Complicaciones y manejo de procedimientos dermatoestéticos: una actualización para el dermatólogo / Complications associated with cutaneous aesthetic procedures: an update for the dermatologist

En las últimas décadas se han desarrollado nuevas técnicas e indicaciones de los procedimientos estéticos mínimamente invasivos, presentando cada vez mejores resultados con un alto nivel de seguridad, sin embargo, estos no se encuentran exentos de complicaciones, las que pueden ser transitorias o permanentes. El conocimiento, abordaje, tratamiento y prevención de las distintas complicaciones son esenciales para los dermatólogos y cirujanos plásticos. Los procedimientos más utilizados son: administración de rellenos, peeling químicos, láser, luz pulsada intensa y ultrasonido de alta frecuencia. La siguiente revisión tiene como objetivo reconocer las principales complicaciones de estos procedimientos y su manejo.

In recent decades, new techniques and indications of minimally invasive aesthetic procedures have been developed, presenting increasingly better results with a high level of safety, however these are not exempt from complications, which may be transient or permanent. The knowledge, approach, treatment and prevention of the different complications are essential for the dermatologist and plastic surgeons. The most used procedures are the administration of fillers, chemical peels, lasers, intense pulsed light and high frequency ultrasound. The following review aims to recognize the main complications of these procedures and their management.

Surgical Outcome of Chemical Peeling of Conjunctival Nevus with Alcohol

PURPOSE: To evaluate the efficacy of chemical peeling using 83% alcohol in patients with conjunctival nevus. METHODS: Chemical peeling using 83% alcohol was performed in 13 patients (13 eyes) who were clinically diagnosed with benign conjunctival nevus. Effects of procedure and recurrence were analyzed by retrospectively reviewing medical records. After topical anesthesia, conjunctival nevus was eliminated by rubbing with an alcohol-soaked cotton ball. Conjunctival nevus close to corneal limbus was removed by 15th blades of scalpel. RESULTS: A total of 13 patients, 8 males, and 5 females had a, mean age of 27 years (12-54 years). Eights of the eyes were right eyes, and 5 were left eyes. No recurrence was detected in any patient during the follow-up period (mean 54 months), and there were no cases of conjunctival scar, granuloma, or permanent conjunctival injection. All patients were satisfied with the cosmetic outcome of chemical peeling. CONCLUSIONS: Chemical peeling using alcohol for conjunctival nevus is a non-invasive technique and has benefits such as no intraoperative hemorrhage, low recurrence rate, easy method, and good cosmetic results. Based on these, this procedure is a good method for eliminating conjunctival nevus.

Tretinoin-based formulations - influence of concentration and vehicles on skin penetration

Tretinoin is used in the management of acne and it is part of a gold standard treatment for photoaging. It has also been reported as an agent for superficial chemical peeling in highly concentrated formulations with few considerations about skin penetration. The aim of this study was to evaluate the influence of drug concentration and vehicles currently used on skin penetration of tretinoin. In vitro permeation tests were carried out using Franz diffusion cells fitted with porcine ear skin and 10% aqueous methanol in the receptor compartment. Formulations studied, cream or hydroalcoholic dispersion, containing 0.25%, 1% and 5% of tretinoin were placed in the donor compartment for six hours. Tretinoin concentration in skin layers was measured by high performance liquid chromatography. The largest amount of tretinoin from both vehicles was detected in stratum corneum with significant differences among the three concentrations. The hydroalcoholic dispersion was the best vehicle. Significant amounts of tretinoin were found even in deep layers of epidermis. The formulation with 0.25% tretinoin showed better results when considered the amount of tretinoin on skin in terms of percentage. Finally, skin penetration of tretinoin was influenced by vehicle and concentration of this drug used in formulation.

