Nonoperative Facial Rejuvenation

1. Nonoperative Facial Rejuvenation Andrew Coughlin M.D. Raghu Athre M.D. University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation February 25, 2010

2. Objectives Discuss the history of cosmetic facial rejuvenation Discuss Aging and Photodamage to the skin Discuss treatment options for adynamic facial conditions and their associated complications

3. History of Facial Rejuvenation 3000 BCE Egyptians Manicures, Make-up, Tattoos of the face (1) 1500 BCE Egyptians Used sandpaper for scars as early form of dermabrasion (2) 100 BCE Roman poet Ovid: The Art of Love Facial mask of barley, bean, eggs, hartshorn, narcissus bulbs, balsam, Tuscany seed, honey (3) 200 CE Jewish Talmud Husband must provide 10 dinars for his wife�s cosmetic needs 900 CE Arabic Physicians Crushed rice, seashells, marble, crystal, limes, eggs, beans, ground lentils (dermabrasion)

4. History of Facial Rejuvenation 1905 Kromayer Mechanical dermabrasion with wheels and rasps (4) 1960�s Facial Peels 1990�s CO2 Laser Resurfacing Most recently filler agents have become increasingly popular **Modern techniques are reminiscent of ancient techniques

5. Layers of the Skin

6. Epidermis Stratum Corneum Keratinized cells to be sloughed off Stratum Lucidum Stratum Granulosum Stratum Spinosum Stratum Basale Basal regenerative cells and melanocytes Regeneration every 12-14 days (1)

7. Epidermis

8. Dermal Layers Papillary Dermis Meshwork of fine type III collagen fibers Anchors epidermis down to dermis Reticular Dermis Thick type I collagen bundles Elastic fibers for resiliency Glycosaminoglycans (GAG�s) Ground substance between fibers Can hold up to 1000x their weight in water (5) Hair, sebaceous/sweat glands, nerve receptors and blood vessels

9. Papillary and Reticular Dermis

10. Hypodermis Connects skin and underlying bone/muscle Loose connective tissue and elastin Predominant Cells Fibroblasts Macrophages Adipocytes

11. Damage to the Dermis Age Decreased ratio of Type I : Type III collagen Photodamage and Tobacco Smoke (6) Increase tissue collagenases and gelatinases Further decrease collagen in the dermis Decrease capillary and blood flow to skin Decreased skin integrity **Ultimately leads to decreased skin turgor and elasticity forming wrinkles and sagging skin (7)

12. Initial Evaluation Patient selection is key Unrealistic Psychiatric history or multiple physician visits Smokers have 12 times increased skin sloughing and scarring Must perform proper: Education Counselling Consistent procedural skills

13. Physical Exam Are rhytids dynamic vs adynamic Traction of skin in antagonistic direction Hypo- or Hyperpigmented skin Associated skin conditions Active infection Thickness of skin Glogau System

14. Glogau System (8) Stratifies patients based on amount of aging and skin damage Category I Photoaging down to stratum granulosum or papillary dermis with minimal wrinkles Dermabrasion or superficial chemical peeling Category II Photodamage down to upper reticular dermis and wrinkles with facial gestures Medium depth chemical peeling Category III Photodamage down to upper reticular dermis and wrinkles at rest Medium depth peels Category IV Photodamage to mid reticular dermis, wrinkles, skin discoloration Deep peel required

15. Treatment Options Dermabrasion Laser Resurfacing Chemical Peels Facial Fillers

16. Dermabrasion Purpose is to level the skin and promote re-epithelialization with new collagen deposition. Used for: Scar revision Acne scarring Rhinophyma Facial rhytids Contraindicated for Keloids and Hypertrophic Scars Must only injure only the papillary dermis Preserves adnexal structures for re-epithelialization Damage through the reticular dermis (Fat visualized) leads to adverse scarring

17. Dermabrasion Performed with high speed diamond fraise or wire brush. Local anesthesia +/- IV sedation Broad surfaces are frozen to maintain rigid tissue (malar region) Brush strokes are made at right angles to the brush rotation to avoid loss of control and damage to normal tissue Feathering: Edges are slightly brushed for blending

