laser resurfacing, dermabrasion, chemical peel in the asian ethnic clientele

Laser Resurfacing, Dermabrasion, Chemical Peel

in the East Asian Clientele

Philip A Young, MDAesthetic Facial Plastic Surgery, PLLC

Face to FaceHo Chi Minh City, Vietnam

2014

1. East Asia is a subregion of Asia that comprises about 12% of the Asian continent including more than 1.5 billion people and 1/5 of the people in the world

2. China, Japan, Korea, Mongolia3. Southeast Asia can further categorize countries such as Cambodia,

Laos, Malaysia, Philippines, Singapore, Thailand, Vietnam4. Skin Types 3-55. Tendency Pigmentary versus Wrinkling. 1-2 decades for Age Matched

Caucasians6. Most important part of discussion is hyper and hypopigmentation7. Melasma, Ephelides, Lentigines, PIH most common conditions

What is Beauty?

The East Asian Patient

1. Beauty is ordered presentation of objects in the face2. Subtleties are paramount from one element to the next3. The appearance of our skin and the presentation of uniformity in color,

texture and the reflection of light in a smooth and non-abrupt manner as it flows from one anatomical location to another plays a major role in facial beauty1

4. Theory on Facial Beauty called the Circles of Prominence

Resurfacing Methods:

1. Chemical Peels

2. Dermabrasion: Rotary, Dermasanding,

Dermarolling,

3. Laser Resurfacing: CO2, Erbium, Fractional

Technology

4. Non Ablative Resurfacing (Non Resurfacing)

Ablative versus Non-Ablative

1. Non Ablative 500-2000nm: Avoiding Epidermal Ablation while targeting

deeper elements: pigments, blood vessels, non specific heating.

Radiofrequency, Ultrasound.

- Advantage: non invasive, quicker recovery, less invasive

- Disadvantage: multiple treatments, hyper | hypopigmentation,

inferior results to ablative techniques, inability to treat both wrinkling and

pigmentation

1. Ablative 2940nm-10600nm Erbium:YAG and Co2:

- Advantage: Can treat both pigmentary disorders and wrinkling |

skin tightening, One treatment, Decreased risk for skin cancers

- Disadvantage: Long recovery time, Pain, Prolonged Redness,

Increased complication rate, Hypo | Hyperpigmentation

Ablative Simple Rules:

• Level of depth of penetration = amount of

down time, amount of results

Selective Photothermolysis: -Electromagnetic Spectrum-Visible Light: Roygbiv-list of lasers:http://en.wikipedia.org/wiki/List_of_laser_types-515 nm Argon-532 nm Nd:Yag-588-590 nm Pulse Dye Laser (Copper Vapor Laser)-695 nm Ruby- 755 nm Alexandrite- 810 nm Diode Laser-1064 Nd:Yag-1550 nm Erbium Doped Fraxel Laser, etc-2940 Erbium Yag-10600nm co2 laser

Pretreatment:

1. Antiobiotics? Keflex Clinda?

2. 4-6 weeks Retinoic Acid, Hydroquinone |

Azelaic Acid, Hydrocortisone

3. Studies showing lack of effectiveness with

Hyperpigmentation

4. More rapid epithelization, More Even

penetration??

5. Acyclovir Valcyclovir starting 2-3 days and

continued until epithelialization

Chemical Peels:

1. Chemical peels: alpha hydroxy (fruit acid), beta hydroxy, jessner’s,

retinoic acid, trichloroacetic acid, phenol

2. Skin preparation: Retin A, Hydroquinone, Hydrocortisone. Does it really

work?

3. Asian Patient Pretreatment from 2-6 weeks

4. Alpha Hydroxy Acid: Citric, Glycolic (10-70%), Lactic, Malic, Tartaric

5. Beta Hydroxy Acid: Salicylic Acid

6. Combo Peel: most common Jessner’s 14% weight volume salicylic 14g,

resorcinol14g, lactic acid 88% 14ml in ethanol

7. Trichloroacetic Acid Peels 10-35%, Gary Monheit Medium Depth with

Jessner’s

8. Phenol Peels

Precautions with Resurfacing:• A current or history of skin cancer, especially malignant melanoma, or recurrent non- melanoma skin cancer, or

pre-cancerous lesions such as multiple dysplastic nevi.

