Plastic surgery

PART II

SKIN AND SOFT TISSUE

CHAPTER 13  DERMATOLOGY FOR PLASTIC SURGEONS I SKIN CARE AND BENIGN DERMATOLOGIC CONDITIONS

RENATO SALTZ AND BIANCA M. B. OHANA

INTRODUCTION

The skin is the largest organ in the human body. It serves as a mechanical and immunologic barrier and is responsible for thermoregulation and sensibility. Healthy skin imparts the impression of health and beauty, while unhealthy skin suggests premature aging and illness. Plastic surgeons require a working knowledge of both benign and malignant skin conditions; appropriate treatment can only be rendered if the correct diagnosis is made. This chapter reviews the most common benign skin changes and presents a protocol for skin care that can be applied before or after facial aesthetic surgery or independent of aesthetic surgery. The next chapter addresses malignant skin conditions.

ANATOMY

The skin is composed of two layers: the thin epidermis and the thicker dermis (Figure 13.1). Deep to the dermis is subcutaneous fat. There are two types of human skin: skin with hair and glabrous skin (without hair). The latter is found on the palms and soles and has a much thicker epidermis.

The epidermis consists of four layers: stratum corneum, stratum granulosum, stratum spinosum, and stratum basale. In glabrous skin, an additional layer (stratum lucidum) lies between the stratum corneum and the stratum granulosum. The epidermis contains predominantly keratinocytes, melanocytes, Langerhans cells and Merkel cells.

The dermis is divided into the more superficial papillary dermis and the deeper reticular dermis. The dermis contains predominantly fibroblasts, mast cells, histiocytes, monocytes, lymphocytes, and Langerhans cells. The integrity of the dermis is maintained by a supporting matrix containing ground substance and two types of protein fibers: collagen, which has great tensile strength and forms the major constituent of the dermis, and elastin, which makes up only a small proportion of the bulk.1 The skin appendages like hair follicles, sebaceous glands, and apocrine and eccrine glands are also found in the dermis.

BENIGN LESIONS

Pigmented Lesions

Nevus or Melanocytic Nevus. Nevi are acquired lesions that present after birth and consist of a concentration of nevus cells that are classified according to their location as junctional (at the epidermal–dermal junction), intradermal, or compound (both in the dermis and at the junction). Junctional nevi are frequently found on the palms and soles and tend to be uniform, macular, and round with smooth and regular borders. Intradermal nevi are found on the face and are usually homogeneous, elevated, dome-shaped, skin-colored lesions. Compound nevi are raised above the epidermal surface and may be round or oval. The color varies with the natural pigmentation of the patient and may be very dark. There is usually little if any pigment on the flat surrounding epidermis in a classic, non-dysplastic, compound nevus.1 Nevi are rarely premalignant. See dysplastic (atypical) nevi below (Figure 13.2).

Congenital Melanocytic Nevus. Congenital nevi are present at birth, usually singular and small. They are classified in three types depending on the size: small, intermediate, and giant (>20 cm) (Chapter 20). They have some potential to develop melanoma, although this risk is low except in the giant variety. Except for size, the overall appearance of congenital melanocytic nevi and acquired nevi is similar.2 Congenital nevi, however, may have dark, thick hair. Histologically, congenital nevi are distinguished by the presence of nevomelanocytes in the epidermis and in the dermis as sheets, nests, cords, or single cells.2 For treatment, see Chapter 20 (Figure 13.3).

Blue Nevus. Blue nevi appear bluish because the nevus cells are deep in the dermis. These lesions are usually benign but the literature suggests they can be malignant. Clinically, blue nevi are solitary, nodular lesions with a smooth surface that tend to be blue or blue-gray. These lesions are generally treated conservatively unless there has been a change in their appearance or the patient requests excision for cosmetic reasons. The excision should include the subcutaneous component to ensure complete removal of deep dermal melonocytes.3

Halo Nevus. When a melanocytic nevus is surrounded by a hypopigmented halo, it is termed a halo nevus. These lesions tend to occur on the torso in older children and teenagers. They are common, frequently multiple, usually acquired and asymptomatic. The central nevus tends to gradually disappear leaving a macular area of non-pigmented skin. This hypopigmented area may persist for years and may gradually return to a normal color. When biopsies are performed, there may be no trace of the original lesion.1 The treatment is expectant, avoiding sun exposure at the hypopigmented areas unless there are cosmetic concerns or the lesions have atypical features.

FIGURE 13.1. Cross-section view of skin.