18. Dermabrasion Upper layers of skin are removed resulting in partial thickness wounds Small pinpoint bleeding of the wound Heal by re-epithelialization in 7-10 days Recovery is 2-3 weeks

19. Microdermabrasion Alternative to dermabrasion that attacks just the upper layer of skin Disadvantages Only good for early photodamage and superficial wrinkles Not useful for dermal pathology Uses Aluminum oxide microcrystals Advantages Repeated at short intervals Painless requiring no anesthesia Minimal erythema and side effects

20. Microdermabrasion Freedman 2001 (9) 10 patients treated with 6 treatments Physical exam and tissue biopsy Thickened epidermis and dermis with newly deposited collagen Karimipour 2010 PRSJ (10) Very good for skin contour irregularities such as rhytids Less effective with dyschromias than glycolic acid peels No RCT to evaluate uses in acne but decision should be based on patients expectations

21. Picture of Debridment Instrument

22. Dermabrasion Results

23. LaserResurfacing

24. Laser Resurfacing Works by targeting chromophores Each laser has a different chromophore: Water, oxyhemoglobin, melanin, etc. Chromophore absorbs the laser heat destroys cells harboring that chromophore Amount of chromophore in a cell is proportional to absorption/destruction Lasers have opened the door for treatment of periocular skin where dermabrasion cannot reach

25. Ablative Lasers Carbon Dioxide (10,600nm) Used with the same indications as dermabrasion Wavelength selectively targets water in soft tissue More collagen production and prolonged redness due to dispersed thermal injury Other advantages Hemostatic properties Depth of treatment is more precise with laser Skin tightening is immediate Skin irregularities are improved immediately

26. Ablative Lasers Erbium:YAG (2,940nm) Reduced thermal damage Less post-therapy redness Less collagen production Newman et al. 1999 (11) Compared Er:YAG and CO2 laser 21 patients with half the upper lip treated by each laser Er:YAG had less days of crusting 3.4 compared to 7.7 63% vs 54% improvement at 2 months favoring CO2

27. Other Lasers Nd:YAG Laser (1,064nm) Infrared, invisible, oxyhemaglobin, deep penetration Good for port-wine stains, telangiectasias, hemangiomas KTP (532nm) Visible, oxyhemaglobin absorption Good for cutaneous lesions Argon (193nm) Visible, broad blue band, oxyhemaglobin Penetrates between CO2 and Nd:YAG Same indications as Nd:YAG Flashlamp Excited Pulsed Dye (595 nm) Visible, yellow light, vascular sensitive Less scarring and hypopigmentation than Nd:YAG & Argon Cutaneous vascular lesions

28. Effectiveness of Lasers Bisson in 2002 evaluated 31 patients (12) At 6 weeks wrinkle depth reduction of 91% At 2 years wrinkle depth reduction of 87% 2001 Lasers are falling out of favor (13) 88% of patients considered post-therapy results very good. 77% would not be willing to have procedure again. **Several studies have shown equivalent results of CO2 lasers compared to dermabrasion (14-16)

29. Laser Resurfacing Results

30. Complications of Dermabrasion/Laser Resurfacing Infection (17) Bacterial infection rates 4.3 to 12% Fungal infection rates 1.8 to 2.2% Hypo/Hyperpigmentary mismatches Dark Skinned Patients Melasma or Cholasma associated with OCP�s Photosensitivity post-procedure should be prevented with UV blocking lotions for 2 months (18-19) Scarring Risk Must stop 13-cis-retinoic acid (Accutane) for 6-12 months prior to therapy (20) Milia Formation Small epidermal cysts common after dermabrasion Can be prevented with occlusive ointments or dressings for 1-2 weeks Can be treated with abrasive cleansers or scalpel Herpes Simplex Risk Roberts et al 1997 (21) Studied 907 patients with CO2 laser treatment and found that HSV infection of 3% was reduced to 1% with acyclovir prophylaxis Therefore patients treated with antivirals for 2-3 days prior and 7-10 days post procedure

