Procedural Dermatology Volume II: Laser and Cosmetic Surgery E-Book

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1021

Veröffentlichungsjahr: 2023

Beschreibung

A comprehensive, practical resource on state-of-the-art cosmetic dermatology procedures

Volume II of Procedural Dermatology: Postresidency and Fellowship Compendium, edited by esteemed dermatologists Yoon-Soo Cindy Bae and David H. Ciocon, provides a comprehensive review of minimally invasive and non-invasive procedures to treat a wide range of cosmetic issues and conditions. Twenty-four consistently organized chapters cover the most up-to-date developments in cosmetic dermatology. Topics include ablative and nonablative resurfacing; body contouring; tissue tightening; laser treatment for vascular and pigmented lesions; scar, acne, and tattoo removal; the use of neuromodulators; soft tissue fillers; hair removal and restoration techniques; blepharoplasty;treatment options for axillary hyperhidrosis; thread lifts; liposuction; and fat transfers.

Key Features:

• Reflects the collective wisdom of dermatology thought leaders and innovators who pioneered the majority of current laser and cosmetic treatments
• Incorporates a patient-centered approach tailored to individual needs, concerns, ethnicity, anatomy, skin type, and functional status
• Firsthand pearls and pitfall prevention strategies throughout the text focus on improving patient outcomes
• Procedural videos demonstrate chemical peels and high-definition body contouring techniques

This practical book provides early-career dermatologists with expert guidance that enriches their existing cosmetic dermatology skills and inspires learning and incorporating new techniques into practice to optimize patient care.

Leseprobe

To access the additional media content available with this e-book via Thieme MedOne, please use the code and follow the instructions provided at the back of the e-book.

Procedural Dermatology

Volume II: Laser and Cosmetic Surgery

Postresidency and Fellowship Compendium

Yoon-Soo Cindy Bae, MDMohs Micrographic Surgeon and Dermatologic OncologistCosmetic and Laser SurgeonLaser & Skin Surgery Center New York;Clinical Assistant Professor of DermatologyNew York University Grossman School of MedicineThe Ronald O. Perelman Department of DermatologyNew York, New York, USA

David H. Ciocon, MDDirector of Procedural Dermatology and Dermatologic SurgeryAssociate Professor of MedicineDirector of Clinical OperationsDivision of DermatologyMontefiore Medical CenterAlbert Einstein College of MedicineBronx, New York, USA

314 Illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG

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Printed in USA by King Printing Company, Inc.5 4 3 2 1

DOI: 10.1055/b000000254

ISBN: 978-3-13-242407-4

Also available as an e-book:

