1. Complications of Superficial and Medium Chemical Peels 2. Nonpermanent Fillers and Permanent Fillers 3. Complications of Fractional Lasers 4. Complications of Vascular Lasers 5. Complications of Removal Lasers 6. Intense Pulsed Light Complications 7. Complications of Photodynamic Therapy 8. Complication of Biorivitalization 9. Complications of Mesotherapy 10. Complications in Radiofrequency (RF) 11. Complications of Botulinum Toxins 12. Management of Complications of Microdermabrasion and Dermabrasion 13. Complications of Needling
Management of Complications of Cosmetic Procedures Antonella Tosti • Kenneth Beer Maria Pia De Padova Editors Management of Complications of Cosmetic Procedures Handling Common and More Uncommon Problems Editors Prof Dr Antonella Tosti Department of Dermatology and Cutaneous Surgery Miller School of Medicine University of Miami Miami, FL USA Prof Kenneth Beer, M.D., FAAD PA- General Surgical and Esthetic Dermatology West Palm Beach, FL USA Dr Maria Pia De Padova Department of Dermatology Nigrisoli Hospital Bologna Bologna Italy ISBN 978-3-642-28414-4 ISBN 978-3-642-28415-1 DOI 10.1007/978-3-642-28415-1 Springer Heidelberg New York Dordrecht London (eBook) Library of Congress Control Number: 2012942342 © Springer-Verlag Berlin Heidelberg 2012 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made The publisher makes no warranty, express or implied, with respect to the material contained herein Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Contents Complications of Superficial and Medium Chemical Peels Maria Pia De Padova and Antonella Tosti Nonpermanent Fillers and Permanent Fillers Murad Alam and Nowell Solish Complications of Fractional Lasers (Ablative and Nonablative) Robert Anolik and Roy G Geronemus 23 Complications of Vascular Lasers Norma Cameli, Giovanni Cannarozzo, Paolo Bonan, Nicola Bruscino, and Piero Campolmi 37 Complications of Removal Lasers Remington 47 Intense Pulsed Light Complications Hillary Julius 57 Complications of Photodynamic Therapy Martin Zaiac, Adriana Abuchar, and Mercedes Florez 65 Complication of Biorivitalization Maria Pia De Padova and Antonella Tosti 73 Complications of Mesotherapy Doris M Hexsel and Juliana Dumêt Fernandes 77 10 Complications in Radiofrequency (RF) Suveena Bhutani and Neil S Sadick 83 11 Complications of Botulinum Toxins Kenneth R Beer and Jacob Beer 97 12 Management of Complications of Microdermabrasion and Dermabrasion 103 Meghan Dubina and Rebecca Tung 13 Complications of Needling 119 Gabriella Fabbrocini Index 125 v Complications of Superficial and Medium Chemical Peels Maria Pia De Padova and Antonella Tosti Key Features • Superficial and medium chemical peels usually cause mild and transitory side effects • Most side effects resolve spontaneously even if several months may be needed • Topical steroids and topical and systemic antibiotics are useful for treatment of most complications 1.1 Since their potency is mild, repeated treatment is required to obtain the desired effects Choice of peel depends on skin type and indication Superficial and medium chemical peels usually cause mild and transitory side effects The most common complication is the development of pigmentary changes, which are especially seen in patients with dark phototypes Development of this complication may be due to utilization of a peeling which is too strong for the patient’s phototype or to inadequate photoprotection in the postpeeling period Introduction Superficial and medium peelings include salicylic acid 25–30%, glycolic acid 70%, pyruvic acid 40–60%, trichloroacetic acid 20–35%, and combination of salicylic acid or Jessner peel with trichloroacetic acid Superficial and medium peelings are utilized to induce a damage limited to the epidermis and papillary dermis This results in epidermal regeneration and postinflammatory collagen neoformation M.P De Padova ( ) Department of Dermatology, Nigrisoli Hospital Bologna, Bologna, Italy e-mail: mdepadova@gmail.com A Tosti Department of Dermatology and Cutaneous Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA 1.2 Technology 1.2.1 Glycolic Acid 30–70%/Pyruvic Acid 40–60% [1–3] Glycolic and pyruvic acid peelings are utilized for the treatment of photoaging, melasma and postinflammatory pigmentation, and acne scars Pyruvic acid can also be used for active acnes Advantages • Mild desquamation • Short postoperative period Disadvantages • Penetration often not uniform for glycolic acid • Pyruvic acid causes intense stinging and burning sensation during the application and produces pungent and irritating vapors for the upper respiratory mucosa A Tosti et al (eds.), Management of Complications of Cosmetic Procedures, DOI 10.1007/978-3-642-28415-1_1, © Springer-Verlag Berlin Heidelberg 2012 M.P De Padova and A Tosti • Require neutralization • High risk of overpeel if time of application is too long or the skin is inflamed 1.2.2 Jessner’s Solution Jessner’s solution is utilized for the treatment of photoaging, melasma and postinflammatory pigmentation, and active acne Advantages • Excellent safety profile • Can be used in all skin types • Substantial efficacy with minimal “down time” • Utilized for combination peels as it enhances the penetration of other agents Disadvantages • Concerns regarding resorcinol toxicity, including thyroid dysfunction • Manufacturing variations • Instability with exposure to light and air • Excessive exfoliation in some patients 1.2.3 Salicylic Acid 20–30% Salicylic acid peeling is utilized for the treatment of melasma and postinflammatory pigmentation, and comedonic and active acne Advantages • Established safety profile in all skin types • Formation of white precipitate