Chemical peeling of eyelids and periorbital area

Heterogeneous crow's feet line patterns and customized botulinum toxin rejuvenating treatment

BACKGROUND

From early dynamic lines in smiling and squinting young people, crow's feet lines in the lateral canthal region evolve through prolonged tissue remodeling into mature, stable rhytids after the mid-to-late thirties and requests for rejuvenating treatment. Because of the heterogeneous fanning behavior of crow's feet lines, individualizing neuromodulation with botulinum toxin injections might be a sound strategy to maximize aesthetic outcomes.

AIMS

To investigate the prevalence of variable crow's feet line patterns at maximum contracture and while smiling and comment on the relative distribution of such patterns and the influence of ageing. These considerations will be the basis and rationale for future studies that will individualize the total 24-unit dose according to the distribution of crow's feet lines.

METHODS

Identifying CFL orientation at maximum frown and while smiling; assessment tool: the four-class 2015-version of Kane's classification further modified by converting the former "central fan pattern" into a new, more precisely defined "extended full-fan pattern" class.

RESULTS

The 323 cohort subjects had a mean age of 51.5 ± 9.28 years. Although with some differences, outcomes in a central-southern real-world European Caucasian population appear similar to the distribution first studied in 2003 in a highly selected population in New England involved in double-blind clinical trials. The full-fan pattern predominated both at maximum contraction and when smiling, followed in prevalence by the upper-fan pattern at maximum contraction and the extended full-fan pattern while smiling. Age significantly influenced the crow's feet line pattern-lower-fan patterns were more frequent than other patterns in the real-world younger middle-age group (40-49 years old); full-fan and extended full-fan patterns progressively more prevalent with ageing.

CONCLUSIONS

The study confirms but somewhat modifies the previous evidence about the non-homogeneous distribution of crow's feet line fanning patterns in different age groups and reinforces the case to individualize the topography of botulinum toxin injections.

Depth Map for Face and Neck Deep Chemical Peel Resurfacing

BACKGROUND

Chemical peels are applied to the face and neck to improve rhytides and the photoaged appearance of the skin. Peels can be applied to different skin depths depending on the types of chemicals, the volume of solution, and the amount of pressure or friction applied. If a peel is applied too superficially, rhytides will not be removed. If a peel is applied too deeply, scarring or hypopigmentation could occur.

OBJECTIVE

To create face and neck depth maps for chemical peeling, which can guide safety when removing rhytides and improving the skin's appearance.

MATERIALS AND METHODS

A multicenter retrospective review of records was conducted of patients who underwent phenol-croton oil peeling, from January 1, 2018, to December 31, 2018. Information was collected on facial and neck cosmetic units peeled, peel formula and strength used, outcomes, and complications.

RESULTS

A total of 410 patients received deep peels. Two depth maps were created that corresponded to the most common patterns of deep chemical peel applications.

CONCLUSION

Different areas of the face and neck are treated with different chemical peel application depths to safely improve rhytides and appearance. Depth maps are created to balance safety and efficacy.

Autologous fat transfer with in-situ mediation (AIM): a novel and compliant method of adult mesenchymal stem cell therapy

Background

In an attempt to engineer a regulatory compliant form of cell assisted lipotransfer in the U.S., the authors developed Autologous Fat Transfer with In-situ Mediation (AIM) for reconstruction of a refractory surgical scar.

Methods

This method incorporates use of accepted standard procedures like autologous fat grafting and intradermal injection of NB6 collagenase to release adipose stem cells from a naturally occurring high concentration stromal vascular fraction (SVF) fat graft. To prevent off-target effects of collagenase, a hyaluronic acid and serum deactivation barrier is placed circumferentially around the operative site.

Findings

This novel protocol was well tolerated by the patient and improved scar appearance, mobility and texture. Deepest scar contour defect correction was 80% and 77% at 4 and 12 weeks respectively.

Conclusion

AIM appears to be a practical and viable option for scar reconstruction requiring small to moderate volume correction.

Periocular rhytidolysis with the wire scalpel

PURPOSE

: To describe and evaluate a technique for minimization of lateral periocular rhytids ("crow's feet") with the wire scalpel surgical instrument.