eISBN (PDF): 978-3-13-242408-1

eISBN (epub): 978-3-13-258257-6

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Contents

Preface

Contributors

1Nonablative Rejuvenation

Daniel Callaghan and Laurel M. Morton

1.1Introduction

1.2Modalities Available

1.2.1Intense Pulsed Light

1.2.2532-nm KTP Laser and 595-nm PDL

1.2.3694-nm Ruby Laser

1.2.4755-nm Alexandrite Laser

1.2.51,064-nm Nd:YAG Laser

1.2.6Mid-InfraredWavelength Lasers

1.2.7Photodynamic Therapy

1.2.8Radiofrequency

1.2.9Microneedling

1.3Indications

1.4Patient Selection, Contraindications, and Preoperative Procedures

1.4.1Patient Selection

1.4.2Contraindications

1.4.3Preoperative Procedures

1.5Techniques

1.6Postoperative Instructions

1.7Potential Complications and Management

1.8Pearls and Pitfalls

1.8.1Pearls

1.8.2Pitfalls

2Ablative Rejuvenation

Mitalee P. Christman and Roy G. Geronemus

2.1Introduction

2.2Modalities/Treatment Options Available

2.3Indications

2.4Patient Selection, Contraindications, and Preoperative Considerations

2.5Technique

2.5.1Anesthesia and Pain Management

2.5.2Intraoperative Safety

2.5.3Operative Technique

2.6Postoperative Instructions

2.7Potential Complications and Their Management

2.8Pearls and Pitfalls

2.8.1Pearls

2.8.2Pitfalls

3Body Contouring

Jennifer L. MacGregor and Amanda Fazzalari

3.1Introduction

3.2Modalities and Treatment Options Available

3.2.1Cryolipolysis

3.2.2Radiofrequency

3.2.3Ultrasound

3.2.4Diode Laser

3.2.5Low-Level Laser Therapy

3.2.6Newer Treatment Modalities

3.3Indications

3.4Patient Selection, Contraindications, Preoperative Considerations

3.4.1Patient Selection

3.4.2Contraindications

3.4.3Preoperative Considerations

3.5Technique

3.5.1Cryolipolysis

3.5.2Radiofrequency

3.5.3Ultrasound

3.5.4Diode Laser

3.5.5Low-Level Laser Therapy

3.6Postoperative Instructions

3.7Potential Complications and Management

3.7.1Cryolipolysis

3.7.2Radiofrequency

3.7.3High-Intensity Focused Ultrasound

3.7.4Nonthermal Focused Ultrasound

3.7.5Diode Laser

3.7.6Low-Level Laser Therapy

3.7.7High-Intensity Focused Electromagnetic Therapy

3.8Conclusions

3.9Pearls and Pitfalls

4Cellulite Treatment

Deanne Mraz Robinson and Yoon-Soo Cindy Bae

4.1Introduction

4.2Modalities and Treatment Options

4.2.1Putting It All Together

4.3Patient Selection

4.3.1Contraindications

4.3.2Indications

4.4Preoperative Instructions

4.5Procedure

4.6Pearls and Pitfalls

5Skin Laxity: Microneedling

Jordan V. Wang, Joseph N. Mehrabi, and Nazanin Saedi

5.1Introduction

5.2Treatment Options

5.3Microneedling

5.4Radiofrequency Microneedling

5.5Indications

5.6Patient Selection

5.7Technique

5.8Postoperative Instructions

5.9Potential Complications

5.10Other Modalities

5.11Pearls and Pitfalls

6Scar Treatments

Daniel P. Friedmann, Michael Zumwalt, and Vineet Mishra

6.1Introduction

6.2Indications

6.2.1Hypertrophic Scars

6.2.2Keloids

6.2.3Atrophic Acne Scars

6.2.4Other Scars

6.3Treatment Options

6.3.1For Hypertrophic and Keloid Scars

6.3.2For Atrophic Scars

6.3.3For Other Scars

6.4Pretreatment Considerations

6.4.1Subcision

6.4.2Soft-Tissue Filler

6.4.3Vascular Light and Laser Devices

6.5Treatment Techniques and Protocols

6.5.1Intralesional Injection Therapy

6.5.2Subcision

6.5.3Soft-Tissue Filler

6.5.4Vascular Light and Laser Devices

6.5.5Microneedling

6.5.6Fractional Radiofrequency

6.5.7Nonablative Fractional Laser Resurfacing

6.5.8Ablative Fractional Laser Resurfacing

6.5.9CROSS Technique or Punch Removal

6.6Postoperative Instructions

6.6.1Intralesional Injection Therapy

6.6.2Subcision

6.6.3Soft-Tissue Filler

6.6.4Ablative Fractional Laser Resurfacing

6.6.5CROSS Technique or Punch Removal

6.7Potential Complications and Management

6.7.1Intralesional Injection Therapy

6.7.2Subcision

6.7.3Soft-Tissue Filler

6.7.4Vascular Light and Laser Devices

6.7.5Microneedling, Fractional Radiofrequency, and Nonablative Laser Resurfacing

6.7.6Ablative Fractional Laser Resurfacing

6.7.7CROSS Technique or Punch Removal

6.7.8Dermabrasion

6.7.9Radiation Therapy

6.8Pearls and Pitfalls

7Pigmented Lesion Removal

Monica K. Li

7.1Introduction

7.2Modalities/Treatment Options

7.3Indications/Uses

7.3.1Epidermal Pigmented Lesions

7.3.2Dermal or Mixed Pigmented Lesions

7.4Patient Selection/Contraindications/Preoperative Care

7.5Patient Selection for Laser Treatment of Pigmented Lesions

7.6Technique

7.7Postoperative Instructions

7.8Potential Complications

7.9Pearls and Pitfalls

8Lasers and Light Devices for Hair Removal

Maressa C. Criscito, Margo H. Lederhandler, and Leonard J. Bernstein

8.1Introduction

8.2Mechanism of Action

8.2.1Hair Anatomy and Physiology

8.3Hair Removal Methods

8.3.1Traditional Treatment Modalities

8.4Preoperative Assessment and Preparation

8.4.1Medical History

8.4.2Physical Examination

8.4.3Patient Expectations

8.5Mechanisms of Laser Hair Removal

8.5.1Specific Laser Systems

8.6Preoperative Preparation for Laser Hair Removal

8.7Postoperative Care

8.8Complications and Their Management

8.8.1Dyspigmentation

8.8.2Leukotrichia

8.8.3Paradoxical Hypertrichosis

8.8.4Acneiform Eruptions

8.8.5Hyperhidrosis

8.8.6Urticaria

8.8.7Reticulate Erythema

8.8.8Ocular Injury

8.9Conclusion

8.10Pearls and Pitfalls

9Tattoo Removal

Richard L. Lin, Alexa B. Steuer, Andrea Tan, and Jeremy A. Brauer

9.1Introduction

9.2Modalities and Treatment Options

9.3Indications

9.4Procedural Planning and Counseling

9.4.1Preoperative Evaluation

9.4.2Treatment Selection

9.5Technique

9.5.1Procedural Preparation

9.5.2Tattoo Removal Procedure

9.6Postoperative Management

9.7Potential Complications and Management

9.8Pearls, Pitfalls, and Future Directions

10Leg Vein Treatment

Jeffrey F. Scott, Nina Lucia Tamashunas, and Margaret Mann

10.1Introduction

10.1.1Treatment Options Available

10.2Indications

10.3Preoperative Considerations

10.3.1Patient Selection

10.4Technical Aspects of Treatment

10.4.1Thermal Ablation of the GSV

10.4.2Nonthermal Ablation of the GSV

10.4.3Ambulatory Phlebectomy

10.5Postoperative instructions

10.6Potential Complications and How to Manage

10.6.1Ambulatory Phlebectomy

10.7Pearls and Pitfalls

10.7.1Thermal Ablation

10.7.2Nonthermal Ablation

10.7.3Ambulatory Phlebectomy

11Lasers and Lights in Acne

Samantha Gordon, Jordan Borash, and Emmy M. Graber

11.1Introduction

11.2Modalities

11.2.1Lasers

11.2.2Lights

11.2.3Photodynamic Therapy

11.2.4Photopneumatic Therapy

11.2.5Handheld at Home devices

11.2.6Radiofrequency

11.2.7Fractional Microneedling Radiofrequency

11.3Patient Selection

11.4Technique/Postoperative Instructions

11.5Potential Complications and Management of Complications

11.6Pearls and Pitfalls

12Chemical Peels

Ezra Hazan, Seaver L. Soon, and Hooman Khorasani

12.1Introduction

12.2Modalities/Treatment Option Available

12.2.1Peel Categorizations

12.2.2Mechanism of Action

12.2.3Peel Categories

12.3Indications

12.3.1Acne

12.3.2Photoaging

12.3.3Postinflammatory Hyperpigmentation

12.3.4Melasma

12.3.5Scarring

12.3.6Actinic Keratosis

12.4Patient Selection

12.4.1History and Physical Examination

12.4.2Contraindications

12.4.3Preoperative and Consideration in Darker SkinTypes

12.5Technique

12.5.1Preprocedure

12.5.2Clinical Endpoints

12.5.3Procedure

12.5.4Specific Peels

12.5.5Neutralization

12.6Postpeel Instructions

12.6.1In-Office

12.6.2At Home

12.7Complications and Their Management

12.7.1Scarring

12.7.2Infection

12.7.3Postinflammatory Pigment Alteration

12.7.4Acne and Folliculitis

12.7.5Pruritus

12.7.6Prolonged Erythema

12.8Pearls and Pitfalls

13Light-Emitting Diode Photomodulation

Robert Weiss and Robert D. Murgia

13.1Introduction

13.2Modalities

13.3Clinical Indications

13.3.1Photorejuvenation

13.3.2Anti-Inflammatory Effects

13.3.3Photodynamic Therapy

13.3.4Alopecia

13.4Patient Selection/Contraindications/Preoperative Care

13.5Procedure

13.6Postoperative Instructions

13.7Potential Complications

13.8Pearls

14Combining Treatments

Rhett A. Kent and Sabrina Guillen Fabi

14.1A General Approach

14.1.1The Ideals of Beautification

14.1.2The Processes of Aging

14.1.3Principles of Combination Aesthetic Therapy

14.2Combining Injections, Implants, and Energy-Based Devices

14.3Combination Laser and Light Therapies for Specific Targets

14.3.1Dyspigmentation

14.3.2Vascular Abnormalities

14.3.3Resurfacing

14.4Combining Other Modalities

14.4.1Photodynamic Therapy

14.4.2Radiofrequency

14.4.3Microneedling

14.4.4Chemical Peels

14.4.5Microfocused Ultrasound

14.5Considerations for Treatments in Skin of Color

14.6Megacombinations

14.7Site-Specific Combination Therapy

14.7.1Periorbital Rejuvenation

14.7.2Midfacial Rejuvenation

14.7.3Perioral Rejuvenation

14.7.4The Lower Face and Neck

14.7.5Chest Rejuvenation

14.7.6Hand Rejuvenation

14.7.7Rejuvenation of Other Body Sites

14.7.8Patient Selection, Patient Preparation, and Recovery

14.7.9Postoperative Care

15Neuromodulators and Injection Technique

Gee Young Bae

15.1Introduction

15.1.1Basic Science of Botulinum Toxin

15.1.2Comparison of Products

15.1.3Preparation for Use

15.1.4Patient Selection and Consultation

15.1.5Ethnic and Gender Consideration

15.1.6Toxicity and Immunogenicity

15.1.7Adverse Reactions

15.1.8Pretreatment Assessment

15.2Upper Face

15.2.1Glabellar Frown Lines

15.2.2Horizontal Forehead Lines

15.2.3Lateral Canthal Lines (Crow’s Feet)

15.3Midface and Lower Face

15.3.1Bunny Lines

15.3.2Nasal Flare

15.3.3Nasal Tip Elevation of Plunging Nose Tip

15.3.4Gummy Smile

15.3.5Asymmetric Lip and Asymmetric Smile

15.3.6Nasolabial Fold and Marionette Fold

15.3.7PerioralWrinkle (Smoker’s Line)

