Skin Rejuvenation

The aging process of the skin is quite natural and the soft full features of youth are eventually replaced by wrinkles, splotches of discoloration and leathery texture. Good skin care can delay many signs of aging.

Various procedures are Gesthetic Surgery to get the uniform complexion can be summarized under three headings:

    1. Lasers
    2. Dermabrasions
    3. Chemical Peels

These procedures when used various in combinations with cream programmes can treat may signs of aging leaving skin with glow more associated with youth.


LASERS

Laser Basics:

Laser technology for treatment of various skin problems has exploded ok last decade. The conditions which could not be treated without risk of scarring the past birth mark pigmented lesions can now be removed with lasers with either or no complications.

Laser is an acronym for light amplification by stimulated Emission of radiation . There are various types of lasers available for medical use and it is the wavelength of emitted light which distinguishes one laser from another.

The wavelength in turn is determined by the substances used for generating laser, for example a ruby crystal in a Q-switched, ruby laser end carbon dioxide gas in a CO₂ laser.

Laser have become increasingly complex and the variations in their wave length, pulse duration, intensity of light and other parameters are important to the engineers, physicists and laser surgeons. Different combinations of parameters available in different machines are used by laser surgeons for treating, different lesions on different skin type. Thus it is not only the machines which provides variability but the experience of laser surgeon also count for successful out come of a laser treatment.

LASER RESURFACING
Resurfacing is a term which encompasses several different surgical techniques; laser resurfacing, dermabrasion, chemical peeling and cryotherapy. Through different modalities each of these techniques removes the superficial layer of the skin (epidermis and upper portion of the dermis), followed by its regeneration. The regenerated skin is also rejuvenated, we therefore see a reduction of sun induced wrinkles, better skin tone, and a uniformity of color and texture.

Mechanical dermabrasion and chemical peeling with phenol or trichloroacetic acid have been used for many years. Laser resurfacing is relatively new and provides many advantages over the traditional approaches including a lower risk of scarring, less post- operative pain, a shorter healing time, and more uniform results.

 

PROCEDURE:
The carbon dioxide laser may be used in a focused mode for cutting or a defocused mode for vaporizing the skin. In the cutting mode it is used in delicate surgical techniques such as eyelid correction. The advantages is that as the laser cuts it seals off the blood vessels and nerve endings which decreases the time for healing and the amount of post – operative pain. In the vaporizing mode the carbon dioxide laser

is used to remove abnormal tissue such as warts and scars and more recently to resurface the skin to stimulate rejuvenation. The wavelength of the CO2 laser heats the cell of the unwanted skin or abnormal tissue to the point where it is vaporized away in a plume of tissue particles and steam. If the heat is excessive there is a risk of scarring or pigment changes to the adjacent normal skin tissue. When the CO₂ laser was first introduced as a surgical tool the light was delivered continuously to the skin. This was only interrupted when the surgeon released the foot pedal to close the shutter and prevent the escape of the laser light beam.

The control over the dissipation of heat was poor and the risk of damage was high. It took a highly skilled surgeon to judge what power and time duration of laser light would remove abnormal tissue without damaging the surrounding tissue. For this reason the use of the CO₂ laser as a surgical tool was relatively uncommon for a number of years and when it was used it was reserved for the removal or alteration of abnormal tissue, such as warts.

Development in CO2 laser technology have focused on controlling the heat produced by the laser light so that only targeted tissue is affected. The Ultra Pulse and Tru Touch CO2 lasers have accomplished this by computerized delivery of extremely short repetitive pulses. The time in between each pulse allows the skin to cool so that the heat does not remain in the tissue long enough to cause more damage than is intended. Other lasers, such as silk touch CO2 laser, have achieved the necessary control over heat dissipation by moving the continuous wave of laser light around very rapidly so it does not dwell in any one area for very long. This is also controlled by computer.

Both type of technology seem to be effective in controlling heat transfer. The deciding factor in the outcome of CO2 laser surgery and especially resurfacing is the skill of the surgeon. Despite testimonials to the contrary, computerized controlled delivery of the laser light cannot do all the work. The laser is the brush and the surgeon is the artist. If a surgeon simply moves the laser light over the surface of the skin obliterating everything in its path then the healing process will be slow and the results less than satisfactory.

