10.1 Introduction

Modern facial rejuvenation surgery offers patients a wide range of possibilities, including dermatologic treatments which are able to improve skin condition as well as enhancing and maintaining the final surgical result. The skin of most patients who seek facial rejuvenation surgery presents clinical and histological changes secondary to intrinsic aging or extrinsic photo-aging. Many noninvasive and non-ablative dermatologic treatments exist, which are able to improve damaged skin without recovery time and may be administered prior to surgery. Ideally all patients should start receiving local treatment with topical retinoic acid, unless a specific contraindication exists. In my practice, as well as the skin care program, adjuvant techniques such as the light chemical peel, microdermabrasion, or carboxytherapy are commonly used. A combination of these treatments improves skin condition, which will allow patients undergoing facial surgery the best possible results for facial rejuvenation.

With time, skin ages due to a combination of both intrinsic and extrinsic factors. It is important to recognize the difference between these two different processes. With intrinsic aging, the functional capacity is decreased, the epidermal/dermal junction is flattened, and there is a reduction in dermal thickness. These patients present with skin laxity, wrinkles, and dry skin. Patients with extrinsic aging present initially with an increase in dermal thickness. This is the result of elastotic material accumulating during elatosis. Clinical signs of extrinsic aging are evident as changes such as lines, wrinkles, dryness, flaccidity, hyperpigmentation, seborrheic and actinic keratoses, and solar lentigos. In addition, in almost all cases, neoplastic growths such as basaliomas and epiteliomas develop in these areas of sun exposure and extrinsic aging.

10.3 Techniques

10.3.1 Skin Care Program

A. Erian ( )

Pear Tree Cottage,

Cambridge Road, Wimpole 43,

SG8 5QD Cambridge, UK

e-mail: plasticsurgeon@anthonyerian.com

C. Santos

Dermatology in Private Practice, Department of Dermatology, Avenida Brasil, 583 Jardim Europa, CEP 01431-000

São Paulo, Brazil

e-mail: clara_santos@terra.com.br

Performing facial surgery without preoperative skin treatment is like building a house without a foundation. Omitting postoperative skin treatment is like building a house without the final interior design. In practice, this can be seen in cases where patients, who have significant skin damage, undergo excellent facial surgery, and yet fail to achieve satisfactory facial rejuvenation. Both patient and facial surgeon are disappointed with the suboptimal result, yet this may be avoided if dermatological techniques are employed. Topical treatments are easy and safe to apply as well as afford excellent

results when correctly performed. Facial skin is particularly responsive to these treatments and signs of aging may be reversed even in the very elderly patient. All patients who seek a facial cosmetic surgery consultation should have a skin treatment program, whether or not surgery is performed. Figure 10.1 shows a case where eyelid surgery was performed in combination with dermatologic skin care program. Good looking, healthy skin improves self-esteem and confidence, promotes attraction and youthfulness, and offers skin in the best possible condition for surgery.

Local treatment is based on the use of topical agents. There are many products on the market, a lot of which unfortunately promise miracles. It is important to understand that, among these, only very few will be effective. Patients require education, so that they may question the products, which the media promote. Examples include advertisements for light fruit acids that can significantly rejuvenate facial skin, for moisturizers that can eradicate sun damage, or for “special agents” applied to the skin that can “fix” dermal damage.

The local treatment program, which is recommended, employs a minimum of topical agents: an active agent at night, a cleanser morning and night, and a sun protection factor morning and afternoon. In most cases, during the skin preparation before surgery, I avoid moisturizers, tonics, and astringents, as the combination of these with the acid at night leads to skin sensitivity. In addition, moisturizers have no power to restore skin function, they cannot treat nor prevent skin aging, and they cannot stimulate collagen growth as they do not penetrate the dermis. The action of moisturizers is temporary as they fill the space between desquamating skin cells.

a

Fig. 10.1 (a) Preoperative. (b) Postoperative eyelid surgery combined with dermatologic skin care program

10.3.1.1 Tretinoin

Topical tretinoin or retinoic acid has been investigated in randomized studies. Regular daily application has shown the ability to compact the stratum corneum, to increase epidermal thickness, and to decrease melanin content. In the dermis, new collagen formation has been demonstrated [1–3]. According to Kligman [4], tretinoin improves not only the structure of the skin but also influences positively its physiological functions. Tretinoin may be used as a single agent, though in cases of darker skin or in cases of hyperpigmentation, tretinoin may be used with hydroquinone and 1% hydrocortisone (Kligman formula) [5, 6]. As some countries forbid the use of hydroquinone, other available bleaching agents such as kojic acid or azelaic acid may be employed [7–9]. In most cases 0.05% retinoic acid applied at night will benefit the skin preoperatively (Fig. 10.2) as well as maintain the skin postoperatively. When used in this manner, skin youthfulness, shine, and quality can be significantly improved.