15.3.8Cobblestone Chin

15.3.9Mouth Corner Elevation in Mouth Frown

15.3.10The Nefertiti Lift, Platysmal Bands, Horizontal Neck Lines

15.4Facial Contouring and Body Contouring

15.4.1Benign Masseteric Hypertrophy

15.4.2Salivary Gland Enlargement: Parotid Gland and Submandibular Gland

15.4.3Botox Lifting or Mesobotox

15.4.4Body Contouring

15.5Other Indications of BotulinumToxin

15.5.1Hyperhidrosis

15.5.2Pain and Pruritus

15.5.3Scar

15.5.4Other Delivery Methods and Uses of Botulinum Toxin

15.5.5Botulinum Toxin Use as an Adjunct

16Soft-Tissue Augmentation with Dermal Fillers

Andreas Boker

16.1Introduction

16.2Commercially Available Devices

16.2.1Hyaluronic Acid Gels

16.2.2Calcium Hydroxyapatite

16.2.3Poly-L-Lactic Acid

16.2.4Polymethylmethacrylate Beads, Collagen, and Lidocaine

16.2.5Liquid Injectable Silicone

16.3Clinical Uses and Technique

16.3.1Preoperative Care

16.3.2Midfacial Rejuvenation

16.3.3Periorbital Region

16.3.4Upper Face

16.3.5Lower Face

16.3.6Lips

16.3.7Neck

16.3.8Hands

16.3.9Scars

16.3.10Other Off-Label Uses

16.4Pitfalls and Complications

16.4.1Postoperative Care

16.4.2Edema

16.4.3Ecchymosis

16.4.4Vascular Occlusion

16.4.5Tyndall Effect

16.4.6Nodularity

16.4.7Inflammatory Reactions and Biofilms

16.5Pearls

17Procedural Hair Restoration: Platelet-Rich Plasma for Hair Loss and Hair Transplant

Benjamin Curman Paul

17.1Introduction to Modern Procedure of Hair Restoration

17.2Platelet-Rich Plasma

17.2.1Introduction

17.2.2Indications

17.2.3Patient Selection

17.2.4Contraindications

17.2.5Technique

17.2.6Postoperative Care

17.2.7Complications

17.2.8Pearls/Pitfalls

17.3Hair Transplant

17.3.1Introduction

17.3.2Indications

17.3.3Patient Selection

17.3.4Procedure Selection

17.3.5Contraindications

17.3.6Technique

17.3.7Posterative Instructions and Follow-Up

17.3.8Complications

17.3.9Pearls/Pitfalls

18Blepharoplasty, Lower Facelift, and Brow Lift

Robert Blake Steele, Rawn Bosley, and Cameron Chesnut

18.1Facelift: Introduction and Modalities

18.1.1Anatomy and Indications: Facelift

18.1.2Layers of Traction and Dissection

18.1.3Preoperative/Patient Selection

18.1.4Incision Considerations

18.1.5Senior Author’s Surgical Technique in a Female Patient

18.1.6Postoperatively

18.1.7Adjuvant Modalities

18.1.8Complications

18.1.9Pearls and Pitfalls

18.2Blepharoplasty and Brow Lift Introduction

18.2.1Brow Lift Modalities

18.2.2Indications/Patient Selection

18.2.3Technique for Deep Plane Temporal Brow Lift

18.3Blepharoplasty

18.3.1Technique: Upper Blepharoplasty

18.3.2Medial Fat Pad Repositioning

18.3.3Internal Browpexy

18.3.4Modalities: Lower Blepharoplasty

18.3.5Transconjunctival Blepharoplasty with Fat Repositioning andDirected Fat Transfer

18.3.6Preoperatively

18.3.7Surgical Technique Exposing the Fat Pads

18.3.8Postoperatively

18.3.9Complications

18.3.10Pearls and Pitfalls

19Devices and Treatment Options for Axillary Hyperhidrosis

Cameron Rokhsar and Austin Lee

19.1Introduction

19.2Prevalence

19.3Assessment and Diagnosis

19.3.1Diagnostic Criteria

19.3.2Assessment of Severity and Response to Treatment

19.4Treatment of Hyperhidrosis

19.4.1Drugs

19.4.2Devices

19.5Conclusion

19.6Pearls and Pitfalls

20Thread Lifts

David J. Goldberg and Lindsey Yeh

20.1Introduction

20.2Modalities/Treatment Options Available

20.3Clinical Outcomes

20.4Histopathologic Findings

20.5Adverse Events

20.6Patient Selection

20.6.1Good Candidates

20.6.2Poor Candidates

20.6.3Setting Expectations

20.7Contraindications

20.7.1Preoperative Instructions

20.8Technique

20.9Postoperative Instructions

20.10Potential Complications and How to Manage

20.11Combination Therapy

20.12Pearls and Pitfalls

20.13Conclusion

21Cosmeceuticals

Emily C. Murphy and Adam Friedman

21.1Introduction

21.2Retinoids

21.2.1Stability and Topical Penetration

21.2.2Evidence for Retinaldehyde

21.2.3Evidence for Retinyl Esters

21.2.4Evidence for Retinol

21.2.5Evidence for Combination Products

21.3Tyrosinase Inhibitors: Hydroquinone and Kojic Acid

21.3.1Stability and Topical Penetration

21.3.2Evidence for Hydroquinone

21.3.3Evidence for Kojic Acid

21.4Azelaic Acid

21.4.1Stability and Topical Penetration

21.4.2Evidence

21.5Tranexamic Acid

21.5.1Stability and Topical Penetration

21.5.2Evidence

21.6Vitamin B3 (Niacin)

21.6.1Stability and Topical Penetration

21.6.2Evidence

21.7Vitamin C (Ascorbic Acid) and Vitamin E (Alpha-Tocopherol)

21.7.1Stability and Topical Penetration

21.7.2Evidence

21.8Curcumin

21.8.1Stability and Topical Penetration

21.8.2Evidence

21.9DNA Repair Enzymes

21.9.1Stability and Topical Penetration

21.9.2Evidence

21.10Peptides and Proteins

21.10.1Stability and Topical Penetration

21.10.2Evidence for GHK-Cu

21.10.3Evidence for Pal-KTTKS

21.10.4Evidence for Growth Factors and Cytokines

21.11Oral Collagen

21.11.1Stability and Systemic Absorption

21.11.2Evidence

21.12Conclusion

22Kybella/Deoxycholic Acid/Off-Label Uses

Sachin M. Shridharani, Teri N. Moak, Trina G. Ebersole, and Grace M. Tisch

22.1Introduction

22.1.1Ultrasound-Assisted Liposuction

22.1.2Power-Assisted Liposuction

22.1.3Laser-Assisted Liposuction

22.1.4Radiofrequency-Assisted Liposuction

22.1.5Helium Plasma

22.2Modalities/Treatment Options Available

22.3Indications

22.4Patient Selection

22.4.1Preoperative Considerations

22.4.2Contraindications

22.5On-Label Technique

22.5.1Step 1: Pretreatment Markings

22.5.2Step 2: Identification of the Treatment Zone

22.5.3Step 3: Injection Pattern

22.5.4Step 4: Administration of Local Anesthetic

22.5.5Step 5: Administration of ATX-101

22.5.6Step 6: Postinjection Ice

22.5.7Step 7: Subsequent Treatment Sessions

22.6Off-Label ATX-101

22.6.1Supplemental Considerations for Off-Label ATX-101

22.6.2Technical Considerations for Off-label ATX-101: Jowls and APAF

22.7Posttreatment Instructions

22.8Potential Complications and Management

22.9Pearls and Pitfalls

22.9.1Pearls

22.9.2Pitfalls

23High-Definition Body Contouring: Advancing Traditional Liposuction through Experience