Spitz Nevus. This is a common and usually acquired lesion predominantly in children and young adults but can be found in older people as well. Spitz nevi are usually firm, domed-shaped, reddish or dark brown nodules, frequently on the head and neck. They are compound nevus variations, which have distinctive histologic features that make the differentiation from malignant melanoma difficult.1The treatment is surgical excision. There is controversy over whether an entity known as a malignant Spitz nevus exists or if these lesions are malignant melanomas. For these reasons, Spitz nevi require complete excision with histologic confirmation of clear margins.

Nevus of Ota. Nevi of Ota are hamartomatous melanocytic lesions that occur on the face in the distribution of the ophthalmic and maxillary division of the trigeminal nerve. They are much more common in women. The sclera is involved in two-thirds of cases.1 The treatment consists of laser therapy, using the Q-switched ruby, neodymium:yttrium-aluminum-garnet (Nd:YAG) or alexandrite lasers,4 or make up camouflage (Chapter 18).

FIGURE 13.2. Melanocytic nevus.

Atypical Moles—Dysplastic Nevi. Dysplastic nevi are melanocytic nevi that have the clinical features of melanoma: asymmetry, border irregularity, color variability, and diameter greater than 6 mm (Chapter 14). When patients present with many atypical moles, they are at higher risk for melanoma. Patients who present with many atypical moles and a strong family history of malignant melanoma are at much higher risk for melanoma and must have at least annual full body examinations for their entire lives. It is difficult for even an experienced dermatologist to know when to recommend excisional biopsy. The best indication for biopsy is a change in clinical appearance. The ideal surveillance involves total body photographs, which are compared annually with the patient’s current condition in order to determine if any lesions have changed over time. The treatment is excisional biopsy. If step-sectioning of the entire specimen reveals melanoma, then further treatment is required (Chapter 14).

FIGURE 13.3. Congenital melanocytic nevus.

Solar Lentigo. Solar lentigines occur on sun-exposed areas of the face, arms, and dorsum of hands, especially in lighter skinned white people with light eye color. These acquired lesions are pigmented macules that can be small or large, with a tendency to confluence and range in size from 0.2 to 2 cm. They become more numerous with advancing age. Treatment is not required. A biopsy is taken to exclude melanoma from any lentigo that develops a highly irregular border, a localized increase in pigmentation, or localized thickening.2 Bleaching agents like hydroquinone are not particularly effective. Topical tretinoin, microdermabrasion, or cryotherapy can be used.

Ephelides (Freckles). These are small, less than 3 mm, red or light brown macules that appear on sun-exposed areas predominantly in fair skinned people with red or blond hair, but can appear in darker skinned individuals as well. There is no increase in the number of melanocytes, but rather an increase in the amount of melanin in the skin. They are common in childhood; however, they can be seen at any age. They are usually confined to the face, arms, and back. The number varies from a few spots on the face to hundreds of confluent macules on the face and arms. Treatment is not required, but sunscreen is recommended. Bleaching agents such as hydroquinone, peels, and intense pulsed light (IPL) can be used for cosmetic reasons.

Epidermal Lesions

Seborrheic Keratosis. This is a common benign, usually pigmented, neoplasm in elderly people, arising from the basal layer of the epidermis and consisting of keratinocytes. The etiology is unknown, and factors like virus infection, genetics, and sun exposure can be related. Usually seborrheic keratoses are not photoinduced. These lesions occur in any body site (frequently in the face and upper trunk) and are usually asymptomatic or associated with itching. They are superficial verrucous plaques, smooth or rough, varying from 1 mm to several centimeters in size and varying from dirty yellow to dark brown. Histologically, they are characterized by hyperkeratosis, acanthosis, and papillomatosis. The classic description is of a “stuck-on,” waxy appearance. Surgical excision or shave excision is appropriate if the patient complains of cosmetic appearance. Other treatment options include curettage, cryotherapy, or trichloroacetic acid (TCA). There are times when the lesion is atypical and an excisional biopsy is indicated for diagnostic purposes (Figure 13.4).

Keratoacanthoma. This is a common epithelial tumor related to sun exposure than may be better placed in the next chapter on malignant lesions. It is more common in white phototypes and is usually found on the face or upper limbs. Classically, it presents as a solitary papule that develops a crater-like central, keratotic core.5 The history is one of rapid growth over a few weeks. Spontaneous regression is said to occur, but most lesions are excised before it becomes clear if regression would have ever occurred. The histology is similar to squamous cell carcinoma and many consider it a low-grade squamous cell cancer. Surgical excision is usually the treatment of choice. Other potential treatment options are curettage, coagulation, and topical 5-fluorouracil.