allows to verify if application is homogeneous • Salicylic acid has an anesthetic effect that is useful in combination peelings Disadvantages • Causes intense stinging and burning sensation during the application • Minimal efficacy in patients with significant photodamage 1.2.4 Trichloroacetic Acid 15–35% Trichloroacetic acid is utilized for the treatment of photoaging and acne scars Low concentrations can be utilized for the treatment of melasma and postinflammatory pigmentation Advantages • Low cost • Uniformity of application • Penetration can be easily evaluated by the color of frost Disadvantages • Stinging and burning sensation during the application • High concentrations are not recommended in skin types V to VI • Can cause hypo/hyperpigmentation 1.2.5 Combination Peeling: Salicylic Acid 25% + TCA 15–30% [4, 5] Pretreatment with salicylic acid permits to obtain a medium peeling with low TCA concentrations and therefore avoids pigmentary complications especially in dark phototypes Combination peeling with salicylic acid + TCA is utilized for the treatment of photoaging and acne scars Combination peeling with low concentrations of TCA can be utilized for the treatment of melasma and postinflammatory pigmentation Advantages • Can be used in all skin types Disadvantages • Risk of overpeeling • Can cause hypo/hyperpigmentation 1.2.6 Contraindications to Superficial and Medium Peelings Contraindications to superficial and medium peelings include: • History of hypertrophic scars • Connective tissue disorders • Active skin disorders on the treatment sites • History of treatment with systemic retinoids in the previous months • Oral anticoagulant treatment • Pregnancy Complications of Super ficial and Medium Chemical Peels 1.2.7 Prepeeling Care This is essential to obtain uniform penetration and avoid postinflammatory hyperpigmentation Prescribe topical products containing 1–2% salicylic acid, 2–3% pyruvic acid, or 0.05% retinoic acid to be applied three times a week for month Prescribe 4% topical hydroquinone three times a week for month Application of these topicals should be interrupted days before the procedure to avoid excessive penetration of the peeling agent Treatment with oral antivirals should be started days before the procedure in patients with history of recurrent herpes simplex infections A detailed informed consent should be given to the patient at this time to give her/him the possibility of understanding the procedure and asking possible questions before treatment We always also provide written information about the procedure It is very important to explain clearly to the patient that superficial and medium peels require multiple sessions and can improve but not completely resolve photoaging, pigmentary disorders, and acne scars to avoid excessive expectations It is mandatory to obtain good quality pictures before starting the procedure This is an essential documentation for follow-up and for possible medicolegal issues 1.2.8 Postpeeling Care It is very important to explain the patient to absolutely avoid sun exposure and prescribe a sun block to be applied several times a day For the immediate postpeeling period, the patient should also apply a moisturizing cream three to four times a day The patient should also be instructed to avoid scratching or peeling the skin A mild skin cleanser can be utilized without rubbing When reepithelization is complete, which usually takes 7–10 days, the patient can resume application of topical products containing 1–2% salicylic acid, 2–3% pyruvic acid or 0.05% retinoic acid, and 4% topical hydroquinone to prepare the skin for the next procedure The patient should regularly wear a total sun block between peeling sessions and up to months after the last session 1.3 Epidemiology of Complications Superficial and medium peels are widely utilized worldwide in both women and men The relative safety of these peelings in dark phototypes explains their utilization in different races 1.4 Clinical Features 1.4.1 Minor Local Adverse Reactions • Intense swelling • Eye irritation due to vapors of the peeling solution (e.g., pyruvic acid and TCA) • Transitory nose and oral irritation is common with pyruvic acid • Irritative contact dermatitis: this may be caused by application of inadequate topical products (scrubs, exfoliating agents) before complete reepithelization • Exudative erosions: this is due to premature removal of scales and crust and is most commonly seen after medium-deep peelings It is very important to instruct the patient to not manipulate the skin after peeling • Prolonged erythema: in some patients, erythema persists after weeks from the procedure (Fig 1.1) These patients require a close follow-up as they are at risk of developing postinflammatory hyperpigmentation If the patient complains of itching, consider contact dermatitis Exclude other skin disorders including lupus erythematosus • Dishomogeneous skin color: this is due to irregular penetration of the peeling agent (Fig 1.2) This occurs more frequently in patients with mixed skin as penetration is higher in greasy as compared with dry skin areas Possible causes include inadequate preparation of the skin to the procedure, incorrect 12 Management of Complications of Microdermabrasion and Dermabrasion refrigerant, which is known to affect melanocytes [37, 38] Skin types III and IV are most frequently affected While the exact mechanism for pigmentation loss is unknown, it is thought to be due to loss of normal melanocyte function [10] For treatment of hypopigmented scars, a series of fractional laser (1,550 nm Fraxel) treatments may be helpful [39] Additional stimulation of melanocytes deriving from