Recognizing, Managing, and Guiding the Patient Through Complications in Facial Plastic Surgery.

Complications in facial plastic surgery can occur in both surgical and nonsurgical procedures. Many complications can be prevented through thorough preprocedural evaluation, patient counseling, and close postoperative monitoring. Despite the best efforts complications will happen and identifying them early is critical to prevent long-term sequelae. It is important to know how to both manage the complication and guide the patient through the recovery process.

Recognizing and Managing Complications in Laser Resurfacing, Chemical Peels, and Dermabrasion.

Skin resurfacing techniques allow improvement of skin texture and color. This includes the effacement of wrinkles, signs of photoaging, and the softening of scars. Laser resurfacing, chemical peels, and dermabrasion are associated with overlapping risks of complications. The most common of these include infection, hypopigmentation, hyperpigmentation, and scarring. Patient evaluation helps provide treatment that gives the maximal benefit with a minimization of risks. This includes understanding the extent of each patient's issues (Glogau scale) and Fitzpatrick type. A thorough knowledge of potential risks will reduce their incidence and optimize early recognition and treatment of these complications when they do occur.

A Split-Scar Study Investigating the Effectiveness of Early Intervention With Electroabrasion on Improving the Cosmetic Appearance of Postsurgical Scars.

BACKGROUND: Electroabrasion, which uses an in-office electrosurgical device, is a method of surgical planning that ablates the skin to the papillary dermis. Several reports demonstrate that intraoperative ablative interventions with lasers or dermabrasion can modulate scar formation more effectively. This investigation uses electroabrasion intraoperatively to mitigate scar formation. OBJECTIVE: To evaluate the effectiveness of intraoperative electroabrasion for scar revision. MATERIALS AND METHODS: This was a prospective, randomized, observer-blinded, split-scar study with 24 linear scar segments resulting from primary closures in patients undergoing Mohs micrographic surgery. After placement of dermal sutures, half of the wound was randomly treated with electroabrasion. The other half was used as the control. Scar appearance was assessed by a blinded observer and by the patient using the Patient and Observer Scar Assessment Scale at 1 to 2 weeks, 1 month, and 3 months after surgery. RESULTS: At the 3-month follow-up, both patient and observer variables measuring scar contour improved on the treated side, whereas erythema was worse. Overall, no difference was seen in total scores between the 2 sides. CONCLUSION: Based on this pilot study, scars treated with electroabrasion revealed improved surface topography but worsened erythema. Future studies with more refined electrosurgical settings are needed for further evaluation.

Depth Map for Face and Neck Deep Chemical Peel Resurfacing.

BACKGROUND: Chemical peels are applied to the face and neck to improve rhytides and the photoaged appearance of the skin. Peels can be applied to different skin depths depending on the types of chemicals, the volume of solution, and the amount of pressure or friction applied. If a peel is applied too superficially, rhytides will not be removed. If a peel is applied too deeply, scarring or hypopigmentation could occur. OBJECTIVE: To create face and neck depth maps for chemical peeling, which can guide safety when removing rhytides and improving the skin's appearance. MATERIALS AND METHODS: A multicenter retrospective review of records was conducted of patients who underwent phenol-croton oil peeling, from January 1, 2018, to December 31, 2018. Information was collected on facial and neck cosmetic units peeled, peel formula and strength used, outcomes, and complications. RESULTS: A total of 410 patients received deep peels. Two depth maps were created that corresponded to the most common patterns of deep chemical peel applications. CONCLUSION: Different areas of the face and neck are treated with different chemical peel application depths to safely improve rhytides and appearance. Depth maps are created to balance safety and efficacy.

Multidisciplinary long-term care and modern surgical treatment of congenital melanocytic nevi - recommendations by the CMN surgery network.

In recent years, our knowledge of congenital melanocytic nevi (CMN) has greatly expanded. This has led to a paradigm shift. The present article represents a commentary by an interdisciplinary group of physicians from German-speaking countries with extensive experience in long-term care and surgical treatment of children and adults with CMN (CMN surgery network, "Netzwerk Nävuschirurgie", NNC). The authors address aspects such as the indication for treatment as well as treatment planning and implementation under these new premises. Adequate counseling of parents on conservative and/or surgical management requires an interdisciplinary exchange among physicians and individualized planning of the intervention, which frequently involves a multi-stage procedure. Today, the long-term aesthetic outcome is at the center of any therapeutic endeavor, whereas melanoma prevention plays only a minor role. The premise of "removal at any cost" no longer holds. Potential treatment-related adverse effects (hospitalization, wound healing disorders, and others) must be carefully weighed against the prospects of a beneficial outcome. In this context, the use of dermabrasion in particular must be critically evaluated. At a meeting of the NNC in September 2018, its members agreed on a consensus-based position on dermabrasion, stating that the procedure frequently leads to impaired wound healing and cosmetically unfavorable or hypertrophic scarring. Moreover, dermabrasion is considered to be commonly associated with considerable repigmentation that usually occurs a number of years after the procedure. In addition, the NNC members saw no benefit in terms of melanoma prevention. In the future, physicians should therefore thoroughly caution about the potential risks and often limited cosmetic benefits of dermabrasion.

