Essentials of Aesthetic Surgery

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TIP: Medi spas can incorporate retail services, salon care, spa services, and noninvasive
and surgical cosmetic procedures into one facility; it depends on the surgeon’s interests,

PRACTICE SETTING


Establish who will care for patients, complications, and emergencies when physician is
away for personal or professional activities in solo practice.

Personal goals, personality, and philosophy are important considerations when
deciding to work in a solo or group practice.

practice, considering “on-call” activities, overhead costs, and ease of becoming

OFFICE
Consider a convenient and accessible location, while maintaining subtlety and privacy.
Ensure adequate parking, adherence to all building and city codes, and standards of
accrediting organizations.

extravagant, or ostentatious décor and atmosphere.
Maintain separation of medical/surgical patients and consumers of retail, salon, and spa
services.
STAFF

Ensure the team is trustworthy, knowledgeable, intellectually curious, and dedicated.
Hire a business manager, patient coordinator, administrative assistant; expand and
focus roles as the practice and business grow.

Encourage environment of working hard, generating business, and putting patient
safety at the forefront of mission.
Maintain professionalism—always lead by example!
TIP:
assets in practice. Interview carefully and take the time to hire wisely!
SENIOR AUTHOR TIP:
employees before you hire them.

how employees can embezzle and how you can prevent it from happening.

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Chapter 12 The Medi Spa and Other Practice Considerations
MARKETING AND GETTING ESTABLISHED2


someone warm and knowledgeable is answering.
Have an attractive and informative start early, even months before the doors
open, and consider a web designer familiar with medi spas.
—an intended
response, which can be as simple as providing education and contact information to
referral sources, potential patients, and community groups.
once patients are in the door



• Unique aspect of medi spa is that spa and noninvasive cosmetic procedures can be
direct referral into the surgical practice for patients who want to take that step.

that combine surgical and nonsurgical treatments.
TIP: Physicians should establish a niche, identify a community’s needs or what it lacks
in other aesthetic surgeons, and identify why they and their medi spa are unique or novel.
to get patients in the door
Early in their career or practice, physicians should make
themselves available to as many community groups, speaking engagements, and
local radio and television shows as possible.
• Meet and engage referral sources by sending educational materials, speaking with

showing sincere gratitude for their support.

Newspaper and magazine advertisements; direct mailings to patients,

Email; text messages; radio and television; the website and other
Internet sites (Facebook and Twitter)

SENIOR AUTHOR TIP: I recommend having a full-time marketing director and a full-
time social media manager. I also recommend a modern, attractive website that needs
to be renewed every 2 to 3 years.
SENIOR AUTHOR TIP: Referrals must be carefully studied at minimum every quarter.
FINANCES

practice expansion, patient management, and experience.
Projections can be time consuming, and trying to calculate the cost of goals can be


tangibles like products, materials, equipment, and property.

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Part IV Skin Care
Expenses include (1) direct expenses like wages, supplies, cost of operating equipment,
and (2) overhead expenses like debt, loans, taxes, monthly bills, equipment rental, and
depreciation.
Careful planning and some research will allow surgeons to project how to balance their
income and assets with expenses and future goals.
Determine when taking on partners or nonphysician providers can increase revenue,
while not necessarily doubling overhead.
AMBULATORY SURGERY FACILITY CERTIFICATION AND STANDARDS
ACCREDITATION4

standards.
Plastic surgeons decided to create a certifying body to oversee safe, reliable patient
care facilities.
They established the American Association for Accreditation of Plastic Surgery Facilities.
It was later extended to facilities for all surgical specialties, becoming


accrediting body of ASCs.


Most State Departments of Health accept accreditation instead of state licensure.

ACCREDITATION OF AMBULATORY SURGERY FACILITY CLASSES
Accreditation requirements based on anesthesia administered in each facility
Far fewer requirements for Class A facilities
Similarities for other classes, with more mandates as anesthesia becomes more invasive
Accreditation of Ambulatory Surgery Facility Class Based on Anesthesia








Topical or local
anesthesia
Oral medications
producing minimal or
moderate sedation
Class A, plus:
IV and parenteral
sedation
Regional blocks
Dissociative drugs
Class A and B, plus:
IV propofol
Spinal or epidural
anesthesia
Class A, B, C-M, plus:
Inhalational agents

intubation






Propofol
Endotracheal

Inhalational agents
Propofol
Endotracheal

Inhalational agents
Propofol, inhalational
agents, spinal and
epidural anesthetics
must be administered
by a CRNA, anesthesia
assistant, or
anesthesiologist
laryngeal mask airway.

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Chapter 12 The Medi Spa and Other Practice Considerations
STANDARDS
ASPS and ASAPS mandated in 1999 that members performing plastic surgery using
more than local anesthesia or oral sedation be in a facility with:
• State licensure

• Accreditation by an organization like AAAASF, Accreditation Association for
Ambulatory Health Care (AAAHC), or Joint Commission on the Accreditation of
Health Care Organizations (JCAHO)
6
AMA and Center for Medicare Services (CMS) have similar mandates for accreditation by
these or similar agencies.1,7

• Maintain hospital privileges for all surgical procedures performed at the ASC
• Maintain admitting privileges or at least emergency transfer agreement with nearby
hospital
• Be a member of an American Board of Medical Specialties board
Surgical procedures performed at the ASC should be within guidelines for that
specialty’s scope of practice.
TIP: ASPS, ASAPS, AMA, and CMS mandate facility accreditation by one of the national
accrediting organizations.
LEGAL CONSIDERATIONS
FEDERAL REGULATIONS1
Code of Federal Regulations requires ASCs to participate in Medicare through CMS.
CMS requires following all state laws for accreditation or licensure.

performing surgery apply for CMS coverage.

minutes and <4 hours of postsurgical recovery, and type of surgery to those that:
• Do not generally result in extensive blood loss
• Do not require major or prolonged invasion of body cavities
• Do not directly involve major blood vessels
• Are generally emergency or life-threatening in nature
STATE REGULATIONS
These vary by state, but usually comply with federal/CMS rules.
Many states, including California, Florida, Ohio, and Pennsylvania, have accreditation
requirements.8
Some such as Arizona and Kentucky require registration with state or licensure.
Most others require credentialing for physicians without nearby hospital privileges,
though some states have no ASC restrictions.
Florida, Pennsylvania, Rhode Island, and Tennessee are the only states with surgical
time limits currently (e.g., 4 hours in Pennsylvania; beyond this time, reporting
violations to state department of health with an explanation is required!).

more unplanned admissions, especially procedures ending after 3 pm.
9,10

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Part IV Skin Care
TIP:
Most are readily available online through state departments of health.
NONPHYSICIAN PROVIDERS: ADVANTAGES, GUIDELINES, AND CAUTIONS
According to ASAPS, more than 13,000,000 cosmetic procedures were performed by
11,12
• Nonsurgical procedures account for 85% of total.
• Increase of 7% in 1 year
• $15 billion spent by Americans; injectables approximately 44% of total expenditure
• 4.6 million botulinum toxin type A injections; 2.5 million hyaluronic acid injections
• From 2012 data, injectable procedures increase by 20% when including those by
nonphysician injectors
12
• Demand for nonsurgical cosmetic procedures is obviously increasing, faster than
physicians alone can accommodate.

providers perform nonsurgical cosmetic procedures.
GUIDELINES
State laws are vague and left open to reasonable interpretation by providers.13
Most imply that tasks and procedures be delegated to competent, trained, licensed
nonphysician providers at the discretion of the physician.
Medical director or physician supervisor may be required to be on site at all times,
occasionally, or only available by electronic communication.
Initial consultation and treatment plan should be created with physician.14
Physician should ensure ongoing training and competency of injectors.
TIP: Physicians’ judgment is the underlying principle, and ultimate responsibility lies
with them!
CAUTIONS
Opinions vary regarding “losing” nonsurgical procedures to nonsurgeons as other
providers become more adept with injectables—physicians need to determine the
culture in their community.
Some patients may be wary of nonphysicians providing most of their nonsurgical
treatment.
State-by-state laws and recommendations vary widely (e.g., in Ohio, physician assistant
laws require physician be within 60 minutes’ travel time, and one physician can
supervise no more than 2 physician assistants at a time).
13,15

reputation.
TIP:
on the training of each provider.

