Combining manual dermasanding with low strength trichloroacetic acid to improve actinically injured skin

Rejuvenation of the Acne-Scarred Face

Since the 1950s, dermaplaning has been used to improve acne scars. However, global improvement is often limited and remains about 50%. By combining the techniques of subcision, subcutaneous filling, laser shrinkage of collagen, dermabrasion, and excision of acne scars, we hoped to achieve a more pleasing aesthetic result. After preconditioning the skin of 62 patients (ages 17—47, mean age 32; 22 men and 40 women) with vitamin A/glycolic conditioning lotions, a Jessner/TCA peel was performed on the neck and décolletage area. The periorbital areas were also peeled if they were not photoaged. The acne valleys were subcised with a semiblunt needle, and the developed pockets were filled with adipose tissue. Then, the surface skin was vaporized with three passes of a CO2 laser, and the deeper acne scars in the midface region were sanded with a diamond fraise abrasion. Remaining scars were relasered, excised, or both, and sutured or grafted. To facilitate healing, a semiocclusive dressing was used for 5 days, then replaced with an ointment-based moisturizer for another 5 days. After 10 days, a moisturizer–sunscreen was used, followed by a bleaching cream at 15 days, if necessary. Patients were usually back to work in 2 weeks. By combining these multiple modalities of dermal subcision and augmentation, collagen shrinkage, and dermal sanding, dramatic improvement of the acne-scarred face was possible.

The management of postacne scarring

BACKGROUND

Therapeutic intervention for postacne scarring has historically been limited by the considerable morbidity of most treatments for only marginal disease improvement. Within the past decade, however, a greater understanding of the pathogenesis of acne scarring has led to the development of techniques that offer more favorable risk-benefit profiles.

OBJECTIVE

The aims of this article are to highlight a number of newer techniques and to assign their appropriateness to particular grades of acne scarring.

MATERIALS AND METHODS

Current modalities are discussed as they relate to disease process and specific acne scar types. Techniques are presented in order of most effectual therapeutic interventions for defined grades of acne scarring. Acne scarring grades have been described previously in terms of disease load, severity, and lesion morphologies.

RESULTS

A comprehensive discussion of updated therapeutic techniques and their biologic rationales in the treatment of acne scarring is presented. These include targeted interventions of inflammatory and postinflammatory processes, angiogenesis, immunologic processes, dermal and subcutaneous fibrosis, hypertrophy, and keloid scarring.

DISCUSSION

A requirement for developing successful treatments for postacne scarring is a greater understanding of its pathogenesis, variability among afflicted individuals, and the inflammatory mediators and immunology of the scarring process. Many innovative techniques introduced in the past decade attempt to counteract these pathologic processes while keeping the procedural and postoperative risks to a minimum.

Botulinum toxin A adjunctive use in manual chemabrasion: controlled long-term study for treatment of upper perioral vertical wrinkles

BACKGROUND

The treatment of perioral vertical wrinkles is a very common request from female patients as of their 40th decade of life. Actinic damage, cigarette smoking, loss of deep structures volume, sleep positions, orthodontic deformities, and dynamic components have been thought to cause this aesthetic problem.

OBJECTIVE

The objective was to investigate the combination of botulinum toxin type A (BoNTA) pretreatment of the orbicularis oris muscle with manual chemabrasion to increase its clinical efficacy in the therapy of upper perioral vertical rhytides.

METHODS

Twelve women presenting moderate to severe upper lip vertical rhytides were randomized to receive two unilateral BoNTA injections at the vermilion border, 1 week before chemabrasion (35% trichloroacetic acid followed by dermasanding) of the upper perioral cosmetic unit. Wrinkle severity was assessed by two blinded observers at baseline, 30 days, 90 days, 180 days, and 3 years by using a four-point Facial Wrinkle Severity Scale (FWSS).

RESULTS

From Day 90 to Year 3, the BoNTA-injected sides showed smaller grades in the FWSS than control sides (p<.05).

CONCLUSION

Previous injections of BoNTA improve short- and long-term results of chemabrasion in the upper lip region.

Simple things that make a difference in nasal reconstruction

The nose is the most common location for nonmelanoma skin cancer. As a result, nasal reconstruction is a frequent challenge for Mohs surgeons. The esthetic outcome of each nasal repair can be improved by replacing nasal skin with the most similar match, restoring the intricate three-dimensional structure of the nose and applying the principle of cosmetic subunits. This article will present techniques and helpful hints, which are useful during nasal reconstruction to improve the selected repair and enhance the final result.

