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From Flashcardlet > KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Non-operative facial rejuvenation. > Flashcards

KEY NOTES CHAPTER 9: AESTHETIC SURGERY - Non-operative facial rejuvenation. Flashcards

0
Q

What are the aims of resurfacing procedures?

A

Remove superficial layers of skin to treat:

  • photo-ageing.
  • fine lines and wrinkles.
  • pigmentation: freckles and melasma.
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1
Q

What are the methods of non-operative facial rejuvenation?

A

Ablative, non-ablative, injectables.

  1. Lasers
  2. Pulsed light
  3. Dermabrasion
  4. Chemical peels
  5. Radiofrequency
  6. Ultrasound
  7. Botulinum toxin
  8. Soft tissue fillers
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2
Q

What techniques of resurfacing do you know?

A

Chemical peels.
Lasers.
Dermabrasion.

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3
Q

What are chemical peels?

A
  • Inflicts chemical burn on skin in a controlled manner.
  • Superficial sun-damaged and pigmented skin is removed leaving skin with more even texture and colour.
  • Classified according to depth of action.
  • Requires pretreatment
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4
Q

What are superficial peels?

A

e.g. alpha hydroxy acids (glycolic, lactic) - needs neutralisation with Na bicarbonate at end of procedure.
e.g. beta-hydroxy acids (salicylic acid).
Jessner’s solution (Resorcinol, salicylic acid, lactic acid, ethanol)

  • exfoliation up to basal layer.
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5
Q

What are medium peels?

A

e. g. TCA 20-35% (trichloroacetic acid).
- peel at epidermal-papillary dermal level.
- mild burning felt.
- desquamation lasts 5-7 days.
- depth determined by ‘frosting’ (coagulation of keratin).

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6
Q

What are deep peels?

A

e. g. TCA 45-50%, Jessner’s soln and TCA, Phenol, Phenol and croton oil (Gordon-Baker formula).
- peel to reticular dermis.
- severe burning sensation, may require sedation.
- re-epithelialisation by 14days.
- erythema may persist for months.

Phenol: require cardiac monitoring. Detoxified in liver and excreted by kidneys.

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7
Q

What are the risks of chemical peels?

A
  • Hyper and hypopigmentation.
  • Infection (Staph, Strep, HSV).
  • Scarring
  • Recurrence: must use high factor sunscreen for minimum 6 months.
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8
Q

What resurfacing lasers do you know of?

A 
Ablative lasers.
e.g. CO2, Er:YAG 
- create wound to dermal level.
- fine and deep lines.
- acne and acne scars.
- telangiectasia.
- actinic keratoses.
'Fractional laser' hand piece: delivers laser energy in many tiny columns rather than a single beam. Avoids confluent epidermal damage. Faster recovery.

Non-ablative lasers

e. g. long pulse PDL, KTP, Er:YAG, diode lasers.
- heats dermis, leaving epidermis intact.
- mild to moderate lines.

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9
Q

What is dermabrasion?

A
  • mechanical removal of superficial skin layers with rotating hand piece
  • promotes reepithelialization with new collagen deposition.
  • Fine perioral rhytids, superficial acne scarring, minor skin tightening.
  • re-epithelialise in 10 days
  • hypopigmentation in 10-20%
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10
Q

What is microdermabrasion?

A

Microdermabrasion uses a handheld, particle-containing device (Aluminium oxide or NaCl) applied to skin to produce a superficial injury to epidermis .
The particle flow rate and strength of the suction control the depth of penetration.
Can improve rough skin, texture irregularities, acne scarring, and mottled pigmentation. fine rhytids inconsistent.

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11
Q

What are the other non-ablative skin tightening procedures?

A 
Radio frequency (Thermage)
Ultrasound
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12
Q

What is an ideal filler?

A
  • Safe and nontoxic
  • Nonallergenic
  • Easy to use
  • Minimal downtime
  • Predictable
  • Potentially reversible
  • Ages appropriately with the patient
  • Nonpalpable
  • Readily available
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13
Q

What are the different types of injectable fillers?

A

Classification: temporary / permanent.

  1. Autologous materials e.g. fat, dermis, fascia, cartilage, laViv: patient’s own cultured fibroblasts.
  2. Biologic e.g. collagen and hyaluronic acid.
  3. Synthetic:
    Semipermanent e.g. Ca hydroxyapatite (Radiesse), poly-L-lactic acid (Sculptra).
    Permanent: Polytetrafluoroethylene (PTFE) and polymethylmethacrylate (Artefill)
  4. Off-label
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14
Q

Please elaborate on autologous fat grafts.

A
  • can be injected under skin for soft tissue augmentation.
  • e.g. infraorbital hollow, malar region, angle of mandible, anterior or posterior jaw line, chin, nasolabial fold, supraorbital and temporal region.
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15
Q

What are the principles of Coleman’s technique on structural fat grafting?

