Minimally invasive or noninvasive procedures account for an overwhelming majority of cosmetic procedures. These procedures include botulinum toxin injections, soft tissue fillers, chemical peel, dermabrasion, and laser hair removal. This article reviews some of the principles involved in these procedures. Plastic surgeons need to be equally familiar with surgical and nonsurgical approaches to cosmetic medicine to provide a complete set of therapeutic options to their patients.
The role of noninvasive procedures as part of a thriving practice is a significant concern according to a panel on practice trends presented at The Aesthetic Meeting 2008, the annual meeting of the American Society for Aesthetic Plastic Surgery (ASAPS). Two surveys conducted in 2007 under the auspices of a Cosmetic Medicine Task Force formed as a joint venture between ASAPS and American Society of Plastic Surgeons (ASPS) examined consumers’ attitudes and perceptions influencing their choice of plastic surgery procedures and the variety of cosmetic services offered in plastic surgery practices. Minimally invasive or noninvasive procedures, including laser and light therapies, injectables, and dermal fillers, now account for 80% of cosmetic procedures. According to the 2009 ASPS statistics, the top 5 minimally invasive procedures in 2009 were
- 1.
BOTOX (Allergan Inc, Irvine, CA, USA) injections (4.8 million)
- 2.
Soft tissue fillers (1.7 million)
- 3.
Chemical peel (1.1 million)
- 4.
Microdermabrasion (910,000)
- 5.
Laser hair removal (893,000).
Most consumers viewed surgical procedures as high risk, but perceived virtually no risk associated with noninvasive or minimally invasive procedures. Despite their popularity, these procedures still comprise a small part of most plastic surgeons’ practices; the survey found that for 91% of surgeons, noninvasive treatments generated less than 25% of their revenue.
Plastic surgeons should remain educated and current on noninvasive or minimally invasive cosmetic surgery procedures. Patients who undergo these procedures will only develop further trust and allow the surgeon the opportunity to offer a more comprehensive set of therapeutic options. This will, in turn provide continuity of care and facilitate a successful practice.
This article provides a basic overview of the common noninvasive and minimally invasive therapies in cosmetic surgery, some areas being discussed in more detail than others. Skin care products and skin types are discussed first.
Topical skin care
The modern skin care industry continues to evolve rapidly with an almost unlimited array of skin care products available. Many products are categorized based on particular skin types. There are 4 parameters for characterizing facial skin types
- 1.
Dry or oily
- 2.
Sensitive or resistant
- 3.
Pigmented or nonpigmented
- 4.
Wrinkled or tight.
These 4 parameters can yield 16 different combinations, each with different skin care needs. Furthermore, each skin type may change over time in the individual (because of intrinsic or environmental causes) and thus change the subsequent management.
Dry or Oily
The role of the stratum corneum (SC) is the most significant factor in the development of dry skin. In patients with dry skin the lipid bilayer of the SC is disturbed, increasing fatty acid levels and reducing ceramide layers. Various extrinsic factors, including UV radiation, detergents, acetone, chlorine, and protracted water exposure or immersion, can disrupt the lipid bilayer. The maintenance of water within skin cells depends on natural moisturizing factor. Aquaporin-3 allows water transfer between the keratinocytes. Sebum, the oily secretion of the sebaceous glands, that contains wax esters, sterol esters, cholesterol, triglycerides, and squalene imparts an oily aspect to the skin and plays a significant role in acne development. In normal skin, sebaceous gland–derived triglycerides are hydrolyzed to glycerol before transport to the skin surface. In sebum-deficient individuals, replacing this glycerol may be a suitable approach to alleviating skin dryness. There are numerous over-the-counter moisturizers available to help hydrate the skin, including occlusives, humectants, and emollients. Occlusives are typically oily compounds that coat the SC to impede transepidermal water loss (TEWL). Many occlusives also impart an emollient effect and are suited for treating dry skin. Examples of occlusives include petrolatum, lanolin, and propylene glycol. None of them impart long-term effects. Once the occlusives are removed from the skin, the TEWL returns to the previous level. Occlusives are usually combined with humectant ingredients because reducing the TEWL by more than 40% can increase the risk of skin maceration and subsequent bacterial infection. Humectants are water soluble and can attract water from the external environment, in conditions with at least 80% humidity, as well as from the underlying skin layers. In low-humidity conditions, however, humectants may take water from the deeper epidermis and dermis, thereby increasing the TEWL. They are thus more effective in combination with occlusives. By drawing water into the skin, humectants may cause minor swelling of the SC and yield a perception of smoother skin with fewer wrinkles. Humectant ingredients include glycerin, urea, hydroxyl acids, and lactic acid. Emollients are primarily composed of lipids and oils and are added to cosmetics to hydrate, soften, and smooth the skin. These compounds fill in the gaps between desquamating corneocytes to render a smooth surface. In short, occlusives coat the SC and reduce the TEWL, humectants attract water from the outer atmosphere and hydrate the skin, and emollients soften and smooth the skin. While several expensive moisturizers contain collagen that manufacturers contend can replace the collagen lost due to aging, most of the collagen extracts have a molecular weight of 15,000 to 50,000 Da. Only substances with a molecular weight of 5000 Da or less can penetrate the SC. The collagen and polypeptides in these products create a film that fills in surface irregularities but only temporarily stretches out fine skin wrinkles.