the hair follicle may be achieved by application of bimatoprost 0.03% solution bid combined with fractional resurfacing with the Fraxel re:store (1,550 nm) [40] Treatment with the 308-nm excimer laser has also been shown to stimulate pigmentation [10] If hyperpigmentation occurs, it is usually temporary and predominantly affects patients with darker skin When hyperpigmentation appears, it usually presents 3–4 weeks after the DA This excess pigmentation can be successfully treated with bleaching agents such as hydroquinone (4–8%) and sustained use of sunscreen with sun avoidance If there are resistant areas of hyperpigmentation, laser (q-switched) or a series of superficial (glycolic acid 30–40%) peels may be employed to hasten resolution More recently, fractional laser treatments have also been successfully employed to resolve unwanted excess postinflammatory hyperpigmentation Rokrsar and Cioccon recently reported a case of treating refractory hyperpigmentation following CO2 laser with a series of fractional laser (Fraxel 750 SR) treatments [41] It is currently believed that fractional laser treatment improves hyperpigmented conditions by introducing channels into the skin which permit selective elimination of epidermal and dermal contents and allow new keratinocytes and melanocytes from surrounding skin to repopulate these same channels of cellular damage This hypothesis has been coined the “melanin shuttle” [42, 43] Demarcation lines may also occur if only a singular area is treated without feathering Most common areas for demarcation lines for DA are similar to that of chemical peels: mandibular, periocular, and perioral regions [44] If a full-face DA is being performed, one should be sure to extend the resurfacing into the submandibular region and to the hairline Another method to 113 avoid a demarcation between a full-face dermabrasion and a photodamaged neck is to perform a superficial (70% glycolic or Jessner’s) to mediumdepth peel (Jessner’s in combination with trichloroacetic acid 25%) on the neck By treating both areas, contrast in color and texture will be diminished It is recommended that the peel be done prior to the dermabrasion so that no peeling solution is inadvertently placed onto abraded skin leading to deeper penetration While post-DA erythema is expected, prolonged erythema of longer than 4–5 weeks can signal impending scar formation [18] Also, any focal bright red patches seen in the first 2–3 weeks should be treated Early detection and rapid treatment is paramount to prevention of this sequela Prolonged redness may be due to genetic predisposition to erythema, exacerbation of prior skin disease (such as rosacea, seborrheic dermatitis, or atopic dermatitis) or contact sensitization Intense redness may also be associated with delayed healing and scarring [45] Potent topical steroid (class I) creams are useful in treating patchy (nonraised) erythema They can be applied twice daily for 1–2 weeks to the affected areas Oral antihistamines such as loratadine (10 mg) or diphenhydramine (25–75 mg) can also be given to calm down redness Lowlevel laser or intense pulse light (IPL) can also be employed on a weekly to every other weekly basis to minimize erythema Specific settings for the pulse dye laser are as follows: VBeam 595 nm – with settings of 10 mm spot size, 5–7 J, and 10 ms pulse, duration with cooling IPL settings will vary according to the specific device For recalcitrant erythema, oral steroids (i.e., prednisone tapers starting at 40–60 mg tapered over 12–18 days or prednisolone dose packs for less severe cases) can be administered Infection can occur after any resurfacing procedure It is important to recognize signs of infection so that the specific diagnosis and appropriate treatment can be started Of note, many of the occlusive ointments we recommend to expedite healing can also encourage the growth of bacterial pathogens such as staphylococcus, streptococcus, and pseudomonas if used excessively Common presenting signs of infection include pain (herpes 114 simplex), pruritus (candida albicans), delayed wound healing, pustules, or folliculitis Swabbing the open area or lesion for bacterial, fungal, or viral cultures is the first step Empiric antibiotics or antifungals can be started to cover suspected organisms If methicillin-resistant Staphylococcus aureus (MRSA) is thought to be the cause, patients can be started on trimethoprim (160 mg)sulfamethoxazole (800 mg) bid, doxycycline or minocycline (100 mg) bid, or clindamycin (300 mg) bid until precise sensitivities are available If candidal infection is presumed, initial therapy can commence with fluconazole 100–200 mg daily until sensitivities are established If viral infection is suspected, direct fluorescent antibody (DFA) or polymerase chain reaction (PCR) testing for herpes simplex and varicella zoster viruses can give an earlier answer (24– 48 h) compared to the 2–7 days for viral cultures [46] Empiric antivirals dosed at herpes zoster levels (i.e., valacyclovir gm tid, acyclovir 800 mg five times daily, famciclovir 500 mg tid) should be given in suspected and confirmed cases until full reepithelialization Post-DA breakouts can occur in acne and folliculitis-prone individuals Emollient creams and occlusive ointments used during the healing phase may be to blame Because postprocedural skin is sensitive, treatment should be predominantly oral Antibiotics such as doxycycline (100 mg bid) or tetracycline (500 mg bid) can be used to clear acne and folliculitis eruptions Resolution can be anticipated in about week Patients should be reminded not to pick or manipulate lesions to avoid scarring Milia, a common minor side effect, typically