Non-surgical facial Rejuvenation Flashcards

1
Q

What is dermabrasion/microdermabrasion, indications, contraindications, compx

A

Def: mechanical resurfacing with wire brush (dermaB) or AlOH NaCl crystals/diamond (microdermaB)

Indication: rhytids, tattoo, rhinophyma, scars, actinic keratosis, SK, syringoma

Contraindications: HTS/keloid, accutane in past yr, Fitz 5-6, absence of adnexal structres, HIV/Hep, poor wound healing

Procedure:

Endpt - paprika bleeding - all epidermis removed, superficial papillary dermis remains

Depth - controlled by operator (dermaB) or by flow rate (microdermaB)

Adv: predictable, cheaper, higher risk for hypopigment

Complx: scar, pigment changes, wound ehaling, milia, dermatitis,

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2
Q

What is a chemical peel and how is it classified

A

Def: application of a chemical exfoliant with destruction of epidermis and portion of dermis with resulting regeneration

Classified according to depth

  • Superficial - to epidermal/dermal jx - good for any Fitz
    • Jessners solution (benzene, Etoh, LA, SA)
    • AHA (alphahydroxyl acid) (glycolic)
    • Salicylic acid
    • Dry ice
  • Medium - to papillary dermis
    • TCA
  • Deep - to mid-reticular dermis
    • phenol - baker jordan
    • Phenol - Croton oil
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3
Q

What are indications and contraindications to chemical peels

A

Indications

  • rhytids
  • pigment - 2’to sundamage, pregnancy, melasma,
  • AK, solar keratoses/elastoses
  • Acne scarring, milia
  • Rosacea

Contraindications

  • medically unfit (heart/liver/lung) for phenols
  • loss of adnexal strucutres (previous burn, radiation, accutane over 2yrs)
  • poor wound healing (DM, immunosup, collagen abn)

* Not useful for stsg scar, vascular lesions, acne

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4
Q

What are complications fo chemical peels

A
  • Scar
  • pigmentary changes
  • pustulocystic acne
  • prolonged erythema
  • delayed wuond healing, burn
  • infection
  • Arrythmia
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5
Q

How do you evalute the patient and prep the patient prior to chemical peel

A

Evaluation

  • fitpatrick (1-3 best)
  • amnt of actinic damage-deeper peel
  • female thinner skin than male
  • nonoily skin results in more even peel

4-6 WEEKs prior to peel

  • Tretinoin 0.1% (retin-A)
    • apply to affected area daily
  • Hydroquinone bleaching cream 4%
    • decrease melanin formation to prevent hyperpigment post peel
  • Glycolic acid 8% daily
    • loosen desquamated skin and accelerate exfoliation
  • No smoking, no sun exposure
  • Stop prep 4days prior to peel
  • Start acyclovir 3days before + 7days after 800mg tid
  • Abx pre and 7days post
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6
Q

What factors affect the depth of penetration of the peel?

A
  • Skin
    • degreasing
    • thickness
    • prep prior to peel
    • cleansing
  • Chemical agent/peel
    • type
    • concentration
    • frequency
    • acid neutralization
    • method of application
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7
Q

List chemical peels

A
  • Phenol =carbolic acid
  • Superficial
    • Glycolic Acid - alpha-hydroxy acid
    • SA (more desquamation, minimal downtime)
    • Jessners - used to prep for TCA peel**
  • Medium peel
    • TCA
  • Croton oil
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8
Q

Describe the MOA of phenol peel, indications, depth determination, ideal patient, complx

A

Phenol = Carbolic acid - deep peel - to upper reticular dermis

Baker Jordan formua =phenol+water+soap+croton oil

  • MOA: keratocoagulant - the higher the %, the greater the coagulation and less deep of a peel. Form new collagen in Grenz zone
    • 88% phenol= medium peel
    • 48.5% Baker Gordan= deep peel
  • Ideal Fitz 1-3 with mod/deep rhytids and sundamage
  • Depth is determined by frost achieved in 10secs (Baker jordan). Can apply w vaseline for deeper. re-epi in 12days (BG) +erythema mths or 8days (phenol) erythema 6wks
  • epithelization is completed in 10-14d but erythema lasts months
  • Phenol is metabolized in liver & kidney - can be nephro/hepatotoxic
  • Compx: laryngeal edema in smokers, cardiotoxic.
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9
Q

