Skin Management by The American Society of Plastic Surgeons, Inc.
Managing Healthy Skin
From early on, we learn that having a smooth, clear complexion is an attribute
of physical attractiveness. However, as we age, maintaining that healthy glow
becomes more difficult. The face is the most exposed part of the body, vulnerable
to the damaging rays of the sun, and a harsh contaminated environment. The
face is also subject to acne, rashes, allergic reactions, and injuries that
may leave permanent scars.
A number of non-surgical refinishing treatments are available
for individuals who want to eliminate or soften imperfections of
their facial skin and achieve a clearer, fresher look. These treatments
include glycolic acids (sometimes called fruit acids),
which are derivatives of food substances blended into facial preparations
and are used to eliminate rough or dried surface skin. Retin-A®,
a vitamin A acid, changes the cellular metabolism of the skins
wrinkles and blotches from sun damage. Retin-A® rebuilds collagen
and elastin in skin, and is an extremely beneficial topical treatment.
Topical antioxidents scavenge the cell damaging free radicals generated
by sun and other pollutants.
What to Expect from Skin-Surface Treatments
Surface-repair, home care, topicals, and in-office treatments can
enhance your appearance and give your skin a smoother, fresher look, but they
wont remove deep scars and flaws or prevent aging. These treatments should
not be thought of as mini-facelifts. Generally speaking, Retin-A® and glycolic
acid treatments offer less dramatic results than surgical approaches such as
deep skin resurfacing procedures like CO2 laser or deep chemical peels.
Planning for the Treatment
Whether youre planning a surgical or nonsurgical skin treatment, its
important that you find a physician or a paramedical aesthetician supervised
by a physician who has training and experience with a variety of skin management
techniques. Youll want a physician who can give you the best possible
single treatment or treatment combination.
In your initial consultation, be open in discussing your treatment goals
with your physician or aesthetician and dont hesitate to ask
any questions or express any concerns you may have. Your physician
or aesthetician should
be equally open with your choice of treatment options based upon your age,
skin condition, and previous plastic surgeries. Your medical history and
skin history will be reviewed at your consultation.
Sun is by far the worst enemy of the skin. The sun creates free radicals, which
cause cell damage. Cell damage eventually results in the destruction of
collagen and elastin and alters DNA, eventually resulting in skin cancers.
Repetitive exposure to the sun is the number one cause of premature aging
and skin cancer.
the natural order of life, that matter changes with time. Extrinsic
aging is due to outside influences on the skins health. The best
example of this is sun exposure. Most scientists now believe that 90%
of aging is due to extrinsic factors. Intrinsic aging is the part of
aging that is due to the actual passing of years, wearing out of the
body and hereditary factors. Family history and ethnic background do,
to a large degree, govern intrinsic skin aging.
can occur prematurely for individuals depending upon skin type and
the amount of sun exposure. There is a long delay between sun exposure
and clinical photo damage. About 80% of sun exposure occurs before
age 20, yet the skin changes caused by sun damage usually are not obvious
for another 10-20 years. The earliest signs of photo damage may be
blotchy pigmentation, fine lines, and a yellowish or sallow discoloration.
The skin never forgets an injury. Childhood ultraviolet injury, i.e.
sunburns, have been associated with a variety of adverse affects that
appear later in adulthood. The most dangerous is the association of
sun burns with malignant melanoma.
These changes occur in distinct layers of the skin, the stratum corneum, epidermis
and dermis. The thickening of the stratum corneum gives rise to a rough, leathery
appearance. The epidermis becomes thinner with the appearance of atypical epidermal
cells. The number of melanocytes change and their distribution becomes irregular.
Photodamaged dermis is markedly altered with thickened elastic fibers, altered
collagen and decreased ground substance or mucopolysaccharides.
There are many
factors that influence aging. Elastosis, which means loss of the elasticity,
is a significant factor in gravitys effects on aging tissue.
Expression lines are dynamic facial lines caused by repetitive movement.