A tretinoína é usada no tratamento de acne e é considerada como padrão de ouro para o tratamento do fotoenvelhecimento. Em altas concentrações, é relatada como um agente para peeling químico superficial, com poucas considerações sobre a penetração na pele. O objetivo deste estudo foi avaliar a influência da concentração do fármaco e os veículos comumente usados na penetração cutânea da tretinoína. Testes in vitro de penetração foram realizados com células de difusão de Franz equipados com pele da orelha de porco e 10% de solução aquosa de metanol no compartimento receptor. As formulações estudadas, creme ou dispersão hidroalcoólica, contendo 0,25%, 1% e 5% de tretinoína foram colocadas no compartimento doador, durante seis horas. A concentração da tretinoína foi medida por cromatografia líquida de alta eficiência. A maior quantidade de tretinoína foi detectada no estrato córneo com diferenças significativas entre as três concentrações. A dispersão hidroalcoólica foi o melhor veículo. Quantidades significativas de tretinoína foram encontradas nas camadas profundas da epiderme. A formulação com 0,25% de tretinoína mostrou melhores resultados em termos de porcentagem penetrada na pele. Por fim, a penetração de tretinoína na pele foi influenciada pelo veículo e pela concentração desta utilizada na formulação.

Otimização do descascamento químico de raízes do yacon (Polymnia sonchifolia Poepp.) / Optimization of chemical peeling of yacon roots (Polymnia sonchifolia Poepp.)

Foi utilizado o delineamento fatorial completo 2³ para estudar o efeito das variáveis de processo no descascamento químico de raízes do yacon, cultivadas na região metropolitana de Curitiba, estado do Paraná. Foram realizados 11 experimentos, com três repetições no ponto central, nos quais foram avaliados em três níveis a concentração da solução de hidróxido de sódio, por cento (g/100 mL) [6, 10, 14], temperatura da solução de hidróxido de sódio, °C [70, 80, 90] e tempo de permanência na solução de hidróxido de sódio, minutos [2,4,6]. Todas as variáveis estudadas afetaram de forma significativa (p<0,05) o rendimento das raízes submetidas ao descascamento químico. A variável mais importante para o rendimento foi o tempo de permanência na solução de hidróxido de sódio. O modelo obtido para a resposta percentual de rendimento foi adequado, com R² aj = 0,8497 e com falta de ajuste não significativa (p = 0,9312), podendo ser utilizado para fins preditivos. No ponto central, foi obtido um rendimento satisfatório (84 por cento a 87 por cento) e elevado percentual de casca removida (96 por cento a 98 por cento), indicando que o tratamento com 10 por cento de solução de hidróxido de sódio a temperatura de 80º C por 4 minutos, pode ser empregado no descascamento químico das raízes do yacon.

A full factorial design 2³ was used to evaluate the effect of process variables in chemical peeling of yacon roots, cultivated in Curitiba, State of Paraná. Eleven treatments, with three central points, were done in which they had been evaluated at three different levels of sodium hydroxide solution, percent (g/100 mL) [6, 10, 14], temperature of the same solution, °C [70, 80, 90], and residence time in the sodium hydroxide solution, minutes [2, 4, 6]. All the studied variables had affected significantly (p<0.05) the yield of yacon roots subjected to chemical peeling. The variable that most affected the yield was the time of permanence in the sodium hydroxide solution. The mathematical model obtained for the yield ( percent) was good with R² aj = 0.8497, and non significant lack of fit (p=0.9312).Therefore, the model can be used for predictive purposes. In the central point a satisfactory yield (84 percent to 87 percent) with a high percentage of removed peel was obtained (96 percent to 98 percent) indicating that the treatment with 10 percent of sodium hydroxide solution, temperature of 80º C per 4 minutes can be used in the chemical peeling of yacon roots.