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Chapter 12 The Medi Spa and Other Practice Considerations
PATIENT SELECTION AND PATIENT SAFETY
PATIENT SELECTION
Consider patient comorbidities before creating a treatment plan (see Chapters 5
through 7).
MINIMIZING PATIENT DISSATISFACTION
Familiarize yourself with and always follow standards of care
Informed consent: Document in detail, engage each patient in a verbal discussion

risks and complications, likelihood of successful treatment, alternatives to the proposed
plan, consequences of declining proposed treatment.
Use well-lit, standardized preoperative and postoperative photography (see Chapter 3).


questions or reciting facts they found on the internet; and make them feel comfortable
from the time they walk in the door.
COMPLICATIONS AND PREVENTION
Commit to a
Conduct internal reviews when complications occur, and report to accrediting
organization and State as mandated.
Have a malignant hyperthermia cart with necessary supplies and dantrolene (see
Chapter 5).
Have a local anesthetic systemic toxicity cart with necessary supplies and lipid
emulsion.22
Common complications seen in ASCs and strategies to minimize their occurrence are
discussed below.
POSTOPERATIVE PAIN, NAUSEA, AND VOMITING
Most unplanned hospital admissions result from
16
and cause the most pain for aesthetic surgery
procedures.23
Pain medication dosing postoperatively should take into account patient’s BMI.
Nausea and vomiting after discharge occur in of patients
and
are risk factors.
(ketorolac, IV acetaminophen), and use of
are known to decrease risk of postoperative nausea and vomiting.24
INFECTION
of all complications reported to AAAASF are infections.
Infection rate is 0.7% overall in all cases performed.
followed by mastopexy, breast
augmentation, liposuction, and facelift.

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Part IV Skin Care
include hypothermia, smoking, obesity, hyperglycemia, heavy alcohol use,
and malnutrition but no conclusive data for patients in ASCs.
Perioperative antibiotics, antibiotic saline irrigation, normothermia, and preoperative
hair removal may help to reduce incidence.26
HEMATOMA
of all complications reported to AAAASF are hematomas.
Overall hematoma rate is 0.14% in all cases performed.
41% of those occurred in breast surgeries (two thirds were augmentations, the
rest reductions or mastopexy), followed by blepharoplasty, abdominoplasty, and
liposuction.
Remain vigilant, avoid hypotensive surgery, and evaluate patients undergoing these
procedures before their discharge from PACU.
VENOUS THROMBOEMBOLISM
1.0% of all complications reported to AAAASF are DVT, and pulmonary embolism are
1.2%.
Deep venous thrombosis rate overall is 0.004% in all cases performed, and pulmonary
embolism rate is 0.005%.
CAUTION:

(see Chapter 11)
Genetic factors, antiphospholipid syndrome, homocysteinemia, and contraceptive or
hormone replacement therapy contribute to risk.16
Consider sequential compression devices in lower-risk patients, and chemoprophylaxis
preoperatively and postoperatively in higher-risk patients.27
MORTALITY
Rare in ambulatory surgery
0.0024% occurrence in all plastic surgery cases
PE associated with
Caution when considering combining abdominoplasty with any additional procedures27
TOP TAKEAWAYS


assets in practice. Interview carefully and take the time to hire wisely.


based on the training of each provider.

State-by-state laws and recommendations vary widely.

Risk factors include hypothermia, smoking, obesity, hyperglycemia, heavy
alcohol use, and malnutrition.

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Chapter 12 The Medi Spa and Other Practice Considerations
REFERENCES

Available at

Nahai F, ed. The Art of Aesthetic Surgery: Techniques and Principles, ed 2. New York: Thieme
Publishers, 2010.

Aesthetic Surgery: Techniques and Principles, ed 2. New York: Thieme Publishers, 2010.
4. Pearcy J, Terranova T. Mandate for accreditation in plastic surgery ambulatory/outpatient clin-
ics. Clin Plast Surg 40:489, 2013.
5. American Association for Accreditation of Ambulatory Surgery Facilities. Regular Standards
and Checklist for Accreditation of Ambulatory Surgery Facilities. Available at
6. American Society of Plastic Surgeons and American Society for Aesthetic Plastic Surgery, Inc.

7. American Medical Association. Office-based Surgery Core Principles. Available at www.


at
9. Fogarty BJ, Khan K, Ashall G, et al. Complications of long operations: a prospective study of

10. Fortier J, Chung F, Su J. Unanticipated admission after ambulatory surgery: a prospective study.
Can J Anaesth 45:612, 1997.
11. American Society for Aesthetic Plastic Surgery. 2016 ASAPS statistics. Available at
org.
12. American Society for Aesthetic Plastic Surgery. News releases: cosmetic procedures increase
in 2012. Available at
https://

14. American Society of Plastic Surgeons. Guiding principles: supervision of non-physician person-

codes.ohio.gov.

surgery setting. Plast Reconstr Surg 110:1337, 2002.

40:371, 2013.
18. Warner MA, Shields SE, Chute CG. Major morbidity and mortality within 1 month of ambulatory
surgery and anesthesia. JAMA 270:1437, 1993.

(NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical

20. Gorney M. Recognition of the patient unsuitable for aesthetic surgery. Aesthet Surg J 27:626,
2007.

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Part IV Skin Care
21. Blackburn VF, Blackburn AV. Taking a history in aesthetic surgery: SAGA—the surgeon’s tool
for patient selection. J Plast Reconstr Aesthet Surg 61:723, 2008.

Techniques and Principles, ed 2. New York: Thieme Publishers, 2010.
23. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg 85:808, 1997.
24. Keyes M. Management of postoperative nausea and vomiting in ambulatory surgery: the big
little problem. Clin Plast Surg 40:447, 2013.
25. Soltani AM, Keyes GR, Singer R, et al. Outpatient surgery and sequelae: an analysis of the
AAAASF internet-based quality assurance and peer review database. Clin Plast Surg 40:465,
2013.
26. Nazarian Mobin SS, Keyes GR, Singer R, et al. Infections in outpatient surgery. Clin Plast Surg
40:439, 2013.

40:389, 2013.