Raising the eyebrows, frowning, and smiling will eventually cause a
crease to occur, just as pants will wrinkle the more you wear them.
Smokers will inevitably get smokers lines around the mouth and eyes.
Sleep habits, such as sleeping on one side or directly on the face,
will eventually create lines and elasticity changes. These are all
examples of intrinsic aging changes.
As time progressives,
the muscles, fat, and skin of our faces undergoes structural changes.
The amount of fat in the subcutaneous layer decreases with age. The
skin of the face is stretched back and forth over a lifetime, causing
an enlarging of the skin, and enhancing the gravitational
skin aging includes an excellent diet and regular exercise. Good health
habits will help the body to nourish the skin better and therefore
help fight aging. Avoiding excess alcohol will also help the body to
function better. A regular aerobic exercise program and a well-balanced,
healthy diet can certainly help an individual live longer and better.
A diet rich in antioxidant foods, or use of antioxidant supplements
such as Vitamin C and E help protect body tissues, including the skin,
from free radical damage, reducing the sign of aging. Good sleep habits
allow the body time to regenerate tissues and repair damaged cells.
Avoiding high amounts of stress certainly helps to avoid premature
aging not only of the skin, but also other organs of the body.
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Chemical Peel Skin Resurfacing Procedures
Chemical peel consists of the application of a chemical solution, usually an
acid, to the skin of the face or body. A chemical peel can be superficial,
medium depth, or deep in terms of the levels of the epidermis and dermis treated.
The goal of the chemical peel is to make the skin look smoother with a more
regular color, but still leave the skin looking as natural as possible. Chemical
peel is most commonly performed for cosmetic reasons. It may also however remove
precancerous skin growths.
Acids (AHAs), such as glycolic, lactic or fruit acids are the mildest
of the chemical peel formulas and produce light peels. These types
of peels can provide smoother, brighter looking skin with just a few
superficial treatments and very little, if any, down time. These lighter
peels are considered more complexion peels. They make the skin look
brighter and fresher by stimulating exfoliation (cell turnover) and
therefore must be repeated at varying intervals to maintain the effect.
Repeated treatments can help to further improve the texture and overall
health of the skin. They can also reduce the effects of aging and sun
damage, including fine wrinkling and pigment irregularities. A topical
skin maintenance program along with regular chemical peels is mandatory
to achieve and maintain optimal results in terms of skin appearance
and skin health. The advantage of light peels is that they minimally
disrupt your schedule and you can look reasonably normal within a few
hours or days. Make-up can be worn the same day and you can easily
go back to work the same day. For patients who have deeper or
more severe problems, a medium depth chemical peel may need to be performed
with trichlorocetic acid, TCA for short. Fine surface wrinkles, superficial
blemishes, and pigment problems are commonly treated with TCA. The
Obagi Blue Peel and the Biomedic Pigment Peel Plus are medium depth
chemical peels typical of this type of treatment.
and medically supervised paramedical estheticians perform both
superficial and medium depth chemical peels in my practice.
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Free radicals are an important factor in the aging process, including aging
of the skin. Topical free radicals scavengers, called antioxidants help neutralize
free radicals before they can attach themselves to cell membranes, eventually
destroying the cell. Chronic irritation to the skin by sun, pollution, smoking,
chemical exposure, and other inflammations lead to cumulative damage to cells
by free radicals. This results in the formation of self-destruct skin enzymes
such as hyaluronidase, elastase, and collagenase which cause the break down
of collagen and elastin fibers and the reduction in the strong supportive effects
of hyaluronic acid.
by supplying electrons to unstable free radical oxygen atoms, which
need these electrons to become stable. Cell membranes have an excess
of electrons. They can provide electrons to free-radical oxygen atoms,
but are severely damaged in the exchange. Antioxidants supply electrons,
neutralizing the free radical atoms before they have a chance to attach
to cell membranes.
occur in normal body cellular and physiologic reactions. Free oxygen
atoms are given off as a result of various chemical reactions within
the body. Smoking, alcohol, stress, and sun exposure also contribute
to significant additional free radical production.
and intrinsic aging is the result of damage to cellular components
by free radicals, which cause oxidation of proteins, lipids, cross
linking of proteins and damage to DNA. The cumulative effect of free
radical activity which is generated by the normal metabolism of the
cell, as well as normal exposure to radiation and toxins, eventually
results in a cell that can no longer function. We now know from extensive
scientific research that diverse diseases such as heart disease, arthritis,
Alzheimers, Parkinsons and various cancers are initiated
by free radical damage.