Jason Emer and Michael B. Lipp

23.1History and Evidence-Based Approaches

23.2Surgical Criteria

23.3High-Definition Body Contouring

23.3.1Anatomy: Importance of Adipose Layers

23.4HDBC Key Steps

23.4.1Step 1: Marking and Placement of Port/Entrance Sites

23.4.2Step 2: Tumescent Anesthesia

23.4.3Step 3: Energy-Based Treatment of Fat

23.4.4Step 4: Extraction and Fat Harvesting

23.4.5Step 5: Superficial Muscular Etching and Defining

23.4.6Step 6: Fat Grafting

23.5Anatomy: Female versus Male

23.5.1Female Physique

23.5.2Male Physique

23.6Surgical Planning and Staging of Procedures

23.6.1Typical Staging of a Female Full-Body Contouring Procedure (without Skin Cutting)

23.6.2Typical Staging of a Male Full-Body Contouring Procedure (without Skin Removal)

23.7Postoperative Aftercare and Follow-Up

23.7.1Lymphatic Massage

23.7.2Hyperbaric Oxygen

23.7.3Ultrasound and Radiofrequency Devices

23.7.4Surgical Drainage Tubes

23.8Conclusion

24Fat Transfer

Wilfred Brown and Amanda Fazzalari

24.1Introduction

24.2Background of Fat Transfer

24.3Principles of Fat Grafting

24.3.1Method of Harvest

24.3.2Cannula

24.3.3Time

24.3.4Processing

24.3.5Injection

24.3.6Recipient Site

24.3.7Additional Considerations

24.4Individual Considerations

24.4.1Medical History

24.4.2Physical Examination

24.4.3Informed Consent

24.4.4Photography

24.5Clinical Applications

24.5.1Tissue Augmentation/Filling

24.5.2Risks and Complications of Fat Grafting

24.6Future

24.7Pearls and Pitfalls

24.7.1Pearls

24.7.2Pitfalls

Index

Preface

This volume represents the collective wisdom and experience of experts in our field who pioneered most of the laser and cosmetic treatments available today. Many of them comprise a new generation of thought leaders and innovators who continue to push the boundaries of treatment possibilities and outcomes. The purpose of this compendium is to address any knowledge gaps in the field of cosmetic dermatology among those who have recently completed their training and lack experience and expertise, particularly with respect to the latest developments in cosmetic technology. Hopefully, this compendium will enrich their existing skillsets and serve as an inspiration for developing additional techniques that best serve our patients.

As we are aware from our annual dermatology meetings, our field continues to evolve as we hear of new products and devices. Some persist, while others we never hear about again. Since the best physicians are life-long students, my hope in producing this textbook is to plant a seed from which further knowledge can continuously grow and expand, particularly as our technology continues to evolve.

This volume discusses the most up-to-date developments in cosmetic dermatology, including topics such as soft tissue fillers and botulinum toxin, laser treatment of vascular and pigmented lesions, ablative and nonablative resurfacing, body contouring, tissue tightening, liposuction, and surgical approaches to cosmetic rejuvenation, to name a few. Our authors adopt an approach that is patient-centered and tailored to the patient’s needs, concerns, and native anatomy/skin type/functional status. The knowledge we share does not exist in a vacuum and owes heavily to the work of luminaries, both past and present. We are grateful to the investments of time and labor of all our contributing authors, without whom this work would not be possible.

Yoon-Soo Cindy Bae, MD

Contributors

Gee Young Bae, MD

Clinical Professor

Department of Dermatology

Asan Medical Center

Seoul, South Korea

Yoon-Soo Cindy Bae, MD

Mohs Micrographic Surgeon and Dermatologic Oncologist

Cosmetic and Laser Surgeon

Laser & Skin Surgery Center New York;

Clinical Assistant Professor of Dermatology

New York University Grossman School of Medicine

The Ronald O. Perelman Department of DermatologyNew York, New York, USA

Leonard J. Bernstein, MD, FAAD

Assistant Clinical Professor

Department of Dermatology

Weill Cornell Medical College – New York Presbyterian Hospital

New York, New York, USA

Andreas Boker, MD

Assistant Clinical Professor

Department of Dermatology

NYU School of Medicine

New York, New York, USA

Jordan Borash, MD

Acne Research Fellow

Department of Dermatology

Dermatology Institute of Boston

Boston, Massachusetts, USA

Rawn Bosley, MD

Chesnut MD Cosmetic Surgery Fellowship

Clinic5C

Spokane, Washington, USA

Jeremy A. Brauer, MD

Clinical Associate Professor

The Ronald O. Perelman Department of Dermatology

New York University Grossman School of Medicine

New York, New York, USA

Wilfred Brown, MD, FACS

Plastic and Reconstructive Surgeon

Private Practice

Middlebury, Connecticut, USA

Daniel Callaghan, MD

Mohs Surgeon

Advanced Dermatology and Cosmetic Surgery

Denver, Colorado, USA

Cameron Chesnut, MD, FAAD, FACMS, FASDS

Dermatologic Surgeon

American Academy of Facial Plastic and Reconstructive Surgery;

Clinical Assistant Professor

University of Washington School of Medicine

Seattle, Washington, USA

Mitalee P. Christman, MD

Dermatologist

SkinCare Physicians

Chestnut Hill, Massachusetts, USA

Maressa C. Criscito, MD, FAAD

Assistant Professor

Mohs Micrographic Surgery and Dermatologic Oncology

The Ronald O. Perelman Department of Dermatology

New York University Grossman School of Medicine

New York, New York, USA

Trina G. Ebersole, MD

Resident Physician

Division of Plastic and Reconstructive Surgery

St. Louis School of Medicine

Washington University

St. Louis, Missouri, USA

Jason Emer, MD, PC

Emerage Medical

West Hollywood, California, USA

Sabrina Guillen Fabi, MD

Goldman, Butterwick, Fitzpatrick, Groff and Fabi

Cosmetic Laser Dermatology

San Diego, California, USA

Amanda Fazzalari, MD

Chief Resident

Department of General Surgery

Stanley J. Dudrick Department of Surgery

Saint Mary’s Hospital - Trinity Health of New England

Waterbury, Connecticut, USA

Adam Friedman, MD, FAAD

Professor and Chair of Dermatology;

Associate Residency Program Director;

Director of Translational Research;

Director of Supportive Oncodermatology

Department of Dermatology

George Washington School of Medicine and Health Sciences

Washington, DC, USA

Daniel P. Friedmann, MD, FAAD

Board-Certified Dermatologist

Westlake Dermatology & Cosmetic Surgery;

Clinical Research Director

Westlake Dermatology Clinical Research Center;

Diplomate of the American Board of Venous and Lymphatic Medicine

Austin, Texas, USA

Roy G. Geronemus, MD

Director

Laser & Skin Surgery Center of New York;

Clinical Professor of Dermatology

New York University Medical Center

New York, New York, USA

David J. Goldberg, MD, JD

Medical Director

Skin Laser & Surgery Specialists;

Director

Cosmetic Dermatology and Clinical Research

Schweiger Dermatology Group;

Clinical Professor of Dermatology;