Revisão sistemática sobre peelings / Systematic review of chemical peelings

Fundamentos: Peelings químicos constituem uma injúria à pele ou uma forma acelerada de esfoliação induzida por agentes cáusticos, com várias indicações. São classifi cados em superfi ciais, médios e profundos. O número de publicações sobre o assunto é elevado, mas há necessidade de análise crítica para conclusões objetivas. Objetivos: Verifi car efi cácia e segurança dos peelings químicos através de revisão sistemática da literatura. Método: No período de 5 de janeiro a 15 de fevereiro de 2009, foram realizadas buscas em três bases de dados: Biblioteca Cochrane, MEDLINE (1966-2009) e LILACS. Foram estabelecidos critérios para seleção dos estudos, com ênfase na qualidade metodológica. Os melhores estudos controlados ou comparativos foram individualmente descritos. Os demais artigos de revisão, descritivos e experimentais, foram analisados em conjunto. Resultados: Detectamos 414 publicações e revisamos 165; 129 ou 78% correspondiam a artigos descritivos (82), de revisão (37) ou experimentais (10). Os outros 36 (22%) eram estudos controlados ou comparativos, sendo 19 ou 53% randomizados e apenas 4 com delineamento ideal, ou seja, controlados com placebo, randomizados e cegos. Os agentes mais referidos foram: ácido glicólico, ácido salicílico, ácido tricloroacético (ATA) e fenol. Poucos estudos avaliaram efeitos histológicos e/ou usaram parâmetros quantitativos para avaliação da efi cácia e segurança. Limitações: Heterogeneidade dos estudos; poucos com boa qualidade metodológica. Conclusões: Não há dúvidas sobre os benefícios dos peelings químicos, demonstrados mais pela experiência prática do que por estudos bem conduzidos e reprodutíveis, que são fundamentais para a elaboração de novos guias de conduta.

Background: Chemical peelings are procedures that employ various agents to produce skin injury and accelerated exfoliation; they are indicated for many conditions and classifi ed as superfi cial, medium-depth, and deep. There are a great number of articles on this matter, but critical analysis is necessary to assure the real benefi ts. Objectives: To evaluate the effi cacy and safety of chemical peelings through a systematic review of the literature. Method: The MEDLINE (1966-2009), LILACS and Cochrane Library databases were searched from January 5 to February 15, 2009. For study selection and assessment of methodological quality, some criteria were established. The best controlled or comparative studies were described. The remaining review, descriptive, and experimental articles were analyzed together. Results: We found 414 articles and 165 were selected for revision; 129 or 78% were descriptive (82), review (37), and experimental (10) articles; 36 or 22% were controlled or comparative, 19 or 53% randomized, but only 4 had the ideal design (placebo-controlled, randomized and blind). The agents more frequently reported were: glycolic acid, salicylic acid, trichloroacetic acid (TCA), and phenol. Few studies evaluated histological aspects or quantitative parameters to assess effi cacy and/or safety. Limitations: Heterogeneity of the studies; few with good methodological quality. Conclusions: There is no doubt about the benefi ts of chemical peelings; nevertheless, these benefi ts have been demonstrated much more by practice than existence of well conducted studies. Therefore, further reproducible studies of high quality are necessary to elaborate new guidelines.

The Efficacy of Peeling with Amino Acid Filaggrin Based Antioxidants(AFAs) / 대한피부과학회지

BACKGROUND: Amino acid Filaggrin based Antioxidants(AFAs) is a recently invented peeling agent and the clinical report of the effects of AFAs peeling is insufficient. OBJECTIVE: The purpose of this study was to investigate the efficacy of peeling with AFAs. METHODS: This is a retrospective case study for the 41 patients treated with AFAs peeling at Sanggye Paik Hospital between January, 2002 to April, 2003. The therapeutic efficay was evaluated by the degree of satisfaction of both the patients and practitioners, regarding the number of peelings and the concentration of AFAs. Adverse effects were also evaluated. RESULTS: The results of this study were as follows. Of the 41 patients, 20 were acne, 14 were melasma, 4 were freckle, 2 were postinflammatory hyperpigmentation, and the other was an acne scar patient. The satisfaction rates of the patients were excellent(> or =70% improved) 17, good(50-70%) 11, fair(30-50%) 8, and poor(<30%) 5 out of 41 cases. And those of the practitioners were respectively 18, 14, 4, and 5 out of 41 cases. The satisfaction rates tended to increase as the number of peelings increased, while the concentration of AFAs showed little relation with the therapeutic effect. 4. The adverse effects were immediate vesiculation probably due to allergic reaction(3/41), persistent erythema(2/41), persistent irritation(2/41), pigmentation(1/41), and tingling sensation(1/41). CONCLUSION: AFAs peeling is an effective treatment modality in Korea and several repeelings improve the therapeutic effect. But futher studies on the adverse effects of this procedure are necessary.