181
ANATOMY1
Stratum basale
Stratum lucidum
Stratum spinosum
Stratum granulosum
Stratum corneum
Papillary dermis
Reticular dermis
Epidermis
Dermis
Hypodermis

EPIDERMIS
The epidermis comprises the following cells:
• Keratinocytes: 80% of epidermis
• Melanocytes: Mostly within basal layer, pigment-producing cell, pigment provides UV
protection
• Merkel cells: Mostly within basal layer, mechanoreceptor, slow-adapting
• Langerhans cells: Antigen-presenting/T-cell activating cells of the epidermis
The epidermis has each approximately 100 µm thick:

Spinelike appearance of cell margins from intercellular bridging
Intracellular granules containing materials to create skin barrier
Clear layer of dead cells devoid of nuclei, prominent in palms/soles

granular layer, providing skin barrier

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Part IV Skin Care
DERMIS
Makes up most of skin
Responsible for the and of the skin


Also inhabited by macrophages and mast cells
The dermis has

(thickness of all layers varies by location)
Deep, makes up most of dermis (2000-2500 µm). Collagen and

VASCULATURE
Small vessels penetrate from the subcutaneous tissue and form a
within the
Arterioles extend vertically from the plexus toward the epidermis, forming the
subpapillary plexus at the interface of the papillary and reticular dermis.
Individual capillary loops then extend from these end arterioles up into each papilla of
the papillary dermis.
LYMPH

substances, and sampling for immune function
NERVES
Nerves follow a distribution and pattern similar to those of the vasculature, with a deep
reticular and subpapillary plexus.
SKIN APPENDAGES
Hair follicles, growth cycle variable by location
Growth phase, 2 years
Programmed cell death, hair loss, 2 weeks
No hair, no growth, 2 months
GLANDS
Sebaceous glands, eccrine glands, apocrine glands
Maintain skin hydration and assist with thermal regulation
Provide source for epidermal regeneration—increased density on face allows resurfacing
procedures, but below the jawline, reduced density delays epidermal regeneration, and
can lead to scarring

SKIN PHYSIOLOGY
NORMAL SKIN FUNCTION

Protection against injury, infection, and water loss
Vitamin D conversion

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Chapter 13 Anatomy, Physiology, and Disorders of the Skin
Sensation, temperature, pressure, and vibration

NORMAL SKIN AGING
YOUNG

Deep
vascular plexus
Melanocyte

Stratum corneum
Mast cell

vascular plexus
Subcutaneus
fat
Histology of aging skin. Aging skin is shown on the right.
HISTOLOGY
Thinning of epidermis
Flattening of the rete ridges

Atrophy of subcutaneous tissue
CLINICAL PICTURE
Thinning skin

Facial laxity
Facial rhytids

WOUND HEALING


migration

most important to regulate growth factors and wound healing

• Fibroblasts predominate, increased collagen synthesis, and angiogenesis

• Equilibrium between collagen deposition and breakdown
• Increased collagen organization and stronger cross-links
• Type I collagen replaces type III to restore 4:1 ratio
• Healing strength begins to plateau at approximately

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Part IV Skin Care


Cells migrate across wound until they meet cells from other side.
As edge cells migrate, cells farther back proliferate to support migration.


to 21, with greater numbers and contraction in full thickness/deeper wounds.
FACTORS AFFECTING WOUND HEALING
GENETIC SKIN DISORDERS


• Skin has coarse texture, droops over all of body, and is diagnosed during neonatal or
early childhood.
• Congestive heart disease, emphysema, pneumothorax, aneurysms, and hernias may
also occur.
• It slowly worsens over time, but




• Disorder of collagen cross-linking



• Poorly understood cause
• Pendulous skin over trunk and extremities, eventually entire body


• Rapid progression and short lifespan, from childhood

abnormalities, and poor wound healing

COMORBIDITIES
Diabetes
Atherosclerotic disease
Renal failure

NUTRITIONAL DEFICIENCIES
Vitamins and minerals (vitamin C, zinc, iron)
Caloric
Protein (check albumin, prealbumin, transferrin, and haptoglobin)
DRUGS
Vasoconstriction and decreased oxygen delivery
Impair wound healing

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Chapter 13 Anatomy, Physiology, and Disorders of the Skin

Decreases collagen synthesis 45%
Prevent collagen cross-linking
LOCAL WOUND FACTORS
Speeds epithelialization
Increased tensile strength
Poor oxygen delivery, infection, chronic wound, denervation,
radiotherapy, free radicals
SKIN ANALYSIS4
SKIN QUALITY
Skin type5 (Table 13-1)
Skin texture
Thickness
Pore size
Sebaceous quality
Discoloration: Hyperpigmentation, solar lentigo, rosacea, telangiectasias
Scarring: Acne, surgery, trauma




I
Pale white, freckles, blue eyes, blond or red hair
Always burns, never tans
II
Fair white, blue/green/hazel eyes, blond or red hair
Usually burns, minimally tans
III
Cream white, any hair or eye color
Sometimes burns, tans uniformly
IV
Moderate brown (Mediterranean)
Rarely burns, always tans well
V
Dark brown (Middle Eastern)
Rarely burns, tans easily
VI
Dark brown to black
Never burns, tans easily
TIP: Patients with Fitzpatrick skin types V and VI are at higher risk for hyperpigmenta-
tion, but show fewer signs of photoaging.
AGING FACE

Redundancy
Rhytids

Accentuated with animation, respond to neurotoxin
Volume loss
Volume displacement (gravity)
SKIN LESIONS
Many patients will request cosmetic nevus removal or scar revision from other procedures.
Surgeons need to distinguish diagnostic features of common skin lesions and cancers to
properly diagnose and treat these patients.

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Part IV Skin Care

6
• accounting for 75% of all nonmelanoma skin cancers (NMSC)
• 30% on nose
7
• Increased with fair skin, blond or red hair, blue or green eyes, UV exposure
• Translucent, rolled border, telangiectasia, central ulceration
• Most often head and neck
• Types:
50% of BCC
Appears as an erythematous, scaly, eczematous-looking patch, often
on trunk
Brown pigmentation, look-alike for melanoma
White scarlike appearance, sometimes atrophic or
depressed
8
• No. 2 skin cancer
• Most arise from actinic keratosis (60%) or SCC in situ (Bowen disease)
• Favor head, neck, dorsal hands, and forearms
•
erythematous and plaque
•
secondary to immune suppression and radiotherapy
• Merits consideration for lymph node evaluation and occasionally

perineural or perivascular invasion, and lip and intraoral lesions.
•
Slowly enlarging erythematous plaque, scaly or slightly verrucous
surface; if untreated, can progress to invasive SCC
Rapidly growing (within a few weeks) crateriform nodule,
often 1-2 cm size, on sun-exposed skin, may slowly involute over a period of
months. Although often known for spontaneous resolution, keratoacanthomas
can metastasize on occasion and can be very destructive locally. Many consider
them to be a variant of SCC.
•
9
10
• Third most common skin cancer, 5% of skin cancer
• Estimated 55,000 invasive, 35,000 in situ in United States per year
• Men: Upper back, upper extremities
• Women: Back, lower extremities
•
4%-10% (melanoma on sun-damaged skin, commonly on the face)
• (Breslow thickness) most important to staging and prognosis,
sentinel node biopsy should be considered for
anything in between.
•

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Chapter 13 Anatomy, Physiology, and Disorders of the Skin



• Treatment of choice for many skin cancers

recurrent tumors
11-15
11,12,13 SCC 96%-97%,14 15
• Standard margins typically taken based on tumor size
and type
•
trunk or extremities, allowed to heal secondarily
• Typical liquid nitrogen used to freeze actinic keratoses and
precancerous lesions, causes epidermolysis and sloughing of lesion
• Typically reserved for patients with combination of numerous
comorbidities, limited lifespan, and number lesions requiring treatment
•




•
usually 1-3 hours, then activated under blue light. For actinic keratosis, less
downtime than 5-FU or imiquimod.


• Rough/scaly erythematous patches/plaques
• Sun-exposed areas, like the scalp, face (especially the forehead, cheeks,
nose, rim of ear), dorsal hands/forearms
• Approximately 10% eventually progress to become SCC, and 60%
of SCC arise within an actinic keratosis.
16


•

umbilicated appearance


•



• Nevi

wrinkling on palpation (see Pigmented lesions)
•

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Part IV Skin Care

•



a warty, rough, or waxy and follicular surface, often appearing “stuck on”; color


melanoma, because the lesions are “dark, ugly, growing, and raised up”
•

to be a variant of a seborrheic keratosis
•

skin; usually, surrounding areas have other similar macules.

