The Ageing Skin – Part 4i – Plastic Surgery

Introduction

The skin is the most superficial part of the body. The signs of ageing are most visible in the skin. Although, ageing skin is not a threat to a person, it can have a detrimental effect on the psychology of a person. A look into the causes of skin ageing, the available treatments and preventive measures for this inevitable change is important to help both the already aged, as well as, the youth.

This is a 4 part article in which:

  1. Part 1 – Discusses the structure of skin and its different components
  2. Part 2 – Discusses cutaneous ageing and its causes
  3. Part 3 - Discusses the characteristics of ageing skin and the changes in skin appearance
  4. Part 4 – Discusses products and treatments for skin ageing
    a) Sunscreen Agents
    b) Moisturizers
    c) Antioxidants
    d) Make Up
    e) Dermal Fillers
    f) Chemical Peels
    g) Botulinum Toxin
    h) Estrogen and Hormonal Treatments
    i) Plastic Surgery (current article)

Plastic Surgery1,2

It is a medical specialty that uses a number of surgical and non‐surgical techniques to change the appearance and function of a person’s body. It is also referred to as cosmetic surgery. Plastic in Greek is ‘plastikos’, means to mold or to shape. The various techniques that can be used to ameliorate skin ageing are as follows:

1] SURGICAL PROCEDURES

There are many surgical procedures that can be performed and going into the details of them is not within the scope of this article. The most common facial surgical procedures are:

a. Blepharoplasty‐ surgical procedure to reshape the upper and lower eyelids by removal or repositioning of excess tissue as well as reinforcement of surrounding muscles and tendons.

b. Rhitidectomy (Face Lift)‐ to lift up the tissue and skin and underlying muscles in order to have tighter and smoother face.

2] NON-SURGICAL PROCEDURES

a. Dermabrasion‐

Surface of epidermis of the skin is removed by abrasion.

Microdermabrasion‐ Uses: It is used for reducing superficial wrinkles, scars, large pores, acne, and age spots. It restores smoother and more useful appearance.

Technique: In this technique there is a mechanical device which directs a stream of fine abrasives (aluminum oxide crystals) using compressed air. Depending on the particle flow rate, the vacuum pressure, the movement of the hand piece and the number of passes, different depths of abrasions are achieved. As these particles hit the skin the superficial layer i.e. stratum corneum, is abraded off.

After Treatment Requirements: After the treatment the patient may experience redness for the first few hours. Creams and ointments may be applied to the area to keep them moist as they heal. The skin may appear as if the person has got a minor sun burn for 2‐3 days and will be more sensitive to sunlight, therefore, use of SPF 15 and greater sunscreen is essential.

Advantages: It is highly effective with low risk. It shows rapid facial skin rejuvenation with a minimal to no downtime. It can be used for all ages and skin types. The technique gives minimal discomfort with no use of anesthesia and no bleeding or visible desquamation. The technique leaves the skin with only temporary erythema.

Disadvantages: Skin exfoliation to a depth of 15‐25μm has been seen with two passes, so this is a superficial treatment for wrinkles on the surface only and not deeper wrinkles. For deeper wrinkles, other methods would have to be used. Particles along with the abraded superficial cellular debris are aspirated into a close separate container and discarded. Thus new particles have to be used for each treatment cycle.

Histological Benefits of Dermabrasion: The procedure leads to fibroblast stimulation, new dermal collagen deposition, epidermal thickening, normalization of stratum corneum, thickening of the papillary dermis with increased deposition of collagen and elastin and an increase in fibroblast. Microcirculatory changes in reticular dermis are also seen.

b. Laser Resurfacing‐

For more than a decade, carbon dioxide laser skin resurfacing has offered precise cutaneous ablation for facial rejuvenation. The controlled removal of epidermis and variable portions of the dermis with associated heating results in predictable collagen shrinkage, remodeling, and dermal tightening. This improves skin texture and appearance. Laser energy on tissue can be reflected, scattered, transmitted, or absorbed, with the latter feature producing the photothermal or photochemical effects on tissue.

By creating a pulsed delivery system that dwells on tissue for less than the thermal relaxation time (which for skin is estimated at approximately 695 μs), the surrounding thermal damage is limited while still delivering sufficient energy (irradiance, measured in joules/s/cm2) to vaporize tissue. The fluence (energy density) estimated to vaporize tissue is approximately 4 to 5 J/cm2 per pulse. In super‐ or ultrapulsed systems, the pulse duration may range from 600 microseconds to 1 millisecond. This technical advance has allowed lasers to become a popular method of cutaneous resurfacing.

Laser skin resurfacing is an ablative technique that offers comparable results to superficial, medium or deep chemical peels with greater surgeon precision and control. The carbon dioxide laser wavelength of 10,600 nm is absorbed by tissue water, resulting in approximately 50 to 70 μm of ablation in a single pass with a similar amount of thermal necrosis. With additional passes, less ablation occurs, and greater thermal necrosis is seen.

As with chemical peels, removal of the epidermis places the skin at higher risk of infection, inflammation, and desiccation. The risks of complications are related to this as well as the depth of resurfacing. Although the indications and complications of laser resurfacing are similar to those of medium and deep chemical peels, full face resurfacing results in a complex postoperative course. Persistent erythema and (for many surgeons and patients) an unacceptable rate of late permanent hypopigmentation have resulted in a recent reduction in demand, yet for severe photoaging, this may be the optimal treatment for skin rejuvenation, especially in those patients with lighter skin types.

The erbium:yttrium‐aluminumgarnet Er:YAG laser wavelength of 2940 nm offers precise ablation with minimal thermal damage. This laser is absorbed by water approximately 13 times more efficiently than CO2 laser radiation. With short pulses, thermal damage of 10 μm or less occurs with ablation. However, this results in increased dermal plexus bleeding during resurfacing. The skin vaporization threshold for the Er:YAG laser is approximately 0.5 to 1.7J/cm2. The depth of ablation of an Er:YAG laser is approximately 4 μm of tissue per each joule per square centimeter. With larger spot sizes, and higher repetition rates, ablation rates of up to 70 μm per second can be attained. Erbium laser resurfacing has an advantage of safely resurfacing skin on more pigmented patients (Fitzpatrick skin types III–VI). Although carbon dioxide laser resurfacing is the optimal treatment modality for severe cutaneous photoaging, the Er:YAG laser offers a level of safety for those patients who are at risk of pigmentary abnormalities.

More recently, the introduction of hybrid lasers allows deeper penetration with improved hemostasis. A variable pulsed Er:YAG laser, a dual‐mode ablation/coagulation pulsed Er:YAG laser, and a combined Er:YAG and CO2 laser are all modulated lasers that offer deeper ablation and greater thermal damage for improved hemostasis. Initial reports offer promise that these lasers provide good efficacy when compared with carbon dioxide or Er:YAG laser systems alone.

Full skin cryopeeling can eliminate precancerous lesions, wrinkles, improves texture, pigmentary problems associated with photoageing. Surgery or dermabrasion improves the skin contour because new collagen and epidermis replaces the abraded skin and gives a smoother appearance to the skin.

References

  1. Elderly skin and its rejuvenation: products and procedures for the aging skin, Marcia Ramos‐e‐Silva et. al., Journal of Cosmetic Dermatology, 6, 40–50
  2. Facial skin rejuvenation, David E. E. Holck and John D. Ng, Current Opinion in Ophthalmology 2003, 14:246–252

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