The Effect of Chemical Peeling on the Dermal Connective Tissue in Facial Wrinkles of Patients with Leprosy

BACKGROUND: Redundant and wrinkled face is a common finding in patients with long-standing leprosy, which is responsible for the appearance of premature aging. Chemical peeling plays a role in dermal regeneration in the treatment of wrinkles. However, the effect of chemical peeling has rarely been studied in patients with leprosy. OBJECTIVE: To investigate the effect of chemical peeling on dermal connective tissue components and clinical improvement of facial wrinkles in patients with leprosy. METHODS: Five patients with clinically and bacteriologically inactive lepromatous leprosy were treated with 70% glycolic acid plus 35% trichloroacetic acid (GA-TCA). Histologic and clinical changes were evaluated at 0 and 90 days postpeel. RESULTS: Histologically, collagen fibers and ground substance increased significantly but elastic fibers did not change at 90 days postepeel. Clinically, fine wrinkles improved considerably, whereas most deep wrinkles remained unchanged at day 90. CONCLUSION: This study demonstrates that chemical peeling with GA-TCA, or medium-depth peeling, causes an increase in collagen and ground substance but not in elastic fibers. These changes result in limited clinical improvement in the facial wrinkles of leprosy patients. Therefore, medium-depth chemical peeling may be insufficient to improve the premature aging appearance in patients with leprosy.

Comparison of the Effect of Various Chemical Peeling Agents on the Skin Barrier / 대한피부과학회지

BACKGROUND: Among the various methods for chemical peeling, it is possible to select a wide range of peeling agents for particular patients. OBJECTIVES: The objective of present study was to investigate the effects of various chemical peeling agents on the epidermal permeability barrier of hairless mice skin and to clarify the histologic alteration in epidermal structure, thus to apply in the clinical practices. METHODS: We have applied 35% and 70% glycolic acid (GA) aqueous solutions, 30% of salicylic acid (SA) solution of PEG400, Jessner's solution and 15%, 30% and 50% of trichloroacetic acid (TCA) aqueous solution to the flank of hairless mice. TEWL (trans-epidermal water loss) values were measured before and immediately after the application and 3, 6, 12 and 24 hours following treatment. Biopsy specimens were evaluated with light and electron microscopy for epidermal structural changes. RESULTS: There were no significant changes in TEWL for the GA and SA solution treated skin, regardless of their concentration. For the TCA and Jessner's solution, TEWL increased immediately after treatment and recovered the basal levels about 90% after 24 hours for Jessner's solution and low concentrated TCA solution, but did not recovered for high concentrated TCA solution. On light and electron microscopic examination, exfoliating effect was seen in every case and as for SA and Jessner's solution treated skin, keratolysis at hair follicles was also seen. Slight epidermal necrosis was seen in every case, except in GA treated skin. CONCLUSION: The present results suggest that using topical agents such as glycolic acid can induce the change in the architecture of the epidermis without disrupting the skin barrier.

The Effect of Premedication with Ketorolac on Pain Relief During Chemical Peeling

BACKGROUND: A majority of patients undergoing chemical peeling complain of pain severe enough to disturb the process of the peeling. However, there has been few controlled studies on pain control during chemical peeling. OBJECTIVES: We evaluated the efficacy and safety of pretreatment with intramuscular ketorolac (Tarasyn, 30 mg) and oral diazepam(Valium, 5 mg) in comparison with control and diazepam groups, and compared the sensitivity of pain between two sexes. METHODS: The patients were randomly assigned to one of three groups; control, diazepam, and ketorolac plus diazepam groups. Pain intensity was assessed 5 times at every ten minutes from the beginning of the peeling using visual analog scale(VAS). RESULTS: At every 10 minutes of pain assessment, ketorolac plus diazepam group recorded the lowest VAS among the three groups. Except at the first 10 minutes, nificant. There was no significant difference in the pain intensity between the sexes at all five times. After application of Jessner`s solution, there was significant increase of VAS in all groups. CONCLUSION: The ketorolac pretreatment is a safe and effective modality of pain relief prior to chemical peeling without the adverse reactions.