The chief defense
against free radical damage is antioxidants. Antioxidants are molecules,
many of them naturally occurring substances such as Vitamin C and Vitamin
E, that block the damaging reaction of reactive oxygen species, i.e.
free radicals. Alphalipoic acid is a unique antioxidant that is both
water and fat-soluble. Antioxidants are also important in the repair
process and are preventative of DNA damage occurring from free radical
an integral part of the aging process. Inflammation is created and
perpetuated by free radical reactions.
Vitamins C, E and alphalipoic acid may also work synergistically to
reduce the amount of photo aging caused by ultraviolet exposure to
the skin by inhibiting inflammation and the inflammatory cascade that
is stimulated by free radical damage caused by sun exposure.
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or Retinoic Acid)
In general, Retin-A® is most effective in patients who have fine facial
wrinkles, or blotchy pigmented areas caused by sun damage. Patients who are
planning to have a chemical peel are instructed to use Retin-A® as part
of the preparation for the peel. Retin-A® thins the skins outer layer,
allowing the acid solution used in a chemical peel to penetrate more deeply,
evenly and predictably. It also stimulates skin cell turnover (exfoliation)
so skin healing and the outcome from a chemical peel is more efficient and
predictable. Under the microscope, Retin-A® has been shown to reorganize the
skin by reestablishing a more normal epidermis, increasing new blood vessel
formation, increasing collagen production, and generally improving damaged
Although no serious
medical problems have been associated with Retin-A®, it is possible
that its use could result in temporary skin irritation and redness.
If this happens, a milder formulation may be recommended. Retin-A® is
not recommended for pregnant women or nursing mothers, because its
effects on the fetus and nursing infants are still being studied.
Your initial instruction
on the application of Retin-A® will include a lesson on how to
begin your skin-care routine at home. After you wash your face thoroughly,
a small amount of Retin-A®, in either cream or gel form, is rubbed
over your face and nose. A gentle formula will be used at the beginning,
especially if you are younger or have a fair complexion. You will be
switched to a stronger formula after your skin becomes accustomed to
Only a very small
amount of Retin-A® - a pea-sized dab is needed to cover
the entire face. You will be instructed to apply Retin-A® every
3rd or 4th night before you go to bed. Because Retin-A® is drying
to the skin, a moisturizer is also recommend once or twice a day. At
periodic follow-up visits, your aesthetician may adjust the strength
of your prescription or its frequency of use. To maintain the benefits
of Retin-A®, it must be continued indefinitely.
Because Retin-A® thins
the outer layer, you will need to consistently use a sun block to protect
yourself from ultraviolet light, and you may have to discontinue using
certain products or cosmetics on your face.
Although the degree
of change varies from person to person, with continued use of Retin-A®,
you will begin to see subtle improvements in the texture and tone of
your skin. Retin-A® users notice a rosy glow during the beginning
months of use, followed by the softening of fine lines and the shrinking
of large pores. After about six months, many Retin-A® users report
that wrinkles are less visible and that age spots have faded significantly.