The Treatment of Hypopigmentation After Skin Resurfacing

BACKGROUND

Hypopigmentation has plagued all methods of skin resurfacing. Whether the physician uses chemical peels, dermabrasion or laser resurfacing hypopigmentation can develop.

OBJECTIVE

To examine the pathogenesis and treatment of hypopigmentation after resurfacing.

METHODS

Areas of hypopigmentation after skin resurfacing were blended in with laser-assisted chemabrasion (LACA). The process begins with preconditioning of the skin with vitamin A/glycolic skin conditioning lotions. Then the area is resurfaced with the LACA. This resurfacing usually requires three to four freeze-sand cycles to remove the areas of hypopigmentation associated with dermal fibrosis. The resurfaced skin is then occluded with a combination of polyethylene/silicone sheeting during the acute phase of wound healing. Ultraviolet photography and histologic examination were used to demonstrate the improvement in dermal fibrosis and hypopigmentation.

RESULTS

The LACA improved areas of hypopigmentation in the 22 cases studied. Under occlusive wound dressings, the melanocytes migrated into the areas of hypopigmentation, and the wounds healed without extensive fibrosis. This produced a blending of skin color.

CONCLUSION

It is possible with skin preconditioning, LACA, and occlusive wound healing to provide for a wound healing environment that blends in areas of hypopigmentation that have developed after previous skin resurfacing.

Chemical peels: their place within the range of resurfacing techniques

The photoaging index has been developed to determine the level of skin rejuvenation required to reduce the visible signs of aging. Minor photoaging is reversed with free-radical avoidance and peeling with a topical skin care regimen consisting of buffing grains, alpha-hydroxy acid normalizing tonics and vitamin A conditioning lotions. The reversal of moderate photoaging requires the addition of light-to-moderate peels using alpha-hydroxy acids combined with microdermabrasion. For the more advanced case the Jessner/trichloroacetic acid (TCA) combination peel (Monheit peel) is used which can be repeated once to twice a year. Laser resurfacing is especially useful to shrink the collagen and produce a 'face-lift bypass'. The phenol peel remains the standard to reverse heavy lines. A new modified formula (Hetter) is used which contains less phenol and less croton oil. Dermabrasion is helpful for removing multiple actinic keratosis. With this combination of skin care, chemical peels, and dermabrasion it is possible to reverse the photoaging index.

Post acne scarring: a review

Historically, post acne scarring has not been well treated. New techniques have been added and older ones modified to manage this hitherto refractory problem. The patient, his or her expectations and overall appearance as well as the morphology of each scar must be assessed and treatment designed accordingly. Upon reaching an understanding of what the pathology of the scar is and where it resides in the skin, the most pertinent treatment for that scar may be devised. Post acne scars are polymorphous and include superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy. The wide variety of new methods includes the latest resurfacing tools such as CO(2) and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous (including fat and blood transfer) and non-autologous tissue augmentation and the advent of tissue undermining has greatly improved the treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males, these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.

Postacne scarring: a review of its pathophysiology and treatment

BACKGROUND

There has been a largely unheralded revolution in the number of techniques that can now be used in the treatment of atrophic postacne scarring. Atrophic scarring is the more common type of scarring encountered after acne.

OBJECTIVE

To illustrate the range of techniques useful in the therapy of postacne scarring, their relative advantages and disadvantages, and their place in treatment.

METHOD

A review of available techniques is used to illustrate the treatment of indented or atrophic acne scars.

RESULTS

The individual architecture of the indented scar must be assessed so that treatment may be designed to maximize its improvement. A variety of new methods now exist, including newer resurfacing tools such as infrared lasers, dermasanding, and others in their infancy such as nonablative resurfacing and radiofrequency methods. A true explosion in autologous and nonautologous tissue augmentation and the advent of tissue undermining and the use of punch replacement techniques has added more precision and efficacy to the treatment of these scars.

CONCLUSION

Atrophic postacne scars may be satisfactorily treated in many patients, but multiple methods are often required to ensure the best results.

Lip rejuvenation

BACKGROUND

The management of the senile lip remains a dilemma. Allogenic fillers often feel unnatural, lip resurfacing is not adequate, and fat transfers may disappear.

OBJECTIVE

To develop a more reliable step-by-step approach to lip augmentation.

METHOD

Lips were divided into types: (1) the simple senile lip that had lost its fullness-treated with fat augmentation; (2) the lip with rhagades-treated with fat augmentation and laser resurfacing; and (3) the duckbill lip-treated with lip advancement, fat augmentation, and laser resurfacing. Tattooing to increase the degree of redness was performed on all types of lips.