•


brown)

population of neval cells present in the dermis; compound nevi also have neval
cell activity along the dermal-epidermal junction.

dermal-epidermal junction

•

up to
risk; risk related to size; small congenital nevi carry relatively low risk.

hidden within the nevus
•

melanoma, these are very common and are most often considered benign.


melanoma are at increased risk for melanoma.

observation and regular screening.
•

changing color to darker shades of brown


• Small, bright red papules, may become purple and venous
• Dilated capillaries
• Dilated capillaries radiating from central arteriole
• Dilated veins
• Venous malformation on the lip

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Chapter 13 Anatomy, Physiology, and Disorders of the Skin
SENIOR AUTHOR TIP: Rosacea is not really a “vascular lesion” per se, but rather more

on the face.
PHYSIOLOGY OF COMMON MEDICAL SKIN THERAPIES
TOPICAL RETINOID THERAPY
DNA binding, decreasing metalloprotease activation
Reverses photoaging, thins stratum corneum, thickens epidermis, reverses atypia,
increases collagen and angiogenesis, and evens melanin dispersion
Most commonly used for acne

HYDROQUINONES
Block conversion of dopamine to melanin by
Useful for preventing hyperpigmentation
KERATINOLYTIC AGENTS/CHEMICAL PEELS
allowing desquamation


hyperpigmentation.
ARAC, EFUDEX
as a thymine analogue


treatment. Patients may also have bleeding and crusting.
SUNSCREEN


• Traditionally pasty white in appearance
• Newer products contain micronized zinc and titanium, which are more translucent.
• Provides good UVB and UVA coverage, typically with longer half-life
• Even protective against wavelengths in the visible light range

• Historically, UVB was main concern, but increasing research showing dangers of UVA
underestimated

atmosphere, and penetrates 5× deeper in skin; therefore 100× more photons
reach dermis.
• Sunscreens and sunblocks do not measure UVA blockage.

• Many sunscreens block UVB well, but block UVA poorly.
• Block by absorption of UV
• Avobenzone is most commonly used for UVA blockage, but is quickly broken down
by UV in 20 minutes, limiting half-life. Helioplex by Neutrogena and Anthelios with

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Part IV Skin Care
TOP TAKEAWAYS


(stratum corneum an dstratum lucidum) are made up of nonviable keratinocytes.

Collagen provides the tensile strength of the skin.

Type 1 collagen replaces type III to restore a 4:1 ratio.

Predictable physiologic and histologic skin changes occur with age.

Patients with increased numbers of atypical nevi and/or a family history of
melanoma are at increased risk for melanoma.
REFERENCES
1. Chu DH, Haake AR, Holbrook K, et al. The structure and development of skin. In Freedberg IM,

McGraw-Hill, 2003.
2. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconst Surg 133:199e, 2014.


4. Baker TJ, Stuzin JM, Baker TM, eds. Facial Skin Resurfacing. New York: Thieme Publishers, 1998.
5. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I though VI. Arch Dermatol
124:869, 1988.
-
patrick’s Dermatology in General Medicine, ed 6. New York: McGraw-Hill, 2003.
7. Gloster HM Jr, Brodland DG. The epidemiology of skin cancer. Dermatol Surg 22:217, 1996.

Fitzpatrick’s Dermatology in General Medicine, ed 6. New York: McGraw-Hill, 2003.
9. Marcil I, Stern RS. Risk of developing a subsequent nonmelanoma skin cancer in patients with
a history of nonmelanoma skin cancer: a critical review of the literature and meta-analysis.
Arch Dermatol 136:1524, 2000.


McGraw-Hill, 2003.

cell carcinoma: implications for patient follow-up. J Dermatol Surg Oncol 15:315, 1989.
12. Cottel WI, Proper S. Mohs’ surgery, fresh-tissue technique. Our technique with a review. J
Dermatol Surg Oncol 8:576, 1982.
13. Mohs FE. The chemosurgical method for the microscopically controlled excision of cutaneous

14. Nguyen TH, Ho DQ. Nonmelanoma skin cancer. Curr Treat Options Oncol 3:193, 2002.
-
neous melanoma. J Am Acad Dermatol 37:236, 1997.
16. Marks R, Rennie G, Selwood TS. Malignant transformation of solar keratoses to squamous cell

191
is a term combining the concepts of cosmetics and pharmaceuticals. These
products are over the counter and considered active cosmetics, delivering more to the skin
than simply color or scent adornment. No U.S. Food and Drug Administration–recognized
category for cosmeceuticals has been established.
1,2
TIP:
Comprehensive treatment involves and
Treatments are aimed at improving the appearance of dry and aging skin.
Aging skin is induced by:3
• UV exposure
• The creation of dermal scars from reactive oxygen species

(collagenase, elastase)
Dry skin can be caused by excessive cleansing and low humidity conditions (air travel,
forced-air gas heat).
CLEANSERS4
Main active ingredients are
These surfactants may be formulated as bar cleansers or liquid cleansers (Table 14-1).
Patients with
(i.e., cleansing cream or oil).
High detergent surfactants may remove skin surface sebum and intercellular lipids,
leading to barrier damage, inability of skin to hold water, and dry skin.
Cleansers remove sebum, perspiration, cosmetics, dust, and microorganisms.
Cleansers based on sodium cocoyl isethionate are low detergent and well tolerated in
those with dry skin.
Individuals with when washing.

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Part IV Skin Care
Key Features of Surfactants


Superfatted soaps
(bar surfactant)

Unreacted fatty acids/oils left in soap or added to soap during production
Transparent soap
(bar surfactant)
High levels of humectants, giving a clear appearance
Can cause irritation but are usually mild products
Combination bars
Combine natural soaps with milder synthetics

Synthetic bars
Sodium cocoyl isethionate most commonly used (adds mildness to product)
Formulated in neutral pH range

Often combined anionic (i.e., alkyl ether sulfate, alkyl sulfosuccinates) and
amphoteric (i.e., cocoamphoacetate, cocamidopropyl betaine)
Nonionic surfactants (i.e., acyl glycinates) increasingly more common
SENIOR AUTHOR TIP: Synthetic moisturizers, also known as syndets, are labeled as
beauty bars and are milder because they remove less sebum.
MOISTURIZERS
Best moisturizers contain occlusives and humectants.5,6
PETROLATUM CCLUSIVE
Second most commonly used active ingredient (after water)
reducing transepidermal water loss by
(occlusive function)
When applied to wounded skin,
migration



LANOLIN CCLUSIVE
Derived from
Contain which is a component of lipids in the strateum corneum
May be a source of

OILS CCLUSIVE
Important in

grape seed oil, and olive oil), cetyl alcohol
Oils are hydrophobic and lipophilic
DIMETHICONE CCLUSIVE
Also very common moisturizer
Silicone derivative
Can function as emollient, making skin smooth by

Does not create greasy shine in patients with oily skin

193
Chapter 14
GLYCERIN UMECTANT
Draws water from dermis and epidermis into dehydrated stratum corneum
Shown to (aquaporins), allowing passage of ions
and solutes
Thought to hydrate and improve overall appearance of skin
SENIOR AUTHOR TIP:
of aquaporins, which adjust skin osmotic balance.
RETINOIDS