occur between and weeks after dermabrasion resurfacing [15] Patients should be advised on this outcome prior to their procedure Trauma from the procedure and occlusive wound care regimens can produce milia in susceptible persons They are best treated with gentle extraction after reepithelialization has occurred The milia can be nicked with an 11 blade and coaxed out using a comedone extractor or two cotton-tipped applicators Telangiectasias can also develop after dermabrasion during the process of wound healing M Dubina and R Tung Fig 12.5 Scar-prone areas: zygomatic arch, bony prominence of the jaw, upper lip, and chin Patients with baseline erythema or rosacea may be more likely to form these lesions Vascular lasers or intense pulse light devices can be employed to remove unwanted vessels Hypertrophic scarring is fortunately rare following dermabrasion but tends to affect the zygomatic arch, upper lip, chin, and bony prominence of the jawline [45] (Fig 12.5) Hypertrophic scarring is usually preceded by prolonged symptoms such as intense erythema, pruritus, and palpable induration Prompt and aggressive management is required Resolving scarring often requires combination therapy delivered over multiple visits A patient with a history of poor wound healing or keloid/hypertophic scar formation can be at greater risk for scarring after dermabrasion Also, if a patient has recently undergone medium to deep chemical peeling or CO2 laser resurfacing, an adequate time interval should elapse to allow healing prior to dermabrading this same area History of radiation or recent isotretinoin therapy affects 12 Management of Complications of Microdermabrasion and Dermabrasion adnexal structure activity and can predispose an individual to scarring after procedures such as dermabrasion, chemical peeling, or laser resurfacing Dermabrading nonfacial areas (neck, chest, hands) also carries an increased risk of postprocedural scar formation Initial treatment of scarring is similar to management of persistent erythema Topical therapy options include high-potency steroid ointment or Cordran® tape (4 mg of flurandrenolide per square centimeter) once to twice daily Patients should come in weekly for followup assessments, photographs, and possible addition of vascular laser or light treatment A study by Alster demonstrated that early intervention with the 585-nm pulse dye laser was effective at reducing erythema and scar volume while also improving texture [47, 48] Katz et al also found combination therapy consisting of lasers (595-nm long-pulsed dye laser and 1,450-nm diode laser) and intralesional medications (triamcinolone and 5-fluorouracil) to be efficacious in resolving hypertrophic scarring following phenol peeling [49] Such a synergistic approach would likely be effective for treating hypertrophic scars induced by other modalities such as DA or ablative lasers as well While there is no consensus on the exact mechanism of action of pulse dye laser on scars, it is known that these lasers act via selective photothermolysis In this process, energy emitted from the laser is absorbed by oxyhemoglobin which produces heat and thermal injury within the microvasculature of the scar The end result is localized ischemia and decreased collagen with the scar At the cellular level, pulse dye lasers reduce TGF-b expression, fibroblast proliferation, and collagen type III deposition while increasing MMP-13 activity [48, 50] Niwa and colleagues found fractional photothermolysis (1,550-nm erbium-doped fiber laser) treatments to be safe and effective in the resolution of hypertrophic scars [51] Hypopigmented scars can also result after dermabrasion (Fig 12.6) In many cases, they can be successfully improved with fractional photothermolysis [42] Glaich and colleagues found that a series of four Fraxel SR (1,550 nm) treatments using settings of 7–20 mJ produced improvement of 51–75% in the majority of 115 Fig 12.6 Example of hypopigmented scar 10 years after dermabrasion for acne scars hypopigmented scars [52] Waibel and Beer also demonstrated efficacy of ablative fractional resurfacing in the treatment of hypopigmented burn scars [53] The exact mechanism of action of fractionated lasers in the treatment of hypopigmentation is unknown, but it is thought there is a repopulation of resurfaced skin with normal melanocytes from adjacent tissue, resulting in increased overall pigmentation Fractional resurfacing may also improve uneven pigmentation patterns through collagen remodeling and increased production of collagen These effects yield improved skin texture which may give the appearance of enhanced color, thereby lessening the prominence of hypopigmentation [42] Expected aftereffects following MDA are mild erythema and edema These generally resolve within hours of the procedure To hasten resolution, we may give the patient a nonsedating antihistamine such as loratadine (10 mg) prior to the MDA to minimize the histamine release response Complications of purpura and petechiae have been reported during or immediately following the procedure, but these events have been transient and resolved without further intervention [54] Poor technique issues such as M Dubina and R Tung 116 excessive application of pressure of the tip or extreme vacuum pressure, which can lead to ecchymoses or pinpoint bleeding, should be avoided Postinflammatory hyperpigmentation following MDA has been reported [6] Should patchy excess pigmentation result, treatment is the same as listed under the dermabrasion section Reactivation of herpes simplex is also possible following MDA and should be treated promptly Paradoxically, acne and folliculitis can also initially flare