RESULT

If there had been a previously full lip, it was possible to rejuvenate the lip by simple augmentation with autologous fat transfer. The average number of fat transfer sessions to generate this pleasing lip was two to three. The lip with rhagades required fat filling, with laser resurfacing to achieve a new contour. The duckbill lip required a lip advancement along with lipofilling and laser resurfacing. All types benefited from lip tattooing.

CONCLUSIONS

It was possible with fat augmentation and/or laser resurfacing to generate a pleasing lip in type 1 and 2 lips. Lip type 3 required a lip advancement along with fat augmentation and laser resurfacing. Lip tattooing accentuated all the lip types.

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.

A history of dermatologic surgery in the United States

BACKGROUND

Dermatologic surgery has a long and distinguished history in the United States.

OBJECTIVE

To examine the specific contributions of American dermatologic surgeons.

METHOD

The medical literature on cutaneous reconstructive and cosmetic surgery for the last century and a half was researched.

RESULTS

Numerous American dermatologic surgeons have had a major impact on scientific and technological discoveries in cutaneous surgery. Dermatologic surgeons have been significantly involved in cutaneous surgery since the second half of the 19th century. Dermatologic surgeons have contributed many important advances to the fields of chemical peeling, cryosurgery, dermabrasion, electrosurgery, hair transplantation, soft tissue augmentation, tumescent liposuction, laser surgery, phlebology, Mohs chemosurgery, cutaneous reconstruction, wound healing, botulium toxin, blepharoplasty, and rhytidectomy.

CONCLUSION

Dermatologic surgeons in the United States have contributed significantly to the history of reconstructive and cosmetic surgery. Dermatologic surgeons have been leaders in advancing this field and are poised to continue in the future.

Management of post-acne scarring. What are the options for treatment?

Post-acne scarring is a very distressing and difficult problem for physician and patient alike. Recently, newer techniques and modifications to older ones may make this hitherto refractory problem more manageable. Options for dealing with post-acne scarring are explored. The patient, his or her overall appearance and the morphology of each scar must be assessed and treatment designed accordingly. To adequately address the patient with scarring, a thorough knowledge of the pathophysiology and anatomy of the different types of scars should be sought. Once an understanding of what the pathology is and where it is occurring is attained, the most pertinent treatment for that scar may be devised. A variety of post-acne scars is produced including superficial macules, dermal troughs, ice picks, multi-channelled fistulous tracts and subcutaneous atrophy. The wide variety of new treatment methods for post-acne scarring includes newer resurfacing tools such as CO2 and erbium infrared lasers, dermasanding and possibly some future techniques such as non-ablative and radiofrequency resurfacing. Dermal and subcutaneous augmentation with autologous and nonautologous tissue augmentation and the advent of tissue undermining have greatly improved treatment of atrophic scars. Use of punch techniques for sharply marginated scars (such as ice picks) is necessary if this scar morphology is to be treated well. One should attempt to match each scar against an available treatment as far as possible. Many of these techniques may be performed in a single treatment session but repeat treatments are often necessary. The treatment of hypertrophic acne scarring remains difficult, but silastic sheeting, vascular laser, and intralesional cytotoxics are interesting developments. Most often occurring extra-facially and in males these distressing scars often require multiple treatments and modalities before adequate improvement is achieved.

New and emerging treatments for photoaging

It is easy to become too busy treating the sequelae of photoaging, actinic keratoses, and skin cancers to discuss prevention adequately with patients. With children, sun-protective measures and sunscreen information should be the main therapeutic intervention. In any young adult with an actinic keratosis or skin cancer, topical and resurfacing treatments should be considered. In older patients with fragile skin and solar purpura, reversal of photodamage can have a positive effect on daily functioning.

Neck rejuvenation by combining Jessner/TCA peel, dermasanding, and CO2 laser resurfacing

BACKGROUND

One of the greatest challenges facing facial cosmetic surgeons today is the simultaneous rejuvenation of the neck and face. Laser resurfacing of the face using the carbon dioxide (CO2) laser or the erbium:yttrium-aluminum-garnet (Er:YAG) laser has enjoyed widespread popularity, but the neck and chest are often avoided. It would be quite helpful to rejuvenate the neck at the same time the face is being resurfaced. This would diminish lines of demarcation and help reduce the signs of aging of the neck. There would be a better match between the new skin of the neck and face.

OBJECTIVE

To develop a safe and effective method to rejuvenate the neck.