Describe the MOA of TCA peel, indications, depth determination, ideal patient, complx

A
  • Medium depth peel - TCA - 10->50% with according depth range epidermis -> reticular dermis
  • MOA: coagulative necrosis with protein denaturation
    • 10-25% superficial
    • 35-50% medium
  • Ideal patient: Acne, pigmentation, mild rhytids, Fitz 1-3, may be 4
  • Ent pt - Depth determined by color - KERATOCOAGULANT
    • cloudy red - superficial
    • white frost - DE jx
    • Pure white frost - papillary dermis
    • yellow-grey - retic dermis
  • Pretreatment critical for consistent result - 6wks AHA/tretinoin(thins s. corneum and suppress melanocyte), hydroquinone, degreasing
  • Since depth detrmined by color - very operator dependant - diluted by water - cant be neutralized
  • Depth depends on prepeel prep, concentration, #glands, ski thickness, rigor of application

Most common compx :

  • hyperpigment
  • HTS
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10
Q

Describe the MOA of glycolic acid peel, indications, depth determination, ideal patient, complx

A

Superficial Peel - AHA Glycolic acid 50-70%

  • MOA: keratolytic (exfolliant)
  • Indications
    • melasma, acne, AK, rhytids, solar lentiges
  • Ideal pt; very mild rhytids, mild dyschromia, keratoses, acne, scars. ANY fitz
  • NO pain!!!
  • Depth - no frost (no denaturation)
  • Can be done q1wk, low downtime/cost
  • Difficult to keep even
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11
Q

Describe the MOA of croton oil, indications, depth determination, ideal patient, complx

A
  • From plant croton tiglium
  • contains phorbol which initiates free radial action on skin
  • concentration 0.05% eyelid - 0.4% forehead
  • Depth increased with more layers
  • End pt
    • pink and white frost = papillary dermis
    • solid opaque frost = reticular dermis
    • no neutraliznig agent
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12
Q

What are complications of chemical peels and management of the complication

A
  • Pigmentation
    • hypo - irreversible
    • hyper - hydroquinone, retin-A, steroid
  • photosensitivity
  • Wound healing
    • delayed - moist dressings, silicone sheet
    • scarring - silicone sheeting, steroids
    • prolonged erythema
  • Pustulocystic acne
  • Infection
    • HSV - acyclovir
    • verruca plana - salicylic acid
    • staph - abx
    • pseudo - acetic acid soaks
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13
Q

What are histologic changes in skin after a chemical peel

A
  • Epidermis
    • more melanocytes (but dont produce same mamnt of melanin)
    • reformation of rete ridge
    • symmetric shape to cells
    • no actinic keratoses
  • Dermis
    • collagen changes from woven disorganized to compact organized rigid
    • dermal thickening, elastic fibers
  • Epidermal lesions
    • keratoses/freckles disappear
    • nevi/telangiectsia more prominent
    • no effect on vascular lesions or hair
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14
Q

What is botox and MOA

A
  • Botulinum Toxin, derived from GPR clostridium botulinum
  • MOA: botox A heavy + light chain
    • heavy chain receptor binds presynaptic nerve R, complex is internalized, light chain is cleaved off and released into cytoplasm
    • light chain inhibits Ach release by lceaving SNAP25 of the SNARE complex = no Ach release at NMJ
  • Onset 3-5days, max effect 2wk, duration 4-6m
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15
Q

How is botox reconstituted, stored and commercially available

A
  • 7 serotypes
  • A and B are available + dysport
  • Stored at 4C before and after recon - can only be held for 6wks post recon
  • recon 100U with 1.1cc to give 10unit per 0.1cc
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16
Q

What are indications and contraindications to botox

A

INDICATIONS

  • Spasticity - bladder, limb, blepharospasm, lower lid spastic entropion, lumbosacral pain
  • Facial asymmetries
  • strabismus
  • TMJ d/o
  • Esophagus - achalasia, stricture
  • sweating, freys, hyperhidrosis