Possible reactions during tretinoin treatment should be explained to the patient, so that the commonly witnessed erythema, dryness, and desquamation will not be misunderstood and lead to noncompliance. It is important to explain that this type of irritation is commonly seen in the initial phases of treatment, but that this subsides. I find it particularly important to teach patients how to apply topical agents. In my clinical practice of almost 30 years, I have found that almost no one has applied these agents correctly. The correct way to apply the topical treatment is similar to the “Friendly Peel” technique that will be explained subsequently.

b

10.3.1.2 Skin Cleansers

Cleansing the skin should be performed gently twice a day, both in the morning and at night. Rather than using multiple agents or scrubbing the skin, an ideal cleansing is performed gently and using a large amount of the product. Many cleansers exist, but it is important to choose one which is pH-neutral and therefore does not change the pH of the skin.

10.3.1.3 Sun Protection

Sun protection may be performed in three different manners: physically, chemically, and in a combined manner. Above all, a sun protector or sunblock should protect the skin against UVB, UVA I, and UVA II radiation [10]. The authors prefer physical sunblocks because they offer better protection, are waterproof, and do not cause skin irritation. Chemical sunblocks can cause a burning sensation when applied to the skin that is undergoing a skin care program or following a resurfacing technique. It is also my belief that this forms a type of chronic irritation to sensitive skin which may worsen or prevent the improvement of melasma.

The authors have also observed in patients with hyperpigmented skin, that the absence of improvement may be related to the suboptimal use of the sun protector. Many patients apply this agent in an amount that is less than ideal or they do not reapply the protector

during the day, both of which leave the skin without complete protection. To obtain the best sun protection, the application should be done gently, carefully, and using an adequate amount. Sun protectors should be applied half an hour before going outside and half an hour before applying makeup.

10.3.1.4 Light Chemical Peel or “Friendly Peel”

There are several chemical agents that can be used as a light chemical peel [11–13]. For many years the authors have used a modified retinoic peel named “Friendly Peel” (Table 10.1) for the skin care program. The Friendly Peel can be performed safely in any facial skin, from skin type I to skin type VI. In a combined program, this is the first step, after which, skin care products must be commenced. Unlike other agents, the Friendly Peel does not give rise to the commonly seen burning sensation. Skin sensitivity is also rarely a consideration in this light peel.

The Friendly Peel and the use of the skin care program are best commenced 2 weeks prior to surgery and will recommence after surgery once the sutures have been removed.

Table 10.1 Friendly Peel composition

If surgery is postponed, the skin care program may continue without interruption. Not only can the Friendly Peel be used for preoperative purposes, but it may be used weekly or biweekly for skin rejuvenation without surgery over the course of 6–12 weeks. Excellent results can be achieved for acne, superficial melasma, fine lines, or when “skin refreshment” is desired. The aforementioned skin care program should be performed between sessions of the Friendly Peel.

During the application of the Friendly Peel, the patient is given a mirror. Not only does this allow the patient to witness the procedure, but it allows the patient to learn the manner in which to apply topical agents at home. After the patient’s skin has been washed, it is gently scrubbed with gauze and 70% alcohol. The application begins at the forehead and follows adjacent anatomic units in a sequential manner. An amount equivalent to a kernel of corn is used, distributing it in circular movements. In each unit, 10–20 circular movements are employed, depending on the sensitivity and oiliness of the skin (Fig. 10.3).

This is repeated in order to cover the entire face. The nasolabial folds, chin, and malar-zygomatic zones are demonstrated to the patient as being areas more prone to irritation, therefore less topical agents may be applied. The eyelids, due to their skin’s thin and

Fig. 10.3 Patient during Friendly Peel session

Fig. 10.4 Patient immediately after Friendly Peel. The product must be removed 6–12 h after

sensitive nature, must be treated differently. A smaller amount of peel is used and applied with one or two passes; circular movements are not employed.

The Friendly Peel is left in situ for several hours (Fig. 10.4), until the next morning when it is removed by washing.

A soft redness will be witnessed. After having the Friendly Peel done, the patient begins the skin care program that has been described above. Light skin peeling will be seen on the fourth or fifth day, lasting about 24 h.

It is also important to teach the patient that when signs of sensitivity appear (e.g., with tretinoin), application over this specific area should be stopped until the skin in this area returns to normal. We have found that teaching the patient how to use local treatments has dramatically improved results, so that the common side effect of skin irritation can be minimized or made absent.

The Friendly Peel can also be used as an adjuvant in the treatment of stretch marks or post-inflammatory hyperpigmentation (PIH).

If the skin is more resistant, we often combine the Friendly Peel with Jesenner solution at the same treatment session. This combination of agents enhances the action of each, resulting in a deeper desquamation.