 

PRE-TREATMENT:
Prior to laser resurfacing certain topical creams are recommended for 6 Weeks. These creams prepare the skin for laser resurfacing.

 

ANESTHESIA:
Local anesthesia is used for most of the cases however full face resurfacing especially un younger age patients is undertake under general anesthesia.



POST OP :
The skin passes through three phases of healing over course of 10-14 days.

 

OOZING/CRUSTING PHASE:
 During the initial healing phase oozing and less often a crust or scab will develop over the treatment site. If a dressing is applied then the following regime is not necessary. Many people find the semi- occlusive dressings annoying after the first couple of days and would like the opportunity to cleanse their skin.

If a dressing is not applied it is important to keep the skin well lubricated and prevent drying until the oozing has stopped. This is usually accomplished with big gobs of petroleum jelly (Vaseline) or aquaphor.as distasteful as this sounds it is the most effective way of trapping the moisture in the skin and preventing it fro drying and cracking. An antibiotic ointment such as fucidin ointment will have been applied immediately after the surgery. Some physician suggest that their patients continue to apply this under moisturizer, although it can be irritating for some people.

During the crusting phase the face should be cleansed with very cold water and a mild cleanser such as nutrogena or pears. For the first two days this is a challenge because the water feels like a million little pin pricks on the face . rather than splashing the water on the face a sterile gauze is recommended to gently pat the area with the cleanser and water.

Serum literally drips down the face during the first 2 to 3 days. Gently wiping the serum away frequently with a cold, wet, sterile gauze and reapplying the moisturizer helps the skin to feel more comfortable.

Extensive swelling during the first 3 days is common with full face resurfacing. It can be disconcerting to look in the mirror and not recognize yourself because of the distortion to yopur facial features. The surgeon may opt to give a dose of cortisone either through injection or tablets to reduce the swelling.

The treatment site usually looks worse than it feel, oral anti biotics and anti- viral cold sore medications, such as valtrex, are rarely required but are often used prophylactically.

If crust form they will begin to seperayte from the skin within a week, although on some areas of the face this may take a longer. Ti is important that the crusts are not picked or dislogedas this may lead to scarring. They will drop off when they are ready.

Towards the end of the oozing and crusting phase the skin becomes very itchy, a the skin heals. The regular application of cold water and petroleum jelly helps to control the desire to itch as does the use of an antihistamine such as reactine.

 

FLACKY PHASE:
 Once the oozing stops or any crusts have been sloughed there will be a period of flackiness for several days during which desquamated (dead) skin comes loose. During this phase the skin should continue to be well lubricated using aquaphor, Vaseline or a moisturizer, such as moisturel cream after gentle cleansing.

Signs of hyperpigmentation develop during this stage in some patients. The skin begins to turn a blotchy brown color. Within 2 months this disappears although it is worthwhile to encourage resolution of hyperpigmentation with bleaching creams.

Sun exposure should be avoided as much as possible. Protection with a broad spectrum sunscreen, such as Nivea lotion with an SPF of 45 or more is essential in order to prevent a severe eruption of hyperpigmentation.

 

ERYTHEMA (Pink) PHASE:
The new skin will be very red at first, then it will gradually fade to pink, then to the color of normal skin. This phase may last from 3 to 6 months.

It is important to avoid rubbing the skin, to apply moisturizers liberally and to protect the skin from sun exposure. A makeup may be used once all the flakiness has disappeared.

If the post- operative red discoloration is mild, an ordinary base makeup will probably be adequate. An opaque makeup is useful when the pinkness is quite instense.

For deeper , red erythema it may be necessary to use a green base foundation under the cream base concealer. This neutralizes the red discoloration.

It is essential to protect the treated skin from the sun with broad spectrum sunscreens, sun hats and sunglasses. If this is not done hyperpigmentation is likely to occur and the skin will become a mottled brown color.

POSSIBLE COMPLICATION:

The potential problems associated with laser resurfacing are:

  • Scarring: problematic scarring may result, but rarely occurs when surgery is performed by an experienced surgeon. When it does occur it is usually due to an inherited tendency for excessive scarring or may be due to laser light having penetrated too deeply.