Sensitive or Resistant Skin
People with resistant skin rarely experience erythema and can use a variety of products without any significant concern for adverse reactions. However, many products are limited in their penetration of resistant skin and thus ineffective. Sensitive skin is more complex and has 4 discrete subtypes (acne, rosacea, stinging, and allergic), all sharing one common element inflammation. Patients may present with more than one subtype. Features of the acne subtype include the adherence of dead keratinocytes in the hair follicles because of elevated sebum production, clogging of the follicle, and production of a papule or pustule. Bacteria migrate into the hair follicle and trigger an inflammatory cascade. Treatment focuses on the 4 primary causal factors (1) decreasing sebum production with retinoids, oral contraceptives, or stress reduction; (2) unclogging pores with retinoids and α-hydroxy acids; (3) eliminating bacteria with antibiotics and topical care; (4) and reducing inflammation. The rosacea subtype includes prominent telangiectasias, in addition to common adolescent symptoms of facial redness, flushing, and papules. Topical treatment focuses on antiinflammatory ingredients to decrease vasodilation. The stinging subtype involves a nonallergic neural sensitivity to certain triggers. People with such a subtype should avoid topical products including those containing α-hydroxy acids, benzoic acid, lactic acid, sorbic acid, certain ammonium containing compounds, propylene glycol, urea, or vitamin C. Approximately 10% of patients with dermatologic conditions who are patch tested are allergic to at least one ingredient common in cosmetics.
Pigmented or Nonpigmented Skin
The 2 general mechanisms interfering with skin pigmentation are inhibition of tyrosinase (preventing melanin formation) and blocking transfer of melanin into keratinocytes. Activation of protease-activated receptor (PAR)-2 transfers melanin to keratinocytes. Soy and niacinamide block PAR-2. Tyrosinase inhibitors include vitamin C, hydroquinone, kojic acid, arbutin, mulberry extract, and licorice extract. Other mechanisms to impede pigmentation include the use of exfoliating agents (α-hydroxy acids, retinoids) and procedures (microdermabrasion) that accelerate cell turnover, preventing melanocytes from producing melanin. Sun avoidance remains the most effective method of preventing pigmentation.
Wrinkled or Tight Skin
The primary causes of extrinsic premature aging are smoking, poor nutrition, and solar exposure. Up to 80% of skin aging can be attributed to sun exposure. The development of rhytides is considered the most salient manifestation of cutaneous aging. Alterations of the lower dermal layers of the skin can cause wrinkles. Few skin care products penetrate far enough. Most antiaging products and procedures are formulated or designed to salvage collagen, elastin, and hyaluronic acid. Products have been unable, however, to deliver these substances to the deep dermis in adequate amounts. Some products can stimulate the natural synthesis of these substances, that is, retinoids, vitamin C, and copper peptide can stimulate collagen production ; retinoids can augment the production of hyaluronic acid and elastin ; and glucosamine may improve hyaluronic acid levels. Antioxidants help with wrinkle prevention by reducing inflammation and subsequent breakdown of hyaluronic acid, collagen, and elastin. Some antioxidants (used as ingredients in many topical skin care products) include green tea, vitamin C/E, ferulic acid, coenzyme Q10, silymarin, Pycnogenol, an extract from the plant Pinus pinaster , and idebenone.
Skin camouflage
Skin camouflage corrects cutaneous flaws with specialized makeup preparations and techniques, useful for patients with chronic macular conditions, such as vitiligo, melasma, rosacea, and port-wine stains. This technique is a valuable adjunct after ablative and nonablative therapies, allowing earlier return to public activities and restoring appearance sooner after nonablative procedures. Skin camouflage can improve appearance immediately and permits surgeons to recommend and perform a greater number of surgically invasive and ablative procedures by allowing patients to reduce and more accurately schedule their expected downtime. Very few medical institutions and physician practices integrate skin camouflage into their care.
