Retinoic acid and CO2 laser resurfacing

Retinoids: Literature Review and Suggested Algorithm for Use Prior to Facial Resurfacing Procedures

Vitamin A-containing products have been used topically since the early 1940s to treat various skin conditions. To date, there are four generations of retinoids, a family of Vitamin A-containing compounds. Tretinoin, all-trans-retinoic acid, is a first-generation, naturally occurring, retinoid. It is available, commercially, as a gel or cream. The authors conducted a complete review of all studies, clinical- and basic science-based studies, within the literature involving tretinoin treatment recommendations for impending facial procedures. The literature currently lacks definitive recommendations for the use of tretinoin-containing products prior to undergoing facial procedures. Tretinoin pretreatment regimens vary greatly in terms of the strength of retinoid used, the length of the pre-procedure treatment, and the ideal time to stop treatment before the procedure. Based on the current literature and personal experience, the authors set forth a set of guidelines for the use of tretinoin prior to various facial procedures.

Aesthetic surgery of the orbits and eyelids

This article discusses the relevant anatomy, the aging process of the eyelid with periorbital structure, and how to evaluate patients for a proper surgical approach. A description is given of how to achieve an aesthetic balance between the forehead, eyelids, and midface to provide the patient with a natural youthful appearance. The paradigm in oculoplastic surgery has shifted to more conservative eyelid skin, muscle, and fat resection as well as more periorbital soft tissue lift, suspension, and volumization. Recent innovations and developments are discussed as well as the most common complications in eyelid and periorbital surgery.

The effects of retinoids on secondary wound healing: biometrical and histopathological study in rats

OBJECTIVE

A wound healing is a complex process, and the role of retinoids in this process is debated and controversial. In this study, the effect of topical tretinoin and oral acitretin on wound healing process was investigated in full-thickness skin lesions on rat model.

METHOD

A circular full-thickness wound was created by 6 mm punch biopsy on the back side of 32 male rats. The rats were seperated into four equal. The first group was assigned as a control group and was observed with no treatment. The second group was administered dexpanthenol once a day over wound area. In the third group, 0.1% tretinoin cream was applied daily. In the fourth group, 2.5 mg/kg/day acitretin was given daily. Additionally, the biopsies were taken from wounds for the histopathologic examination.

RESULTS

The complete recovery time was remarkably longer in the tretionin group than the control group and the dexpantenol group (p < 0.05). The average complete recovery time was significantly longer in the acitretin group than the control and dexpanthenol groups whereas it was statistically shorter in the acitrein group than the tretionin group (p < 0.05).

CONCLUSION

Based on our findings, topical tretinoin and oral acitretin can delay secondary wound healing, epithelization and angiogenesis.

Vitamins and cutaneous wound healing

BACKGROUND

Vitamins have long been thought to modulate the various stages of wound healing through a variety of proposed mechanisms. Our goal was to investigate relevant studies examining the role of different vitamins in wound healing.

METHODS

MEDLINE, Cochrane Database of Systematic Reviews, and Google Scholar were searched for basic science and clinical studies examining the role of vitamins as adjuncts in wound healing.

RESULTS

Mechanisms of action for each of the vitamins are reviewed. It was suggested by many of the studies that the major vitamins A, C, E, D, K, and B have demonstrated utility as adjuncts in wound care in basic science and clinical trials.

CONCLUSION

There is a vast amount of literature on the effect of vitamins on wound healing at the basic science level. Further understanding and controlled trials will help better understand how to utilize vitamins in wound care.

DECLARATION OF INTEREST

None.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of side effects. Although the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.

Follicular Anatomy of the Anterior Temporal Hairline and Implications for Rhytidectomy

BACKGROUND

Incisions made perpendicular to the hair follicles during anterior frontal hairline brow lifts or forehead shortening procedures help produce an inconspicuous forehead scar. The success of this "hidden" incision relies on the anteriorly directed frontal hairline follicles and their growth vector. The authors hypothesized that a similar incision could be made perpendicular to the hair follicles in the temple region during rhytidectomy. A well-designed anterior hairline beveled incision over the temple would allow for improved leverage during soft-tissue repositioning and a concealed hairline incision in the temple region.

METHODS

Anterior temporal hairline strips 4 cm in length at the level of the lateral canthus were excised from 16 fresh cadavers. Hairline follicles (n = 227) were assessed for direction and angle of growth after appropriate tissue preparation and staining (hematoxylin and eosin). The hair follicle angle was analyzed microscopically as it approached the epidermis.