High-quality evidence to support use in prescription treatment of photoaging

retinaldehyde)
TIP:
ANTIOXIDANTS

L-ascorbic acid
inhibits elastase


Many formulations unstable and cannot penetrate dermis

Tocopherols and tocotrienols
Primary preventing lipid oxidation and protecting cellular membrane from
free radicals
Shown to in animals

manufactured by the body
after UV radiation
Considered a tertiary antioxidant
ALPHA YDROXY ACIDS S
Found in nature
Include glycolic acid, lactic acid, malic acid, citric acid, and tartaric acid
Glycolic and lactic acid most commonly used in cosmetic preparations
• Glycolic acid, known as the
• Must be neutralized after use

Salicylic acid, a beta-hydroxy acid, is a chemical exfoliant used in over-the-counter

194
Part IV Skin Care

Aid in treating photodamage, hyperpigmentation, and melasma
Also used for treating dry skin, acne, rosacea
SENIOR AUTHOR TIP: Glycolic acid disrupts the ionic bonds in the skin inducing
exfoliation, however it also rapidly penetrates to the dermis causing stinging and
burning. It should be used with care in patients with sensitive skin.
SUNSCREENS
3
UVA radiation is responsible for

UVB radiation causes

TIP: A well-formulated sunscreen should protect against both UVA and UVB radiation.


whitening that can occur.
Sunscreens can prevent photoaging but cannot reverse damage.
BOTANICALS
Primary role as
Three main categories:
• Flavonoids (soy, silymarin)
• Polyphenols (curcumin, green tea)
• Carotenoids (retinol) (Table 14-2)
Common Botanicals


Soy


Silymarin
Derived from milk thistle plant
Decrease formation of pyrimidine dimers in mouse model
Curcumin
Derived from turmeric
A hydrogenated form acts as moisturizer and maintains lipids in
formulation
10,11
Green tea
Decreases formation of pyrimidine dimers12
Retinol
Naturally occurring vitamin A
Topically functions as antioxidant
Cutaneously converted to retinoic acid, which is known to improve
photodamaged skin

Found in fruits and vegetables (tomatoes, watermelon)
Shown to lower oxidative stress
Often found in various eye creams and moisturizers
Grape seed extract
Potent free radical scavenger

195
Chapter 14
OTHER NATURAL INGREDIENTS

• Active constituents include salicylates, magnesium lactate, and thromboxane
inhibitors



Thought to improve elasticity and texture of skin
• Some patients report allergic contact dermatitis, use with caution
Derived from a small bush with citrus leaves


Protects against cellular oxidative damage
TREATMENT OF PIGMENTED SKIN
Regimens should include a cleanser (glycolic acid) followed by tyrosinase-inhibiting
serum/moisturizer (i.e., kojic acid or hydroquinone)
Hydroquinone and kojic acid (derived from and
fungal species), inhibits tyrosinase

melasma
TOP TAKEAWAYS

Cosmeceuticals are cosmetics, which are not regulated by the FDA.

Comprehensive treatment involves cleansing, moisturization, and UVA/UVB
broad-spectrum sun protection.

Petrolatum (oil based) and dimethicone (oil free) are commonly used occlusive
moisturizer ingredients.

Retinaldehyde is a retinol-based cosmeceutical with evidence to support an


UVA radiation is responsible for photoaging, whereas UVB radiation induces
sunburn.
REFERENCES

2010.
2. Babamiri K, Nassab R. Cosmeceuticals: the evidence behind the retinoids. Aesthet Surg J 30:74,
2010.

epidermis: an assessment using a novel 32P-postlabeling technique. Biochem Biophys Res
Commun 229:590, 1996.


1993.
6. Spencer TS. Dry skin and skin moisturizers. Clin Dermatol 6:24, 1988.

196
Part IV Skin Care
7. Duell EA, Derguini F, Kang S, et al. Extraction of human epidermis treated with retinol yields
retro-retinoids in addition to free retinol and retinyl esters. J Invest Dermatol 107:178, 1996.
8. Torras H. Retinoids in aging. Clin Dermatol 14:207, 1996.

20:287, 2011.
10. Maheux R, Naud F, Rioux M, et al. A randomized, double-blind, placebo-controlled study on


Med Biol 595:105, 2007.
12. Katiyar SK, Perez A, Mukhtar H. Green tea polyphenol treatment to human skin prevents forma-
tion of ultraviolet light B-induced pyrimidine dimers in DNA. Clin Cancer Res 6:3864, 2000.

197
People of color are 40% of the population in the United States.1
• Hispanics and blacks are the groups growing in number most rapidly.
Racial minorities receive approximately 20% of all cosmetic procedures.
Unique issues to ethnic skin care can include:2,3
• Restoring uniform pigmentation
• Hair removal
• Acne care
• Skin hydration

• More cell layers in stratum corneum (22 layers in black skin versus 17 in white skin)4
• Increased lipid content
• Increased desquamation
• Decreased ceramide content
Increased photoprotection with darker skin, but also robust response to epidermal/
dermal injury5
TIP: Understanding the subtleties of treating various ethnicities is essential to
maximize results.
PATIENT EVALUATION
Fitzpatrick scale was developed by Dr. Thomas Fitzpatrick, a Harvard dermatologist, in
1975 (Table 15-1).

6




I
Pale white, freckles, blue eyes, blond or red hair
Always burns, never tans
II
Fair white, blue/green/hazel eyes, blond or red hair
Usually burns, minimally tans
III
Cream white, any hair or eye color
Sometimes burns, tans
uniformly
IV
Moderate brown (Mediterranean)
Rarely burns, always tans well
V
Dark brown (Middle Eastern)
Rarely burns, tans easily
VI
Dark brown to black
Never burns, tans easily
TIP:
skinned individuals produce more melanin.

198
Part IV Skin Care
SENIOR AUTHOR TIP: Fitzpatrick skin types are not always accurate presently as many
individuals are now biracial. Persons with an African father and an Irish mother may
have dark skin, but freckle with sun exposure.
Obtain accurate patient history.
Identify natural hydration level of skin:
• Normal
• Dry
• Oily
• Combination
Dark-skinned people can be predisposed to oily or dry skin.7
• Also can have severe reactions to treatment and poor wound healing with

hyperpigmentation
HYDRATION
Darker skin tends to dry and crack more easily and has a higher propensity to develop
acne.
• Associated with
Pigmented skin scale produces ashy appearance, magnifying dry skin problems.
• Drying over-the-counter products should be avoided.

hyperpigmentation after treatments.
TIP: Gentle cleansers and emollient moisturizers smooth skin scale and help to
optimize appearance in skin of color.
DYSCHROMIA
Melanocyte underproduction of melanin
A condition of skin depigmentation from absent melanin production
• Particularly noticeable in people with darker skin, causing emotional distress
• Possible autoimmune condition directed at melanocytes
• Commonly associated with thyroid disorders (Hashimoto thyroiditis), pernicious
anemia, diabetes
• Diagnosis with Wood lamp (black light)

tanning lotions.
Phototherapy, immunomodulators, topical steroids

response resulting in increased pigmentation
Skin-lightening agents suppressing melanin production by inhibiting
tyrosinase
• Hydroquinone typically used in concentrations of 2% over-the-counter or 4%
prescription strength
• Irritation and contact dermatitis common complications
• Commonly used pigmentation inhibitors listed in Table 15-2

199
Chapter 15 Ethnic Skin Care
SENIOR AUTHOR TIP: Infrared A is the source of heat from the sun, but may also
induce hyperpigmentation, especially in individuals of higher Fitzpatrick skin type. Thus,
persons with hyperpigmentation should also avoid heat exposure.
Commonly Used Pigmentation Inhibitors