after MDA Since the skin has just undergone exfoliation and may be more vulnerable to potentially harsh topicals, we prefer treating inflammatory acne with oral antibiotics Conclusion Microdermabrasion and dermabrasion represent superficial and deeper approaches to skin resurfacing While microdermabrasion produces more subtle results and requires multiples sessions for optimal results, it can successfully address indications such as photodamage, acne, dyschromias, striae, keratosis pilaris, and mild scarring in all skin types Dermabrasion can be employed to treat deeper cutaneous issues such as deeper acne and varicella scars, surgical scars, and static but pronounced rhytides Provided the clinician has obtained proper training on DA and utilizes careful surgical technique, most potential complications can be avoided We have outlined all major adverse events and have provided an accessible reference of our recommended therapy supported by evidence from the current literature References 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KM, Coleman WP (2011) Complications In: Tung RC, Rubin MG (eds) Chemical peels, 2nd edn Elsevier Saunders, London Duffy DM (2011) Avoiding complications In: Tung RC, Rubin MG (eds) Chemical peels, 2nd edn Elsevier Saunders, London Espy MJ, Uhl JR, Svien KA (2000) Laboratory diagnosis of herpes simplex virus infections in the clinical laboratory by LightCycler PCR J Clin Microbiol 38:795–799 Alster T (2003) Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional steroids Dermatol Surg 29:25–29 Elsaie ML, Choudhary S (2010) Lasers for scars: a review and evidence based appraisal J Drugs Dermatol 9:1355–1362 Katz TM, Glaich AS, Goldberg LH, Friedman PM (2010) 595-nm long pulsed dye laser and 1450-nm diode laser in combination with intralesional triamcinolone/5 fluorouracil for hypertrophic scarring following phenol peel J Am Acad Dermatol 62: 1045–1049 Kuo YR, Wu WS, Jeng SF (2005) Suppressed TGFbeta1 expression is correlated with up-regulation of matrix metalloproteinase-13 in keloid regression after flash lamp pulsed-dye laser treatment Lasers Surg Med 36:38–42 Niwa Mello AP, Torezan LA, Osorio N (2009) Fractional photothermolysis for the treatment of hypertrophic scars: clinical experience of eight cases Dermatol Surg 235:773–777 Glaich AS, Rahman Z, Goldberg LH, Friedman PM (2007) Fractional resurfacing for the treatment of hypopigmented scars: a pilot study Dermatol Surg 33:289–294 Waibel J, Beer K (2008) Fractional laser resurfacing for thermal burns J Drugs Dermatol 7:59–61 Farris PK, Rietschel RL (2002) An unusual acute urticarial response following microdermabrasion Dermatol Surg 28:606–608 Complications of Needling 13 Gabriella Fabbrocini Key Features • Skin needling is a procedure useful for treating acne scars, facial wrinkles, stretch marks and other dermatologic pathologies • It is minimally invasive, painless, safe and low-cost • Complications are rare and predictable from a careful history • The major advantage over other techniques (laser resurfacing, chemical peels and dermabrasion) is that the skin remains intact and there are no risks of hypo- or hyperpigmentation • It can be used in any type of skin 13.1 Introduction Skin needling or microneedling is a form of collagen induction therapy (CIT), one of the most effective skin treatments available for the treatment of different dermatologic pathologies It is carried out by puncturing the skin multiple times by using a G Fabbrocini, M.D Department of Systematic Pathology, Division of Dermatology, University of Naples “Federico II”, Naples, Italy e-mail: gafabbro@unina.it special medical device [1] (a rolling barrel covered by 96 or 192 stainless steel microneedles with a length of 1.5 mm and a diameter of 0.25 mm, distributed in rows) (Figs 13.1 and 13.2) in order to induce tiny wounds Each tiny wound goes through the classic phases of wound healing which induces growth factors Growth factors are responsible for the production of new collagen and elastin which are deposited in the upper dermis [2] 13.2 Technology • Indications – Acne scarring – Facial aging – Stretch marks – Lax skin on the arms and abdomen • Contraindications – Patients who have not pretreated their skin with vitamin A or alpha-hydroxy acids – Presence of skin cancers, warts, solar keratoses or any skin infection – Active acne or herpes labialis infections – Anticoagulant therapy like warfarin, heparin and other oral anticoagulants: the presence of these drugs may cause excessive, uncontrolled bleeding Patients previously on such treatment should have their coagulation status checked before the treatment to confirm that they have a normal clotting/bleeding profile A Tosti et al (eds.), Management of Complications of Cosmetic Procedures, DOI 10.1007/978-3-642-28415-1_13, © Springer-Verlag Berlin Heidelberg 2012 119 120 G Fabbrocini Fig 13.1 Skin needling is carried out by using a rolling barrel covered by a variable number of microneedles with different length and diameter – Daily salicylic acid therapy for medical or health reasons It should be stopped at least days before the procedure – Allergy to local anaesthetic agents or general anaesthesia – Patients on chemotherapy, high doses of corticosteroids or radiotherapy – Patients with uncontrolled diabetes mellitus Fig 13.2 This medical device is used to induce tiny wounds by puncturing the skin multiple times 13 Complications of Needling 121 – Patients who had facial surgery in the past months – Patients with scars that are less than months old – Patients who had ‘permanent’ fillers, injected in the past months – Patients with an extremely rare but severe form of keloid scarring in