CONTRAINDICATIONS

  • Allergic to botox components (albumin)
  • infection at site
  • non-responder 2’ neutralizing ab when>200u
  • Relative
    • NMJ Disorder
    • peripheral motor enuropathic d
    • pregnant/lactating
    • drugs interfering w NM trasnmission
      • aminoglycoside - gent
      • penicillamine - used in RA
      • CCB - adalat nifedipine norvasc amlodipnie verapamil
        *
17
Q

What are complications of botox

A
  • Location specific
    • brow - lid ptosis, diplopia
    • oral incompetance
  • Bruising and pain
  • infection
  • headache
  • systemi weakness if >200u
  • LD50 = 40u/kg
  • atrophy and demyelination after multiple injections
18
Q

List the amount and how you would inject each site

A
  • Frontalis 10-20, up to 30
    • 1-2cm above brow
  • Glabella 20-30
    • 5 pts in female for arch, 7tps for male to keep brow flat
  • Crow feet 8-16
    • superficial
  • Bunny line 3-5
  • Marionette groove 3-5
    • puse lip, 1cm lateral and inferior to angle
  • upper 1/3 NL fold 3-5
    • between alae and NL
  • Dimpled chin 3-5
    • at point most prominent
  • Masseteric hypertrophy
    • 20-30 per side - goal to cause atrophy
  • Perioral 4-10
    • upper lip - aviod midline and angle
    • do not treat lower lip =>incompetance
  • Platysma 10-30
    • 3-5 sites per band 1cm apart
  • Hyperhidrosis 5-u/armpit
    • subdermal injection
19
Q

List the fillers available for facial rejuvenation

A

AUTOLOGOUS

  • Fat, dermis
  • cartilage, fascia
  • Collagen - Autologen
  • Fibroblats - Isolagen
  • PRFM - platelet rich fibrin matrix

BIOLOGIC

  • Acellular dermla matrix
    • Alloderm - solid
    • Cydoderm - injectable
  • Hyaluronic acid
    • Restylane
    • Juvederm
    • Hylaform -animal
  • Collagen
    • cosmoderm/cosmolpast - human
    • zyderm/zyplast - animal

SYNTHETIC

  • PMMA (+collagen) - artecoll
  • Ca hydroxyapetite - radiesse
  • PLLA - Sculptra
  • Bioalcamid - polyamide imide
20
Q

What are indications for alloderm

Adv/disAdv, compx

A
  • Acellular demal matrix
  • Indicated- volum loss/depression, lip augmentation, breast, tympanoplasty, parotiddectomy, rhinoplaty, septl perforation
  • Compx - variable extrusion, infection
21
Q

What are indications for restylane/juvederm

Adv/disAdv, compx

A

Juverdem/restylane - from bacteral fermentation

  • Indicateddeep rhytids, lip aug
  • Disadv- macule or acne at injection site
  • duration 6mth

Compared to zydern

  • which has risk of allergic rxn, need steroids/immunosuppression
22
Q

Which are the largest particles - therefor require deep erinjection

A

Perlane, Juverderm plus - voluma, hyalform plus

Contrary to ultra products juv/rest - inject at middermis

and restylane fine line - at DE jx

23
Q

What is artecoll, mechanism, longevity

A

Synthetic permanent filler of PMMA w bovine collagen

  • collagen fibers are pahgocytosed by macrophages
  • PMMA microspheres encapsulated by fibroblast
  • permanent
  • compx - granuloma, difficult to remove
24
Q

What is radiesse

A
  • Ca hydroxyapetite
  • permanent filler
  • for deep rhytids
25
Q

What is sculptra

A
  • PLLA, permanent filler injected subdermal
  • Comx of granuloma, infection
26
Q

WHat steps do you take if htere is intra-arterial injection of filler

A
  • abort procedure
  • warm compress
  • massage area to dispense
  • NTG paste to promote vasoilatation
  • hyaluronidase injection

PREVENTION

  • aspirate before injection
  • low volumein high risk areas around NL folds
  • treat one side at a time
  • recall vascular anatomy
27
Q

What is the tyndall effect

A

blue discoloration is filler i sinjected too superficailly

28
Q

What can be achieved with resurfacing techniques (whether it be laser, mechanical or chemical resurfacing)?

A
  • improvement of
    • dyschromia
    • actinic changes
    • collagen reorganization
  • more youthful appearance
29
Q
A