Hydroquinone
Inhibits tyrosinase by inhibiting DNA and RNA synthesis
Kojic acid
Chelates copper bound to tyrosinase rendering it inactive
Azelaic acid
Naturally derived from grain products and by oxygenation of oleic acid
Cytotoxic to melanocytes

Suppresses formation of melanocytes
Retinoids
Inhibits tyrosinase activity
Arbutin
Found naturally in cranberries
Inhibits melanosome maturation

ACNE
Darker-skinned individuals have 8

• More likely to keratinize and form comedones
• Can give appearance of skin irritation
• Commonly seen on face, back, shoulders, upper chest
• Nodules and cysts can form, which can be complicated by keloid or hypertrophic
scar formation
Major goal is to
• Early intervention needed


retinoid, benzoyl peroxide
Commonly used agents are listed in Table 15-3.
Commonly Used Agents in Treating Acne in Ethnic Skin


Kojic acid
Fungal-derived antibacterial
Patch test because of possibility of contact dermatitis

Promotes desquamation of stratum corneum and inhibits tyrosinase
Increases water content of epidermis (humectant)
Azelaic acid

Retinoids
Vitamin A family
Normalize follicular keratinization
High risk of irritation associated with retinoic acid prevented with retinol



Salicylic acid

Penetrates sebaceous plugs
Minimal risk of topical irritation

200
Part IV Skin Care
SUNSCREEN
Role of sunscreen in preventing skin cancers is important in skin of color.

dioxide, but these inorganic sunscreens can cause skin whitening in skin of color.
SENIOR AUTHOR TIP: Organic sunscreens take solar radiation and transform it to heat
thereby preventing skin damage. However, heat can trigger a variety of skin conditions,
including rosacea. Inorganic sunscreens are a better choice in persons with rosacea.
HAIR REMOVERS
Use is higher in blacks because of
Hair removers, or chemical depilatories, cause
bonds and

Most common active ingredients are and

Blacks typically require stronger ingredients because of the coarseness of their hair;
therefore the following ingredients are used:


• Potassium hydroxide
• Sodium hydroxide
TIP: Chemical depilatories can be very irritating, inducing postinflammatory
hyperpigmentation in skin of color.
SOFT TISSUE FILLERS

injection in those with lighter complexions.
TOP TAKEAWAYS

Unique issues to ethnic skin care can include restoring uniform pigmentation,
hair removal, acne care, and skin hydration.


light.

Vitiligo is a condition of skin depigmentation from melanocyte dysfunction.



Darker-skinned people are less likely to develop nodulocystic acne, but their skin
is more likely to keratinize and form comedones.

9

Black patients typically require stronger ingredients for hair removal because of
the coarseness of hair.

201
Chapter 15 Ethnic Skin Care
REFERENCES
1. American Society for Aesthetic Plastic Surgery. 2013 Cosmetic Surgery National Data Bank.
Available at
2. Berardesca E, Maibach HI. Sensitive and ethnic skin. A need for special-skin care agents? Der-
matol Clin 9:89, 1991.
3. Cole PD, Hatef DA, Taylor S, et al. Skin care in ethnic populations. Semin Plast Surg 23:168,
2009.

1979.

permeability barrier function. Arch Dermatol 131:1134, 1995.
6. Odunze M, Cohn A, Few JW. Restylane and people of color. Plast Reconstr Surg 120:2011, 2007.
7. Montagna W, Prota G, Kenney JA Jr, eds. Black Skin Structure and Function. San Diego: Aca-
demic Press, 1993.
8. Weigand DA, Haygood C, Gaylor JR. Cell layers and density of Negro and Caucasian stratum
corneum. J Invest Dermatol 62:563, 1974.
9. Taylor SC. Utilizing combination therapy for ethnic skin. Cutis 80(1 Suppl):15, 2007.

(Trang không có chữ)

PART V
Noninvasive and Minimally
Invasive Therapy

(Trang không có chữ)

205
PHYSICS OF LASERS1
COMPONENTS OF LASERS


• Can be (crystal as in YAG and Ruby lasers or semiconductor as in diode laser),
(helium-neon laser)
• Determines the wavelength of the light emitted by the laser


MECHANISM OF ACTION
Energy is transmitted from the excitation mechanism to the medium.
Electrons in the medium are excited to a higher-energy state.
As the electrons fall back to their baseline state, they release a photon.
Photons result in waves of light (energy) that can exit the medium to provide a uniform
wavelength of light or that can hit an adjacent electron to further excite the medium
and amplify the energy.

The exiting mirror can be manipulated so that only photons that hit it exactly
perpendicular may exit, creating coherent waves that move in phase.
NOTE:
shutters open, releasing the entire cavity at once. Q-switching creates very high powers.
PROPERTIES OF LASER LIGHT
In phase
Monochromatic
Coherent
EFFECT ON TARGET







• The less target in the medium, the more the light will be transmitted through the

206
Part V Noninvasive and Minimally Invasive Therapy


• Energy converted to thermal energy in target chromophore
or with extremely high energies and short-wavelength Q-switched
lasers, which generate acoustic energy

• Heat can transmit to surrounding tissues and cause a wider zone of damage if the
principles of selective photothermolysis are not followed.
CHARACTERISTICS OF LASERS


• Within the visible light spectrum (approximately 400-750 nm), the longer the
wavelength, the deeper the penetration.

• Continuous: More likely to cause

• Short pulses (nanoseconds), as in Q-switched laser

• Smaller spot sizes have more scatter and may therefore not reach the dermis.

Beam shape
• Most lasers have a Gaussian distribution of intensity within the beam (lower
intensity along the periphery).
• Therefore some overlap between treatment zones is needed.
Allows protection of the epidermis while heating the deeper targets
in the dermis
Duration of time tissues are exposed to the laser
Energy delivered per surface area (J/cm2)
Time for tissues to lose 50% of their heat
MAJOR TYPES OF LASERS
ABLATIVE LASERS see C
Chromophore is
Vaporize the epidermis and possibly part of the dermis

injury
Have a and than nonablative lasers
Erythema longer than nonablative and is depth dependent

Most commonly used ablative lasers: CO2 (10,600 nm) and the
(2940 nm)
NONABLATIVE LASERS
Spare the epidermis and cause thermal damage in the
• Collagen is denatured when heated to 60°-70° C, stimulating

207
Chapter 16


2
Skin tightens, and irregularities decrease.3
TIP: Although nonablative lasers allow skin rejuvenation with minimal downtime, their

FRACTIONAL LASERS
Coagulate columns of tissue in regularly spaced arrays, while sparing intervening tissue

2

15%-40% of the skin area coagulated with every treatment session
NOTE:


Spare the stratum corneum4 and epidermis if settings are appropriate
OTHER RESURFACING MODALITIES
INTENSE PULSED LIGHT

Wavelengths range from 500-1200 nm.

rep rate, and pulse duration. Familiarity with the system used is essential to achieve
optimal results and minimize complications.
MONOPOLAR RADIOFREQUENCY
Radiofrequency waves have a much longer wavelength than laser light.
As the polarity of the current within the capacitive coupled electrode changes at high
frequency, electrons in the tissue change direction rapidly.