FIGURE 13.4. Seborrheic keratosis.

Verrucous Nevus. These are congenital lesions that present as verrucous papules or plaques that are skin colored or brown. A linear configuration is common and it can be found in any body site. Malignant transformation is very rare. The treatment options due to cosmetic concerns are surgical excision, laser, electrodissection, dermabrasion, cryotherapy, TCA, or topical retinoic acid.

Skin Tags (Acrochordon). Skin tags are composed of loose fibrous tissue and usually occur as multiple skin-colored or tan, filiform or smooth-surfaced papules that are 2 to 3 mm in diameter. These small, soft, pedunculated lesions are frequently located on the neck or major flexures. The simplest and most expeditious treatment is shave excision with scissors or a scalpel blade.

Premalignant Lesions

Actinic Keratosis. Actinic keratoses may be the most common of the premalignant skin conditions. Caused by sun exposure in people with Fitzpatrick skin types I, II, and III, they are macules or papules with a scaly surface, generally between 1 mm and 2 cm in diameter. Actinic keratoses occasionally evolve into squamous cell cancers and are therefore considered premalignant. These lesions frequently require biopsy to rule out a carcinoma. Multiple lesions are usually treated with 5-fluorouracil or the immune stimulator imiquimod (Aldara) (Figure 13.5).

Leukoplakia. Leukoplakia is white intraoral plaque and is the most common precancerous lesion of the oral cavity. These lesions do not frequently become squamous cell cancer but must be followed and biopsied if they persist or undergo a change in appearance.

Cutaneous Horn. A cutaneous horn is different from a skin tag and is considered a premalignant lesion. They are usually yellowish brown protuberant “horns” and are found on the face and ears. Histologically, they are characterized by a compact proliferation of keratin. The treatment is surgical excision.

Bowen’s Disease. Bowen’s disease is squamous carcinoma in situ of the skin. This tumor presents as a slowly growing, red lesion with a scaly surface and irregular borders. Ulceration or bleeding may be a sign of invasive malignancy. The treatment of choice is surgical excision, but cryotherapy, curettage, cauterization, topical agents like 5-fluorouracil, and topical photosensitizer can also be considered.

FIGURE 13.5. Actinic keratosis.

HAIR FOLLICLE TUMORS

Trichofolliculoma

This is a rare hamartoma of the pilosebaceous follicle. They are typically solitary, small, raised nodules with two or three hairs, usually white, protruding together in a tuft. They frequently appear on the face and scalp. Malignant change is not typical but has been reported in a single case with perineural invasion.1 The treatment recommended is surgical excision.

Pilomatricoma, or Benign Calcifying Epithelioma of Malherbe

A pilomatricoma is a hamartoma characterized by a firm, solitary nodule covered with intact but often discolored skin. The calcification makes the lesions particularly firm. They can occur on any body part but are most commonly found on the face and upper extremities. In general, the lesions are 0.5 to 5 cm in diameter. There is no malignant potential. The treatment is surgical excision.

Trichoepitheliomas

Trichoepitheliomas are hamartomas of the hair follicle typically found in the center of the face. They tend to be small, skin-colored or slightly pink papules that are usually distributed symmetrically on the cheeks, eyelids, and the nasolabial region. Treatment is not required; excision may be contemplated for cosmetic reasons. Other options include electrodissection and curettage or cryotherapy. Recurrence is common.

ECCRINE TUMORS

Syringomas

This is a benign tumor that usually presents as firm, skin-colored to yellowish dermal papules on the lower eyelids, predominantly in females. Syringomas can be sporadic or familial and are frequently associated with Down’s syndrome. The treatment is punch or surgical excision for cosmetic reasons only. Electrodissection, curettage, and carbon dioxide laser can be considered.

Eccrine Poroma

An eccrine poroma is a solitary, firm, skin-colored or erythematous papule, usually on the sole or palm in adults. Ulceration and bleeding may occur at points of pressure. The treatment is surgical excision.

Cylindroma

Cylindromas can be solitary or multiple. The multiple lesion type has a genetic component. They are classically found on the scalp as numerous small papules or large nodules with smooth surfaces. Sometimes they cover the entire scalp like a turban explaining the name turban tumor. They are usually benign, but malignant development has been reported. Treatment options include surgical excision, electrosurgery, and carbon dioxide laser.