Efficacy and safety of daylight photodynamic therapy after tailored pretreatment with ablative fractional laser or microdermabrasion: a randomized, side-by-side, single-blind trial in patients with actinic keratosis and large-area field cancerization.

BACKGROUND: Physical pretreatments can potentiate the efficacy of daylight photodynamic therapy (dPDT), but clinical comparative studies remain limited. OBJECTIVES: Performed in large skin areas with actinic keratoses (AKs) and photodamage, this blinded, randomized clinical trial compared the efficacy and safety of dPDT after tailored skin pretreatment using ablative fractional laser (AFL) or microdermabrasion (MD). METHODS: Two ≥ 50-cm2 side-by-side skin areas were randomized to receive a single treatment with AFL-dPDT or MD-dPDT. Pretreatment parameters were tailored according to AK grade and skin constitution to ensure standardized immediate end points. Subsequently, methyl aminolaevulinate was applied, followed by 2-h daylight exposure. The primary outcome comprised blinded assessment of AK clearance at the 3-month follow-up. RESULTS: In 18 patients with 832 AKs, AFL-dPDT provided significantly higher AK clearance (81% vs. 60%, P < 0·001), led to fewer new AKs (P < 0·001) and showed superior improvement in dyspigmentation (P = 0·003) and skin texture (P = 0·001) vs. MD-dPDT. Peaking at days 3-6, AFL-PDT induced more intensified local skin responses (P = 0·004), including instances of Staphylococcus aureus infection (n = 3). Patients nonetheless preferred AFL-dPDT (P = 0·077), due to lower pretreatment-related pain (P = 0·002) and superior cosmesis (P = 0·035) and efficacy compared with MD-dPDT. CONCLUSIONS: AFL-dPDT is an effective treatment for patients with AK with extensive field cancerization, although AFL pretreatment is associated with intensified local skin reactions.

ASDS Guidelines Task Force: Consensus Recommendations Regarding the Safety of Lasers, Dermabrasion, Chemical Peels, Energy Devices, and Skin Surgery During and After Isotretinoin Use.

BACKGROUND: Currently, the isotretinoin (13-cis-retinoic acid) package insert contains language advising the discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. It is common practice to follow this standard because of concerns regarding reports of sporadic adverse events and increased risk of scarring. OBJECTIVE: To develop expert consensus regarding the safety of skin procedures, including resurfacing, energy device treatments, and incisional and excisional procedures, in the setting of concurrent or recent isotretinoin use. MATERIALS AND METHODS: The American Society for Dermatologic Surgery authorized a task force of content experts to review the evidence and provide guidance. First, data were extracted from the literature. This was followed by a clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS: The task force concluded that there is insufficient evidence to justify delaying treatment with superficial chemical peels and nonablative lasers, including hair removal lasers and lights, vascular lasers, and nonablative fractional devices for patients currently or recently exposed to isotretinoin. Superficial and focal dermabrasion may also be safe when performed by a well-trained clinician.

Clinical Improvement and Safety of Ablative Fractional Laser Therapy for Post-Surgical Scars: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Ablative fractional laser (AFL) therapy for scars is an area of increasing interest. While the enthusiasm for these treatments is high, a systematic review of their use on surgical scars has not been done. OBJECTIVE: To identify randomized trials that study the efficacy of ablative fractionated laser therapy for treatment of surgical scars. METHODS AND MATERIALS: EMBASE, Web of Science, and Pubmed databases were searched for randomized trials with 10 or more surgical wounds. No restrictions were placed on the language of the publications. RESULTS: Three randomized trials were identified that met the criteria for the review. One study found superior efficacy of ablative fractionated laser treatment of surgical scars compared to pulsed dye laser while the others found equivalent efficacy when compared to dermabrasion or pulsed dye laser. One study found a superior safety profile for ablative fractionated laser treatment over dermabrasion. No studies compared fractionated laser therapy to sham therapy or observation. CONCLUSIONS: AFL compares well with the scar amelioration techniques of dermabrasion and pulsed dye laser. Additional studies are needed to further contrast AFL to these and other modalities as well as to observation alone.

Comparison between the efficacy and safety of platelet-rich plasma vs. microdermabrasion in the treatment of striae distensae: clinical and histopathological study.