The amount of heat generated depends on the tissue’s impedance and the energy
delivered.
Collagen heated to 60°-70° C denatures, and new collagen forms over 6 months.
INDICATIONS AND CONTRAINDICATIONS
INDICATIONS
Mild to moderate static rhytids
Acne scars
Immature burn scars
Atrophic scars
Dyschromia (solar lentigines, melasma)5
Skin hypervascularity (telangiectasias, rosacea)

208
Part V Noninvasive and Minimally Invasive Therapy
Undesirable tattoo
Undesirable hair
CONTRAINDICATIONS
Unrealistic expectations
Collagen vascular disease
History of wound-healing problems
Immunologic skin condition (such as vitiligo)
Pregnancy (higher risk of hyperpigmentation)
Isotretinoin use within the past 12 months6
History of photosensitivity or recent use of photosensitizing drug
Tattoo containing gunpowder


Skin cancer
Fitzpatrick IV-VI skin type with laser wavelengths in the visible light spectrum

• Pigment may paradoxically darken with laser treatment.7
NOTE:

8
PREOPERATIVE EVALUATION
HISTORY
Wound-healing problems
Scarring problems
Family history of wound-healing problems or excessive scarring
Recent medication use
Of most importance is a which is the most common cause
of complications when treated with a laser using visible light.
Patient expectations
TIP: Clarification of patient expectations preoperatively is essential for patient
satisfaction.
PHYSICAL EXAMINATION

(Table 16-1)

hyperpigmentation with laser.

erythema.

209
Chapter 16




I
Pale white, freckles, blue eyes, blond or red hair
Always burns, never tans
II
Fair white, blue/green/hazel eyes, blond or red
hair
Usually burns, minimally tans
III
Cream white, any hair or eye color
Sometimes burns, tans uniformly
IV
Moderate brown (Mediterranean)
Rarely burns, always tans well
V
Dark brown (Middle Eastern)
Rarely burns, tans easily
VI
Dark brown to black
Never burns, tans easily

Fine wrinkles
Fine to moderately deep wrinkles, moderate number of wrinkle lines
Deep wrinkles, numerous wrinkle lines, redundant folds










SENIOR AUTHOR TIP: Bleaching agents like hydroquinone should not be used for
patients with Fitzpatrick III and higher skin types.

aggressive treatments.
Patients with Fitzpatrick skin types IV and higher are at increased risk of hyperpigmenta-
tion with most nonablative and ablative lasers.
PREPARATION FOR TREATMENT
Pretreatment
• Hydroquinone 4% and tretinoin 0.05% 4-6 weeks pretreatment

• Discontinue oral isotretinoin (Accutane) products 6 months to 1 year before
treatment because of increased risk of scarring.
Prophylaxis
• Antivirals 48 hours before and 7-10 days after in all patients undergoing ablative
treatment, and in patients with a history if undergoing nonablative treatment

210
Part V Noninvasive and Minimally Invasive Therapy
MEDICATIONS
Herbal supplements that may increase bleeding time and should be discontinued
2-3 weeks before treatment
Arnica, danshen, feverfew, garlic, ginger, Ginkgo biloba, kava, licorice, St. John’s wort,
vitamin E
•


thromboembolism)

moderate to high risk

PRETREATMENT
Antiviral therapy for herpes simplex
Acyclovir 400 mg by mouth three times per day, famciclovir 250 mg by mouth twice
per day, or valacyclovir 500 mg by mouth twice per day for 1-3 days before treatment
until reepithelialization at 5-14 days
BACTERIAL INFECTIONS
Dicloxacillin or azithromycin may be prescribed if history of bacterial infections of the
face
1g cefazolin intraoperatively
Chlorhexidine face scrub
Intranasal mupirocin
ANTIFUNGAL

postoperatively to prevent cutaneous candidiasis
Controversial because of the low risk of infection

INFORMED CONSENT
TIP:
Patients must understand that nonablative resurfacing methods do not have the same

Patients must understand that to
especially with nonablative treatments.

• Unsatisfactory result
• Prolonged erythema
• Prolonged edema
• Hypopigmentation

211
Chapter 16
• Hyperpigmentation
• Scarring

Alternative procedures include:
• Chemical resurfacing
• Dermabrasion
TOP TAKEAWAYS


to resurface the skin.



Skin treatment, both before and after laser resurfacing is an important
component to a successful result.
REFERENCES
1. Atiyeh BS, Dibo SA. Nonsurgical nonablative treatment of aging skin: radiofrequency

33:283, 2009.

Nd:YAG laser therapy in the treatment of acne vulgaris. J Am Acad Dermatol 56:432, 2007.
3. Friedman PM, Skover GR, Payonk G, et al. Quantitative evaluation of nonablative laser
technology. Semin Cutan Med Surg 21:266, 2002.
4. Cohen SR, Henssler C, Johnston J. Fractional photothermolysis for skin rejuvenation. Plast
Reconstr Surg 124:281, 2009.

a report of eight cases with long-term follow-up. Dermatol Surg 36:1273, 2010.
6. Rubenstein R, Roenigk HH Jr, Stegman SJ, et al. Atypical keloids after dermabrasion of patients
taking isotretinoin. J Am Acad Dermatol 15:280, 1986.

8. Alster TS. Q-switched alexandrite laser treatment (755 nm) of professional and amateur tattoos.
J Am Acad Dermatol 33:69, 1995.

212

of a scalpel. They originally used a continuous wave CO2 laser. As technology advanced,
high-energy pulsed CO2
tissue with minimal residual thermal damage (RTD). This resulted in improvement of many
signs of photoaging, scars, and lesions on the skin. Throughout the years, newer laser
technologies have been developed to include erbium:yttrium aluminum garnet (Er:YAG)
lasers and fractional lasers. The goals of all these devices are to eliminate or reduce
sun-damaged collagen and encourage new collagen deposition and remodeling through a
combination of tissue vaporization and collagen denaturation.
EQUIPMENT
ABLATIVE CARBON DIOXIDE 2 ASER
wavelength
Target chromophore:


Visible helium-neon laser is projected on the skin to show the targeted treatment area.
Produces and 1-3
• Pulse duration must be <1 millisecond to prevent residual thermal damage (RTD) to
surrounding tissue.
• 5 J/cm
1
• ~ 20-30 µm of ablative tissue penetration per J/cm 1
between the number of passes and depth of tissue
ablation


4

• 70-120 µm area of RTD
• Surface temperatures reach 120°-200° C
CO2
• Produces dramatic results but requires a longer healing time because of deeper RTD
compared with erbium

results require up to 6 months.
1-3




pattern of up to 80 pulses with a 2.25 mm spot size

Darrell Wayne Freeman, Molly Burns Austin, Alton Jay Burns

213
Chapter 17
• Scanned



diameter and performs the ablation.

ABLATIVE ERBIUM:YTTRIUM ALUMINUM GARNET R 1
wavelength
Chromophore:
2 laser (12,000 cm )
Produces and than CO2
lasers1
• 1-3 µm of ablative tissue penetration per J/cm2
• 5-30 µm area of RTD
• Produces 1-50 mJ/ cm2 of energy in 300 microseconds to 10 milliseconds
• 2-7 mm collimated or focused spot size

healing times, or it can be much more aggressive and ablative than CO2 with less

as needed).





secondary collagen deposition); however, the RTD never reaches that of CO2
mode (tunable erbium)
5
• Most versatile ablative laser

usually require repeat treatments
• Can produce the deepest of all wounds because of the extremely high ablation
threshold of 5 J/cm
2
• Excellent results possible with even the deepest rhytids
2, even for the same
depths (5-20 nm residual thermal damage [RTD], compared with 70-120 µm RTD
for CO2)
ABLATIVE FRACTIONAL LASERS
CO2, Er:YAG, and yttrium scandium gallium garnet (YSGG) models available

depths.
Produces with surrounding layer of
denatured collagen heated to 55°-62° C for optimal long-term collagen deposition/
remodeling

2

214
Part V Noninvasive and Minimally Invasive Therapy
• Settings relate to laser used and desired target (dyschromia, pores, rhytids).
• The deeper the ablation depth, the greater zone of coagulation and denatured
collagen.
• Decreased postprocedure erythema and complications
• Complete healing and reepithelialization by 1 week
9
• For more aggressive treatments, erythema may last up to 6-8 weeks.