Clear Cell Hidradenoma

Clear cell hidradenoma is an eccrine sweat gland tumor. It occurs as a slow growing usually solitary nodule. Classically, it is a firm nodule, 0.2 to 5 cm in size. Some of these tumors discharge serous material, whereas others tend to ulcerate. Lesions may occur on any body part, but are most frequently found on the arms, thigh, and scalp. They can develop malignant tumors. The treatment is surgical excision.

APOCRINE TUMORS

Apocrine Cystadenoma

This lesion results from a cystic dilatation of an apocrine secretory gland. It is generally a solitary, nodular lesion on the face that tends to be skin colored to bluish. The treatment is surgical excision.

Chondroid Syringoma

This tumor is a firm intradermal nodule usually found on the head and neck that is composed of both sweat gland elements and cartilaginous elements.4 It is rare and there can be malignant degeneration. Surgical excision is recommended.

Syringocystadenoma Papilliferum

These lesions are benign tumors, present at birth, usually on the scalp and neck, that present as multiple translucent or pigmented plaques or papules. The lesions can be verrucous with a central depression that oozes fluid. Treatment options include surgical excision and electrocoagulation.

SEBACEOUS TUMORS

Sebaceous Nevus

Sebaceous nevi are common tumors of childhood. Two-thirds are present at birth; the remaining one-third develop in infancy or early childhood. The lesions are usually solitary, oval to linear, yellowish in color, varying from 0.5 cm to several centimeters, and frequently present on the scalp. Surgical excision is recommended before adolescence because of the potential for development of basal cell carcinoma (BCCA) and other malignant tumors. The rare nevus sebaceous of Jadassohn syndrome consists of the triad of a linear sebaceous nevus, convulsions, and mental retardation.

Sebaceous Epithelioma

This lesion looks like a BCCA, but tends to be more yellowish because of the sebaceous cellular elements. It is most frequently located on the scalp and face. Treatment is recommended for cosmetic reasons only. Options include surgical excision, radiation, electrocoagulation, curettage, and carbon dioxide laser.

Sebaceous Hyperplasia

This is a small tumor composed of sebaceous glands that is commonly located on the forehead, cheeks, lower eyelids, or nose. It begins as a pale yellow and slightly elevated papule and can become dome shaped, and sometimes umbilicated. Sebaceous hyperplasia does not have any relationship with solar exposure. Treatment options are electrodissection, curettage, cryosurgery, or surgical excision.

Rhinophyma

Rhinophyma is a localized telangiectatic enlargement of the nose, most often in men. Histologically, it is characterized by sebaceous gland hyperplasia, fibrous infiltration, and lymphedema. Rhinophyma is considered a glandular form of acne rosacea. The reported incidence of occult cancer in the setting of rhinophyma varies from 15% to 30%. BCCA is the most common malignant neoplasm.2 Treatment options include dermabrasion or other form of deep resurfacing or surgical excision with reconstruction using a forehead flap (Figure 13.6).

CYSTS

Epidermal Cyst (or Sebaceous Cyst)

This is the most common type of cyst and occurs because of proliferation of surface epidermal cells within the dermis. Epidermal cysts are rare in children but common in adults. They are generally round, protruding, smooth-surfaced masses, varying in size from a few millimeters to several centimeters. Epidermal cysts grow slowly and are not symptomatic unless they become infected. Once infected, rupture is common. The only effective treatment is surgical excision. If infected, a course of antibiotics is recommended in an effort to prevent rupture and drainage so that excision can be accomplished. Staphylococcus aureus is the most common pathogen. The entire capsule must be removed to avoid recurrence. Genetic syndromes like Gorlin and Gardner may be associated with epidermal cysts.

Milium

A milium (plural: milia) is a superficial, white epidermal cyst that appears immediately beneath the epidermis. They are most common on the eyelids and cheek and often appear along a healing upper blepharoplasty incision. The treatment is unroofing and removal of the central kernel with a #11 blade or needle, or light electrodissection.

Pilar Cyst

A pilar cyst is similar to an epidermal (sebaceous) cyst and is a common scalp lesion containing keratin. The treatment of choice is surgical excision. Like epidermal cysts, if they present in an inflamed, infected state, they may require drainage. A course of antibiotics to “cool off” and shrink the lesion is worth an attempt, in hopes that the lesion can be excised.

SMOOTH MUSCLE TUMORS AND MESENCHYMAL TUMORS

Leiomyomas

Like leiomyomas elsewhere, these benign smooth muscle tumors present as solitary, firm, round, flesh-colored nodules, more commonly in the limbs, which are either subcutaneous, or in the deep dermis. The recommended treatment is surgical excision to eliminate what can be a tender lesion and rule out a malignant lesion.