Histopathological changes of skin in freckle patients after phenol chemical peel / 中华医学美学美容杂志

Objective To study the histopathological changes of skin after phenol chemical peeling.Methods Immunohistochemical staining (ABC method) and transmission electron microscopy were used to investigate the skin of changes 15 cases of freckle.Results After phenol chemical peeling,the melansomes in basal layer cells decreased dramatically, the elastic and collagenous fibers in dermis enlarged ,and the skin thickened .Conclusions After phenol chemical peeling,the melansomes in cuticular layer cells decrease remarkably and the freckle disappears.The proliferative activitities of fibroblasts in dermis have been improved,resulting in thickness of elastic and collagenous fibers in dermis. It may be the reason why the skin delays to be aged.

Skin Resurfacing

Surgical techniques for facial rejuvenation have become highly progressed in the last decade. Until recently, little attention has been paid to the intrinsic mechanisms of skin changes, such as wrinkling, surface irregularities, and alterations of pigmentation, and other various aging phenomena. Superficial facial wrinkling was not embraced seriously. This attitude has changed for the better, and among the many methods and techniques now available are Trichlor Acetic Acid(TCA), Phenol, Alpha Hydroxy Acid, and several different types of laser peeling methods. Skin resurfacing has undergone many changes and still is in the process of evolution. My personal experience with Phenol, TCA, and dermabrasion began in 1990. In this article, I tried to explain the basic methods of skin resurfacing for physicians and surgeons who are not in the esthetic fields. Chemical peeling, laser peeling, and dermabrasion share common characteristics of would healing. For compiling the subtopic that relates to the resurfacing, I rather concentrated my writing on chemical peeling due to the short life-cycle of laser peeling technique with ever-developing new laser machines. New techniques and procedures continue to evolve rapidly. I have no doubt that what is written in this article will be improved or become obsolete, or even be discarded in the future. Since the ideas and techniques are not static, but incessantly moving forward toward perfection.

Chemical Peeling and Laser Resurfacing

The chemical peeling is the process that involves the application of one or more exfoliating agents to the skin, resulting in the destruction of portions of the epidermis and/or dermis with subsequent regeneration. These techniques produce a controlled wound with instant vascular coagulation resulting in skin rejuvenenation with reduction or disappearance of actinic keratoses and changes, pigmentary dyschromias, rhytides, and selected superficial depressed scar. We herein introduce brief skin resurfacing techniques, indications, effectiveness, side effects of chemical peeling, dermabrasion, laser resurfacing.

The Study of Surgical Treatment for Acne Scars:the Principle of a Three Staged Operation

BACKGROUND: Acne scars are not effectively corrected by a single treatment modality because of their widely varied depths and widths. OBJECTIVE: This study was performed to assess the effectiveness of staged combinations of several surgical modalities in the treatment of various acne scars. METHODS: Chemical peeling, CO₂ laserbrasion, scar excision, punch grafting, and dermabrasion were included in this study as surgical modalities. Initially, chemical peeling was performed on all patients and then CO₂ laserbrasion, scar excision and punch grafts were used for deep scars. Finally, dermabrasion was done for the remaining scars. Questionnaires were completed for clinical assessments by the patients and clinicians. RESULTS: Clinicians assessed the results as "excellent and good" in 75% of patients. However, only 53% of patients gave this same result. The degree of satisfaction escalated as the followup periods and number of chemical peeling procedures increased and as the sequence of the 3 staged operation progressed. CONCLUSION: We suggest that the principle of 3 staged operations would be effective in the treatment of patients with various types of acne scars.

