From Sonoma Medicine, Volume 62, Number 2. Spring 2011
Unwrinkling the Skin
Ashley Smith, MD
During the past decade the number of cosmetic procedures performed by physicians has increased dramatically, in keeping with the rapid development and release of new technologies and products to relax wrinkles, fill folds, add volume and rejuvenate the skin. It is important for physicians to understand what products and devices are available and what the active substances are, along with FDA indications, off-label uses, potential side effects, and black box warnings.
Botox is probably the most familiar new cosmetic product. Approved by the FDA for cosmetic use in 2002, it is indicated for temporarily improving the appearance of moderate to severe glabellar rhytids (forehead wrinkles). Botox is a brand-name formulation of botulinum toxin type A. A similar product, Dysport, was approved by the FDA in 2009, and other formulations are currently under review.
Botulinum toxin is a purified protein derived from the bacterial toxin, Clostridium botulinum type A. Although the naturally occurring toxin can cause life-threatening respiratory depression or even death, scientists discovered a way to use it to human advantage by injecting small diluted amounts directly into specific muscles. Doctors should be aware that the highly publicized cases of botulism in Florida in 2004 were due to administration of unpurified botulinum toxin by a physician with a suspended license.
Botulinum toxin exerts its effect by binding to acceptor sites on motor or sympathetic nerve terminals. It then blocks the release of acetylcholine, thereby preventing contraction of the associated muscle fibers and reducing wrinkles. Because of its action, botulinum toxin is predominantly used to treat areas with dynamic rhytids. Static etched-in wrinkles do not respond well to botulinum toxin but may be treated with a resurfacing laser.
A typical botulinum injection office visit may take 15 minutes. The initial portion of the visit (and all cosmetic visits) is dedicated to discerning the patient’s wishes for cosmetic enhancement, ensuring proper expectations, deciding on areas of treatment, reviewing risks, and preparing the patient. Injection technique is simple, requiring a 30-gauge needle and the appropriate amount of botulinum toxin. The toxin is supplied as a freeze-dried compound, which is then diluted with sterile saline. Although the package insert specifies a certain approved dilution, different dilutions are used by different physicians. Some doctors prefer a more concentrated solution for more precision, while others opt for more dilute concentrations for a smoother overall effect.
Potential side effects include pain, bruising, injection site swelling, asymmetry, or temporary headache. Eyebrow or eyelid drooping is a potential complication of glabellar and forehead treatment that tends to be dose and technique dependent. Importantly, the FDA issued a black box warning in 2009 for all botulinum toxin products highlighting the possibility of life-threatening distant spread of toxin effect from the injection site after local injection. The cases that led to this warning were largely cerebral palsy patients who received large doses of botulinum toxin. Fortunately these effects have never been reported with cosmetic patients when treated as indicated. Due to the mechanism of action, patients with neuromuscular disorders should only receive botulinum toxin injections with caution.
The differences between Botox and Dysport appear to be modest. Some physicians report that Dysport takes effect more quickly (within 2-7 days) than Botox (typically 7 days). Both products last 3-4 months, and repeat treatments are required for maintained benefit. No adverse effects have been reported for patients who opt not to repeat a toxin procedure.
In the 1996 movie The First Wives Club, Goldie Hawn’s lips receive an over-zealous augmentation with collagen. While her outcome was not aesthetically pleasing, it certainly brought attention to this filler technique, which now results in more modest outcomes.
Myriad filler materials are available worldwide. In the United States, the FDA has approved about a dozen fillers, which may be absorbable, non-absorbable, synthetic or natural. They include brand-name formulations of collagen, hyaluronic acid, calcium hydroxyapatite, L-polylactic acid, and polymethyl methacrylate microspheres. Collagen products are derived from human fibroblast cell cultures. Hyaluronic acid products come from either rooster combs or gram-positive (strep) bacterial fermentation. The remaining products are synthetic.
In general, dermal filler devices are approved on-label for injection into the mid to deep dermis for the correction of moderate to severe wrinkles and folds. One filler (Sculptra) was initially approved by the FDA as an orphan drug for facial fat loss (lipoatrophy) in HIV patients. Another filler (Radiesse) also carries an HIV lipoatrophy indication.
A less common filling is fat injection, which includes fat harvesting via liposuction, fat separation, and fresh or frozen transfer to the patient. The benefits of fat transfer include using the patient’s own fat and the longer duration of effect (years versus months). The limitations include the need for a harvesting procedure, a laboratory for fat preparation, a separate transfer procedure, and less predictable outcomes.
A typical office visit for filler injection begins with application of topical anesthesia cream and/or injection nerve block anesthesia. Many of the filler materials now come with premixed lidocaine. The hyaluronic acid products tend to cause the most immediate swelling due to their hydrophilic nature. Bruising is the most likely adverse effect. Lumps or bumps after injection are a feared complication that tends to be placement dependent.