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The aging, wrinkling and skin cancer inducing effect of ultraviolet radiation
of the sun is recognized as an important health consideration, and ultraviolet
absorbers or blockers are an effective preventative. The suntan that became
fashionable in 1920s, suggesting an image of leisure and affluence has
become much less important to the health conscious consumer, as the adverse
health considerations have become known. Skin care has become the key, whether
the effect is to prevent sunburn, prevent skin cancer or premature aging of
There are three
general categories of ultraviolet radiation, UVA, UVB, and UVC. UVA
radiation has a wave length in the range of 320-400 nanometer, is capable
of tanning the skin with only very weak reddening (erythema).It falls
more evenly during the day than does UVB radiation. It is known to
inhibit the DNA repair process of damage that is caused by UVB radiation.
It is also implicated as a causative factor in cataracts of the lens
of the eye. UVB radiation has a wavelength of 290-320 nanometers, is
the major cause of sunburn and also stimulates the tanning response.
It is concentrated more at mid-day, approximately two hours either
side of the noon hour. Maximum erythema effect occurs at 308-311 nanometers.
UVB radiation is known to cause cell mutations. UVC radiation has a
wavelength of 200-290 nanometers, and has a germicidal and erythemal
effect, but does not reach the earths surface.
are high energy rays that are capable of deranging the molecular structure
of DNA at a cellular level. UVA penetrates the skin more deeply, causing
changes in blood vessels and premature aging. Overexposure to UVA can
cause long term eye damage, and aggravation of various allergies or
skin conditions. UVA and UVB actually enhance the effect of one another
synergistically. They are potentially a lethal cancer producing combination.
UVB damages the skin, while UVA interferes with the bodys ability
to repair the damage at a cellular level. This then causes cell mutations
because of the alteration of genetic information in molecular DNA,
hence abnormal cells which grow out of control, i.e.: cancer cells.
Exposure to UV radiation clearly has an adverse and dangerous effect
on the bodys immune system.
A suntan is actually
a reaction to injury, whereby special cells called melanocytes release
granules of protective melanin pigment, which absorbs and scatters
subsequent doses of ultraviolet rays. In the face, most of what we
think of as skin aging is actually accumulated sun damage. The relentless,
cumulative, everyday exposure to UV radiation is much more dangerous
than the occasional sunburn! Tanning booths are a potential source
of excessive ultraviolet radiation. The UVA rays used may be upwards
of 100 times stronger than natural sunlight. The lighting has up to
5 percent UVB contamination, with intensities of both UVA and UVB that
are dangerously high. There is strong evidence that UVA exposure in
the tanning industry is harmful to your health.
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Sensitive Skin & Rosacea
Sensitive skin is very thin, fragile looking and pink colored. Because of sensitive
skins thinness, the blood vessels and nerve endings are much closer to
the surface. This is why this type of skin reddens so easily, and also why
it becomes irritated by cosmetics and surface treatments more easily. Sensitive
skin will often react to internal factors such as eating spicy foods, and stimulants
such as caffeine, tobacco or niacin. These substances are called vasodilators.
Vasodilators dilate the blood vessels, making more blood flow through surface
skin vessels. This dilation often shows up in the skin of sensitive skinned
individuals as red blotchy patches.
It is extremely
important to protect the barrier function of sensitive skin, which
in general does not have a natural barrier function that is as effective
as that of normal skin. Decreased barrier function results in a more
permeable epidermis, and irritants are more likely to cause inflammation
because it is easier for them to penetrate the skin surface, where
they come in contact with poorly protected nerve endings. If skin is
already irritated because of a diminished barrier function, it is much
more likely to react to skin care products and cosmetics.
Rosacea is a type
of sensitive skin. Rosacea is a condition of the skin in which it turns
red very easily, known as flushing. Rosacea normally affects persons
older than 30 years of age, but can appear as early as the 20s
or as late as 70-80 years of age. The sudden rushing of blood to the
face can stimulate sebaceous glands and irritate follicles causing
large red papules and pustules to form in the cheek, nose and chin
areas. When pustules and redness occur in a person with rosacea this
is known as a flare of rosacea.
Even though many
aspects of rosacea may closely mimic the description and characteristics
of acne, it is a completely separate entity. It is often difficult
to diagnose rosacea because the lesions so closely resemble acne. Rosacea
is much more prevalent among females, but when men do get rosacea,
it is usually far more severe.