which virtually every pinprick becomes a keloid Patients often have keloids on the palms of the hands or soles of the feet 13.3 Pretreatment Care As skin needling works best when combined with a scientific skincare programme to restore a youthful appearance, the skin must be treated with a topical product containing vitamin A for at least weeks (preparation phase) before the skin needling begins Immediately before beginning the treatment, the patient is prepared in a similar manner to a surgical procedure: the facial skin is disinfected; then a topical anaesthetic (EMLA) is applied, which is left for 60 Then the medical device is rolled four times in four different directions: horizontally, vertically and diagonally right and left (Fig 13.3) This ensured an even pricking pattern, resulting in about 250–300 pricks⁄cm2 The microneedles penetrate through the epidermis but not remove it; the epidermis is only punctured and heals rapidly The needles seem to separate the cells from each other rather than cut through them, and thus many cells are spared Because the needles are set in a roller, every needle initially penetrates at an angle and then goes deeper as the roller turns Finally, the needle is extracted at a converse angle, therefore curving the tracts and reflecting the path of the needle as it rolls into and then out of the skin for about 1.5–2 mm into the dermis The epidermis, and particularly the stratum corneum, remains intact, except for the minute holes, which are about four cells in diameter [3] Immediately after the treatment, the skin bleeds for a short time When bleeding stops, a Fig 13.3 During skin needling, the medical device has to be rolled four times in four different directions serous ooze forms and is removed from the surface of the skin using sterile saline solution For better deposition of collagen in the upper dermis, it is necessary to undergo two to three or more sessions of treatment which are performed at 4–6-week intervals Results generally start to be seen after about weeks, but the full effects can take at least months to occur and, as the deposition of new collagen takes place slowly, the skin texture will continue to improve over a 12-month period 13.4 Post-treatment Care Further wound treatment is not necessary and consists of applying cold compresses (no ice!) and vitamin C mask Some authors recommend soaking the skin with saline swabs for an hour or two and then cleaning the skin thoroughly with an oil-based cleanser A thin layer of Vaseline or its equivalent may be applied to reduce skin humidity loss The patient is encouraged to use topical vitamin A and vitamin C as a cream or an oil to promote better healing and greater production of collagen No products have to be applied on the treatment areas for 36 h after treatment Makeup and sunblock can be applied on day post-treatment if the treatment area is dry and unbroken Normal skincare can be recommended once the treatment area is completely healed It is G Fabbrocini 122 Fig 13.5 Erythematous reaction after Skin Needling Fig 13.4 Bleeding after Skin Needling 13.5 very important to continue using the topical vitamin cream for at least months post-procedure to ensure the production of healthy collagen and elastin Advantages • Skin is indistinguishable from normal skin, and the epidermis shows more dermal papillae • Skin becomes thicker with a great increase in collagen deposition and significantly more elastin • The healing phase is short (2–4 days): the skin appears reddened and swollen only for 48 h • Skin needling can be safely performed on all skin colours and types There is no risk of post-inflammatory hyperpigmentation or hypopigmentation as the melanocytes remain intact during treatment, so it may be safely done in people with darker pigmented skin • There is reduced risk of infection • The skin is not sun sensitive • It is not as expensive as laser resurfacing • A major advantage is that needling can be performed on people who have had laser resurfacing or have thin skin • It can be repeated without any risk Disadvantages • This procedure is relatively bloody (Fig 13.4), much the same as dermabrasion • Skin needling cannot achieve as intense a deposition of collagen as laser resurfacing, but the treatment can be repeated to get even better results that will last as long as, if not longer than, laser resurfacing Epidemiology of Complications Skin needling complications are rare and are independent of age, sex and race Minor complications include: • Irritation (Fig 13.5) • Fine scabs • Milia (Fig 13.6) • Tiny pustules (Fig 13.7) The major complications include: • Herpes simplex • Retinoid reaction (Fig 13.8) • Scarring • Long-lasting haematomas 13.6 13.6.1 Management of Complications Irritation It is the most common type of reaction after skin needling procedures and is characterized by various degrees of dermal localized inflammation It is produced by histamine and other inflammatory substances released by mast cell release Skin may appear red or pink and feel warm and itchy for 12–24 h following needling 13.6.2 Fine Scabs, Milia and Tiny Pustules Fine scabs may form on the surface when the skin has not been thoroughly cleaned They may cause 13 Complications of Needling 123 Fig 13.8 Erythema and desquamation after Skin Needling draining Tiny pustules are more common and usually found in patients treated for acne scars It is important to open them early and make sure that the skin has been cleaned thoroughly and that there is no serous residue on the surface 13.6.3 Herpes Simplex It is an uncommon complication, but if the patient is prone to herpetic outbreaks, he or she needs to be on an antiviral medication prior to