Past Director

Mohs Surgery and Laser Research

Icahn School of Medicine at Mount Sinai

New York City, New York, USA

Samantha Gordon, MD

Dermatologist

Department of Dermatology

Dermatology & Aesthetics

Chicago, Illinois, USA

Emmy M. Graber, MD, MBA

President

Department of Dermatology

The Dermatology Institute of Boston

Boston, Massachusetts, USA

Ezra Hazan, MD

Clinical Instructor

Department of Dermatology

Icahn School of Medicine at Mount Sinai

New York, New York, USA

Rhett A. Kent, MD

Department of Forefront Dermatology

Arlington, Virginia, USA

Hooman Khorasani, MD

Associate Professor

Department of Dermatology

Icahn School of Medicine at Mount Sinai

New York, New York, USA

Margo H. Lederhandler, MD

Mohs Micrographic and Reconstructive Surgeon and Dermatologist

Department of Dermatology

Weill Cornell Medicine

New York, New York, USA

Austin Lee, BS

Research and Medical Assistant

New York Cosmetic, Laser, and Skin Surgery

Center

New York City, New York, USA

Monica K. Li, MD, FRCPC, FAAD

Department of Dermatology and Skin Science

University of British Columbia

Vancouver, British Columbia, Canada

Richard L. Lin, MD, PhD

Dermatologist

New York University

New York, New York, USA

Michael B. Lipp, DO, FAAD

SKINAESTHETICA

Redlands, California, USA

Jennifer L. MacGregor, MD

Clinical Professor

Department of Dermatology

Columbia University Medical Center

New York, New York, USA

Margaret Mann, MD

Associate Clinical Professor

Department of Dermatology

Case Western Reserve University

Cleveland, Ohio, USA

Joseph N. Mehrabi, MD

Resident

Maimonides Medical Center

Brooklyn, New York, USA

Vineet Mishra, MD

Associate Professor of Dermatology

Department of Dermatology

University of California San Diego

San Diego, California, USA

Teri N. Moak, MS, MD

Resident Physician

Department of Surgery

Division of Plastic and Reconstructive Surgery

Washington University, Barnes Jewish Hospital

St. Louis, Missouri, USA

Laurel M. Morton, MD

Physician

SkinCare Physicians

Chestnut Hill, Massachusetts, USA

Robert D. Murgia, DO, MA, FAAD

Dermatology and Skin Health

Peabody, Massachusetts, USA

Emily C. Murphy, MD

Resident

Department of Dermatology

George Washington School of Medicine and Health Sciences

Washington, DC, USA

Benjamin Curman Paul, MD

Facial Plastic Surgeon

Otolaryngology – Head and Neck Surgery

Lenox Hill Hospital

New York, New York, USA

Deanne Mraz Robinson, MD, FAAD

Assistant Clinical Professor

Department of Dermatology

Yale New Haven Hospital

New Haven, Connecticut, USA

Cameron Rokhsar, MD, FAAD, FAACS

Founder and Medical Director

New York Cosmetic, Laser, and Skin Surgery Center

New York City, New York, USA

Nazanin Saedi, MD

Dermatology Associates of Plymouth Meeting

Plymouth Meeting, Pennsylvania, USA

Jeffrey F. Scott, MD

Assistant Professor

Department of Dermatology

Johns Hopkins School of Medicine

Baltimore, Maryland, USA

Sachin M. Shridharani, MD, FACS

Director

Department of Aesthetic Plastic Surgery

LUXURGERY

New York, New York, USA

Seaver L. Soon, MD

Courtesy Staff Physician

Department of Dermatology

Scripps Green Hospital

La Jolla, California, USA

Robert Blake Steele, MD

Fellow

Department of Facial Cosmetic and Mohs Micrographic Surgery

Chesnut Institute of Cosmetic and Reconstructive Surgery

Spokane, Washington, USA

Alexa B. Steuer, MD, MPH

Dermatology Resident Physician

The Ronald O. Perelman Department of Dermatology

New York University Grossman School of Medicine

New York, New York, USA

Nina Lucia Tamashunas, BS

Medical Student

School of Medicine

Case Western Reserve University

Cleveland, Ohio, USA

Andrea Tan, MD

Resident

Department of Dermatology

Stony Brook University Hospital

Stony Brook, New York, USA

Grace M. Tisch

LUXURGERY

New York, New York, USA

Jordan V. Wang, MD, MBE, MBA

Medical Research Director

Laser & Skin Surgery Center of New York

New York, New York, USA

Robert Weiss, MD

Former Associate Professor

Department of Dermatology

Johns Hopkins University School of Medicine

Baltimore, Maryland, USA

Lindsey Yeh, MD

B.TOX.BAR

Los Gatos, California, USA

Michael Zumwalt, MD

Dermatologist/Mohs Surgeon

Skin Cancer and Dermatology Institute

Reno, Nevada, USA

1 Nonablative Rejuvenation

Daniel Callaghan and Laurel M. Morton

Summary

Nonablative rejuvenation can be achieved with a number of devices and is successfully used to treat many components of the aging process including texture irregularities, pigment irregularities, and tissue laxity. As the name implies, it does so without ablating the epidermis, which provides a lower potential for side effects and a shorter downtime than ablative lasers. The devices used for nonablative rejuvenation are diverse and include intense pulsed light, lasers in the visible light and mid-infrared spectrums, microneedling, radiofrequency, and photodynamic therapy. This chapter explores these interventions in detail and provides clinicians with a roadmap to be able to select the most appropriate treatment for each unique patient.

Keywords: nonablative rejuvenation laser IPL microneedling radiofrequency PDT

1.1 Introduction

“Rejuvenation” is a broad term that describes the process of making the skin appear younger. The aging process, whether it is intrinsic aging programmed by genetics or extrinsic aging due to factors such as the sun, is composed of a number of core features including the following: volume loss, texture irregularities including fine or deep rhytides and acne scars, and pigment irregularities such as telangiectasias, lentigines, or melasma. Today, dermatologists have a widespread number of treatment options available to help rejuvenate their patients’ skin. Although this is no doubt beneficial for patients, as everyone ages differently, it can also be overwhelming and challenging to determine which treatment is best suited for each patient.

Despite the vast number of treatment options available, they all function with the same goal, which is to deliver targeted energy or trauma to the skin to either destroy a lesion such as a lentigo or to stimulate collagen remodeling and neocollagenesis. The devices in our rejuvenation armamentarium include intense pulsed light (IPL), lasers, photodynamic therapy (PDT), microneedling, and radiofrequency (RF). IPL devices work by producing incoherent light of multiple wavelengths to deliver energy to the tissue, whereas lasers use specific wavelengths to target chromophores in tissue including melanin, hemoglobin, or water. PDT combines a photosensitizer such as 5-aminolevulinic acid (5-ALA) with light to target actinic keratoses. Microneedling uses physical trauma, whereas RF devices produce heat through electrical impedance. Beyond this, there are some devices that combine the above, such as microneedling and RF. There is a huge variety of treatment options available made by multiple device companies and all with different treatment parameters.

Ablative technologies such as the carbon dioxide laser, either fully or fractionally ablative, produce impressive results and may be considered by some as the “gold standard” for rejuvenation. However, these devices are associated with a number of adverse effects and a prolonged recovery time, which make them unrealistic options for many patients. For this reason, nonablative rejuvenation treatments have become increasingly popular over the years and are the focus of this chapter.