A Clinical Review of the Deep Sedation Anesthesia with Midazolam, Fentanyl and Esmolol for the Facial Chemical Peeling / 대한마취과학회지

To investigate the clinical usefulness of the intravenous anesthesia of the facial chemical peeling with midazolam(0.1 mg/kg)-fentanyl(3 ug/kg) - esmolol(initial 500 ug/kg,maintenance 200 ug/kg/min), the authors took 133 cases into consideration. The results of the statistical evaluation were as follows: 1) Most of the cases were small pox scar(70.7%). 2) One point five percent of the cases dreamed during anesthesia. 3) Ninety-four point seven percents of the cases were in the emotion of "Peaceful and relaxed" and 60.1% of them were in the mood of Pleased or very pleased and the others were "So and so". 4) Ninety-one point seven percents of the cases were willing to choose the same anesthetic method next time. 5) Fifty-two point six percents of the cases showed hypertensive episodes during anesthesia. 6) The incidence of the cases with SaO lower than 85% was 36.8%. The anesthetic technique with intravenous midazolam-fentanyl-esmolol for the facial chemical peeling with trichloroacetic acid(TCA) gives the patient comfortness and preference for this anesthetic technique. Close monitoring of the respiration is needed, because it can depress respiratory function. And control of the high blood pressure during anesthesia seems to be needed.

The Anesthesia for Outpatient Facial Chemical Peeling Using Ketamine and Midazolam / 대한마취과학회지

The surgeries based on the outpstient department have increased recently. One of the indications of outpatient surgery is chemical peeling of the face that usually re- quires only deep sedation of short duration. The purpose of this study was to evaluate the effeets of ketamine and midszolam for out patient facial chemical peeling. Fifty-nine unpremedicated patients undergoing chemical peeling of the face were anesthetized with bolus intravenous injection of 1mg/kg of ketamine and 0.1 mg/kg of midazolam. Additional dose of ketamine(10-20mg) was given as needed. During operation, we observed systolic and diastolic blood pressure with noninvasive blood pressure monitor and peripheral oxygen saturation(SpO2) with pulse oximeter. All patients were allowed to breathe spontane- ously without ventilatory support during the operation. There was no case of airway ob- struction and SpO2 value was over 97% in most cases. The systolic and diastolic blood pressure and pulse rate were increased after the injection of ketamine and midazolam. And we observed the untoward effect of anesthetics such as the purposeless movement(6.8%), involuntary phonation(3.4%), skin rash(3.4%) and headache(1.7%). In postoperative analysis about the recall, bad dream, mood, and the degree of satisfaction of this type of anesthesia, the rate of patient's positive acceptance was high(86.4%) and the reeovery time was 58min. We conclude that combination of intravenous ketamine and midszolam can produce satisfactory anesthesia with few complications for outpatient chemical peeling surgery of the face.

Epidermal Nevus Syndrome with Various Skin Manifestations

We report a case of epidermal nevus syndrome showing various skin manifestations improved with CO₂ laser and chemical peeling in a 11-year-old girl. Skin lesions were composed of linear verrucous plaques and numerous papillomatous papules on the face, neck, scalp and trunk, multiple congenital nevocellular nevi on the face, and extensive cafe au lait spots on the trunk. The associated findings of skeletal involvement were gingival hemihypertrophy and benign bone lesion of the 7th rib. CO₂ laser and chemical peeling MCA, 50% TCA) were applied to remove these skin lesions which improved considerably.

Epidermal Nevus Syndrome with Various Skin Manifestations

We report a case of epidermal nevus syndrome showing various skin manifestations improved with CO₂ laser and chemical peeling in a 11-year-old girl. Skin lesions were composed of linear verrucous plaques and numerous papillomatous papules on the face, neck, scalp and trunk, multiple congenital nevocellular nevi on the face, and extensive cafe au lait spots on the trunk. The associated findings of skeletal involvement were gingival hemihypertrophy and benign bone lesion of the 7th rib. CO₂ laser and chemical peeling MCA, 50% TCA) were applied to remove these skin lesions which improved considerably.