  • Acne/ perioral dermatitis: after laser resurfacing the oil gland openings are temporarily swollen and prone to blockage. If we add to this the occlusion of a dressing, petroleum jelly and other topical preprations, acne and/ or preioral dermatitis, wherein the glands become inflamed, may occur. These conditions are readily treated with medications that open the pores, cleanse them and allow ongoing drainage. Usually topical mixtures of mild cortisone and antibiotics suffice, but oral antibiotics may be required. Strong cortisone mixtures actually worsen the problem if used for ore than a very brief interval.

  • Pigmentation change: altered pigmentation may occur. This depends on the depth of the laser resurfacing, the color of the patient’s skin, and the unpredictable nature of repigmentation and rejuvenation of the skin.

  • Milia: tiny, white cysts are rare, but may occur. They are easily removed with electrodesiccation or the CO₂ laser.

  • Other problems: although rare, infection, persistent redness, and a lack of response to the treatment may occur.

RESUMPTION OF NORMAL ACTIVITIES
Normal and social activities and work amy be resumed once a scabs have fallen off (in 10 to 14 days), even though the skin is still quite red. The redness may last for 3 to 6 months.

DERMABRASION
Dermabrasion is mechanical abrasion of skin with the help of rotating wire brush Diamond drill. Basically it achieves the same purpose as laser resurfacing, but being less precise it is being replaced by laser which are more precise and less traumatic leading to less healing time.

It still has a place in patient with thick heavy skin who have experienced loss of elasticity due to acne scarring or wrinkling.

 

PROCEDURE:

  • Test sites of approximately 2centimeters (3/4 of an inch) in diameter is carried out in front of the ear or along the temple. The test provides some idea of potential problems that may result with a complete dermabrasion and therefore assists in deciding whether or not to proceed. If only small areas are to be resurfaced, a test is not always necessary.

  • Superficial dermabrasions may be preceded by three weeks to three months of cream application in the belief that the skin will heal faster. if the patient has a history of cold sores ( which may be activated by the surgery) they are given a course of anti- viral medication, such as Acyclovir , orally before and after surgery to decrease the risk of the cold sore spreading into the abraded areas.

  • A local anesthetic is injected. Then ice, artificial ice bags or clod sprays, are applied to the skin for 15 minutes prior to the sanding procedure. This helps makes the skin rigid and therefore easier to sand.

  • The skin in sanded to segments and the duration of the procedure varies according to the speed of the surgeon, the extent and depth of the sanding, and the patient’s co-operation. A full face dermabrasion may last between 10 and 45 minutes. The sound of the whirling burr is similar to a dentist’s drill.
  • Deeper dermabrasions leave the skin raw, red and seeping immediately after the procedure. Blood – clotting agents as well as an antibiotic ointment such as fudicin or antibiotic soaked gauzes such as fudicin Sofratulle are often applied to the skin. The skin is then covered with surgical dressings, special surgical dressings are sometimes used to encourage rejuvenation of the epidermis (top layer of the skin). Use of these new dressings is of particular benefit because they do not stick, causing less discomfort of the patient. Healing is faster and thick crusts are less likely to occur, but it is uncertain that any of these surgical dressings improve the cosmetic result.

 

POST OP:
 A superficial dermabrasion does not improve deep wrinkles and scars but removes fine wrinkles and leaves the skin with a healthy glow. A scab usually falls off within 5 days of the procedure. The underlying skin is pink in color and gradually fades to a normal skin tone over several weeks.

Deeper dermabrasions initially leave the face red and raw. This is followed by a swollen, scabby phase. The scabs generally take 10 to 14 days to fall off. The final phase of healing is characterized by an initial period of redness which gradually fades to a normal skin tone over a 3 to 6 month period.

CHEMICAL PEELS
Chemical peels are now accepted and well recognized procedures, particularly for treatment of sun damaged and aged skin.
A variety of chemical agents are used to cause inflammation and irritation to the superficial layers of the skin. Three of the most commonly used peeling agents are phenol and its derivatives, trichloroacetic acid, and alpha hydroxyl acids. The subsequent realignment of the skin’s collagen building blocks after the chemical peels leads to a smoother, younger look.

