2006 ANNUAL SCIENTIFIC SEMINAR A C RITICAL EVALUATION OF PROCEDU RAL COSMETIC DERMATOLOGY Zoe Diana Draelos, M.D. Dermatology Consulting Services zdraelos@northstate.net 403 The development of new materials and technologies has expanded the field of procedural cosmetic dermatology. These procedures are part of the armamentarium of the dermatologist that must be combined with skin care and cosmetic products to achieve an optima] anti-aging result. lllis presentation critically evaluates procedural cosmetic dennatology to include antiaging therapies for wrinkles at rest, wrinkles in motion, and texture abnormalities exploring new opportunities that have arisen within this realm. Botulinum Toxins The adaptation of neurotoxins, originally developed to treat medically significant muscle spasms, into cosmetic procedural dermatology was a major change in the treatment algorithm for the aging face. For the first time, hyperkinetic lines of facial expression could be temporarily minimized to create a facial appearance more consistent with the internal disposition of the mature individual. There are many types of botulinum toxin in existence, known as subtypes A through G, but only botulinum toxin A (Botox, Reloxin) and botulinum toxin B (Myoblock) have been commercialized. The most commonly used neurotoxin worldwide is Botox. It is the longest lasting with the lowest protein load, thus conferring decreased resistance to the toxin itself. Yet, there still exists concern that the effectiveness of botulinum toxin A may decrease with prolonged use, although I have not personally experienced this phenomenon. Botulinum toxin B offers the benefit of storing the vials at room temperature before opening, which is in contrast to botulinum toxin A that must be kept frozen until the bottle is diluted, but injection pain is more pronounced and the duration of action decreased. Botulinum toxins are used primarily above the nose on the face for wrinkles that occur with facial expression, known as wrinkles of motion. The parnlyzing effect lasts for 3 months with a one-week delay before onset of action. Hyaluronic Acid Injectables Hyaluronic acid has quickJy become the gold standard filler for use in facial reconstruction. FilJers are used for wrinkJes predominantly below the nose that are present at rest. Most of 1hese wrink.Jes are due to loss of the bony architecture of the face accompanied by subcutaneous fat loss. Hyaluronic acid is a nonnal constituent of the dermis and functions as a humectant to regulate skin hydration. Injectable hyaluronic acid (Restylane, H)·laform, Captique) is inserted into the dermis to attract and hold water, thus expanding the skin fold. In addition to attracting water, the hyaluronic acid also attracts blood, thus bruising and swelling for 48 hours after injection are common. The hyaluronic acid is also painful to inject requiring the use of topical and injectable Jidocaine prior to insertion. Hyaluronic acid fillers are extremely \'ersatile and can be used in the lips, around the mouth, in the chin, in the cheeks, in the forehead, and around the eyes. The typically duration of the correction is about 6 months, except in persons who smoke or when the hyaluronic acid is placed in areas of the face with frequent movement. In these cases, the correction lasts for a shorter period of time. Collagen lnjectables The first filler introduced in the United States and the only filler available for many years was bovine collagen (Zydenn, Zyplast). This was followed by a synthetic human collagen (Cosmodenn, Cosmoplast), since skin testing was required prior to use of the bovine collagen. The collagen fillers have the benefit that they contain lidocaine, which is sufficient to minimize the pain of injection. Swelling and bruising are not as common with collagen compared to the hyaluronic acid fillers, but the collagen fillers generally only last 3 months. Collagen is a stiffer filler than hyaluronic acid and is best used for folds around the mouth. It is not suitable for use arowid the eyes or in the frown area between the eyes. Miscellaneous lnjectables There are a variety of longer lasting injectables that have been approved for use in the United States to include Sculptura and Radiesse. Sculptura is a poly-lactic acid gel, similar to the material used in absorbable sutures, approved for use in the facial Jipoatrophy associated with HIV medications. Radiesse is a hydroxyapatite material used for bladder stem supJX)rt in the treatment off emale incontinence. Both of

404 JOURNAL OF COSMETIC SCIENCE these substances last 6 months, possibly longer, but have the side effect of granuloma formation, manifested as the presence of tender nodules due to an inflammatory reaction within the skin. Proper injection technique with these longer lasting fillers is essential to achieving an acceptable result. Autologous Fat Transfer An autologous filler can be created by performing a mini-liposuction and removing wiwanted fat from the hips and thighs for transplantation to the face. Extra fat can be removed and frozen for use up to one year later. Fat transfer is best suited for facial areas where large volume replacement is required, such as the cheeks. Bruising and swelling are expected following the transfer procedure, but the fat may be permanent if properly implanted in small quantities in a given area. The fat is placed subcutaneously, in between the muscle bundles, and on top of the bone. Autologous fat transfer is more of a surgical procedure than a true filling procedure, but for the patient requiring many tubes of filler, the procedure is the most cost effective method for restoring a youthful facial contour. Microdermabrasion Microdermabrasion is the use of a particulate, such as alwninum oxide, silica, or baking soda, to physically bombard the skin and push away desquamating corneoc)1es. A vacuum is employed to collect the used particulate mixed with skin scale. Microdennabrasion originated in the dermatology office, but is now largely performed in medical spas, esthetician offices, and at home. It is a method of physically exf oliating the skin, as opposed to chemical peels. Superficial Peels Superficial peels chemicall}' exfoliate the skin through the use of glycolic or salicylic acid. The depth of the peel can be adjusted by varying the strength of the acid and/or the contact time with the face. Glycolic acid peels in the dermatology office are typically performed in strengths of 20-70% and salicylic acid peels arc performed in strengths of 10-30%. These peels improve the skin surface texture, but are not efficient at impro,·ing dyspigmcntation or wrinkling unless perfonned frequently or in high concentration. The major benefit is the increased smoothness appreciated when facial foundation is applied. Salicylic acid peels may be useful in individuals with comedonal acne (blackheads, whiteheads) to act as a keratol�1ic. Medium Depth Peels Medium depth peels are a true surgical procedure with a 4-day recovery period. Trichloroacetic acid in strengths of 25-35% is most commonly used in combination with a prepeel agent, such as glycolic acid, carbon dioxide slush, or a resorcinol/lactic acid/salicylic acid mixture (Jessner's solution). The intent is to destroy the stratwn comewn, epidermis, and possibly even the superficial dermis. Thus, the photoagcd skin is chemically destroyed and replaced by newly healed skin. Scarring is a possibility, however the skilled clinician can control the depth of the injury to insure an optimal result. After the peel, the face resembles a second degree swibum and is kept moist with petroleum jelly until re-epithelialization is complete. The newly healed skin must be meticulously protected from sun or irregular pigmentation may reoccur. Summary Procedural cosmetic dermatology involves the combination of treatments for the \\Tinkles of facial expression, lines and folds present on tJ1e face due to subcutaneous fat loss, and texture abnormalities arising from photodamage. These procedures must be complimented by skin care products and colored cosmetics to achieve an optimal facial appearance.