31. Laser Resurfacing Redness

32. Melasma/Chloasma

33. Milia

34. Chemoexfoliation Controlled wounding of skin to induce regeneration and a more youthful appearance Most commonly used for photodamage that leads to Thickened Stratum Corneum Thinned Stratum Spinosum Disorganized maturation and elastin Decreased dermal collagen and GAG�s Irregular melanin dispersion Skin is rough, wrinkled and mottled

35. Damaging Levels Stratum Corneum Skin feels smoother Epidermal Basement Membrane Melanocytes live here Lighter and evenly pigmented Upper Reticular Dermis Smoother and lighter skin Deposition of new collagen, elastin, GAG�s Subsequent reduction of fine wrinkles Middle Reticular Dermis More collagen production with reduction of deeper wrinkles Deep Reticular Dermis Collagen production can produce a scar

36. Factors that increase solution penetration Solution Concentration Condition of Skin Pre-treatment tretinoin, electrolysis, surgery, waxing. Pre-peel degreasing with alcohol or acetone Application (brush, swab, sponge) Rubbing Time of contact Occlusion with tape or petroleum jelly

37. Individual Results Some argue that test patching is important because each person reacts so differently to each type of peel Depth of penetration Wrinkling response Scarring Post-therapy care should include ointment to promote healing, sun avoidance, and proper wound care to prevent infection

38. Patient Selection Post-therapy appearance can be frightening Make sure patients are: Psychologically stable Compliant with post-therapy care Willing to stay out of the sun Willing to wear makeup Be sure to perform proper informed consent and document it appropriately

39. Topical Retin-A First line therapy Advantages Reverses all the previously discussed findings of sun damage Also decreases fine wrinkles, evens pigmentary differences, smoothes the skin Disadvantages Photosensitivity Dries the skin out making moisturizers necessary Class C pregnancy media Can be combined with alpha hydroxy acids which are less effective but potentiate tretinoin preparations

40. Process of Skin Peeling Cleansing Septisol and acetone to decrease oil and scaliness of the skin Jessner�s or 70% glycolic solution can be used first to break initial barriers and allow TCA to penetrate deeper (8) Application Superficial? blotchy white and red frost Medium? white frost with surrounding erythema Deep? solid white with no erythema Healing Cool saline presses to decrease inflammation Vinegar soaks Q2 hours while awake for 5-7 days Regular follow up to look for infection

41. Superficial Peels Glycolic Acid Trichloroacetic Acid 10% Jessner Solution (lactate+salicylate+resorcinol+ethanol) Apply for a few minutes then rinse with water or neutralize with bicarbonate solution Stinging sensation and slight flush Smooth glowing skin with no activity restrictions Repeated doses Q week/2 weeks/4 weeks If you want to peels down to the basement membrane Slightly stronger concentration of solution desquamation for 2-3 days

42. Superficial Peel Results

43. Medium Depth Peel Amount of collagen depends on depth of peel and individual variations Scarring occurs with any subepidermal wound but is unpredictable TCA >50% have higher incidence of scarring (22-24) TCA 35% in combo with Jessner or glycolic solution first help with penetration Post treatment Skin turns dark brown Exfoliates for 4-7 days Socially incapacitated for 7 days New skin is very pink

44. Medium Peel Results

45. Deep Peels Baker-Gordon Peel Formulation 3cc 88% phenol 2cc water 8 drops of septisol 3 drops croton oil Treatment Agitate solution prior to usage Cotton tip application to 1 section of face at a time Slow application to regional subunits Prevents systemic absorption and arrhythmias Post Treatment Frosting of skin is immediate Swelling intense and release of epithelium over 1-2 days Re-epithelialization takes over 1 week Constant serous exudate hourly Very red skin for months Hypopigmentation expected Results Robust collagen formation is long-lasting Fine and deep wrinkles respond well

46. Baker�s Peel Progression

47. Complications Landau 2007 (23) 181 patients with full face peels 10-15 minutes between each face section 6.6% arrhythmias Increased with Diabetes, HTN, depression Prevention Sedation IV hydration EKG, LFT�s, Kidney function prior to therapy Monitoring with close follow up

48. Complications Infection Usually result of poor post-procedural care Bacterial, Fungal, or Herpetic Prophylactic antivirals Post-procedure antibiotics Vinegar washes very important Culture any non-healing wounds