• Multiple treatments are needed, because only a fraction of the skin is treated per
session.
• Open wounds last 3-4 days, with erythema lasting 2-8 weeks for aggressive
treatment protocols.

5
TECHNIQUE
SAFETY ASER INSTITUTE, OCCUPATIONAL SAFETY
American National Standards Institute (ANSI)10 provides policies for laser safety.
Occupational Safety and Health Administration (OSHA)11 provides oversight.
Proper documentation of safety training is required for all perioperative personnel.

engineering controls.

for eyewear, and have limited access by trained personnel.
Windows must be covered with appropriate opaque material.


extinguishers
Smoke evacuation to remove laser plume

MARKINGS
Each aesthetic unit to be treated is outlined.

Full-face treatment gives best blend but is not always indicated.
ANESTHESIA
therefore, when treating
areas not easily blocked by local anesthesia, general anesthesia may be indicated for
more aggressive settings. Patient preference for comfort is also a consideration.


before procedure
benzocaine, 6% idocaine, and 4% etracaine)

12
• Cold-air cooling
NOTE:

215
Chapter 17

including central forehead, cheek, nose, upper and lower lips
• 1%-2% lidocaine with 1:100,000 or 1:200,000 epinephrine

• 2% lidocaine with 1:100,000 epinephrine, 0.5% bupivacaine, 1:10 8.4% NaHCO3, and
75 U hyaluronidase
• Or, equal parts of 1% lidocaine with 1:100,000 epinephrine and 0.5% marcaine with
1 ml hyaluronidase for every 9 ml local anesthesia
4% articaine hydrochloride
• Supraoribital nerve
• Supratrochlear nerve
• Infraorbital nerve
• Maxillary nerve
• Mandibular nerve
• Mental nerve

• Three drops of 0.5% proparacaine ophthalmic solution to each eye before
application of lubricated eye shields

• Kessels et al14 reported using 0.11% solution of 500 ml lactated Ringer solution,
20 ml 1% ropivacaine, 20 ml 2% xylocaine, and 0.5 ml epinephrine
• Minimum of 6 ml/kg
CAUTION:



• 10 mg diazepam 30 minutes before procedure

• 100 mg meperidine 30 minutes before procedure
• 25 mg hydroxyzine 30 minutes before procedure

4
• Propofol 1-2 mg/kg loading dose, 4-8 mg/kg/hr continuous infusion
• Midazolam 0.05-0.1 mg/kg
• Fentanyl 50-100 µg
• Ketamine 10-20 mg (must administer glycopyrrolate 0.2 mg, propofol, and


TIP: Adding NaHCO3 to the local anesthesia to the lateral face neutralizes the pH,

TIP: A wetting solution of 0.1% lidocaine and 1:1,000,000 epinephrine anesthetizes
the cheeks.
TIP: All procedure rooms need adequate ventilation systems, smoke evacuators, and
laser protective masks to control toxic gases from the laser plumes.

216
Part V Noninvasive and Minimally Invasive Therapy
TIP: Surrounding the treatment area with saline-soaked towels helps to prevent an

TIP: Safety glasses do not protect against direct laser exposure.
CARBON DIOXIDE 2 ASER TECHNIQUE
• Resurfacing begins by ablating tissue in the treatment area in a
manner and only once.


as the papillary dermis is exposed.
• A second pass is performed in a manner.

completely dried.
and the dermis will contract.
to achieve optimal
results.




• Additional laser treatment may be applied to deep rhytids to soften transition zones.

necrosis and charring of the skin.
CAUTION:


TIP: Water remaining on the skin surface during laser treatment may block dermal
penetration.
TIP: Applying a single pass of Er:YAG at the conclusion of CO2 treatment removes
debris and decreases reepithelialization time.
ER:YAG LASER TECHNIQUE1
Resurfacing begins by ablating tissue in the treatment area in an manner
by free hand or a scanner.
NOTE:



This is
unequivocally false. The erbium laser can penetrate deeply if an adequately powered
system is used.

217
Chapter 17
2; therefore it ablates dermis much
more readily than CO2.
• If no coagulation is used, then the endpoint is the bleeding pattern common with

larger bleeding spots that are less dense imply reticular bleeding.
• The proper endpoint is

CAUTION:

visible when a short-pulsed laser is used but may
be seen with a variable-pulsed laser, which increases dwell time and coagulation
with increased pulse widths.


dressing like Flexzan is applied.
POSTOPERATIVE CARE


• CO2
4,15-19

Pharmaceuticals), hydrogel 2nd Skin (Bionet), plastic mesh N-Terface

– Exudate buildup through perforations is removed with normal saline
solution.
– Meticulous wound care with frequent dressing changes minimizes
increased risk of infection with occlusion.

– More expensive than open wound care
– Improved patient comfort

infection


soaking for 20-30 minutes every 2-3 hours while awake
– Frequency of soaks decreased to every 3-4 hours while patient is
awake, and a petroleum-based ointment is applied after soaks until
reepithelialization
– After reepithelialization, transition from soaks to gentle cleansing and
application of a mosturizer and sunscreen


postoperatively for 20-30 minutes every 2-3 hours
– Removes exudate buildup
– Minimizes edema

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Part V Noninvasive and Minimally Invasive Therapy



their face by allowing certain areas to dry out, or may abrade wound


20




Continuation of antiviral therapy
Dicloxacillin or azithromycin if the patient has a history of bacterial infections
Pain control: Acetaminophen or oxycodone

• Application of a bleaching mixture containing 2% hydroquinone and 15% glycolic
acid; or Klingman regimen consisting of 5% hydroquinone, 0.1% tretinoin, and 1%
dexamethasone
21

required, but more expensive
• Sunscreen

reepithelialization.

22 suggested sunscreen containing licochalcone-A and


• Avoidance of sunlight
TIP: Avoiding antibiotic ointments such as mupirocin, bacitracin, and bacitracin-
polymyxin B helps to prevent dermatitis.
COMPLICATIONS
CO2







SENIOR AUTHOR TIP: Usual signs of infection are not present without epithelium;
therefore a multimodality approach is often initially indicated with post-laser/pre-
epithelium infections.

1,27,28


photodamaged skin

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Chapter 17

photodamaged skin to soften the transition between the treated and
untreated areas

1


be attempted





29,30


23








SENIOR AUTHOR TIP: Care is needed when treating areas that have decreased
skin appendages that are usually helpful in reepithelialization (e.g., extensive and
comprehensive laser hair removal, electrolysis, and Accutane).

31





4)

2




reepithelialization
14


• Edema

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Part V Noninvasive and Minimally Invasive Therapy



SENIOR AUTHOR TIP:
because this may be a sign of a complication such as infection or deeper injury.

2,31





23

ER:YAG

• Hypopigmentation33

• Prolonged erythema

• Edema
• Hyperpigmentation

FRACTIONAL ABLATIVE LASER
Erythema
• Short-term 100%


Edema 82%-100%
Flaking 60%

Pruritus 37%

OCULAR DAMAGE AND BLINDNESS
Protective eyewear with appropriate optical density (OD) for everyone present in the
treatment area
Protective eye shields for patients
FIRE

All makeup should be removed.
Alcohol prep and skin cleansing solutions are allowed to completely dry.