FIGURE 13.6. Rhinophyma.

Pyogenic Granuloma

This lesion is a common vascular nodule that exhibits rapid growth, not unlike a keratoacanthoma, but pyogenic granulomata are totally benign. They can appear at any age and vary in color from brown to bluish-black. They are compressible and do not pulsate, with a thin surface. Treatment options include curettage and surgical excision.

FIBROUS TUMORS

Dermatofibroma

This lesion is a myofibroblast proliferation, characterized by a firm, skin-colored or reddish brown sessile papule or nodule, more commonly in women. They vary in number from 1 to 10 and can be found anywhere on the extremities and trunk. They appear as 3- to 10-mm slightly raised, pink-brown, dome-shaped, sometimes scaly, hard growths that retract beneath the skin surface during attempts to compress and elevate them. They tend to remain stable for years as discrete solitary lesions. Treatment options include surgical excision for cosmetic reasons only, cryotherapy, or 600-nm pulsed dye laser (Figure 13.7).5

GENERALIZED DISORDERS

Telangiectasias

Telangiectasias are vascular malformations characterized by chronically dilated capillaries or small venules. They are small, red and linear and may appear like a spider or star design (Figure 13.8).

FIGURE 13.7. Dermatofibroma.

Xeroderma Pigmentosum

This is an autosomal recessive disorder, characterized by damage to DNA repair. These patients have extreme sun sensitivity and develop many cutaneous malignancies. The lesions require surgical excision, but the outcome is usually poor.

Dystrophic Epidermolysis Bullosa

This disorder is characterized by fragility and blistering after trauma to the skin. It can be autosomal recessive or dominant. It does not have any specific treatment, except to avoid trauma. The slightest friction or scrape may result in skin lesions that are also prone to infection.1,3

Cutis Laxa

This is a rare elastolysis disorder with lax skin and loss of elastic tissue. It can be autosomal dominant or recessive. The skin develops large redundant folds. Treatment consists of plastic surgical procedures such as facelift and blepharoplasty.

FIGURE 13.8. Telangiectasias.

Pseudoxanthoma Elasticum

This can be an autosomal dominant or recessive disorder causes calcification of elastic tissues and blood vessels arteriosclerosis. Skin lesions generally appear as yellow papules or plaques and skin laxity. The most important aspect of treatment is to ensure that complications from vascular involvement are prevented or dealt promptly.1 Plastic surgical procedures can be performed to improve appearance.

Ehlers-Danlos

This is a connective tissue disorder, characterized by skin and blood vessel fragility, hyperextensibility, and hypermobility. There are 11 subtypes.1 Patients must avoid pregnancy and trauma to soft tissues and be referred for genetic counseling.

Acne Rosacea

This is a common chronic disorder of the face, usually in white skin characterized by flushing, erythema, and telangiectasias. Bouts of inflammation with swelling, papules, and pustules may occur. The goal is to avoid skin irritation and use sunscreen creams. Oral medications like tetracycline and isotretinoin (retin-A) can be effective. Topical treatment with metronidazole 1%, phototherapy, and makeup camouflage are also helpful.

Hidradenitis Suppurativa

This is a disorder of apocrine glands, more commonly in dark skin, and usually in the axilla, perineal regions, or beneath the breasts. The disease can be devastating with numerous, interconnecting comedones or subcutaneous pustules. Local care and antibiotics tend to keep the lesions somewhat quiescent but the only definitive treatment is surgical excision. The heavily contaminated wounds usually have to heal by secondary intention, which is a slow, painful process.

Pyoderma Gangrenosum

This is rare disorder, which is not infectious in origin, and presents as solitary or multiple, fragile papules that can progress to ulcers and necrosis. Treatment options include antibiotics, topical or systemic steroids, and immunosuppressant agents.

SKIN CARE

Nonsurgical skin care plays a role in the preoperative and postoperative management in many aesthetic surgery practices. Some plastic surgeons choose to provide services and treatments to complement surgical rejuvenation procedures. Topical treatments, soft tissue fillers, neurotoxins, skin tightening devices, chemical and laser peels, facial treatments, makeup consultations, lymphatic drainage massage (LDM), and a wide variety of other medical spa services have become integral components of many practices. Other plastic surgeons develop relationships with dermatology colleagues who provide these treatments.