METHOD

A step-by-step skin care program was instituted. The patients preconditioned their face and neck skin with vitamin A/glycolic skin conditioning lotions for 6-8 weeks prior to surgery. Following this the chest and neck area was treated with the Jessner-trichloroacetic acid (TCA) peel. Then the middle section of the neck was sanded with 150 grit sandscreen. Finally, the central area was resurfaced with the UltraPulse CO2 laser using reduced power settings. Usually two passes was adequate to shrink the skin of this central section of the neck. A petrolatum-based ointment was applied during the initial 7-day postoperative period. After reepithelialization a sunscreen-moisturizer was used during the day and hydrocortisone moisturizer was applied at night.

RESULTS

The neck skin was able to tolerate this step-by-step skin rejuvenation. The blending from the décolleté area to the hairline produced a rejuvenation without a line of demarcation. There were no examples of scarring in the 12 cases that were evaluated for 6 months. Two cases developed persistent erythema that responded to silicone gel sheeting. Although no patients complained of hypopigmentation, a decrease in pigment was found using special UV photography.

CONCLUSION

It is possible with this gradient, step-by-step method to produce a rejuvenation of the neck. An improved texture of the neck developed without visible scarring.

Disappointing results following resurfacing of facial skin with CO2 lasers for prophylaxis of keratoses and cancers

BACKGROUND

With the development of the short-pulse CO2 laser it was hoped that this resurfacing would prevent recurrent actinic keratoses and basal cell cancers similar to resurfacing with dermabrasion, laser abrasion, and deep chemical peel. However, we have begun to see patients that are developing keratoses and cancers within months following laser resurfacing.

OBJECTIVE

To document the problems of recurrent keratoses and basal cell cancers in patients following CO2 laser resurfacing.

METHODS

Thirty-five patients with extreme sun damage were seen at 3, 6, and 12 months following CO2 laser resurfacing for repeat color and ultraviolet photography and clinical examination to look for erythematous dyskeratotic lesions or papules with pearly borders.

RESULTS

Five of our patients (14.3%) who had undergone recent CO2 resurfacing developed actinic keratoses and basal cell cancers.

CONCLUSION

CO2 laser resurfacing is not as effective as dermabrasion, chemabrasion, and deep chemical peel for the prophylaxis of actinic keratoses and basal cell cancers, especially in Fitzpatrick type I and II patients.

Resurfacing the acne-scarred face

BACKGROUND

: Dermabrasion has been a useful method for the improvement of acne scars since 1953. However, the improvement is often limited. Adjuvant procedures are often necessary to improve results.

OBJECTIVE

: To improve the results of resurfacing the acne scarred face. By combining the techniques of subcutaneous filling, laser shrinkage of collagen, dermabrasion, and excision, we hope to achieve better results.

METHODS

A Jessner/TCA peel is performed on the neck and décolleté area after the skin has been preconditioned with vitamin A conditioning lotions. The acne scars are subcised with a semi-blunt needle, and the developed pockets are filled with adipose tissue. Following this, the surface skin is vaporized with three passes of the CO2 laser, and the deeper acne scars in the mid-face region are sanded with a diamond fraise. Residual scars are excised and sutured. A semi-occlusive dressing is used for 5 days, then replaced with an ointment-based moisturizer. After 10 days, a moisturizer-sunscreen is used, followed with a bleaching cream at 15 days. Make-up may be applied after 14 days.

CONCLUSION

: By combining these multiple modalities it is possible to produce a dramatic improvement of the acne-scarred complexion.

Simultaneous face lifting and skin resurfacing

Although face lifting and skin resurfacing both produce dramatic facial rejuvenations, the simultaneous combination has never been popularized. The development of new methods of lifting and resurfacing may now allow a reevaluation of this combination. The objective was to evaluate the safety and efficacy of this combined face lift and skin resurfacing. The facial skin was resurfaced with a trichloroacetic acid peel or a "short-pulse" CO2 laser and, then, lifted after liposuction and superficial musculoaponeurotic system tightening. A dramatic rejuvenation was produced in these 25 cases. There were no incidents of persistent erythema, pigmentation, hyperpigmentation, or full-thickness flap necrosis. Side effects were the usual sequelae of edema and ecchymoses. The small areas of "dusky" erythema of the skin flaps were no more significant than those after a face lift alone. By following the guidelines developed in this report, the combination of controlled skin resurfacing with face lifting is safe and effective. Other procedures, such as blepharoplasties, can also be added. After one recovery period of 6 to 8 weeks, these patients reported that they looked 15 to 20 years younger. The complexion continued to improve during the 1-year follow-up period.

Small volume fat transfer

BACKGROUND

The use of autologous fat has been advocated for tissue augmentation for over a century. However, this technique remains controversial and many investigators have made suggestions to increase its potential.

OBJECTIVES

To develop a less traumatic method to collect, purify, and reinject fat to obtain more dramatic augmentations for the cosmetic improvement of contours and tissue defects.