49. Complications Hyperpigmentation Dark skin, OCP�s and pregnancy Prophylaxis with hydroquinone Treatment with Tretinoin, alpha hydroxy acid, and steroid cream Sun avoidance before and after treatment plus sunscreen Repeeling is an option if poor results occur

50. Complications Scarring Post-therapy infection Use of oral accutane Healing is by re-epithelialization from pilosebaceous units Accutane destroys sebaceous units Recently radiated skin Recently operated skin (undermining) History of keloids

51. Complications Hypopigmentation Occurs after deep peeling More apparent in very dark or very light skin Feathering of the peel with dermabrasion can camouflage the edges

52. Soft Tissue Augmentation

53. Soft-Tissue Augmentation History Began in 1893 Neuber harvested arm fat and injected it into the patients facial defects (24) Fillers now used for Scars from trauma and acne Static or dynamic rhytids Lip augmentations Melolabial fold augmentation 1900s paraffin injection used but fell out of favor due to paraffinomas (granulomatous reactions) 40-50�s Silicone introduced Granulomatous reactions and scarring limited its use 1970�s Stanford used human and animal collagen Still in use today in bovine form (25)

54. Modern Injectable Fillers Research is huge in this area for the ideal filler Inert, long lasting, abundant, low cost, no allergy, not carcinogenic, fixable Patient demand high Outpatient injection No surgery Minimal recovery 48-72 hours Lower short term cost Dermis is the #1 place of injection Fibroblasts that produce type 1 collagen are most abundant in this region

55. Types of Fillers Xenografts Homografts Autografts Synthetics

56. Xenografts Bovine Collagen Most widely used and is the �Gold Standard� All are dissolved in saline and lidocaine and Pepsin proteolysis to decrease antigenicity Zyderm I (35mg/mL) Injected into upper dermis Poor long term effect because of low concentration Overcorrection necessary 100% (26) Zyderm II (65mg/mL) Injected into mid dermis Longer effect with higher concentration Overcorrection necessary 50% (26) Zyplast (35mg/mL) Cross linked with glutaraldehyde to decrease degredation Injected into reticular dermis for longer duration/less resorption No overcorrection recommended

57. Bovine Collagen Complications Hypersensitivity reaction Tenderness Induration Erythema Pruritis Skin testing before definitive use 3-4% with positive skin test (27,28) 20 to 30% may show delayed reaction Must examine skin test site in 4 to 6 weeks prior to initiating therapy Some argue that second skin test necessary as reactions can occur with repeated injections Other complications Tissue necrosis (29) Foreign body reaction Headache/Nausea/Arthralgias (30)

58. Homografts Cosmoderm and Cosmoplast Bioengineered collagen from fibroblasts No antigenicity so no skin testing required Packaged and concentrated analogously to Zyderm I and Zyplast respectively Cosmoderm for superficial wrinkles Cosmoplast for deeper scars and grooves On average they last 3-6 months but duration is less than bovine equivalents (26)

59. Homografts Alloderm (Cymetra = injectable form) Acellular dermal graft from cadaveric skin Freeze drying process removes cells but leaves collagen IV, VII, proteoglycans and elastin Requires reconstitution with lidocaine prior to injection No skin testing required Duration of 3 to 6 months (31)

60. Xenografts Hyaluronic Acid A Glycosaminoglycans (GAG) Can hold 1000x its weight in water leading to increased skin turgor Overcorrection not required Identical in all species leading to minimal immunogenicity <1% chance of hypersensitivity Correction achieved for 6-9 months with HA (32) Hylaform (500 micron, 5.5mg/mL) Purified from rooster combs Few reports of local or systemic reactions from avian protein Shortened lifespan due to lower concentration (33) Restylane (400 micron, 20mg/mL) Bacterial cultures of Equine steptococci Cross linked with epoxides Also has �Fine Lines� and �Perlane� formulations with diffent particle sizes Isovolumetric contraction where matrix does not disperse water until all hyaluronic acid particles are degraded leading to prolonged effects (34)

61. HA Pitfalls Must inject intradermally Injection too deep Decreased duration of action Injection too superficial Unappealing bumps **Undesirable injections can be corrected with hyaluronidase injection.