INDICATIONS:
Sun damaged skin characterized by fine to moderately coarse wrinkles, irregular pigmentation, dilated blood vessels, and scaling would all benefit from a chemical peel. Light skinned patients are better candidates than those with darker skin because they tend to have fewer pigmentation problems, such as blotchy color, after the procedure. Individuals with sagging and excessive skin are not candidates for this procedure, since chemical peeling improves skin quality but does not reduce excess skin. An eyelid lift, for example, removes redundant skin, but chemical peeling may be necessary to remove the fine wrinkles.

 

PROCEDURE:
 Chemical peel can be categorized as mild, moderate and aggressive. The extent of skin damage determines the type of peel which is used and the depth of peeling necessary.

Mild Chemical Peels : Glycolic acid
Moderate Chemical Peels : TCA Peel.
Aggressive Chemical Peels : It is better to use Phenol, Baker solution Peels a series of application rather than using more aggressive agents on a single occasion to obtain the best results with the least amount of risk.

THE STEPS:

    1. With all type of peels, the skin is cleaned with degreasing agents, such as acetone, alcohol, or povidone- iodine (betadine), as these encourage better penetration to deeper levels and greater uniformity of the peel.

    2. The chemical agent of choice is usually applied with Q- tips or gauze over the designated areas. Feathering, using less or lower concentrations of the agent, is performed s the physician moves from the face into the neck or hairline regions. This avoids any obvious demarcation between peeled and untreated skin.

    3. Phenol preparations , such as baker’s formula, penetrate deeper than do other agents and can be absorbed into the body, causing internal damage. Strict time parameters must, therefore, be observed. This controlled absorption minimizes the risk of damage to the heart, liver, or kidneys. The heart must be monitored for irregularities throughout the procedure when phenol solutions are used.

    4. The time needed to apply an agent to the entire face may range from a matter of minutes to 2 hours depending on which agents are used. More aggressive peels take longer.

    5. The chemical is neutralized with cold water once the required effect has been achieved.

    6. Post- operative care is similar to that for other resurfacing techniques.

Post Peel Appearence
 The extent of cosmetic disability after a peel depends on the depth of the peel. Superficial , or " freshening peels," using lower chemical concentration cause mild inflammation and swelling which softens the appearance of wrinkles for a short period of time and may lighten blotchy areas of pigment on the skin.

Deep peels ,will result in redness, swelling, and, in some cases, oozing. Peeling and crusting ( if oozing occurs) normally disappear within 5 to 7 days. The underlying skin is light pink and gradually fades to normal skin color over a period of several weeks. For some patients, a series of moderate peels provides the best results while minimizing the risk factor.

When can normal activities be resumed?
After surgery, bed rest with the head elevated is recommended for more aggressive peels. If a large area is treated, 48 hours of bed rest is required. Normal activities at home may be resumed, but a return to work and social life is not advised until after the crusts have fallen off ( 5 to 21 days depending on the type of peel ).


POSSIBLE COMPLICATION:

  • Scarring:
    • Of the complications that may occur, scarring is the most common and cosmetically debilitating. Scarring occurs more often with deeper than with superficial peels, particularly over the angle of the jaw and around the mouth. This scarring may result in a band around the mouth resembling a purse string with gathered folds. Older skin takes longer to heal than does younger skin, but may actually scar less. Generally, darker skin has a greater risk of scar formation and irregular pigmentation.

  • Hypopigmentation: another complication is hypopigmentation, or loss of color, particularly with deeper peels. The opposite effect, hyperpigmentation, or too much color, may also occur and is more often seen with superficial peels.

  • Infection: secondary bacterial infection or activation of herpes simplex is a potential problem in the areas peeled. As with other forms of resurfacing, many physician provide anti – viral medications, such as Acyclovir prophylactically.

  • Toxicity: internal toxicity is a potential risk with phenol agents causing damage to the heart, liver, or kidneys. Trichloroacetic acid and glycolic acid (an alpha hydroxyl acid) are not toxic.

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