• Any active skin infection

• Disease which may be stimulated by light at 560nm to 1200nm, such as history of recurrent Herpes simplex,

systemic lupus erythematosus, or porphyria.

• Use of photosensitive medication and / or herbs that may cause sensitivity to 560-1200m light exposure such as

Isotretinoin, tetracycline, or St John’s Wort. Accutane could warrant 1-2 years cessation before deep skin ablation

methods.

• Immunosuppressive disease, including AIDS and HIV infection, or use of immunosuppressive medications.

• Patient history of hormonal or endocrine disorders, such as polycystic ovary syndrome or diabetes, unless under

control.

• History of bleeding coagulopathies, or use of anticoagulants.

• History of keloid or hypertrophic scarring.

• Very dry skin or conditions that would create healing issues in post procedure phase.

• Exposure to sun or artificial tanning during the 3-4 weeks prior to treatment. Sunblock should be applied 2 weeks

or more before any ablative procedure using a product that is sensitive for the skin and contains titanium dioxide

or zinc oxide-containing sunblock.

• Skin types 5-6

• Pregnancy and nursing.

• Ectropion, outward turning of the lower eyelid and excessively dry eyes, previous lower Blepharoplasty.

• Koebnerizing diseases, prior radiation therapy leading to a loss of adnexal structures, extensive fibrosis resulting

from prior cosmetic treatments (e.g., dermabrasion, deep chemical peels, silicone injections).

Chemical Peel Anatomy:

Variables: Pink, White, Grey

Epidermal Sliding

Skin Anatomy:

Results:

Gary Monheit Medium Depth Peel Jessner’s and TCA30% with Dermabrasion Techinques

Results:

Jessner’s 2 passes: level 2

Laser Resurfacing:1. Erbium Yag 2940 nm (late 1990):

-threshold for ablation 1.5J/cm2, thermal relaxation time 50 microsec,

thermal injury is 5-10 micrometers

-advantages: less thermal injury, dermis transudate allows deeper

resurfacing without increased thermal damage

-disadvantages: less collagen tightening, no coagulation of vessels – bloody,

treating deeper wrinkles lead to more bleeding and cumbersome | messy

(need more passess, higher fluences, new technology have been developed.

1. Co2 Laser Resurfacing 10600 nm (1990):

-threshold for ablation 4-5J/cm2, thermal relaxation time 1000 microsec, 1

millisec, thermal injury is 20-60 micrometers

-advantages: More versatile, deeper treatment, faster, much less bleeding,

proven effective, long history

-disadvantages: healing, complications, long post operative course,

Laser Resurfacing:

1. Fractional co2 laser resurfacing of photoaged

facial and non-facial skin: histologic and

clinical results and side effects.gordon h.

sasaki, heather m. travis & barbara tucker.

Journal of Cosmetic and Laser Therapy, 2009;

11: 190–201.

This is a must read

Average skin thickness, adnexal structures

Average Parameters for Fractional Resurfacing

Fluence Changes and Depth of Penetration:J/cm2

Deep FX

Intra Op: 2 passes and dermabrasion in progress: Pinpoint Bleeding End point

Traditional Resurfacing:

• 1. Face 1st pass 100mj den 5, 2nd pass 90mj den 4

• 2. Eyelids 70-90 mj den 4, 60-80 den 3

• 3. Neck and Body Fractional 80-100mj den 1, 15-20mj

den 1

• 4. Clinical End Points: 1. The elimination of the scar,

lesion, or wrinkle; 2. A yellow-brown discoloration (or

chamois-brown); or 3. No further shrinkage.

Results:Fractional Resurfacing

Deep 10mj den2Active 100mj density 2-3

Results:Traditional Resurfacing

100mj den 5; 90 mj den 4; dermabrasion


100mj den 5; 90 mj den 4; dermabrasionPrevious Facelift


100mj den 5; 90 mj den 4; dermabrasionPrior Subcision Techinques


100mj den 5; 90 mj den 4; dermabrasionPrevious Facelift

Results:Traditional

Resurfacing100mj den 5; 90 mj den 4; dermabrasio

n

Dermabrasion:

Dermasanding Indicators:

laser resurfacing, dermabrasion, chemical peel in the asian ethnic clientele

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