Dermatologic Surgical Skin Rejuvenation

Chemical Peeling
Chemical peeling, also called chemexfoliation or dermapeeling, is a facial skin rejuvenation procedure that does what its name implies—it peels the skin. Its use is usually in the treatment of superficial to moderate photoaging skin damage. Mild chemical peels can be applied to people in their 20s, to prevent effects of aging from becoming apparent too early in life.

In a chemical peeling treatment, a chemical solution is applied to facial skin, causing the skin to blister and peel off over a period of days. As the treated skin blisters and peels, new skin forms to take its place. The new skin is usually smoother and less wrinkled than the old skin.

A mild chemical peel is usually all that is necessary to treat fine lines and wrinkles around the eyes and mouth. Patients with minimal skin damage often respond best to a series of light peels in combination with a skin care program including retinoids and a sunscreen protection program. A medium-depth peel is often more effective for patients with moderate skin damage, including age spots, freckles and actinic keratoses. A medium-depth peel may be combined with another treatment such as laser resurfacing to achieve maximum effectiveness.

Depending on the objectives of the treatment as determined jointly by the patient and dermatologist, the condition and type of the patient’s skin, and the degree of skin damage, the dermatologist by performing dermatologic surgery individualizes the strength of the chemical solution and the depth of the peel. Peeling solution may include one or more chemicals such as alpha-hydroxy acids, trichloroacetic acid, or carbolic acid. The procedure can be performed in the dermatologist’s office, or in an outpatient surgery center. In addition to skin rejuvenation, chemical peeling is effective in reduction of some acne scars. Peeling does not remove deep scars.

The immediate after-effect of a chemical peel is similar to a sunburn. After a mild or superficial peel, redness and scaling of the skin last 3 to 5 days. Medium-depth or deep peeling can result in redness, swelling, blistering and peeling for 7 to 14 days. Medications are prescribed to alleviate discomfort. Overexposure to sun must be avoided for a period of time to prevent sun damage while the new skin is susceptible to injury.

Chemical peeling is effective only for surface skin damage. Effects of aging in deeper tissues, such as sagging jowls and drooping eyelids, must be addressed by other procedures that can be recommended by your dermatologic surgeon.

Soft-tissue Augmentation
In soft-tissue augmentation, a substance that is compatible with the patient’s body tissues is injected under the skin to elevate irregularities such as wrinkles, pits and scars. The substances used for injection are primarily:

• Collagen—a fibrous protein substance of all human and animal tissue. It gives toughness and structure to skin, bones, and ligaments. Most of the collagen used for soft-tissue augmentation is derived from cattle. However, for people who are allergic to bovine (cow-derived) collagen, collagen or collagen-related substances may be self-donated by the patient or obtained from a tissue donor. The dermatologist tests the patient prior to collagen injection to determine if the patient is allergic to bovine collagen. Collagen injection is usually given in a series of treatments, until the desired effect of "filling out" a wrinkle or depression is achieved. A local anesthetic minimizes discomfort from the injection needle. The effects of collagen injection may last for 3 to 12 months.

• Self-donated body fat. Fat is harvested from the patient’s own body and prepared for the procedure called microlipoinjection. This fat-transfer procedure is sometimes called "body sculpturing". The injected body fat is used to replace fat lost from under the skin in the aging process. Defects improved by microlipoinjection include creases around the nose, mouth and chin, and the "drawn look" created by loss of fat pads in the cheeks. The improvements in appearance vary between patients. Some follow-up treatments may be necessary. Microlipoinjection is performed in an outpatient clinic. An after-effect of tissue swelling or bruising fades in a few hours to a few days.

Botulinum Toxin
Dermatologists have harnessed the potent biological effects of botulinum toxin to dramatically improve effects of aging such as frown lines, crows feet, and facial wrinkles. Botulinum toxin is the powerful agent of botulism food poisoning, but botulism cannot be contracted from cosmetic use of botulinum toxin. The toxin’s biological effects in food poisoning are to block nerve impulses transmitted from the brain to muscles, causing generalized paralysis including paralysis of muscles used in breathing.

Dermatologists use purified botulinum toxin in very tiny amounts to inject into a targeted facial muscle. The resulting nerve blockade of that muscle causes a local immobilization of muscle movement. This immobilization prevents "crinkling" and "wrinkle" lines from forming when the patient frowns or squints. Results of treatment last 3 to 4 months. To be maximally effective, treatment with botulinum toxin is repeated over several sessions and is combined with a program of muscle behavioral training to minimize "wrinkling" facial expressions. Botulinum toxin treatment may be used in combination with other procedures for facial rejuvenation to achieve a more lasting effect. A botulinum toxin treatment is accomplished in about 30 minutes in a dermatologist’s office

Dermabrasion
Dermabrasion is a treatment with many applications in dermatology and dermatologic surgery, from removal or reduction of acne and chicken pox scars to facial skin rejuvenation. The procedure, sometimes called surgical skin planing, consists of planing off the surface layer of skin with a rapidly rotating brush. The planing action removes the skin surface, and a new layer of skin grows to replace the skin removed. The principal after-effect is redness of the skin similar to a severe sunburn; medications are prescribed to alleviate discomfort. Healing usually is complete in about 10 days. Patients must avoid sunlight for 3 to 6 months after treatment. A technique that removes less surface skin is called microdermabrasion; it is used most often for superficial skin defects and may be repeated at intervals.

Each potential candidate for dermabrasion needs thorough evaluation by a dermatologist to make certain that dermabrasion is the correct procedure for that individual and that the patient fully understands possible after-effects. For example, pigmented skin may be permanently lightened in the area of dermabrasion, and a person prone to form keloids after skin injury could be at risk for scarring. Post-procedure treatments are available to minimize most after-effects. Dermabrasion may be combined with other procedures such as soft-tissue augmentation to maximize effectiveness.