The nonsurgical treatments mentioned above appeal to several groups of patients:

1.  Younger patients who seek preventive measures to “slow” the aging process.

2.  Patients who cannot afford or who do not have the time to recover from expensive and more extensive surgical procedures.

3.  Patients who do not want surgical intervention and prefer procedures with reduced morbidity, rapid recovery, and a more rapid return to work.

THE COMPLETE AESTHETIC PACKAGE

In the senior author’s practice, surgical and nonsurgical treatments are integrated in a comprehensive team approach. The “consulting team” includes the plastic surgeon, surgical nurse, medical aesthetician, and patient coordinator. The extended team of providers includes a massage therapist, micropigmentation artist, personal trainer, nutritionist, and others (Figure 13.9, Case 1). Admittedly, this form of practice does not appeal to all plastic surgeons who prefer to concentrate on surgical procedures or who perceive the benefit of cross-referral from other specialists who offer these modalities.

THE CONSULTATION AND EVALUATION

The objectives of the consultation are to evaluate the patient and provide education and recommendations on the different nonsurgical and surgical alternatives including a discussion of risks, complications, and the financial implications of the various options.

The evaluation, or aesthetic consultation, is performed by the plastic surgeon accompanied by the nurse and the aesthetician. A facial evaluation regarding skin type (dry, oily, or a combination), texture, thickness, photoaging damage, wrinkles, and age-related and gravitational changes is included in every patient. A skin care regimen may be recommended before or after the surgical procedure.

COMPREHENSIVE SKIN CARE PROGRAM

A skin care program consists of cleansing, hydration, moisturizing, repair, protection, and prevention.

Cleansing

Dirt, oil, grease, makeup, and microorganisms are removed from the skin in order to allow skin care renewal and cosmetic creams to be absorbed. Cleanser is prescribed according to the skin type and is applied in the morning and again at night. Application of cleanser is important at night because the lower pH increases microcirculation and allows greater absorption of the skin products.

Hydration

Water is required to maintain the smoothness of the skin. The simplest and most important way to maintain hydration is by drinking water. Moisturizers are a helpful adjunct by augmenting the barrier function of the epidermis. Moisturizers contain humectants, emollients, and occlusives. The emollients are lipids that hydrate the skin. The occlusives decrease transepidermal water loss. Humectants enhance water absorption from the dermis into the epidermis, and in humid conditions they also help the stratum corneum to absorb water from the external environment.6

Repair

To achieve repair, the formulations must reach the basal layer of the epidermis and the superficial dermis. The most effective are alpha-hydroxy acids (AHA) and topical tretinoin (retin-A).

Glycolic acid (sugarcane), lactic acid (milk), malic acid (apple), citric acid (citrus fruits), and tartaric acid (grape) are examples of AHA. Glycolic and lactic acid are the most commonly used and are safe and effective. AHAs are indicated for dryness, rough texture, acne, rosacea, photodamage, melasma, and hyperpigmentation disorders. They can be found in different vehicles and concentrations, such us within moisturizers or in the form of peels. They can also be used in dark skin types. In the case of melasma and hyperpigmentation disorders, AHAs can be used in combination with bleaching agents.

Tretinoin (retin-A) is a vitamin A derivative that, when used for the long term, is extremely effective in reversing sun damage. It promotes histologic changes such as increased epidermal and granular layer thickness, decreased melanin content, compaction of the stratum corneum, decreased cytologic atypia, increased collagen synthesis, an increase in collagenous anchoring fibrils, and an increase in the number of blood vessels. Tretinoin can be found in cream, gel, and liquid preparations. Available concentrations include 0.02%, 0.025%, 0.05%, and 0.1%.

The clinical changes from long-term tretinoin use include smoother skin texture, reduced fine wrinkles, decreased sallowness, improved skin appearance, and a decrease in actinic keratoses. The treatment can cause irritation, and some patients find tretinoin difficult to tolerate. During the treatment sunscreen is mandatory. If patients undergo a facelift, the tretinoin can be restarted after 3 to 4 weeks.

FIGURE 13.9. Case 1—Complete aesthetic package. This 56-year-old woman presented with significant sun damage and facial aging. The complete aesthetic package was performed. She had an aggressive skin care treatment preoperatively, with intense pulsed light treatments to the face and neck every 21 days, alternated with facial peels. She then underwent an endoscopic brow lift, bilateral ptosis repair, rhytidectomy with SMASectomy, and cervicoplasty. The lymphatic drainage massage treatment was started 5 days postoperatively and continued once a week for 3 weeks. She is shown 1 year postoperatively.