RESULTS

The anterior temporal hairline follicles were oriented at a mean angle with the epidermis of 16 +/- 3 degrees anteriorly and inferiorly.

CONCLUSIONS

The anterior temporal hairline follicles of the scalp are oriented anteriorly and inferiorly with the epidermis, providing the surgical rational for using a beveled hairline incision angled 30 to 45 degrees to the external skin surface to undercut the distal flap. This incision is perpendicular to and transects the temporal hair follicles during rhytidectomy, permitting hair growth through and anterior to the scar. This modified anterior temporal hairline incision reduces visibility of the scar at the hairline for patients in whom scar show and hairstyle versatility are important concerns.

The effect of topical tretinoin on tissue strength and skin components in a murine incisional wound model

BACKGROUND

Vitamin A derivatives modulate the inflammatory phase in wound healing. Retinoic acid can restore decreased tensile strength and collagen content in steroid- or diabetes-impaired wounds. It is hypothesized that retinoic acid can lead to accelerated healing with improved breaking strength in unimpaired incisional wounds.

MATERIALS AND METHODS

Skin incisions were made in 45 CD-1 mice. The sutured wounds were treated once daily with topical all-trans-retinoic acid 0.1% (n = 15), vehicle ointment (n = 15), or left untreated (n = 15). Skin biopsies at 1-, 2-, and 3-week intervals were examined using hematoxylin and eosin (H&E), Masson's trichrome, and immunoperoxidase staining methods. Wound breaking strength was determined by biomechanical analysis.

RESULTS

Incisions treated with retinoic acid exhibited a significantly reduced breaking strength at week 1 when compared to the vehicle and control group. Histologic examination showed a prolonged inflammatory reaction with abundant deposition of granulation tissue. Despite an increased fibroplastic proliferation in the tretinoin-treated wounds, the production of collagen was diminished.

CONCLUSIONS

Topical retinoic acid does not enhance the healing of unimpaired incisional wounds. The inadequate tensile strength in the early phase of the healing process is possibly the result of an increased dermal inflammatory response and the decreased collagen content. Although these adverse effects disappeared by 3 weeks postwounding, we found no discernible benefit of supplemental retinoic acid in unimpaired wounds.

Modified Temporal Incision for Facial Rhytidectomy: An 18-Year Experience

An 18-year experience with the senior author's temporal incision is expounded. First, the existing sideburn is outlined with a marking pen. A sideburn is designed approximately 2 cm wide and 2 cm long, regardless of the extent of the existing sideburn providing the minimum sideburn. The posterocaudal portions of the newly designed sideburn will correspond to that of the existing dense portion of the sideburn. After dissection and removal of excess skin, the entire vertical portion of the scar will remain within the hair-bearing skin, eliminating the potential for visibility unless preoperatively the sideburn is less that 2 cm wide. There are several advantages to this approach. First, the configuration of the sideburn remains essentially unaltered. Second, the length of distribution for the redundant redraped facial skin is increased in comparison with most other incisions, thus avoiding a dog-ear regardless of the extent of the excess facial skin. Rhytidectomy is more effective because the distance from the incision to the nasolabial crease and the oral commissure is reduced, thereby effectively transmitting the traction forces to these sites compared with the conventional temporal incision that is placed above the ear. In addition, exposure of the surgical field is significantly enhanced by the added ability to rotate the skin flap medially. The potential disadvantage is that the operative time is increased to accommodate meticulous repair of the temporal incision. A slight modification of this incision has been implemented over the past 18 years, placing the anterior vertical incision farther posterior compared with the original report. The horizontal and posterior vertical portions of the incision are positioned at the hairline, resulting in an inconspicuous scar. None of the 125 patients in this latter group required a scar revision compared with 37 (4.28 percent) of 865 patients before this modification. This technique effectively achieves the goal of facial rhytidectomy and maintains a natural appearance without discernible scars for most patients. Patient and surgeon satisfaction with this method has been very high, and consequently, it has been used for almost all patients in the senior author's (Guyuron's) practice.

Tretinoin treatment before carbon-dioxide laser resurfacing: A clinical and biochemical analysis

BACKGROUND

Tretinoin is often prescribed before laser resurfacing in an attempt to enhance results.