1.2 Modalities Available

1.2.1 Intense Pulsed Light

IPL sources are not lasers but flashlamp devices that produce noncoherent, multiwavelength light at wavelengths between 400 and 1,200 nm. Clinicians can utilize filters that block wavelengths shorter than the selected filter, thereby emitting only longer wavelengths that can penetrate the skin more deeply. Other factors that can be adjusted with IPL include fluence, pulse duration, and frequency of pulses administered. These are selected based on skin type, target, and severity of the target. IPL provides the benefit of minimal downtime. To reduce the risk of side effects, darker skin types should be treated with filters that employ longer wavelengths, longer pulse durations, and conservative fluences, whereas lighter skin types can be treated with a broader range of wavelengths, narrower pulse durations, and higher fluences. The clinical endpoint for IPL is often described as a mild amount of erythema and darkening of ephelides or lentigines, which develop within minutes of a pulse.

A systematic review by Wat et al found that IPL had a strong or moderate indication for the treatment of lentigines, melasma, rosacea, capillary malformations, and telangiectasias.1 In a split-face study comparing IPL with the 755-nm nanosecond Q-switched (QS) alexandrite, it was demonstrated that IPL was equivalent to QS nanosecond alexandrite for the treatment of solar lentigines, although the QS nanosecond alexandrite was more effective for the treatment of ephelides.2 Wang et al also evaluated IPL for the treatment of melasma and found that the IPL group experienced 39.8% improvement compared with the control group, which was treated with hydroquinone and sunscreen and had a more modest (11.6%) improvement.3 Unfortunately, as has been the case with other melasma studies, results did not prove to be consistently sustainable. In a split-face, randomized, blinded trial, IPL was found to be equivalent to the pulsed dye laser (PDL) for the treatment of facial telangiectasias.4 Additionally, Goldberg and Cutler demonstrated that IPL has some effect at improving facial rhytides.5

Several studies have evaluated IPL for “rejuvenation” in general, including the overall treatment of rhytides, skin coarseness, irregular pigmentation, pore size, and telangiectasias. One study, in particular, selected 49 subjects who were treated with a series of four or more full-face treatments at 3-week intervals and found that 100% of subjects reported some degree of satisfaction and 96% would recommend the treatment.6

1.2.2 532-nm KTP Laser and 595-nm PDL

Based on the theory of selective photothermolysis, there are a number of devices that use a unique wavelength to target a specific pigmentary defect, typically brown or red. Oxyhemoglobin, which is the chromophore targeted by vascular lasers, has absorption peaks at 542 and 577 nm. Absorption of the laser energy heats the oxyhemoglobin and leads to vessel wall damage. Along with IPL, the other energy-based devices that are most frequently used to treat telangiectasias and facial redness include the 595-nm (and rarely 585-nm) PDL and the 532-nm potassium titanyl phosphate (KTP) laser. Patients can typically expect at least 50 to 90% improvement after a series of one to three treatments with these devices7 (Fig. 1.1).

Fig. 1.1(a) Postinflammatory erythema (PIE) secondary to acne. (b) Improvement of PIE after three sessions of pulsed dye laser at monthly intervals using the following parameters: 10 mm, 7.5 J/cm2

2 Ablative Rejuvenation

Mitalee P. Christman and Roy G. Geronemus

Summary

Ablative rejuvenation is still considered the gold standard for nonsurgical treatment of photoaging. Treatment options include both traditional full-field ablative and fractional ablative carbon dioxide and erbium:yttrium aluminum garnet lasers. The ideal candidate has fine static rhytides and appropriate expectations regarding recovery and results. A thorough preoperative consult is performed and antiviral and antibacterial prophylaxis is provided to the patient. A multipronged anesthetic strategy is often necessary for optimal pain management. During the treatment, careful attention is paid to the clinical endpoint of visible wrinkle effacement and total energy delivered to the treatment area. Laser-assisted drug delivery of poly-L-lactic acid, postprocedure peptide serums, and photomodulation might enhance results and patient satisfaction. Close clinical follow-up is warranted to monitor for infectious complications. Recognition of symptoms and signs of other possible complications including erythema, dyspigmentation, and scarring is critical to allow for early intervention. With careful preoperative, intraoperative, and postoperative care, ablative rejuvenation can be a very satisfying and successful procedure.

Keywords: ablative resurfacing ablative rejuvenation ablative lasers resurfacing carbon dioxide erbium:YAG

2.1 Introduction

Ablative laser resurfacing is still considered the gold standard for nonsurgical rejuvenation of fine rhytides and photoaging. The spectrum of ablative rejuvenation procedures spans from ablative full-field traditional resurfacing to ablative fractional resurfacing with carbon dioxide (CO2) and erbium:yttrium aluminum garnet (Er:YAG) lasers. Careful consideration of each patient’s goals and lifestyle—along with their skin type, severity of photoaging, depth of rhytides, and scars—informs the ideal treatment for that patient. Once a device is selected, attention to preoperative evaluation, intraoperative technique, and postoperative care will produce reliable clinical results and limit the risk of complications.

Understanding the mechanism and history of ablative lasers requires an understanding of the theory of selective photothermolysis. Briefly, for a laser to treat its target, the wavelength of the laser must be absorbed greatly by the desired chromophore, the pulse duration should be shorter than the thermal relaxation time of the tissue to allow for heat confinement, and the fluence should be sufficient for therapeutic effect while minimizing collateral damage.1,​2 Applying the tenets of this theory for resurfacing the epidermis, the ideal wavelengths target water (the chromophore of the epidermis); the ideal pulse duration is less than 1 millisecond, and the fluence is at least 5 J/cm2—a lower fluence will produce diffuse heating without vaporizing the epidermis.2 Using sufficient fluence or energy will vaporize the epidermis and produce a zone of residual thermal damage that denatures collagen, triggering neocollagenesis. The size of this zone of residual thermal damage is a function of the laser beam energy and the laser dwell time or pulse duration—the wider the pulse, the greater the thermal damage.

Ablative resurfacing was born in the 1980s with continuous wave (CW) CO2 lasers. The infrared 10,600-nm CO2 laser is absorbed by water, vaporizing the epidermis and forming coagulated debris by denaturing collagen and cauterizing small blood vessels in the dermis. Whereas these destructive and hemostatic features of the early CO2 lasers made them invaluable for the removal of epithelial neoplasms as well as incisional surgery, these same capabilities produced excess thermal injury and an unacceptably high risk of scarring and pigment alteration due to their tissue dwell times being much greater than the thermal relaxation time of the epidermis.

The 1990s saw the introduction of technologies with shorter pulse durations and high peak power and rapidly scanning CW technology, which were relatively safer but still with prolonged recovery time. Initial “superpulsed” high-peak power devices produced high-frequency short pulses (200–1,000 pulses per s) or shuttering of the continuous beam to create a 0.1- to 1-second burst of energy. Subsequent devices either produced a high-energy pulse of 1 millisecond or shorter (ultrapulsed CO2) or rapidly scanned a CW laser beam so that the tissue dwell time at any individual location was less than 1 millisecond (rapidly scanning CW CO2). Either of these approaches delivered high energy that allowed penetration of the laser up to a depth of 20 to 30 µm into the skin in a single pass, and the ultrashort pulses ensured that the exposure was shorter than the thermal relaxation time of the epidermis, limiting collateral thermal injury. Further passes with the CO2 laser produce deeper residual thermal damage that extends about 100 to 150 µm into the dermis and stimulates collagen contracture and skin tightening, clinically translating into improvement of photoaging, rhytides, and scars.3

The millennium brought the introduction of the erbium:YAG laser (2,940 nm). This laser has an absorption coefficient for water that is 16 times higher than that of the CO2 laser. This translates into a lower depth of penetration of about 5 to 15 µm, a narrower zone of residual thermal damage of about 10 to 40 µm leading to a shorter recovery time, albeit at the cost of lower efficacy for neocollagenesis.