Laser Skin Resurfacing
The use of lasers in dermatology has advanced rapidly over the past 30 years. Today, lasers have a broad range of dermatologic applications, including:

• removal or improvement of wrinkles, lines and other effects of aging and photoaging

• treatment of superficial brown pigmented lesions such as age spots, and deep pigmented lesions such as port wine stains and birthmarks

• removal or improvement of scars

• removal of some skin cancers

• removal or improvement of vascular moles

• removal of tattoos

• removal of warts

• removal of unwanted hair

The principal applications of lasers in facial skin rejuvenation are reduction or removal of wrinkles, lines and age spots, to "resurface" the skin.

The laser (Light Amplification by the Stimulated Emission of Radiation) is a "light pump".  It applies principles of radiation physics to narrowly segregate light of selected wavelength and "pump" the light radiation to high intensity. These beams of selected wavelength can be varied in intensity and in the duration of emitted pulses.

For example, powerful, rapid pulses of the infrared-wavelength carbon dioxide laser can vaporize targeted skin. The pulses of the carbon dioxide laser can be directed toward resurfacing skin without bleeding. The benefits of laser skin resurfacing include bloodlessness, plus:

• reduced risk of infection

• precisely controlled surgical effects

• one-day outpatient treatment in many instances

After-effects and recovery times vary with different laser procedures. A dermatologist will explain the risks, after-effects and benefits of recommended procedures.

Lasers are powerful instruments and laser surgery should be performed only by a dermatologist or dermatologic surgeon with experience in the procedure. To learn more about lasers and laser surgery, go to the Web site of the American Society for Dermatologic Surgery.

Electrosurgical Resurfacing
An alternative to laser skin resurfacing is electrosurgical resurfacing, also called "cold ablation." This technique uses a micro-electrical radio frequency to deliver a pulse of energy to the skin, removing or improving superficial to moderate skin damage. The procedure has few after-effects, and recovery from mild to moderate swelling is usually complete within a month. Electrosurgical resurfacing offers the advantage of being applicable to most skin types and colors, without loss of skin pigmentation.

Superfluous Hair Removal
Removal of superfluous hair may contribute to overall improved appearance, with or without concomitant facial skin rejuvenation. In women, especially, hair on the chin, over the upper lip, or on arms and legs can create an appearance of older age or masculinization. Traditional methods of dealing with superfluous hair include: (1) bleaching with hydrogen peroxide to make the hair less visible, (2) shaving to temporarily remove hair, (3) plucking hairs, (4) coating the skin with wax, then removing hair with the waxy coat, (5) using a chemical depilatory to "dissolve" unwanted hair, and (6) electrolysis or electrothermolysis to destroy hair follicles for relatively permanent hair removal.

Chemical depilation of facial skin may be irritating and should be performed under the guidance of a dermatologist with a depilating agent prescribed for individual needs.

The safety and effectiveness of electrolysis or electrothermolysis is dependent upon the training and skill of the operator and the equipment used. In these methods a fine electrode is inserted into each hair follicle to destroy the cells from which new hair could grow.

Laser hair removal has been proven effective in recent studies. Hair loss for two or more years has been documented, and may well prove to be long-term or permanent as patients are followed up for longer periods of time. Laser hair removal in most current use is accomplished by photothermolysis—using a laser to generate heat in hair follicles and render them incapable of growing new hair. Skin color and hair color are among factors that a dermatologist considers in determining the type of laser to use, duration of treatment, and number of treatments that may be necessary to accomplish desired results. Side effects of laser hair removal include post-treatment pain for a few hours to a few days, and skin redness. The treating dermatologist can prescribe medicines to alleviate the side effects. Laser hair removal is a procedure that should be performed only by a dermatologist experienced in the use of lasers.

Non-ablative Skin Treatments

Liposuction
Wrinkles, crease lines and age spots are visible effects of aging, and unwanted fat deposits are another. Despite diet and exercise undertaken to keep looking young and trim, fatty deposits may remain on the face, chin, neck, breast, abdomen, hips, thighs, buttocks, knees and ankles. A dermatologist experienced in the procedure can use tumescent liposuction to remove these localized fat deposits. Tumescent liposuction is performed only after a full medical evaluation.

This dermatologic surgery is performed in an outpatient setting, usually under local anesthesia and anti-bleeding medication. In some cases, ultrasound is used to break down and liquify fat cells in the area to be treated. Fat is removed from the targeted area with a vacuum inserted through an incision in the skin. Many patients do not require postoperative pain medication. It is usually possible for the patient to resume physical exercise 3 to 7 days after the procedure. Liposuction is not a substitute for diet, exercise or weight reduction. It complements other efforts to keep a young and trim look.  Go to the Web site for the American Society for Dermatologic Surgery for more information about liposuction.

Surgical Excision
Sometimes facial skin rejuvenation cannot be accomplished to the patient’s satisfaction by removal of surface defects. Long-term effects of gravity may affect deeper layers of tissue, with resulting sags in eyelids, forehead, cheeks, shin, and areas around the mouth. In these instances, a dermatologic surgeon should be consulted regarding the possibility of surgical procedures:

• blepharoplasty (eyelid surgery) to correct "droopy" eyelids by removing excess fat pads and skin

• brow lift to reduce severs lines in the forehead and raise the eyebrows

• rhytidectomy (fact lift) to tighten and trim excess skin on cheeks, chin, neck, and around the mouth

An educational program brought to you by the American Academy of Dermatology.