A

• Fatty tissue is more fragile than most other human tissues and is damaged easily outside the body by mechanical insults. • To survive harvesting, transport, and implantation with cannulas and syringes, fat must be harvested in intact parcels, small enough to be inserted through a small cannula but large enough so that the tissue architecture is maintained. • Fat is living tissue that must be in close proximity to a nutritional and respiratory source to survive. • Placement by keeping the fat parcels separate from one another promotes longevity and stability. • It is essential to maximize the contact surface area of each fatty tissue parcel with the surrounding host tissues for successful integration and anchoring of newly placed tissue. • Whenever possible, incisions are placed in wrinkle lines, folds, or hair-bearing areas to facilitate placement of the fat grafts in at least two directions when indicated. • To strengthen bony or underlying support, the fat can be layered against bone or cartilage in the deeper levels. • To support the skin, fat is layered immediately under the skin. • For filling and plumping or restoring fullness, tissues are placed in the intermediate layers between skin and the appropriate underlying layers.

16
Q

Describe Coleman’s technique.

A
  • Harvest with Coleman 14-gauge harvesting cannula or a Lambros 3 mm cannula, 10-20 cc syringe held at 1-2 cc of negative pressure.
  • Centrifuge for 1 min at 1500 RPM to remove blood, oil, and local anaesthetic
  • Fat has memory and will gain lose volume with patient.
  • Fat should be deposited with 1mm syringes as 0.1ml micro parcels per pass.
17
Q

What is a hyaluronic acid filler?

A
  • a normal component of ground substance responsible for dermal hydration (absorbs water and expands after injection).
  • a linear polysaccharide of repeating disaccharide units of N-acetylglucosamine and N-acetyl-glucuronic acid.
  • no immunologic activity (NO SKIN TEST REQD).
  • injections are painful: use LA.
  • massage immediately if lumps appear.
  • do not overfill.
18
Q

What factors should be considered when choosing an HA filler?

A 
Largest particles (Perlane, Juvederm Ultra Plus): deepest dermal layer.
Midsized particles (Restylane, Juvederm Ultra): mid-dermis.
Smallest particles (Restylane fine lines): dermo-epidermal junction.

Belotero Balance: midsize particles formulated to create a low-viscosity product that can be injected at the middle dermis or dermal-epidermal junction.

19
Q

What is the aftercare?

What are the potential complications?

A
  • Lasts 6-9mths, with longer lasting effects and less volume with each subsequent dose.
  • Erythema (Rx topical steroids), edema 3-5 days (cold compresses for 24hrs), ecchymosis (~1.5wks), and acneiform dermatitis.
  • Telangiectasia
  • Abscesses: drain with 18-gauge needle.

Intralesional hyaluronidase injection is used for reversal in overcorrection, asymmetries, nodules, and compressive vascular compromise.

20
Q

Tell me about Poly-L-Lactic acid (Sculptra aka New-Fill)

A
  • synthetic polymer that is biodegradable, biocompatible, and immunologically inert.
  • approved for deep facial rhytids and folds, and volume restoration of HIV lipoatrophy, INJECTED DEEPLY.
  • no skin test required.
  • causes inflammatory tissue reaction, macrophages and fibroblasts cause capsule formation around microspheres, microparticles are broken down by non enzymatic hydrolysis and collagen is formed.
21
Q

How is Sculptra administered?

A
  • Reconstitute and keep agitating
  • 26G needle
  • Multiple criss cross injections, deep dermal subcut or over periosteum
  • Moisturise and massage for 5mins, then ice packs.
  • Daily massage.
  • May require 3-6 sessions, effects last up to 2yrs.

Side effects
- delayed subcutaneous papules, bleeding from injection site, discomfort, erythema, inflammation, ecchymosis, granulation formation, and oedema.

22
Q

What are the complications of injectable fillers?

A

Early

  • nodule formation.
  • localised inflammation / infection (bacterial, HSV).
  • bruising.
  • allergic reaction.
  • technical error: over injection, incorrect plane.
  • intravascular injection or vascular compromise: treat with warm gauze, topical nitrates (vasodilatation), hyalase may disperse a hyaluronic acid filler.

Late

  • migration.
  • skin pigmentation changes.
  • scarring.
  • atrophy.
  • foreign body granuloma.
23
Q

What is botulinum toxin?

A

Exotoxin A-G produced by Clostridium botulinum.

Licensed for:
Type A: Botox, Dysport.
- focal spasticity (CP/stroke).
- blepharospasm.
- hemifacial spasm.
- spasmodic torticollis.

Botox
severe axillary hyperhidrosis, severe migraine prophylaxis.

Azzalure, Bocouture, Vistabel.
- temporary improvement of moderate to severe wrinkles between eyebrows under 65, when severity of the lines have a psychological impact for the patient.

Off-licence use:

  • improvement of head and neck wrinkles.
  • chemical brow lift.
  • paralysis of depressor anguli oris and mentalis.
  • softening of platysmal bands.
24
Q

What is the GMC prescribing guidance?

A
  • should explain to patients use is off-licensed.

- should be after physical examination.

25
Q

What is the mechanism of action of botulinum toxin?