METHODS

: Six patients with significant crow's feet were prospectively selected for treatment with the wire scalpel. Preoperative and postoperative photographs were evaluated for severity of crow's feet.

RESULTS

: Significant improvement in the appearance of crow's feet was noted in 5 of the 6 patients.

CONCLUSIONS

: The wire scalpel surgical instrument can reduce the severity of lateral periocular rhytids via minimally invasive subcutaneous dissection.

Treatment of periorbital wrinkles by repeated medium-depth chemical peels in dark-skinned individuals

BACKGROUND

The periorbital region serves as a barometer of chronological and environmental age and, as such, persons often seek its cosmetic rejuvenation.

OBJECTIVE

This study was conducted to determine the efficacy and safety of repeated, medium-depth chemical peels in the treatment of periorbital wrinkles in dark-skinned individuals.

SUBJECTS AND METHODS

A total of 12 subjects (10 women and 2 men) with fine and/or medium-sized wrinkles were included in the study, the ages ranged from 30 to 55 years with a mean of 41.25. Focal, medium-depth peels of periorbital area including crow's foot wrinkles were performed using a combination of Jessner's solution followed by the application of 35% trichloroacetic acid (TCA). The study involved a four-session regimen. To be included in this study, the subject completed at least two peeling sessions, 1 month apart, and returned for follow-up according to the research schedule.

RESULTS

Improvement occurred in 11 of 12 subjects. Marked improvement occurred in four subjects (33%), moderate improvement in three (25%), mild improvement in another three (25%), minimal improvement in one subject (8%), and no response in one subject (8%). There were seven patients with fine and five with medium periorbital wrinkles. For statistical analysis, the no and minimum response groups were categorized as nonresponders. The improvement that ranged between marked to mild occurred in 100% of subjects with fine wrinkles and 60% of subjects with medium wrinkles. Mild side effects appeared in four subjects (33%).

CONCLUSION

It can be concluded that fine and/or medium periorbital wrinkling responds favorably to repeated, medium-depth chemical peels even in dark-skinned individuals with few mild side effects.

Periorbital Ablative and Nonablative Resurfacing

Ablative resurfacing using laser systems for facial rejuvenation, especially in the periorbital areas, has effectively replaced chemical peels. Refined methods yield outstanding efficacy with significantly fewer side effects as compared with the prototypical lasers of decades past. Despite these technologic refinements, the trend toward minimally invasive rejuvenation techniques has placed a substantial emphasis on the many nonablative modalities available to the practitioner. Although the clinical efficacy to date has been less with the nonablative devices, the lack of substantial morbidity has made the devices marketable to a large population of patients despite their modest results at best and highly unpredictable results at worst. Numerous options, ablative and nonablative, are now available for the patient desiring improvement in periorbital rhytids.

Classification of Crow???s Feet Patterns among Caucasian Women: The Key to Individualizing Treatment

One of the most common complaints of aging patients is the appearance of crow's feet lines in the lateral canthal region. Many different treatment methods, including chemical peels, surgical procedures, filler material injections, botulinum toxin injections, and laser resurfacing, have been used for effacement of these lines among aging patients and patients with sun damage. Despite the fact that many scientific articles have been written regarding the treatment of crow's feet lines, the actual patterns of these lines have not been adequately studied or classified. Several different patterns of animation in this area have been observed. These different patterns and their frequencies are described. All crow's feet patterns are not the same, and it follows that treatment of different patterns of crow's feet lines should be adapted to the particular patterns.

Complications of chemical resurfacing

Complications of chemical resurfacing may occur even though a controlled chemical wound has been induced. The surgeon must be totally familiar with the types of peels and the management of postoperative wound care based on the skin type of the patient. A thorough understanding of the concepts involved will enable early treatment and avoidance of permanent sequelae, such as pigmentary dyschromias, infection, or scarring.

