
