Rosacea is a progressive
skin disease that must be taken seriously. Most recent research indicates
that the cause of rosacea may involve a variety of possibilities and
factors that cause or exacerbate the condition. One thing that is absolutely
certain, cumulative sun exposure and the resulting sun damage always
plays a role in flares of rosacea.
Rosacea is not curable. Rosacea is treatable and can be controlled.
Rosacea is varied and complex. Treatment requires dedication and perseverance.
The patient must be compliant and flexible in treatment options.
In general, patients
should avoid all known irritants and sources of local irritation. A
broad-spectrum sunscreen is an absolute must. Topical prescription
products should be in a non-alcohol base.
to respond extremely well to a combination of azaleic acid, glycolic
acid, and salicylic acid. Patients report a lessening of redness and
fewer lesions. Additional treatment options may include intermittent
oral and topical antibiotics. Investigational treatments include utilizing
oral antihistamines to decrease the inflammatory cascade.
Pulse Dye Vascular
Laser is an effective new treatment for rosacea. By reducing the blood
vessels of rosacea, flushing and flares are significantly reduced in
frequency and severity.Rosacea is not curable but it is treatable and
can be controlled.
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The most common form of acne is called acne vulgaris. This type of acne is
often associated with teenagers. Almost all teenagers have some acne. That
is because at the onset of puberty, teens undergo surges in hormone production
causing a stimulation of the sebaceous glands, which produces an overabundance
of sebum. This waxy substance can block the skin pores causing open or
closed comedones. Infection in closed comedones caused by the common skin
bacteria P-acnes then causes infected skin pores called pustules (pimples).
Acne is graded
on its severity on a 4-point scale. Grade 1 acne is mostly open and
closed comedones with an occasional pimple. Grade 2 has many more closed
comedones with occasional pimples. Grade 3 acne is thought by most
people as typical teenage acne. It involves a large number of open
and closed comedones and inflammation and redness as well. Grade 4
acne is commonly referred to as cystic acne, with many deep cysts,
subsequent scarring and scar pit formation.
Scars form when
the skin attempts to heal itself, producing collagen, which may overgrow,
producing a raised, red type of scarring. When acne pit scarring
occurs, there is actual destruction of tissue in the inflammatory process
that then causes a large or small depression.
specifically male hormones called androgens is the mechanism that causes
stimulation of sebaceous glands. The sebum and cell debris then block
skin pores that subsequently causes inflammation, cell build up and
full-blown infection due to the P-acnes bacteria. Testosterone is the
male androgen that converts to dihydrotestosterone (DHT), the main
form of the male hormone that switches on the oil gland.
flairs in women is often referred to as adult onset acne. This type
of acne can also be caused by comedogenic cosmetics, stress, and hereditary
acne factors, although hormones probably play the most significant
role in adult female acne. Androgen flares in the blood stream cause
this type of flare-up in adult onset acne. Premenstrual flares are
caused by a sudden predominance of androgen, which corresponds to the
decrease in estrogen during the normal menstrual cycle. The elevation
in androgen is more related to a decrease in overall estrogen levels
in the blood stream versus a significant rise in androgen production
so that this is more of a relative type of change.
Sun exposure although
it may have an immediate drying effect on acne lesions, actually damages
the skin further causing more cell build up within the pores and increasing
the risk of acne flare-ups later.
is an important factor in the aggravation of acne symptoms. Repeated
exposure to detergents and facial cleansers can aggravate the condition,
causing enough irritation to precipitate active acne, and bringing
forth other sensitivities as well. Over cleaning over stimulates the
sebaceous glands so that they actually produce more sebum and therefore
increase the risk of active lesions.
to control flare-ups and scarring clearly does need to include a dedicated
cleansing regime, but with appropriate cleansing agents and the avoidance
of comedogenic topical products that may aggravate the problem.
may also be recommended to unblock the pores and remove the sebum.
