Non-surgical facial Rejuvenation Flashcards
What is dermabrasion/microdermabrasion, indications, contraindications, compx
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,
What is a chemical peel and how is it classified
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
What are indications and contraindications to chemical peels
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
What are complications fo chemical peels
- Scar
- pigmentary changes
- pustulocystic acne
- prolonged erythema
- delayed wuond healing, burn
- infection
- Arrythmia
How do you evalute the patient and prep the patient prior to chemical peel
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
What factors affect the depth of penetration of the peel?
- Skin
- degreasing
- thickness
- prep prior to peel
- cleansing
- Chemical agent/peel
- type
- concentration
- frequency
- acid neutralization
- method of application
List chemical peels
- 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
Describe the MOA of phenol peel, indications, depth determination, ideal patient, complx
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.
Describe the MOA of TCA peel, indications, depth determination, ideal patient, complx
- 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
Describe the MOA of glycolic acid peel, indications, depth determination, ideal patient, complx
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
Describe the MOA of croton oil, indications, depth determination, ideal patient, complx
- 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
What are complications of chemical peels and management of the complication
- 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
What are histologic changes in skin after a chemical peel
- 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
What is botox and MOA
- 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
How is botox reconstituted, stored and commercially available
- 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
What are indications and contraindications to botox
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
*
What are complications of botox
- 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
List the amount and how you would inject each site
- 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
List the fillers available for facial rejuvenation
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
What are indications for alloderm
Adv/disAdv, compx
- Acellular demal matrix
- Indicated- volum loss/depression, lip augmentation, breast, tympanoplasty, parotiddectomy, rhinoplaty, septl perforation
- Compx - variable extrusion, infection
What are indications for restylane/juvederm
Adv/disAdv, compx
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
Which are the largest particles - therefor require deep erinjection
Perlane, Juverderm plus - voluma, hyalform plus
Contrary to ultra products juv/rest - inject at middermis
and restylane fine line - at DE jx
What is artecoll, mechanism, longevity
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
What is radiesse
- Ca hydroxyapetite
- permanent filler
- for deep rhytids