OBJECTIVE

We sought to assess the clinical and biochemical effects of preoperative tretinoin use before laser resurfacing.

METHODS

Patients were randomized to apply tretinoin to one forearm and placebo to the other for 3 weeks. Patients' photodamaged forearms were focally treated by carbon-dioxide laser resurfacing. Biopsy specimens were obtained at baseline and various times posttreatment. Real-time polymerase chain reaction technology was used to quantify messenger RNA levels of types I and III procollagen and matrix metalloproteinases-1, 3, and 9. Wounds were assessed for degree of re-epithelialization using a computer graphics-generated template. A colorimeter was used to quantify postoperative erythema.

RESULTS

No substantial differences in either biochemical markers or clinical end points were identified between tretinoin and placebo pretreated forearms.

CONCLUSIONS

We found no evidence of enhanced collagen formation, accelerated re-epithelialization, or quicker resolution of postoperative erythema with tretinoin pretreatment before laser resurfacing.

Techniques for creating inconspicuous face-lift scars: avoiding visible incisions and loss of temporal hair

Patients seeking rhytidectomy desire an improved neckline, jawline, and midface, but rarely at the price of signs that betray a face-lift, namely, visible incisions. We describe our face-lift incisional planning and the rationale behind specific surgical maneuvers for preventing unwanted sequelae. The telltale signs of poorly placed incisions include temporal hair loss, conspicuous scars, an unnatural appearance to the tragus, and a posterior hairline distorsion. Special considerations are given to the male patient and to the salvage of readily visible incision lines from previous surgery.

Laser surgery in dark skin

Although challenging, effective laser surgery in patients with darker skin tones can be achieved despite a higher inherent risk of untoward side effects. While the incidence of undesirable postoperative sequelae has decreased with the development of advanced laser technology and individualized treatment parameters, these risks may never be eliminated completely. Consequently, thorough patient preoperative preparation and education regarding the risks of cutaneous laser therapy will remain an essential component of treatment in darkly pigmented patients. In the future, as more refined laser techniques evolve, the ability to safely and effectively treat these patients will improve.

Hair transplantation in women: treating female pattern baldness and repairing distortion and scarring from prior cosmetic surgery

The role of hair transplantation in men is well established. In women, the procedure is much less common, but has a definite role in the management of female pattern baldness and the repair of alopecic scarring and hairline distortion as a result of prior facial plastic surgery. When performing hair transplantation in women, there are differences in technique from that used in men to consistently achieve excellent results and minimize complications. Over the past 3 years, I have performed 86 hair transplant procedures on women. Most of these cases were for female pattern baldness. The techniques used and typical results are presented herein. When performed properly for the appropriate indications, hair transplantation is an effective procedure with a very high level of patient satisfaction.

Erbium:YAG cutaneous laser resurfacing

The short-pulsed Er:YAG laser system is an excellent ablative tool for cutaneous resurfacing. This system is most efficacious for patients with milder cutaneous involvement, including mild photoinduced facial rhytides, mildly atrophic scars, and textural changes caused by fibrosis and dermatochalasis. The Er:YAG laser cannot achieve the same dramatic clinical and histologic improvements produced with the CO2 laser but does offer some distinct advantages that make it a valuable addition to the laser surgeon's armamentarium. The Er:YAG laser, because of its higher affinity for water-containing tissues, effects a much finer level of tissue ablation. Although erbium laser resurfacing results in decreased postoperative morbidity with a shorter recovery period, it cannot effect the same degree of improvement in photodamaged skin as can the CO2 laser. Excellent results, however, can be achieved with this laser, up to 50% or more overall clinical improvement, in patients with milder photodamage and scarring (Glogau classes I and II). In darker-skinned patients, the Er:YAG laser is often the preferred treatment modality. Continued research in the field has already led to the development of longer-pulsed Er:YAG lasers, which offer a compromise between the CO2 laser and the short-pulsed Er:YAG lasers in terms of clinical benefits while maintaining the safety profile of the traditional short-pulsed system. In addition, many surgeons now use a combination approach with the CO2 and Er:YAG lasers in an effort to maximize collagen contraction in certain areas and limit postoperative morbidity. As more research is conducted within the field of cutaneous resurfacing, newer systems will be developed in the continuing effort to create the ideal laser system--one which ameliorates the signs of photoaging without risk of major side effects or significant postoperative recovery.