skin needling procedure Fig 13.6 In this patient, the appearance of milia was a complication of Skin Needling 13.6.4 Retinoid Reaction After the skin has been needled, it becomes easier to penetrate, and much higher doses of vitamin A or alpha-hydroxy acid become available in the depth of the skin Higher doses of vitamin A may cause a retinoid reaction that will aggravate the pink flush of the skin and also cause dry skin A hydrating cream can be used to soothe the dry sensation Fig 13.7 Tiny pustules are another possible complication of Skin Needling obstruction and the development of simple milia or tiny pustules Milia are uncommon, but when they occur, they should be treated by pricking and 13.6.5 Scarring Overaggressive needling may cause scarring This scarring, however, does not seem to occur when using the medical device G Fabbrocini 124 13.7 Fig 13.9 Some tips bended like a fishhook after an improper use can cause long-lasting haematomas 13.6.6 Long-Lasting Haematomas A medical roller is a single-use device It is absolutely recommended to not use badly tooled and copied version of the medical device: the material is too soft and the tips easily bend like a fishhook (Fig 13.9) Its use results in cutting and ripping tissue, nerves, vessels and the lymphatic system when rolled through the skin and in producing severe and long-lasting haematomas Summary Skin needling is a simple and minimally invasive procedure with rapid healing and low downtime It has undisputable advantages compared with conventional methods The most important is that the epidermis remains intact because it is not damaged, eliminating most of the risks and negative side effects of chemical peeling or laser resurfacing As melanocytes are not negatively impacted, risks of postinflammatory hypo- or hyperpigmentations are minimized, so it can be safely performed on Asian and darker skins, as well as skins that have been previously treated with laser or had dermabrasion References Fabbrocini G, Fardella N, Monfrecola A et al (2009) Acne scarring treatment using skin needling Clin Exp Dermatol 34:874–879 Aust MC, Fernandes D, Kolokythas P et al (2008) Percutaneous collagen induction therapy: an alternative treatment for scars, wrinkles, and skin laxity Plast Reconstr Surg 121:1421–1429 Fernandes D (2005) Minimally invasive percutaneous collagen induction Oral Maxillofac Surg Clin North Am 17:51–63 Index A Ablative fractional resurfacing (AFR) laser See Fractional lasers Acneiform eruptions AFR, 28 pyruvic acid peeling, 4–5 removal lasers, 50 ALA See 5-Aminolevulinic acid (ALA) Alexandrite laser, 39 5-Aminolevulinic acid (ALA) and MAL-PDT complications erythema, edema and exfoliation, 68–69 hyper/hypopigmentation, 69 pain, 67 pain management, 67–68 residual photosensitivity, 70 scarring, 69–70 ulceration and necrosis, 69 vesiculation and crusting, 69 onycholysis, 71 protocol for, 66 Atrophic scars, superficial and medium chemical peels, Atypical mycobacterial infection, 79 B Biorivitalization clinical features, 74–75 epidemiology of complications, 73 management, 75–76 technique, 73 Bipolar RF, 87 Blistering IPL, 61 Nd:YAG, 42 PDL, 42, 43 removal laser, 49–50 Botulinum toxins adverse events antibody formation, 101 dose-related events, 100 etiology, 97 medications, 98 non-pharmaceutical grade product-related events, 100–101 site-and needle-related events, 98–100 structure and function of, 97 Brow ptosis, 99 Bruising botulinum toxin, 98–99 filler injection, 11–12 mesotherapy, 74, 75 C Cardiac arrhythmia, Cellulite See Mesotherapy Checkerboarding, IPL, 61 Cicatricial ectropion, 28, 31–32 Comfort pulse technology (CPT), 86 Contact dermatitis fractional lasers, 32 postpeeling moisturizers, Corneal damage, superficial and medium chemical peels, Crusting PDT, 69 removal lasers, 52 D Dermabrasion (DA) advantages, 109 clinical signs, 106 complications, 112–116 description, 103–104 disadvantages, 109 indications for, 108 patient expectations, 110 postprocedure care, 112 preconditioning program, 110–112 Dermal infusion, 104 Dermatitis, fractional lasers, 28 Diode laser, 39 RF, 87–88 Dishomogeneous skin color, 3–4 Dyspigmentation, 28–29, 32 A Tosti et al (eds.), Management of Complications of Cosmetic Procedures, DOI 10.1007/978-3-642-28415-1, © Springer-Verlag Berlin Heidelberg 2012 125 Index 126 E Edema mesotherapy, 74 PDT, 68–69 vascular laser, 40 Erosive pustular dermatosis of scalp (EPDS), 70, 71 Erythema mesotherapy, 74 PDT, 68–69 vascular laser, 40 Exudative erosions, 3, Eyelid ptosis, 99 F FACES technology, 87 Fractional lasers clinical features acne/milia, 27–28 anesthesia complications, 28 dermatitis, 28 dyspigmentation, 28–29 eruptive keratoacanthomas, 29 infection and papules, 29 prolonged edema and erythema, 29 recall phenomenon, 29 scarring, 30 side effects, 25–27 epidemiology of complications, 24–25 management acne/milia, 31 anesthesia toxicity, 31 cicatricial ectropion, 31–32 contact dermatitis, 32 dyspigmentation, 32 edema, 32 erythema, 32–33 infection, 33 pain and scarring, 33 petechiae or purpura, 33 technology, 23–24 G Glycolic acid peeling, 1–2 H Herpes simplex reactivation, TCA peeling, Herpes simplex virus (HSV) description, 51 management, 54 Honeycomb appearance, PDL, 41 Hybrid monopolar bipolar RF complications, 94–95 description, 89–90 preoperative considerations, 92 Hyperpigmentation IPL, 60 Nd:YAG, 41, 42 PDT, 69 Hypertrophic scars dermabrasion, 114 superficial and medium chemical peels, Hypopigmentation IPL, 60, 61 Nd:YAG, 41–42 PDT, 69 Hypopigmented spots, glycolic peeling, I Infraorbital nodule, 15 Intense pulse light (IPL) advantages, 58 complications blistering, 61 checkerboarding, 61 hyperpigmentation, 60 hypopigmentation, 