This would include light alpha hydroxy acid peels with both glycolic
and salicylic acid. Other measures needed in certain cases may include
long-term treatments with topical or oral antibiotics to control skin
a prescription drug is commonly used to treat severe acne. Its use
is described elsewhere, but suffice it to say as with any other topical
skin treatment there may actually be an increase in acne lesions in
the early use of Retin-A® due to the deep action of the medication.
Positive results should be noticed after 2-3 weeks of treatment, but
it may take several months before significant, definite benefits are
Acne is one of
the most frustrating skin diseases to treat, both for the aesthetician
and the physician overseeing that treatment. The patient must be compliant,
educated, and motivated to obtain the most effective improvement in
their acne symptoms.
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One of the main signs of photoaging is hyperpigmentation. It is one of the
main concerns of sun-damaged patients in terms of dealing with irregular,
scattered pigmentation. It can be very difficult to manage depending upon
the depth of the pigment. Hyperpigmentation is primarily due to sun exposure
but can also be related to changes in hormonal activity, particularly in
female patients, that results in over activity of the melanocytes in the
which are the cells that produce melanin, are located in the lower
epidermis or the upper dermis. Melanin is stimulated by sun exposure
as a protective mechanism to reduce UVA/UVB radiation penetration into
the deeper layers of the skin. Melanocytes can also be stimulated by
hormonal fluctuations, exposure to chemicals causing inflammation,
injuries to the skin including deep skin resurfacing and various forms
of topical skin irritation or inflammation, including acne. The hyperpigmentation
associated with chronic acne is called post inflammatory hyperpigmentation
and is due to chronic irritation from infected acne lesions.
Three types of
products and therapy are effective in reducing skin pigment. These
are chemical exfoliation, melanin suppressive agents, and sunscreens.
Normally, a combination of modalities needs to be used in treating
hyperpigmented, photodamaged skin.
including alpha hydroxy acids and Retin-A® are both utilized to
stimulate cell turn over, therefore evening out the melanin deposition
in the epidermis. Chemical exfoiliants remove dead surface cells containing
melanin, therefore helping to fade the skin. They also clear hyperkeratonized
areas of cell build up on the skin surface, enabling more effective
skin treatment with other topical products.
agents interfere with the chemical process of melanin production. Many
inhibit tyrosinase, an enzyme that is used to convert the amino acid
tyrosine, into melanin. Various other skin lightening agents including
kojic acid, some antioxidants and azelic acid are less effective in
melanin suppression, but may be adjunct treatments or primary treatments
depending upon skin sensitivity. The most commonly used topical melanin
suppressive agent is hydroquinone, which is generally applied to the
skin in 4%-10% prescription formulations. Drawbacks to hydroquinone
include its irritative and drying properties as well as possible skin
sensitivities that may develop with its use. It is a strong oxidant,
which means it neutralizes and turns darker fairly quickly on exposure
to oxygen. It must therefore be carefully manufactured and added to
topical vehicles such that it remains effective, yet does not discolor.
sunscreens or sun blockers, which limit UVA UVB penetration to the
skin, are critical in the treatment of hyperpigmentation. It is counter
productive to attempt to lighten hyperpigmentation and continue to
expose the skin to the primary factor in the cause of hyperpigmentation,
chronic sun exposure.
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Actinic/Solar Keratoses are rough areas of damaged skin, characterized by dysplastic
cell growth. Dysplastic means abnormal cell growth. Actinic keratoses are frequently
found on the faces of individuals who have had chronic sun exposure. They are
most prevalent in light-skinned individuals. They are red patches of skin that
can be crusty, scaly, and rough to the touch. Because they are dysplastic in
nature, they are considered to be precancerous. Actinic keratoses can be treated
in a number of ways. Cryosurgery (freezing with liquid nitrogen), or deep spot
chemical treatment, versus superficial cautery type techniques treat these
superficial lesions. They can also be treated with superficial chemotherapy
using a drug called Efudex.