Formulation of trichloroacetic acid peeling solution: a bibliometric analysis

Since the beginning of this century, trichloroacetic acid solutions of various concentrations have been used for chemical exfoliation. These solutions have been prepared by using four different formulas. To prepare a 50% solution, for instance, water may be added to 50 g of trichloroacetic acid crystals until 100 ml of solution is obtained (weight-to-volume solution). Alternatively, 50 g of water may be added to 50 g of trichloroacetic acid crystals (weight-to-weight solution), or 50 g of trichloroacetic acid crystals may be solved in 100 ml of water (weight-plus-volume solution). Finally, a saturated trichloroacetic acid solution (or "100% solution") may be diluted by an equal volume of water (dilution). Depending on the method used, these so-called 50% solutions contain 40 to 71 weight-to-volume percentages of trichloroacetic acid. From a review of 120 publications on trichloroacetic acid peeling that have appeared since 1926, it was concluded that the authors of 87 of these publications (73 percent) did not report their formula for the trichloroacetic acid solution. Any one of the four methods was reported to have been used by the 33 authors who did report their formula. Eight of 10 internationally reputed pharmacopeias were found not to include the formula of a trichloroacetic acid solution. Proper evaluation of results and prevention of complications of trichloroacetic acid chemexfoliation is only feasible if both the concentration and the formula of trichloroacetic acid solution are reported by the author. Practitioners who use a trichloroacetic acid solution need to establish that the concentration of the solution they apply corresponds with that of the solution reported in the literature.

Diagnosis and treatment of postoperative complications after skin resurfacing

Chemical peel, dermabrasion, and laser skin resurfacing are alternative methods to achieve skin resurfacing for reconstructive or cosmetic applications. The potential postoperative complications are similar with all of these techniques. These postoperative complications and their therapy are reviewed.

Interaction between bovine collagen and glycolic acid peeling: a proposal of a new protocol

For the past 10 years the alfa-hydroxyacids and the bovine collagen injection have been used for peeling and the correction of multiple skin diseases. Until now, such progressive achievement has occurred in separate parallels just like the indications that have been held distinct. However, the studies carried out in order to clarify the mechanical action of the two substances have shown a common and fundamental denominator: the stimulation of synthesis of the new collagen in the patient's skin. On the basis of these results and the existence of common clinical indications of the use of glycolic acid and collagen, the authors have worked out a protocol involving a combined and contemporary application in progressive steps. They developed the rationales of such protocol and analyzed the results of its application on a number of carefully selected patients for a clinical comparison and on a sample of rats for a histological comparison. They have concluded that the contemporary use of glycolic acid and bovine collagen is a simple and safe method whose synergy action leads to more intense and long-lasting effects than the ones observed in the isolated application of the two substances. The authors have also obtained interesting and significant histological results.

Ultrapulse carbon dioxide laser removal of periocular wrinkles in association with laser blepharoplasty

Removal of periocular wrinkles is a common yet difficult problem. There are many techniques currently available, all of which have some drawbacks. With the advent of new generation ultrapulse carbon dioxide lasers, skin can now be resurfaced successfully with minimal risk and side effects. In our study of 36 patients we assessed the benefit of using ultrapulse carbon dioxide (CO 2) laser to resurface the periorbital skin in association with transconjunctival lower lid CO 2 laser blepharoplasty. We found that 36/36 (100%) patients had good to excellent results. The incidence of side effects was very low. We also found that 2/36 (5.6%) of patients developed mild clinically insignificant hypopigmentation and 1/36 (2.8%) developed mild scarring, which resolved with one injection of triamanalone 10 mg/ml. No patients had hyperpigmentation. In addition, 1/36 (2.8%) patients developed transient ectropion, which resolved spontaneously in 6 weeks. We conclude that ultrapulse CO 2 laser is an excellent method for treating periocular wrinkle lines and can be readily performed in conjunction with a transconjunctival lower lid blepharoplasty.

Complications of blepharoplasty

Although blepharoplasty is a technically straightforward procedure, many postoperative complications may occur. Some of the untoward effects may be only a transient nuisance for the patient, such as mild ocular dryness, whereas other sequelae can lead to severe visual loss. An extensive review of the prevention, diagnosis, and management of complications associated with blepharoplasty is presented.