A

Produces chemodenervation of muscle by targeting SNAP/SNARE docking protein complex thus preventing binding and release of acetylcholine at NMJ.

Type A toxin consists of heavy chain and light chain.
Heavy chain binds to presynaptic neuronal cell membranes at NMJ.
Toxin is internalised by endocytosis.
Light chain cleaves SNAP-25 (synaptosomal-associated protein 25), so vesicles can no longer fuse to membrane and neurotransmitter is not released into synapse.

Type B toxin cleaves synatobrevin.

26
Q

How does the toxin take effect?

A
  • 24-72hrs to take effect.
  • 7-10 days to reach peak effect.
  • lasts 12-16 weeks (new nerve sprouts form synaptic contacts).
27
Q

How is Botox prepared?

A
  • Potency is not standardised between different brands (Botox is 3x as potent as Dysport).
  • Botox powder 100U is reconstituted with 1-10ml 0.9% sodium chloride solution (no preservative).
  • 2.5ml in 100U = 4U/0.1ml.
  • Do not agitate.
  • Store at 2-8 degrees C.
  • Recommended to use within 4 hours, but most people store for >1 week (up to 4-6wks).
  • Dysport can be stored at room temperature for 12 months.
28
Q

What doses are needed for botulinum toxin injections?

A

Every patient is different, men > women.

Glabella: 10-30U W, 20-40 M (up to 7 sites).
Frontalis 6-15U W (up to 8 sites)
Crow’s feet - up to 15U per eye (up to 5 sites).

Manufacturer’s recommendation <360U per 3months. (LD50 3000U).

29
Q

What are the complications of Botox?

A
  • pain, bruising, swelling
  • transient headache
  • unwanted effects on adjacent muscles: blepharoptosis, brow ptosis, strabismus, drooling, dysphagia.
  • generalised weakness, tiredness, flu-like symptoms.
30
Q

What are the contraindications for Botox?

A
  • motor neurone disease.
  • myasthenia gravis.
  • Eaton-Lambert myasthenic syndrome.
  • neuropathies.
  • pregnancy and lactation.
  • allergy to ingredients.
  • psychological instability.

Aminoglycoside antibiotics can interfere with NM transmission.

31
Q

What after care instructions do you give your patients after Botox?

A

2 weeks before procedure
- Avoid taking anticoagulants, Vitamin E, Ginger, Ginko, Bilboa, Ginseng, and Garlic pills.

1st 2 hrs
- exercise muscles injected (not absolutely necessary).

< 6-8hrs post-treatment:

  • do not massage
  • keep upright

< 24hrs

  • avoid rigorous exercise, sun/heat, alcohol
  • avoid NSAIDs, can use cold compresses to reduce redness, swelling, headache.

Start noticing effect in 3-5 days,
May take up to 2wks to take effect,
A few wrinkles may return in 2-3 months.
Usually lasts 4-6 months.

32
Q

What are the causes of therapeutic failure for Botox?

A
  • misdirected treatment of state lines (unrelated to muscle contraction).
  • poor injection technique.
  • denatured toxin.
  • primary non-responders (rare: may be caused by undressing, genetics or preformed antibodies).
  • secondary non-responders (up to 15% of repeated users, may require change to Toxin B).
33
Q

What are the Botox face injection sites?

A 
Glabella furrows.
Forehead lines.
Brow lift.
Crow's feet.
Lower eyelid creases.
Bunny lines.
Depressor septi nasi.
Upper lip wrinkles.
Cobblestone chin.
Cheek lines.
Marionette lines.
34
Q

What is the LD50 for Botulinum toxin A for a 70kg person?

A

Calculated mean lethal dose (LD50) = 2700IU.

35
Q

What are the target muscles for glabellar and forehead lines? What doses do you use?

A

Glabellar complex and vertical forehead lines:

  • corrugated supercilli, procerus, orbic oculi.
  • 4-6 injection points
  • 20-30U (F) 30-40U (M)
  • Stay away orbit and direct injections - outside orbital rim.

Horizontal forehead lines:

  • frontalis
  • 4-8 injection points
  • 10-20U / 20-30U
  • Stay 2cm above brow (to avoid ptosis)
  • note brow ptosis before injecting, can alter doses.
  • avoid centralising injections (quizzical look!)
36
Q

How are crow’s feet lines injected?

A

Target: lateral portion of orbicularis oculi
12-30U
2-4 injections per side, 1cm lateral to bony orbit
Snap test: if +ve, patient is at risk of ectropion. Avoid low injections.
Do not inject below zygomatic arch (will cause lip and cheek ptosis due to zygomaticus muscles)
Caution: dry eyes, recent laser eye or blepharoplasty surgery.

37
Q

How are bunny lines injected?

A

Target: nasalis and procerus muscles.
3-6U
3 injections - stay superficial
Do not inject levator labii superioris & alaeque nasi - causes drooping of upper lip.

38
Q

What are the other areas that can be injected with Botox, but with caution?

A

Perioral rhytids
Dimpled chin
Marionette lines
Platysmal bands

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