Bleaching agents may be helpful in some patients, such as hydroquinone, kojic acid, azelaic acid, and also retinoic acid. Hydroquinone is used for reversible pigmentation of skin, usually at 4% concentration. It can be combined with other agents, such as prepeeling creams. The 1% kojic acid and 20% azelaic acid may be equally effective.1 All these topical agents can cause skin irritation and should applied first as a patch test.

Protection and Prevention

Antioxidants and sunscreen are used to protect what has been achieved and prevent further damage. Antioxidants act to eliminate the free radicals caused by sunlight. The most popular are vitamins C (ascorbic acid) and E (tocopherol and tocotrienols), alpha-lipoic acid, soy isoflavones, tea extracts, grape seed extracts, niacinamide, and coenzyme Q 10.

Vitamin C is a topical antioxidant agent that stimulates collagen synthesis, inhibits elastin synthesis, reduces pigmentation, improves epidermal barrier function, regenerates the oxidized forms of vitamin E, and has anti-inflammatory effects. Smoking cigarettes appears to deplete vitamin C from the skin.

Vitamin E (tocopherol) is an antioxidant found in vegetables, seeds, and meat. Vitamin E prevents lipid peroxidation and therefore protects the cellular membrane from free radicals. Vitamin E is a helpful ingredient in daytime moisturizers and sunscreen, because of its photoprotective properties and also as an anti-inflammatory agent. Alpha-lipoic acid is another strong antioxidant with anti-inflammatory proprieties. It is stable and easily absorbed and should be applied every other day initially and then daily when the skin permits.7

Isoflavones work by raising hyaluronic acid production, increasing the thickness and collagen of the skin.7 Topical green tea and grape seed extracts are antioxidants with anti-inflammatory action.7,8Vitamin B improves protein production, decreases melanosome transfer, and reduces redness.7 Coenzyme Q10 is used to combat sun damage and therefore reduces wrinkles, reducing oxidation levels.7,8

Sunscreens are important to protect the skin from ultraviolet light. The sun protection factor indicated on the container only indicates the extent to which that product blocks UVB. Since UVA causes wrinkles and skin cancer, it is also important to use a product that also blocks UVA. Unfortunately, UVA blocking agents are not as well developed as UVB blockers. At best, the current UVA blocking agents only partially block UVA. The only complete sun blocker is zinc oxide, but it is thick and greasy and not practical to cover all of one’s exposed skin. Sunscreen should be applied daily, before makeup, and reapplied during the day (Figure 13.10, Case 2; Tables 13.1–13.3).

NONSURGICAL TREATMENTS FOR SKIN QUALITY

The most effective nonsurgical procedures are microdermabrasion, dermabrasion, IPL, laser resurfacing, chemical peels, neurotoxins, and fillers. The procedures will be mentioned briefly because they are covered in depth in other chapters.

Microdermabrasion

Microdermabrasion is a nonsurgical procedure that uses aluminum oxide (AL2O3) or sodium chloride (NaCl) crystals to exfoliate the skin. Topical anesthesia is not required and it is a safe and well-tolerated procedure. The treatment may be helpful for three to six sessions, every 2 weeks, before surgical procedures on the face. The best indications are oily skin, dilated pores, thick skin, mild acne scarring, melasma, and solar lentigines. Contraindications include severe acne rosacea, telangiectasias, uncontrolled diabetes, active acne, skin cancer, dermatitis, sunburned skin, oral isotretinoin, and blood thinners.

FIGURE 13.10. Case 2—Sunscreen. This 70-year-old woman presented with a combination of sun damage and facial aging. A complete aesthetic package was performed, with sun protectors daily, avoidance of sun exposure and skin care treatment preoperatively, and microdermabrasion treatments. Surgically, she underwent an endoscopic brow lift, rhytidectomy with SMASectomy, and cervicoplasty. The lymphatic drainage massage was introduced during the first week postoperatively. She is shown 1 year postoperatively.

Dermabrasion

Dermabrasion is the mechanical removal of epidermis and superficial dermis that will stimulate re-epithelialization. This can be performed with sandpaper, wire brush, or diamond fraise powered by a hand engine. The technique is performed under anesthesia in the operation room. Indications include wrinkles, facial scars, rhinophyma, syringoma, and epidermal nevus (Chapter 41).3

Intense Pulsed Light

The IPL is a noninvasive system used for photorejuvenation (Chapter 18). It is a system that emits a broad spectrum of non-coherent, polychromatic light in the range of 500 to 1,200 nm. These features allow great variability in adapting to different skin types and indications by varying the light spectrum, impulse length, impulse sequence, and fluence.7 Three to six sessions are recommended, every 2 to 3 weeks.