Finally, the erbium:yttrium scandium gallium garnet (Er:YSGG) proprietary 2,790-nm wavelength introduced in the late 2000s had an absorption coefficient for water that is about five times that of the CO2 laser, and was thought to represent a hybrid between CO2 and Er:YAG in terms of its ratio of penetration to residual thermal damage.4

The downtime and complication rates of ablative resurfacing inspired the development of nonablative resurfacing and, in 2004, fractional resurfacing, to minimize risk and improve recovery time. Nonablative resurfacing (Chapter 1) improves wrinkles and photodamage by producing dermal thermal injury while sparing the epidermis; however, multiple treatments are required and the modality is generally considered less effective than ablative resurfacing.5 Fractional resurfacing thermally ablates microscopic columns of epidermis and dermis in regularly spaced arrays.6,​7 The surrounding tissue is preserved and acts as a reservoir for quicker re-epithelialization and faster healing.6 This intermediate approach increases efficacy compared to nonablative resurfacing, but with shorter downtime and risks compared to ablative resurfacing.8 Although high-quality comparative trials are lacking, multiple passes of ablative fractional resurfacing are thought to approach the coverage of traditional full-field resurfacing, and ablative fractional resurfacing has now widely supplanted full-field ablative resurfacing in the therapeutic armamentarium for photoaging.9

2.2 Modalities/Treatment Options Available

For the physician wishing to choose a device for ablative rejuvenation, evidence-based selection of a modality is compromised by the quality of data available from uncontrolled studies and a few small randomized controlled trials, and also by the wide variety of criteria used to assess clinical responses among trials. As such, selection of a modality is driven by laser availability, clinical expertise, and patient-specific factors. The differences in the wavelengths available for ablative rejuvenation are detailed in Table 2.1, and select devices currently available are compared in Table 2.2. Devices vary based on wavelength, scanning versus stamped delivery, depth of ablation, and extent of thermal injury produced.

2.3 Indications

Ablative resurfacing effectively treats many components of photoaged skin including rhytides, dyspigmentation, elastosis, and actinic damage. Fine rhytides in the periorbital, cheek, and perioral areas can be completely effaced with ablative lasers.5 In addition to photoaging, other indications for ablative resurfacing include actinic cheilitis, scars, rhinophyma, epidermal nevi, angiofibroma, sebaceous hyperplasia, seborrheic keratoses, adnexal tumors, squamous cell carcinoma in situ, and superficial basal cell carcinoma.

2.4 Patient Selection, Contraindications, and Preoperative Considerations

During the consultation visit, the patient’s goals, expectations for the procedure, recovery process and results, contraindications (Table 2.3), preoperative considerations (Table 2.3), and their tolerance for complications should be carefully assessed in addition to their photoaging profile. The ideal candidate for ablative resurfacing is a patient with skin types I to III with fine static rhytides, mild laxity if any, and appropriate expectations regarding recovery and results. Many patients’ photoaging profiles merit a multipronged approach: dynamic rhytides are best targeted with neuromodulators (Chapter 15), telangiectasias are better targeted with vascular lasers, and moderate-to-severe laxity is best treated with plastic surgery procedures—patients who emphasize dissatisfaction with these features should be directed toward these other modalities in combination with ablative resurfacing.

Table 2.3 Contraindications for ablative resurfacing

Contraindication

Rationale

History of keloids or abnormal scarring

Greater scar risk

History of radiation therapy

Connective tissue diseases such as scleroderma or morphea

Reduction in adnexal structures → absence of bulge stem cells → reduced ability for re-epithelialization

Isotretinoin therapy, concurrent or past 6 mo

Risk of atypical scarring or delayed healing → avoid fully ablative lasers

Insufficient evidence to delay fractional ablative lasers during this time10

History of facelift or blepharoplasty in the past 6 mo

Altered blood circulation in undermined skin → increased risk of necrosis and scarring

Current cutaneous infection in area to be treated (bacterial or viral)

Potential for local and/or hematogenous spread

Table 2.4 Preoperative considerations for ablative resurfacing

Preoperative consideration

Action

Darker skin phototype (IV or higher)

•Caution regarding postinflammatory pigment alteration

•Avoid fully ablative CO2 resurfacing in favor of Er:YAG or fractional CO2

•Consider a test area

•Consider multiple treatments with nonablative fractional laser using conservative settings in lieu of ablative lasers

Pregnancy/nursing

Delay this elective procedure due to lack of safety data and limitations on treatment of any complications

Psoriasis, vitiligo, lichen planus

Potential for koebnerization → relative contraindication

Ask about family history

Nonfacial sites such as neck, hands, chest

High risk of scarring → avoid full-field CO2 resurfacing, caution with fractional ablative and Er:YAG lasers

Presence of ectropion

Postoperative skin tightening may exacerbate or induce ectropion

Dermatographism

Consider pretreatment with antihistamines

Smoking

Delayed wound healing; avoid smoking before procedure and during postoperative course

Acne

Consider empiric antibiotics if there is recent history of inflammatory lesions

History of herpes simplex virus

Emphasize the importance of compliance with antiviral prophylaxis, which should be offered to all patients

Rosacea

Consider combination with vascular laser; counsel patient to anticipate flare postoperatively

As this procedure calls for considerable logistical planning, we recommend development of a practice-specific preoperative checklist (Table 2.5). Showing patients photographs of the expected recovery and results is critical (Fig. 2.1a–h) for informed consent and patient satisfaction. A variety of pretreatment regimens with glycolic acid, tretinoin, and hydroquinone have failed to reduce postoperative pigmentary alteration; so, we do not recommend these in our practice.11,​12 Antiviral prophylaxis is provided to all patients regardless of history of herpes simplex virus infections.13,​14 Although the evidence for antibacterial prophylaxis is mixed,15,​16 the authors prescribe antibiotics for patients undergoing full-face resurfacing as bacterial superinfection can be devastating in this setting. In the authors’ practice, all patients undergoing laser resurfacing are given antiviral prophylaxis with valacyclovir 500 mg twice daily starting from the day prior to the procedure and continuing until re-epithelialization is complete, and all patients are given antibacterial prophylaxis with dicloxacillin 500 mg twice daily for 7 days starting from the day of the procedure. If a patient is on anticoagulation for medical indications, it should be continued as the risks of thromboembolism outweigh the risks of bleeding, which can be controlled during the procedure.17

Table 2.5 Preoperative checklist

Presence of static fine rhytides and/or mild laxity

Review of past medical history, medications, and allergies to assess for absence of contraindications or relative contraindications detailed in Table 2.3 and Table 2.3

Review of photographs of typical healing process and typical results

Prescription of antiviral and antibacterial prophylaxis:

•Valacyclovir 500 mg twice daily to be started the day prior to the procedure and continued at least 7 d or until re-epithelialization is complete

•Dicloxacillin 500 mg twice daily for 7 d starting from the day of the procedure

Arrangement and documentation of medical risk assessment for intravenous sedation

Informed consent

Clinical photography

Arrangement of postoperative transportation home. Patients undergoing intravenous (IV) sedation will need an escort

Arrangement of home skincare supplies including provision of topical products

Scheduling of procedure and clinical follow-up visits

Provision of postoperative instruction handout

Fig. 2.1 Timeline of treatment and recovery after fractional ablative resurfacing. (a) Baseline. (b) Thirty minutes postoperative appearance. (c) Postoperative day 1. (d) Postoperative day 3. (e) Postoperative day 5. (f) Postoperative day 7. (g) Postoperative day 14. (h) Follow-up at 1 month. (i) Follow-up at 3 months.