METHODS

Fat was collected from the donor site following tumescent infiltration of tissue. A "vented" syringe with an atraumatic Mercedes tip was used to collect the fat and, after washing with lactated Ringers or saline, the fat was transferred to small syringes for controlled injections. Small filaments of fat were placed in multi-layers throughout the area of the defect or area of desired contour change. The unused fat was frozen for a second or third injection session.

RESULTS

The fat transfer method yielded augmentations of 40%-120% of injected volume in the 339 areas treated. After 45-60 days, the implant was stabilized and remained for the length of our study (up to 10 years). In several cases excessive fat had to be removed. Other than slight bruising, occasional divots at the donor site, and three cases of bacterial infection, the autologous tissue transfer was an uncomplicated event.

CONCLUSION

Fat grafting has proven to be a safe and effective procedure for correcting and enhancing tissue defects and contour deficiencies.

Carbon dioxide laser resurfacing: preliminary observations on short-term follow-up. A subjective study of 100 patients' attitudes and outcomes

BACKGROUND

Carbon dioxide (CO2) laser resurfacing is enjoying broad medical acclaim. It is useful to assess patient morbidity and satisfaction with this procedure.

OBJECTIVE

Review the procedure from the patients' perspective with particular focus on the immediate and medium term postoperative period, the patient's progress after the initial 6-8-week period, the postoperative morbidity and complication rate, and the results and patient satisfaction with the procedure.

METHOD

One hundred resurfacing patients, who were treated after the advent of the computer pattern generator on a high-energy short-pulse CO2 laser, were studied. Patients were at least 3 months into their postoperative phase.

RESULTS

Outcomes of patients' problems were classed as good to excellent 78.8% of the time. Patient outcomes met the patients' preoperative expectations 68.9% of the time. Patients would have the procedure again if needed 78% of the time, and 84% would recommend the procedure to others. Patients reported continuing improvement after the initial 6-8-week healing period 72% of the time. Short-term morbidity was high (49%). Long-term complications were registered in 7% of patients but were mostly minor in nature.

CONCLUSIONS

Major indications for laser resurfacing such as wrinkles, sun damage, and acne scarring all appeared to do well with CO2 laser resurfacing.

New directions in surgical therapy

Surgical dermatology continues to evolve rapidly. The field is blessed with a number of bright and enthusiastic young surgeons who are willing to spend to necessary time investigating new techniques. The horizon has changed dramatically over the last 5 years and promises to change even more in the years to come.

Manual resurfacing and trichloroacetic acid for the treatment of patients with widespread actinic damage. Clinical and histologic observations

BACKGROUND

A facial resurfacing regimen combining manual abrasion of the skin and 25% trichloroacetic acid has been reported to produce excellent results, but the histologic depth of injury produced by this technique has not been studied.

OBJECTIVE

To describe our experience with this technique treating patients with extensive actinic damage and to determine the histologic depth of injury produced.

METHOD

We treated 40 patients using manual resurfacing and trichloroacetic acid, primarily for widespread actinic keratoses. Resurfacing tools included silicone carbide sandpaper, drywall screen, electrocautery tip cleaners, abrasive pads, scalpel blades, and curettes. Four patients underwent sequential biopsies to evaluate the depth of wounding using this technique.

RESULTS

Manual resurfacing combined with trichloroacetic acid consistently produced excellent cosmetic results and nearly complete eradication of actinic keratoses. Histologically, treated areas showed replacement of the dermal elastotic band by newly formed collagen, a significantly deeper level of wounding than the Jessner's/35% trichloroacetic acid peel. There was no evidence for foreign body granulomas clinically or histologically as a result of the abrasive materials.

CONCLUSIONS

The deeper level of this peel explains the improved cosmetic outcome and greater eradication of actinic keratoses. This treatment is particularly well suited for patients with extensive photodamage and widespread actinic keratoses.

Medium-depth chemical peeling

Trichloroacetic acid (TCA) alone or in combination with other agents is the mainstay of medium-depth chemical peels. Indications for medium-depth chemical peels include both medical conditions, such as diffuse photodamage with contiguous actinic keratoses, and cosmetic conditions, such as the aging face and solar lentiginosis. Medium-depth chemical peeling with TCA is relatively simple and is associated with a favorable risk/benefit ratio. However, proper patient selection, with attention to both medical and psychological factors, requires significant experience. The histological basis of the rejuvenating effects of TCA peels is well established, with a consistent correlation between wound depth and TCA concentration. The clinical effects of medium-depth chemical peels are generally gratifying for both patient and physician.