62. Autografts Fat Very abundant No antigenic potential Requires additional procedure for harvesting Liposuction Questions regarding how much is reabsorbed Adynamic melolabial folds have prolonged duration of action compared to dynamic glabella (26)

63. Autografts Isolagen (Fibroblasts) Postauricular punch biopsy of patients skin Cultured in vitro with growth factors for 4-6 weeks Overnight delivery for injection the following day Several Treatments required for desired outcome Cost and time considerations make it impractial 6 month histologic evaluation showed integration of fibroblasts but is on hold by FDA due to growth factors and further studies (35)

64. Synthetic Material Silicone Been used for over 50 years Requires multiple microdroplet injections over 4 weeks Injections performed into deep dermis 1 to 3mm apart No overcorrection because innate reaction to the product was part of the process Webster studied 235 pts over 2800 injections (36) Good results and few complications Others have shown extensive reactions (37-39) Chronic inflammation Migration Extrusion ulceration Skin necrosis Granulomatous hepatitis Pulmonary emboli Silicosis (pneumonitis) FDA declared it illegal in 1991 but recent use for retinal detachment is bringing off label use back American Academy of Dermatology (1993) (7) �There is a wealth of clinical experience in dermatology with the use of liquid injectable silicone by the micro-droplet technique which shows its efficacy and safety in many individuals over many years.�

65. Synthetic Material ArteFill Combined 20% polymethylmethacrylate and 80% bovine collagen Skin testing required As collagen is degraded (4 months) the PMMA is encapsulated to maintain augmentation Injected into the subdermis to prevent persistent painful nodule Individual results are unpredictable so multiple injections are required over 3-4 months with 50 to 75% permanent correction (25) Overcorrection not recommended because each result is different Lemperle (Bailey37) showed good results with minimal complications Others report granulomatous reactions and scarring (Bailey38). Not approved in US but Europe has shown long term correction of >10 years (7)

66. Synthetic Material Radiesse (25 to 45 micron size) 35% synthetic hydroxyapatite particles in water, glycerin, and sodium carboxymethylcellulose Injeted into deep dermis or subdermally due to viscosity Massage is necessary to contour product Produces augmentation in 2 ways Collagen ingrowth by fibroblasts Encapsulation of crystals by fibroblasts to prevent degredation Radiographic evidence of implant for up to 6 years (40) Pitfalls Injection into lips can produce painful nodules Palpable implant for 2 to3 months until the product is replaced by collagen Tzikas studied 90 patients and found 88% patient satisfaction at 6 months (41)

67. Post-therapy Findings Post-injection pain Redness Ecchymosis Swelling Nodularity Palpability **Should be transient and resolve over 1-2 days

68. Complications: 0-2 days Overcorrection Know the properties of the injectable filler and whether to overcorrect or not Implant visibility HA can produce bluish nodule Other fillers cause white nodule Massage can help Hyaluronidase or mechanical deroofing of nodule Vascular compromise Arterial: Immediate skin blanching with necrosis (glabella) Aspiration, massage, warm compress, 2% nitropaste +/- hyperbaric oxygen for impending necrosis Venous: violaceous discoloration with dull ache Nitropaste and warm compresses **Skin breakdown treated with Abx and gentle debridment

69. Venous Injury

70. Complications: 3-14 days Noninflammatory Nodules Observation, gentle massage, reassurance Early Inflammatory Nodules Treat with antibiotics for 4-6 weeks Macrolide and Tetracycline I&D plus culture if fluctuance is observed Close f/u visit at 48 hours If no response to therapy get tissue culture

71. Tissue Infection

72. Complications: >14 days Hypersensitivity Bovine collagen 3-4% + skin test HA <1% Nodules Saline injection and vigorous massage Inflammatory nodules Evaluate for infection and treat as necessary No infection but no response at 7-10 days?add intralesional steroid injection to avoid resistant granuloma Still no response?biopsy and culture True Granulomas (0.01-1%) Massage and Intralesional steroids

73. Summary There are a variety of treatment options available Proper knowledge of the product or procedure is necessary to avoid complications Patient expectations, informed consent, and proper patient selection is paramount

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