Jain Dermatology Chapter 6: Cosmetic Surgery (Botox, Fillers, Lasers) – Flashcards
Unlock all answers in this set
Unlock answersquestion
Chemical peels and isotretinoin
answer
Do not resurface if patient with recent (6-12 months) isotretinoin; Accutane causes atrophy of the pilosebaceous unit, which is where re-epithelialization after peel originates from possible impaired wound healing with ↑ scar formation
question
Antiviral prophylaxis for what level of chemical peels
answer
Medium and deep peels
question
Frost intensity and peel level
answer
Level 1: Irregular light frost (erythema with streaky frosting): Superficial Epidermis; Level 2: Uniform white frost with underlying erythema: Papillary Dermis; Level 3: Solid white enamel frosting: Reticular Dermis
question
Superficial peels
answer
Epidermis only: Glycolic acid or other alpha-hydroxyl acids, Jessner's, TCA 10-30%, Salicylic acid, Tretinoin solution
question
Medium peels
answer
Papillary dermis: 35-40% TCA, 70% glycolic acid + 35% TCA, Jessner's solution + 35% TCA, 88% phenol (rarely used)
question
Deep peels
answer
Reticular dermis: TCA>50%, Phenol/Baker's formula; Complications: prolonged erythema (most common), scarring, permanent hypopigmentation, hyperpigmentation, milia, acne
question
TCA for peels
answer
10-20% concentration for very light superficial peels, 25-30% concentration for light superficial peels, 35% concentration with glycolic acid or Jessner's for medium peels 40% concentration when used alone for medium peels, >50% for deep peels
question
Salicylic acid for peels
answer
Used for superficial peels; Keratolytic and comedolytic
question
Which of the following chemical peel solutions need neutralization: Glycolic acid, Jessner's solution, Salicylic acid, TCA
answer
Glycolic acid needs to be neutralized with sodium bicarbonate; Jessner's, TCA, Salicylic acid do not need neutralization
question
Jessner's solution is used for superficial or medium (with 35% TCA) chemical peels and composed of
answer
Salicylic acid, Lactic acid, Resorcinol, Ethanol
question
Phenol
answer
Keratocoagulant, Must use IV sedation with full face procedure, Cardiotoxic (do not exceed 60-90 minutes) and need cardiac monitoring, Hepatotoxic, Nephrotoxic
question
Baker formula - Used for deep peels
answer
Phenol, Distilled water, Croton Oil (active ingredient), Liquid Hexachlorophene,
question
What level chemical peel used for AK, SK, Lentigines, dyschromia, Rhytides
answer
Medium peel
question
Botox A vs B are clostridium purified protein derivatives that cause temporary paralysis of striated muscle by inhibiting Ach release: Mechanism of Action
answer
BTX A light chain cleaves SNAP25, BTX B light chain cleaves synaptoBrevin
question
Botox A FDA approved for
answer
Glabellar rhytides, Hyperhidrosis, Most effective at reducing dynamic facial lines
question
Botox and saline reconstitution
answer
Instructions recommend reconstitution in sterile, non-preserved saline but preserved saline results in less pain on injection and does not reduce stability of toxin
question
Botox contraindications
answer
Neuromuscular disorder, Infection/Inflammation at injection site, Known hypersensitivity to product, Pregnancy category C
question
Botox for glabellar rhytides
answer
Stay 1 cm above orbital rim, Toxin can cause eyelid ptosis (starts within 2-14 days, lasts 2-12 weeks) if it diffuses to levator palpebrae muscle, Apraclonidine 0.5% eyedrops (a-agonist) may help lift lid by 1-2 mm by causing Muller's muscle contraction to compensate for levator palpebrae weakness
question
Botox for horizontal forehead lines
answer
Weakens frontalis muscle; Too much botox results in unopposed action of eyebrow depressors and angry expression, Injecting lateral but not superficial frontalis fibers results in quizzical appearance, If narrow brow fewer injection sites (4 instead of 5)
question
Botox for Crow's Feet (horizontal to oblique lines radiating from lateral canthus)
answer
Weakens orbicularis oculi muscle, Do not inject while patient smiling as toxin may affect ipsilateral zygomaticus complex, causing ptosis of upper lip
question
Botox for Perioral Rhytides
answer
Weakens orbicularis oris muscle, Vertical lines radiating outward from vermilion border; 8 doses (1-2 units per lip quadrant) sufficient for cosmesis and to avoid paresis and speech interference
question
Botox for Bunny Lines
answer
Weakens nasalis muscle, Inject anterior to nasofacial groove on lateral wall of nose; Avoid angular vein, Avoid nasofacial groove as this can affect levator labii superiorir and levator superior alaeque nasi