Fillers need to be injected into the proper layer of the skin, which usually means the mid to deep dermis. Placing the filler too superficially can cause a bluish discoloration due to the Tyndall effect. Fortunately, an injectable reversing agent, hyaluronidase, can dissolve misplaced hyaluronic acid. Lumps or bumps produced by other fillers may require surgical removal. Uncommonly the fillers can cause granulomas.
Contraindications to fillers may include bleeding disorders, patients susceptible to keloid formation, or connective tissue disorders. Fillers should not be injected into skin with active inflammation or infection, or into blood vessels. Patients with a history of herpes infection should probably receive prophylaxis.
Most of the fillers last about 6-12 months, but Sculptra lasts two years or longer, and one of the synthetic fillers (Artefill) is permanent. Fat injections also tend to be long lasting. Many patients receive a combination of different fillers over time, and no adverse effects from filler combinations have been reported.
Lasers and Light Technologies
For safe and effective use of lasers, it is important to understand how they work. A laser is composed of a single wavelength of light. The laser wavelength should be matched to the “target” or skin chromophore of interest, such as hemoglobin in capillaries or vascular malformations; melanin in the epidermis, dermis or hair follicles; tattoo pigment in the dermis; water in the epidermis and dermis; or fat in the hypodermis. The more closely the laser’s wavelength matches the target absorption peak, the more potential the laser has for achieving the expected outcome.
Advances in laser treatments began with the theory of selective photothermolysis in 1983. The theory refers to the precise targeting of a structure or tissue using a specific wavelength of light with the intention of absorbing light into that target area alone. The energy directed into the target area produces sufficient heat to damage the target while allowing the surrounding area to remain relatively untouched. Unfortunately most targets have some overlapping absorption peaks, so there is always some potential absorption of the laser by the nonintended structure, which can lead to hypo- or hyperpigmentation. Physicians must be familiar with the absorption pattern of different chromophores to maximize improvement and minimize complications.
Lasers are excellent at treating unwanted skin discoloration, such as redness from normal aging or brown pigmentation from sun damage. Lasers are also good at targeting dark hair follicles or tattoos, whether artistic or traumatic. More recently laser technology has been advanced to lift, tighten and treat wrinkles without the previously required prolonged recovery time. Classically, resurfacing lasers (which target water within the epidermis and dermis) for the reduction of wrinkles required a full week of at-home recovery due to the complete ablation of the epidermis, akin to a burn victim. While wrinkle reduction was tremendous, so was the recovery time and risk for permanent hypopigmentation or scarring.
Fractionated resurfacing lasers, introduced during the last decade, have solved many of the problems posed by resurfacing lasers. Fractionated lasers can be either ablative (superficial tissue is removed) or nonablative (epidermis is intact). A fractionated laser treats a programmed percentage or fraction of the skin. The physician is able to reduce the intensity of the laser by reducing the fraction of skin being treated or to increase the intensity by increasing the treated percentage.
Since there is intervening normal healthy skin between the fractions of treated skin, the healing is dramatically hastened. Even with the ablative fractionated lasers, complete re-epithelialization occurs within 24-48 hours. This rapid recovery eliminates the weeping, oozing, burn-like healing phase of traditional ablative lasers.
Several non-laser light technologies may rejuvenate the skin. Popular techniques include intense pulsed light machines, red lights, infrared lights, blue lights, light-emitting diodes, radiofrequency, and ultrasound. These technologies can be used to treat capillaries, erythema, acne, unwanted hair growth, excess fat deposits, and potentially many other indications. Researchers have suggested that these technologies build collagen, thereby reducing wrinkles, smoothing skin texture and lifting skin laxity.
For safety, all laser and light treatments require the absence of a sunburn or suntan, as this will increase the risk of discoloration or scarring. Patients with naturally darker skin tones need to be treated with greater caution and adjustment of laser parameters.
Most of the aforementioned treatments cause mild discomfort. For the more powerful devices or more sensitive areas, topical numbing cream may be applied once the patient arrives at the office. Patients should not use numbing cream prior to arrival because of the risk of overuse. This risk was unfortunately highlighted by the death of a patient in Florida who applied lidocaine cream to both legs prior to laser hair removal and had resultant cardiotoxicity.
Recovery time ranges from no downtime and the ability to go right back to work, to mild redness or swelling, to dramatic sunburn appearance and swelling. In general, the more dramatic the expected result, the more recovery time. Simple gentle cleansers, lotions, physical sun blocks, and strict photoprotection and/or photoavoidance are required after all laser treatments.
Caution or contraindications for laser use may include photosensitizing medications or certain conditions, such as lupus or porphyria. Absolute contraindication is use of any laser or light device within six months of isotretinoin (Accutane) treatment due to the risk of scarring.