2.5 Technique

2.5.1 Anesthesia and Pain Management

The discomfort associated with ablative procedures is considerable and a multifaceted anesthetic strategy is imperative for patient comfort especially in full-face procedures. For treatment of individualized cosmetic units, local anesthesia is often sufficient. For very superficial ablative procedures, topical anesthesia may suffice. For full-face procedures, most physicians and patients prefer intravenous (twilight) sedation with an anesthesiologist present for intraoperative monitoring and emergency equipment. In combination with intravenous sedation, the authors use a combination of topical anesthesia with EMLA (lidocaine and prilocaine) cream for 1 hour, followed by sensory nerve blockade using lidocaine 1% with 1:100,000 epinephrine and 1:10 NaHCO3 8.4%.18 As the lateral face is not effectively targeted with nerve blocks, a multi-injector needle is used in these areas with a mixture of lidocaine 1% with epinephrine, normal saline, and NaHCO3 in a 5:4:1 ratio. HCO3 neutralizes the pH of the mixture and decreases the burning sensation during the injection. In the cases where patients opt against intravenous sedation, inhaled nitrous oxide 50%/oxygen 50%19 is used to further ease the pain of injections.

2.5.2 Intraoperative Safety

The physician and surgical assistants should wear appropriate protection with laser safety glasses, mask, and gloves. The patient should be provided with protective eyewear as well. If treatment will be performed within the orbital rim, lubricated metal ocular shields should be inserted after administration of anesthetic drops. If applicable, the nitrous oxide device should be removed from the room before switching on the laser to limit the risk of ignition. The operative field should be kept clear of flammable materials including alcohol and aluminum chloride.

2.5.3 Operative Technique

Many aspects of the treatment are device dependent; however, some universal treatment principles apply. The topical anesthetic cream is removed and skin dried thoroughly. Hair is secured with a headband and the patient is positioned supine (Fig. 2.2). Intravenous or local anesthetic is administered. The skin is prepped with chlorhexidine and completely dried. Eyelashes and eyebrows are protected with sterile lubricating jelly or a tongue depressor. The authors use a fractional CO2 laser (Fraxel re:pair, Solta Medical Ltd., Hayward, California, United States), which creates microscopic treatment zones with depth of penetration determined by pulse energy. For patients with deep rhytides, we typically use an energy of 70 mJ (corresponding to a depth of 1,580 µm), density of 50% within six passes (Table 2.6); however, importantly, the actual number of passes per cosmetic subunit is determined by energy delivery goals for that subunit. The 135-µm 15-mm tip is used to deliver one nonoverlapping “first pass” over the treatment area. The debris is gently wiped with distilled water–soaked gauze and dried to reveal pink partially denatured dermis. Deeper rhytides are stretched with the nondominant hand to ensure complete treatment. Subsequent passes are placed with careful attention to the total energy and the clinical endpoint of visible wrinkle effacement and pinpoint bleeding, indicating the papillary dermis has been reached (Fig. 2.3). Yellow or brown color present after wiping indicates thermal injury and charring, so no further passes should be performed. The perioral and periocular skins are treated with the smaller 135-µm 7-mm tip for more precise energy delivery, using lower settings (40 mJ corresponding to a depth of 1,061 µm, 30% coverage within four passes). Perioral skin is treated over the vermilion border (Fig. 2.4). The transition of the mandible to the neck is also feathered with these lower settings to prevent a sharp demarcation line. Partially desiccated tissue from the final pass is not wiped to serve as a wound dressing. Again, attention to total energy applied to each subunit is critical (Table 2.7) and nonfacial sites such as the hands, neck, and chest especially merit lower energies and lower densities given the prolonged healing time and scar risk. For patients with less severe photodamage, we frequently combine a more superficial resurfacing approach with poly-L-lactic acid (PLLA) overlay (Table 2.6). Immediately after a full-face procedure, the authors apply about 3 mL of a mixture of PLLA prehydrated with 8 mL of diluent 24 hours prior for laser-assisted drug delivery and enhanced neocollagenesis.20 Although this approach has been described with lower-density ablative fractional treatments, we have also found success applying PLLA after ablation with the higher-density settings described earlier. Finally, sterile gauze soaked in distilled water is applied to the treated area for 10 to 20 minutes for hemostasis and reduction of crust formation (Fig. 2.5). A postprocedure peptide serum is applied21 and patients are provided with a nonadherent postprocedure face mask. Vital signs are documented. Once the patients are oriented and ambulatory, they are discharged home with their escort.

Table 2.6 Example settings for Fraxel re:pair CO2 ablative fractional resurfacing

Deeper rhytides

Lighter photodamage followed by PLLA overlay

Rest of face

70 mJ, 50%, 6 passesa

70 mJ, 15%, 4 passesa

Periocular and perioral

40 mJ, 30%, 4 passesa

Consider using smaller tip for more precise treatment in hard-to-reach areas

Same as above

(no PLLA applied to the periocular area)

Abbreviation: PLLA, poly-L-lactic acid.

aActual number of passes depends on energy goals in Table 2.7.

Table 2.7 Authors’ energy goals using Fraxel re:pair CO2 ablative fractional resurfacing

Location

Energy goals for deeper rhytides (kJ)

Energy goals for lighter photodamage followed by PLLA overlay (kJ)

Each cheek

2–2.5

0.45

Nose and glabella

0.25–0.35

0.1

Upper cutaneous lip

0.3

0.1–0.25

Lower cutaneous lip/chin

0.35–0.5

0.2

Forehead and temples

0.8–1

0.4

Each lower eyelid

0.1–0.2

0.05 (no PLLA on eyelid)

Each upper eyelid

0.1–0.2

0.05 (no PLLA on eyelid)

Neck

1–1.8

0.25 kJ

Abbreviation: PLLA, poly-L-lactic acid.

Fig. 2.2 Preoperative positioning with patient supine, headband in place, metal intraocular eye shields in place.

Fig. 2.3 The clinical endpoint is visible effacement of rhytides.

Fig. 2.4 Perioral skin is treated over the vermilion border.

Fig. 2.5 Immediately after treatment, cool compresses made with distilled water are applied to the treatment area for 10 to 20 minutes to reduce crust formation.

2.6 Postoperative Instructions

Patients at the authors’ practice are given a postoperative instructions handout (Table 2.8) detailing expectations of recovery and home care instructions. Patients often experience significant swelling and serous exudation in the first 1 to 3 days postoperatively (Fig. 2.1c). Edema is often most severe on postoperative days 2 and 3 and may be managed with ice packs, head elevation, and, if severe, oral corticosteroids (prednisone 40 mg for 3 days). Cool distilled water compresses are used for wet debridement throughout the first week and reapplied frequently to keep the skin moist, followed by the application of postprocedure ointment or petrolatum or other bland healing ointment. Some physicians advocate for wound dressings for the first 1 to 3 days,5,​22,​23