question
Botox for depressor anguli oris (DAO)
answer
Weakening DAO eliminates downward pull and negative facial expression; Inject 3-5 units at level of posterior margin of mangible close to anterior margin of masseter; Complications: Asymmetric smile and flaccid cheek. Patients who use perioral muscles intensely not good candidates
question
Soft tissue augmentation locations
answer
Used on: Lips, Nasolabial folds, Wrinkles
question
Injectactable filler composition
answer
Hyaluronic acid, Collagen, Fat, Calcium hyroxylapatite
question
Filler side-effects
answer
Bruising, Granuloma formation, Hematoma, Infection
question
Hair transplant follicular unit composed of
answer
1-4 terminal hairs, 1-2 vellus hairs, Associated glands, Arrector pili, Adventitial collagen
question
Hair transplant: Follicular units taken out intact through stereomicroscopic dissection, follicular unit density is
answer
Typically >30 follicular units/cm2
question
FDA-approved medical treatments for male-pattern alopecia
answer
Minoxidil (Rogaine), Finasteride (Propecia)
question
Finasteride MOA, SE
answer
MOA - 5a-reductase inhibitor, decreases convertion of T to DHT; SE - Decreased libido, Gynecomastia, Decreased prostate-specific antigen (PSA) level
question
Filler made from neonatal foreskin that lasts 3-4 months
answer
Cosmoderm I - Human collagen + plain lidocaine, Injected in superficial to mid-dermis, No pretesting
question
Filler made from bovine collagen + lidocaine that is injected into superficial to mid-dermis
answer
Zyderm - Requires pretesting (two tests, two weeks apart, Zyderm lasts 3-4 months, Zyderm II lasts 3-6 months
question
Filler made from hyaluronic acid product of bacterial fermentation lasting 4-6 months
answer
Restylane - No pretesting, Mid-dermis
question
Filler made from hyaluronic acid product from rooster comb lasting 3-6 months
answer
Hylaform/Hylaform plus - No pretesting, Mid-dermis
question
Filler made of collagen from patients own skin lasting 4-9 months
answer
Autologen - No pretesting, Mid-dermis
question
Filler made of polymethylmethacrylate beads in bovine collagen suspension that is permanent
answer
Artecoll- Pretesting, Deep dermis
question
Filler made of human collagen cross-linked with glutaraldehyde + plain lidocaine that lasts 3-4 months
answer
Cosmoplast
question
Filler made of hyaluronic acid (bacterial fermentation) lasting 3-9 months
answer
Perlane - Deep dermis
question
Filler made of bovine collagen cross-linked with glutaraldehyde + plain lidocaine lasting 3-5 months
answer
Zyplast - Deep dermis, Pretesting
question
Filler made of cultured autologous human fibroblasts with unclear duration
answer
Isolagen - Versatile implantation level
question
Filler made of hyaluronic acid lasting 3-6 months
answer
Juvederm - Dermis, Level varies if ultra or plus
question
Filler made of calcium hydroxylapatite microspheres in polysaccharide gel lasting 9 months - 5 years
answer
Radiesse - Subdermal, Can be seen on x-ray
question
Filler made of Poly-L-lactic acid lasting 24 months and FDA approved for HIV lipodystrophy
answer
New-Fill, Sculptra, Subdermal
question
Filler made of acellular human cadaveri dermis lasting 3-6 months
answer
Alloderm - Subdermal implant
question
Filler made of fat harvested from patient lasting 6-24 months
answer
Autologous graft
question
Fillers requiring pretesting
answer
Zyderm I/II, Artecoll, Zyplast
question
Fillers made from hyaluronic acid
answer
Juvederm; Hylaform - Rooster comb; Restylane, Perlane - Bacterial fermentation
question
Fillers made from bovine collagen
answer
Zyderm I/II - lidocaine; Artecoll - Polymethylmethacrylate beads; Zyplast - cross-linked with glutaraldehyde + plain lidocaine
question
Fillers made from human collagen
answer
Cosmoderm I - plain lidocaine, Autologen - Patient's own skin, Cosmoplast - cross-linked with glutaraldehyde + plain lidocaine
question
Laser light characteristics
answer
Monochromatic - Single, discrete wavelength; Spatially coherent - Light in phase; Collimated - Light in parallel fashion
question
Laser: Selective thermolysis
answer
Targeted lesion may be destroyed by chromophore absorption of laser light without significant thermal damage to surrounding normal tissue
question
Laser: Pulse duration and thermal relaxation time time) < or equal to target thermal relaxation time (TRT, cooling time or time for target to lose 50% heat) to confine thermal damage
answer
Pulse duration (exposure
question
Laser: Pulse Duration and Thermal Damage Time (TDT)
answer
Pulse duration < or equal to TDT allows for efficacy with ↓ epidermal damage