The best indications are photoaging, telangiectasias, port wines stains, poikiloderma, red hypertrophic scars, hypertrichosis, irregular pigmentation (lentigines, melasma, and ephelides), and postinflammatory hyperpigmentation. The contraindications are an abnormal response to sunlight, current treatment with oral tretinoin, suspicious lesions, pregnancy, conditions that affect wound healing, and blood thinners.

Before treatment, the skin is cleansed and topical anesthetic applied for comfort. The skin can look like a sunburn and have some swelling from 2 to 48 hours after the procedure. The pigmented lesions appear much darker immediately after treatment. After a week, the skin starts to clear and microdermabrasion can be added to expedite this process (Figure 13.11, Case 3).

Radiofrequency

Radiofrequency is a nonsurgical treatment for skin rejuvenation. It causes a thermal injury to the dermis, stimulates the fibroblasts, increases collagen production, and provides some skin tightening.

The indications are skin laxity in the face, neck, limbs, and abdomen. The best candidates are patients between 30 and 60 years and who have reasonably good skin quality and have no history of smoking. The response is variable.7

Lasers

Lasers produce stimulation of fibroblasts and increase collagen deposition. They can be used for rejuvenation, hair removal, and treatment of vascular lesions.

The most popular lasers for skin resurfacing are carbon dioxide and erbium:YAG, which, as described in Chapter 18, can be fractional or not (Chapters 18 and 41).

Chemical Peels

Chemical peels can be superficial, medium, or deep depending on their penetration into the dermis where they result in improvement of collagen organization. A variety of chemical peels can be used, such as glycolic acid, TCA, beta-hydroxy acid, Jessner solution, and Croton oil. Each one has specific characteristics and indications (Chapter 41).

FIGURE 13.11. Case3—Intense pulsed light (IPL). This 65-year-old woman was concerned about her appearance after a cutaneous facelift. An aggressive skin care regimen of IPL treatments to the face and neck every 21 days was initiated and continued after surgery. An endoscopic brow lift, rhytidectomy with SMASectomy, and cervicoplasty were performed. The lymphatic drainage massage treatments were started 5 days postoperatively and continued once a week for 3 weeks. She is shown 7 years postoperatively.

Neurotoxins

Botulinum toxin is a temporary paralyzing agent that works by causing a chemical denervation at the neuromuscular junction providing temporary improvement in dynamic wrinkles. Patients should be informed that wrinkles that are present at rest will not be improved by botulinum toxin, although they will not get deeper with animation (Chapter 43).

Fillers

Fillers are designed to replace volume in dermis or subcutaneous tissue of the face. The most commonly used are hyaluronic acid (such as Juvederm and Restylane), calcium hydroxyapatite (Radiesse), poly-lactic acid (Sculptra), and others mentioned in Chapter 42.

Lymphatic Drainage Massage

LDM is a helpful tool that can be started before or after surgery. It is meant to decrease swelling, bruising, and recovery time. Preoperatively, LDM helps to remove stagnant fluids, increase blood flow, and provide the psychological benefit of reducing stress/anxiety and focusing the patient on positive results. Postoperatively, the technique decreases inflammation, speeds up recovery time, reduces bruising, opens lymphatic channels, reduces the scar tissue buildup, and continues to reduce stress and tension.7

References

1.  Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of Dermatology. Malden, MA: Blackwell Publishing; 2004.

2.  Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders Elsevier; 2006.

3.  Wolff K, Goldsmith LA, Katz ST, Gilchrest BA, Paller AS, Leffell DJ. Fitzpatrick’s Dermatology in General Medicine. Columbus, OH: The McGraw Hill Companies; 2008.

4.  Thorne CH, Beasley EW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL, eds. Grabb & Simth Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

5.  Lee EH, Nehal KS, Disa JJ. Benign and premalignant skin lesions. Plast Reconstr Surg J. 2010;125(5):188-198.

6.  Kraft JN, Lynde CW. Moisturizers: what they are and a practical approach to product selection. Skin Therapy Lett. 2005;10(5):1-8.

7.  Saltz R, ed. Cosmetic Medicine & Aesthetic Surgery. Strategies for Success. St Louis, MO: Quality Medical Publishing, Inc.; 2009.

8.  Bogdan Allemann I, Baumann L. Antioxidants used in skin care formulations. Skin Therapy Lett. 2008;13(7):5-8.