Striae distensae is a challenging cosmetic problem for which various treatment modalities have been applied. To compare between the efficacy and tolerability of intradermal injection of autologous platelet-rich plasma (PRP) vs. microdermabrasion in the treatment of striae distensae. Sixty-eight patients with striae distensae were randomly assigned to three groups according to therapeutic modalities. Patients of group I were treated by intradermal injection of PRP alone, patients of group II were treated with microdermabrasion alone, and patients of group III were treated with combination of intradermal PRP and microdermabrasion in the same session. Each patient underwent maximum of six sessions at 2-week interval. Skin biopsies were taken from some patients at baseline, and 3 months after the last sessions stained with hematoxylin and eosin stain, Masson trichrome, orceun, and Van Gieson stains to study of histopathological changes and efficacy of treatment. There was significant clinical improvement of striae distensae in patients treated with PRP injection and patients treated with combination of PRP and microdermabrasion when compared with patients treated with microdermabrasion. However, combination of PRP and microdermabrasion in the same session showed better results in short duration. Collagen and elastic fibers were markedly increased in the dermis at the end of treatment sessions. Platelet-rich plasma alone is more effective than microdermabrasion alone in the treatment of striae distensae, but it is better to use the combination of both for more and rapid efficacy. However, each one of them is well tolerated by the patients, safe and cost effective.

Complications of aesthetic medicine procedures: five case studies.

The paper presents the cases of five patients who developed complications after aesthetic medicine procedures. Four of the cases involved women who reported to the Department of Forensic Medicine, Medical University of Lodz, for a description and legal qualification of bodily injuries suffered as a result of aesthetic medicine procedures, whereas one was related to the assessment of accuracy of medical management at the request of the prosecutor handling the case. The reported cases concerned acid exfoliation treatments, photoepilation and cryotherapy. The authors attempt to discuss the most common complications that may occur after aesthetic medicine procedures, and measures to avoid them.

Unattractive consequences: litigation from facial dermabrasion and chemical peels.

BACKGROUND: Facial dermabrasion and chemical peel are common cosmetic procedures that are generally safe yet do possess inherent risks. The patient's expectations, formed well in advance of treatment, strongly correlate with overall satisfaction. OBJECTIVES: The authors reviewed and analyzed litigation related to the performance of facial dermabrasion and chemical peel. METHODS: The authors searched the WestlawNext legal database for relevant litigation and examined factors such as allegations raised, patient demographics, defendant specialties, final outcomes, and payments. RESULTS: Proceedings from 25 cases were analyzed, involving 22 female and 2 male plaintiffs; in 1 case, sex was not specified. Sixteen cases (64%) resulted in a decision for the defendant and 9 (36%) were resolved with payments. The median difference between out-of-court settlements (median, $940 000) and jury-awarded damages (median, $535 000) was not statistically significant. Factors raised in litigation included poor cosmetic outcome (80%), alleged intratreatment negligence (68%), permanent injury (64%), informed-consent deficits (60%), emotional/psychological injury (44%), posttreatment negligence (32%), and the need for additional treatment/surgery (32%). CONCLUSIONS: Out-of-court settlements and jury-awarded damages were considerable in cases where physicians practicing various (or multiple) specialties were named as defendants. These findings emphasize the need for physicians to thoroughly document potential complications prior to treatment, during the informed-consent process. Additionally, general considerations should be taken into account, such as patient expectations and the potential need for other procedures, which may enhance pretreatment communication and ultimately minimize liability. Finally, it is important to stress that physicians may be held liable for procedures performed by nonphysician ancillary staff.

Superficial dermabrasion versus topical tretinoin on early striae distensae: a randomized, pilot study.

BACKGROUND: Striae distensae (SD) is a common skin condition, with a prevalence ranging from 40% to 90%, depending on the population studied. OBJECTIVES: To evaluate the efficacy of superficial dermabrasion and compare it with that of topical tretinoin cream in the treatment of narrow and early SD. MATERIALS AND METHODS: Prospective, single-center, randomized, open-label study. Thirty-two women presenting with early, untreated SD (striae rubra) were included in this study. One group received 16 weekly sessions of superficial and localized dermabrasion, and the other used 0.05% tretinoin cream daily. Striae width and length were measured and compared between groups and over time. Global Aesthetic Improvement Scale scores and subject satisfaction were also assessed. Biopsies were performed for subjects who agreed to undergo this procedure, followed by histologic analyses of the skin samples. RESULTS: Both treatments were efficacious, with significant improvement in early SD from baseline, but there was no significant difference between the two treatments. Histologic assessment showed improvement in epidermal and dermal layers for the dermabrasion treatment group. CONCLUSION: Both treatments had similar efficacy, but superficial dermabrasion had a lower frequency of side effects and better adherence of the patients.