60, 61 scarring, 61 treatment, 61–63 epidemiology of complications, 59–60 IV–VI skin type patients, 58 posttreatment care instructions, 59 side effects, 60 treatment of, 61–63 wavelength range, 57 J Jack Nicholson brow See Spock eyebrows Jessner’s solution, K KTP laser See Potassium titanyl phosphate (KTP) laser L Lasers fractional clinical features, 25–30 epidemiology of complications, 24–25 management, 31–33 technology, 23–24 removal (see Removal lasers)vascular clinical features, 40–44 management, 44–45 technology, 38–40 Leukotrichia description, 50 management, 53 Lip abscess, 14, 15 Lip edema, 11 Long-lasting haematomas, 123–124 M MAL See Methyl aminolevulinate (MAL) Medium-term undesired effects, fillers hypersensitivity responses, 16–17 Index nodule formation, 13–16 visible implants, 13 Mesotherapy clinical features, 78–80 epidemiology, 78–80 management, 80 technology, 78 Methyl aminolevulinate (MAL) See also 5-Aminolevulinic acid (ALA) description, 65 PDT complications contact dermatitis, 70 EPDS, 70, 71 urticaria, 71 Methylprednisolone, 6, Microdermabrasion (MDA) advantages, 105 description, 104 disadvantages, 105 indications for, 104–105 postprocedure care, 112 preconditioning program, 110–112 Microepidermal necrotic debris (MEND), 24 Microneedling See Skin needling Milia, Monopolar RF technology complications, 92–94 description, 85–87 preoperative considerations, 91 Myobloc, 97 N Nd:YAG See Neodymium:yttrium-aluminum-garnet laser (Nd:YAG) Needling See Skin needling Neodymium:yttrium-aluminum-garnet laser (Nd:YAG), 39–40 Nonablative fractional resurfacing (NAFR) laser See Fractional lasers Nonablative rejuvenation technologies, 83, 84 Nonpermanent fillers compatibility with laser, 19 infection, 17–18 injection-site necrosis, 18–19 medium-term undesired effects hypersensitivity responses, 16–17 nodule formation, 13–16 visible implants, 13 short-term undesired effects bruising, 11–12 injection-associated discomfort, 9–10 overcorrection and undercorrection, 12–13 redness and swelling, 10–11 systemic illness, 18 O Ochronosis, Ocular complications, 50, 53–54 Onycholysis, 71 127 P Paradoxical hypertrichosis description, 50 management, 52–53 PDL See Pulsed dye laser (PDL) PDT See Photodynamic therapy (PDT) Periocular nodules, 74, 75 Permanent fillers problems with, 19 Photodynamic therapy (PDT) ALA-and MAL-PDT complications erythema, edema and exfoliation, 68–69 hyper/hypopigmentation, 69 pain, 67 pain management, 67–68 residual photosensitivity, 70 scarring, 69–70 ulceration and necrosis, 69 vesiculation and crusting, 69 ALA-PDT complications, 71 MAL-PDT complications contact dermatitis, 70 EPDS, 70, 71 urticaria, 71 Photo-onycholysi See Onycholysis Pigment alteration, 49 Polaris, 87–88 Potassium titanyl phosphate (KTP) laser, 39 Prolonged erythema, TCA peeling, 3, Propionibacterium acnes, 67 Pulsed dye laser (PDL), 39 Purpura laser hair removal, 50–51 PDL, 40–41 Pyruvic acid peeling advantages, disadvantages, 1–2 uses, R Radiofrequency (RF) in aesthetics, 84 bipolar RF and vacuum, 87 complications, 92–95 delivery forms, 85 hybrid monopolar bipolar RF, 89–90 monopolar, 85–87 and optical energy, 87–88 preoperative considerations bipolar RF and vacuum, 92 hybrid monopolar bipolar RF, 92 monopolar radiofrequency, 91 RF and optical energy, 91 selection of candidates, 90–91 treatment strategies, 90 properties of, 85 tripolar, 88–89 Index 128 Removal lasers clinical features acneform eruptions, 50 blistering and crusting, 49–50 HSV, 51 leukotrichia and ocular complications, 50 paradoxical hypertrichosis, 50 pigment alteration, 49 purpura, 50–51 reticulate erythema, 50 scarring, 50 epidemiology, 48–49 management acneform eruptions, 54 blistering and crusting, 52 HSV, 54 leukotrichia, 53 ocular complications, 53–54 pain, 51 paradoxical hypertrichosis, 52–53 posttreatment hyperpigmentation, 51–52 posttreatment hypopigmentation, 52 purpura, 54 reticulate erythema, 53 scarring, 53 technology, 47–48 Reticulate erythema description, 50 management, 53 S Sadick classification, of aging, 83, 84 Salicylic acid peeling, Salicylism, 5–6 Scarring IPL, 61 laser hair removal, 50, 53 PDL, 42–43 Short-term undesired effects, fillers bruising, 11–12 injection-associated discomfort, 9–10 overcorrection and undercorrection, 12–13 redness and swelling, 10–11 Skin needling epidemiology of complications, 122–123 management, 123–124 post-treatment care, 121–122 pretreatment care, 121 technology, 119–121 Skin rejuvenation mesotherapy (see Biorivitalization)strategies for, 83, 84 Spock eyebrows, 99 Superficial and medium chemical peels clinical features major local adverse reactions, minor local adverse reactions, 3–5 systemic adverse reactions, 5–6 contraindications to, epidemiology, complications, glycolic acid, 1–2 Jessner’s solution, management, 6–7 postpeeling care, prepeeling care, pyruvic acid, 1–2 salicylic acid, salicylic acid+TCA, trichloroacetic acid, T Telangiectasias, 114 Telangiectatic matting, 44 Textural changes, Nd:YAG, 43 Thermage device, 85–86 Thermal relaxation time (TRT), 38 Transcutaneous nerve stimulation (TENS), 68 Transient urticaria, 43 Trichloroacetic acid peeling, Tripolar RF, 88–89 True eyelid ptosis, 99 U Upper lip ecchymoses, 11 Urticaria, PDT, 71 V Vascular lasers clinical features blistering, 42 edema, 40 erythema, 40 footprint sign, 44 honeycomb appearance, 41 pain and discomfort, 42 pigmentary changes, 41–42 postage stamp mark, 44 purpura, 40–41 scarring, 42–43 telangiectatic matting, 44 textural changes, 43 transient urticaria, 43 wound infection, 43 management, 44–45 technology Alexandrite, 39 diode, 39 KTP, 39 neodymium:yttrium-aluminum-garnet, 39–40 PDL, 39 W Wound infection, Nd:YAG, 43, 44