question
Chomophores
answer
Components of skin which absorb laser light; Endogenous - Hemoglobin, Melanin, Water; Exogenous - Tattoo ink
question
Fluence vs Power
answer
Fluence - J/cm2; Power - J/s
question
Time required to irreversibly damage target with sparing of surrounding tissue
answer
Target Damage Time (TDT)
question
Time for target to lose 50% heat
answer
Target Thermal Relaxation Time (TRT); Proportional to square of target diameter (shortest TRT in chromophore with smallest size)
question
Gain medium
answer
Determines wavelength of light; Liquid (Dye Lasers), Gas (Argon, CO2, helium-neon), Solid (Nd:Yag, ruby)
question
Pulse duration (Exposure time of laser)
answer
Best if pulse duration less or equal to TRT and TDT
question
Spot size
answer
Larger size allows for deeper energy penetration (less scattering)
question
Cooling Types
answer
Different types of cooling minimizes epidermal damage; Passive (aqueous gel); Active contact cooling (water encased in sapphire or glass housing); Dynamic active cooling (cryogen spray); Forced air cooling
question
Q-switch - Quality switched
answer
Allows accumulation of excessive energy in laser cavity prior to emission; Extremely short pulses of very high power (nanosecond range); Used mainly for removal of tattoo pigment and superficial pigmented lesions
question
Laser Hair Removal Target
answer
Bulge of hair follicle and dermal papilla
question
Laser Hair Removal pulse duration
answer
Optimum pulse duration 10-50 ms; or equal to TRT of epidermis (3-10 ms)
question
Pigmented lesions (epidermal pigment)
answer
Q-switched lasers with very short pulse duration; QS KTP, QS ruby, QS Nd:Yag; Endpoint: Uniform but faint whitening, no epidermal disruption (higher fluences will have solid whitening with epidermal disruption and pinpoint bleeding)
question
Second harmonic generation (SHG)
answer
Frequency doubled
question
Type of lasers used to remove tattoo pigment
answer
Q-switched
question
Reason why white/peach/pink/flesh-toned tattoo color may turn dark gray immediately after treatment with Q-Switched laser
answer
Ferric oxide reduced to ferrous oxide
question
Number of treatments to clear amateur vs professional tattoo with Q-Switched laser
answer
Amateur - 3 to 5 treatments; Professional - 10 or more treatments
question
Best lasers for pigmented lesions, hair and tattoo removal (melanosome absorption range: 300-1000 nm - peak 335 nm)
answer
Nd:Yag - 532nm, KTP - 532nm, PDL - 585-595nm, Ruby - 694nm, Alexandrite - 755nm, Diode - 800-810nm
question
Best lasers for ablative and non-ablative remodeling, actinic cheilitis (water aborption peaks at 1450 nm, 1950 nm, 3000 nm)
answer
Nd:Yag - 1320 nm, Diode - 1450 nm, Erbium - 2940nm, CO2 - 10,600nm,
question
Reason why higher wavelength lasers used for hair removal and pigmented lesions despite melanin peak aborption in 300-600nm range
answer
Increased scattering, decreased penetration and competing chromophores (Hgb) occur with lower wavelength
question
Best laser for psoriasis (Chromophore: Protein)
answer
Excimer (XeCl) 308nm
question
Best lasers for vascular lesions (Hemoglobin absorption peaks at 418 nm, 542 nm, 577 nm)
answer
Argon - 488nm, Copper vapor - 511/578nm, KTP - 532nm, PDL - 585-595nm
question
Best lasers for hair removal (melanosome absorption range: 300-1000 nm (peak 335 nm)
answer
Ruby - 694nm, Alexandrite - 755nm, Diode - 800-810nm, ND:Yag (long-pulsed) - 1064nm, IPL - 515-1200nm
question
Best laser for red/orange/yellow, purple tattoos
answer
QS ND:Yag - green light (frequency doubled) - 532 nm; Pulsed dye - green light (short wavelength) - 510 nm
question
Best lasers for blue/black/green tattoos
answer
QS Ruby - 694 nm (red light); QS Alexandrite - 755nm (red light)
question
Best laser for blue/black tattoos
answer
QS Nd:Yag (long-pulsed) - 1064nm
question
Best laser for nevus of Ota
answer
Ruby - 694 nm
question
Best laser for verrucae
answer
PDL - 585-595nm
question
Best laser for actinic cheilitis
answer
CO2 - 10,600nm
question
Best laser for hypertrophic scars
answer
PDL - 585-595 nm
question
Best lasers for blond, red, white, gray, brown hair removal
answer
Ruby - 694nm - significant dose-related side effects vs alexandrite or Nd:Yag (crusting, dychromia 2/2 increased melanin aborption)
question
Best lasers for red, gray, brown hair removal
answer
Alexandrite
question
Best laser for brown/black hair removal
answer
Diode - 810nm
question
Laser which can cause retinal damage
answer
Ng: Yag (long pulsed) - 1064 nm (Long wavelength with deep penetration and invisible radiation)