Successful treatment of melasma using a combination of microdermabrasion and Q-switched Nd:YAG lasers.

BACKGROUND AND OBJECTIVE: A common, disfiguring problem in women, melasma is often refractory to treatment, and long-term remissions are difficult to achieve. This study assessed the safety and effectiveness of a procedure combining microdermabrasion, a topical regimen, and low fluence Q-switched Nd:YAG laser treatment. MATERIALS AND METHODS: In this observational study of 27 female subjects, phototypes II-V, referred for treatment of mixed-type melasma refractory to previous therapies, low-fluence QS Nd:YAG laser treatment of 1.6-2 J/cm(2) with 5 or 6 mm spot was administered immediately following microdermabrasion. Daily application of a broad-spectrum sunscreen began immediately; subjects used a topical skin care regimen of hydroquinone with tretinoin or vitamin C. Treatments were repeated at 4-week intervals. Follow-up assessment was done 3-12 months after the last treatment. Adverse effects were recorded at each visit. Standardized digital photographs obtained before each treatment session and at follow-up visits were objectively assessed by blinded comparison using a quartile grading system. RESULTS: Treatment was successful in all skin types, deemed painless by all subjects, and required no anesthesia. Average number of treatments was 2.6. Twenty-two subjects (81%) had >75% clearance of melasma; 11 subjects (40%) achieved >95% clearance. Most subjects showed >50% clearance of their melasma 1 month after the first treatment. Side effects were limited to mild post-treatment erythema, which developed after the microdermabrasion and lasted approximately 30-60 minutes. Four subjects noted temporary exacerbation of melasma after inadvertent sun exposure, but this resolved within several weeks of resuming the topical skin care regime. Remission lasted at least 6 months. CONCLUSION: Microdermabrasion plus low-fluence QS Nd:YAG laser treatment is a simple, non-invasive procedure with minimal risk, no recovery time, and long-lasting remission. Treatment works on all skin phototypes in just two to three treatment sessions. Subject compliance with skin care was excellent, probably due to the dramatic improvement observed within 4 weeks.

In vivo vitiligo induction and therapy model: double-blind, randomized clinical trial.

In this study, we developed an in vivo vitiligo induction model to explore the underlying mechanisms leading to Koebner's phenomenon and to evaluate the efficacy of therapeutic strategies. The model consisted of 12 pigmented test regions on the back of generalized vitiligo patients that were exposed to three Koebner induction methods: cryotherapy, 755 nm laser therapy, and epidermal abrasion. In addition, four cream treatments (pimecrolimus, tacrolimus, steroid and placebo) were randomly applied. Koebnerization was efficiently induced by all three induction methods. In general, cryotherapy was the best method of Koebner induction, followed by 755 nm laser therapy and epidermal abrasion. Reproducible results were obtained, which showed enhanced depigmented surface areas and higher amounts of T lymphocytes in placebo-treated test zones compared to active treated areas. Tacrolimus and local steroids were better inhibitors of Koebner's process (P < 0.05) compared to pimecrolimus. Our in vivo vitiligo induction model is very informative to investigate vitiligo induction and to determine the efficacy of topical treatments in vitiligo. This proof of concept confirms the efficient comparison of head-to-head therapeutic strategies intra-individually in a standardized, specific and better timed way.

Enhancement of facial scars with dermabrasion.

This article describes the physiology of wound healing, discusses considerations and techniques for dermabrasion, and presents case studies and figures for a series of patients who underwent dermabrasion after surgeries for facial trauma.

Aesthetic dermatology for aging ethnic skin.

BACKGROUND: Dark-skinned patients manifest the signs of skin aging differently than their fair-skinned counterparts in that the former exhibit more intrinsic facial aging, whereas the later shows more photodamage. Nevertheless, common cosmetic procedures can be used in skin of color to treat the signs of aging. OBJECTIVE: To provide updated clinical information on the use of cosmetic procedures for skin aging in darker phototypes for the safe treatment of this population. METHODS: A Medline literature search was performed for publications on the safety and efficacy of botulinum toxin, dermal fillers, chemical peels, laser and light-based devices, and microdermabrasion for the treatment of skin aging specifically in ethnic populations. RESULTS: Similarly to light-skinned patients, botulinum toxin and dermal fillers provide fast, effective results in skin of color, with fewer complications than with traditional surgery and no downtime. More-invasive procedures, such as chemical peeling, laser resurfacing, and microdermabrasion, can also be effective, but it is important to exercise caution and remain within certain parameters given the greater risk of dyschromias in this population. CONCLUSION: With the proper knowledge of how to treat aging skin of color, these patients can experience the benefits of cosmetic procedures while minimizing the risks.