Postsurgical camouflage preparations are applied to newly epithelialized skin. These preparations are oil or cream based with pigment content up to 45% to 50%; conventional liquid makeup typically contains no more than 10% to 15% pigment. Paste makeup formulations are typically opaque and can camouflage abnormal tones that contrast with adjacent normal skin, seen with bruises, vitiligo, and port-wine stains. These preparations can also act as filler substances to fill in small indentations. A fixing spray can be used off the face to set a longer duration of use. Mineral makeup may be unsuitable early in the postoperative course of ablative procedures because the skin must be completely epithelialized, dry to the touch, and no longer require healing ointments. Mineral makeup is typically easier to apply than paste formulations and is currently the makeup of choice for erythema after chemical peels and laser resurfacing (once epithelialized), acne erythema, acne rosacea, melasma, facial lentigines, and postinflammatory hyperpigmentation.
Skin camouflage is used after planned incisional and ablative procedures and after accidental unexpected discoloration from trauma and procedures. There are 3 basic techniques for camouflaging skin defects: concealing, color correcting (neutralizing red, blue, or yellow tones to more natural tones of complimentary colors), and contouring (creating highlights and shadows to disguise swelling). These techniques cannot mask the 3-dimensional conditions such as focal edema, keloids, acne scars, and deep furrows. In preparation, patients should bring their own makeup and preoperative pictures to maximize postoperative results once the skin has completely epithelialized and sutures have been removed.
Cosmetic surgery practices commonly offer cosmeceutical and skin care products. Very few of them also offer makeup, the only remaining product that their patients may require to complete their facial grooming.
Skin camouflage
Skin camouflage corrects cutaneous flaws with specialized makeup preparations and techniques, useful for patients with chronic macular conditions, such as vitiligo, melasma, rosacea, and port-wine stains. This technique is a valuable adjunct after ablative and nonablative therapies, allowing earlier return to public activities and restoring appearance sooner after nonablative procedures. Skin camouflage can improve appearance immediately and permits surgeons to recommend and perform a greater number of surgically invasive and ablative procedures by allowing patients to reduce and more accurately schedule their expected downtime. Very few medical institutions and physician practices integrate skin camouflage into their care.
Postsurgical camouflage preparations are applied to newly epithelialized skin. These preparations are oil or cream based with pigment content up to 45% to 50%; conventional liquid makeup typically contains no more than 10% to 15% pigment. Paste makeup formulations are typically opaque and can camouflage abnormal tones that contrast with adjacent normal skin, seen with bruises, vitiligo, and port-wine stains. These preparations can also act as filler substances to fill in small indentations. A fixing spray can be used off the face to set a longer duration of use. Mineral makeup may be unsuitable early in the postoperative course of ablative procedures because the skin must be completely epithelialized, dry to the touch, and no longer require healing ointments. Mineral makeup is typically easier to apply than paste formulations and is currently the makeup of choice for erythema after chemical peels and laser resurfacing (once epithelialized), acne erythema, acne rosacea, melasma, facial lentigines, and postinflammatory hyperpigmentation.
Skin camouflage is used after planned incisional and ablative procedures and after accidental unexpected discoloration from trauma and procedures. There are 3 basic techniques for camouflaging skin defects: concealing, color correcting (neutralizing red, blue, or yellow tones to more natural tones of complimentary colors), and contouring (creating highlights and shadows to disguise swelling). These techniques cannot mask the 3-dimensional conditions such as focal edema, keloids, acne scars, and deep furrows. In preparation, patients should bring their own makeup and preoperative pictures to maximize postoperative results once the skin has completely epithelialized and sutures have been removed.
Cosmetic surgery practices commonly offer cosmeceutical and skin care products. Very few of them also offer makeup, the only remaining product that their patients may require to complete their facial grooming.
Chemical peels
The most significant alterations resulting from chronic sun damage occur in the dermis. Chemical peels can treat the most superficial aspect of the skin all the way to the deepest portion of the reticular dermis. Pretreatment evaluation includes an emphasis on history of abnormal or keloid scarring, herpes simplex virus infection, 13- cis retinoic acid (Accutane) therapy, prior laser resurfacing, and use of photosensitizing medications. Many physicians wait a minimum of 6 months after the last Accutane dose before performing a chemical peel. Fitzpatrick skin types III (average tanning ability) and IV (easily tan) often develop limited and transient hyperpigmentation, especially with deeper or more aggressive chemical peels. Skin types that tan even easier (Fitzpatrick skin types V and VI) should be approached with great caution because the risk of permanent pigment alteration is quite significant.
There are 3 basic types of chemical peels. Superficial peels (glycolic and salicylic acids) may penetrate to the papillary dermis. Medium-depth peels (trichloroacetic acid) reach the deep papillary and, often, superficial reticular dermis. Deep chemical peels (phenol) can penetrate into the midreticular dermis. After assessing the depth of photoaging, the proper peeling agent can be selected.
Postoperatively, patients should maintain a moist environment using a petrolatum-based emollient. Superficial peels may be followed by a medium to thick moisturizer in place of an emollient, but with frequent applications. The deeper the peel the longer the need for postoperative moisturizer use. Once reepithelialization is complete, a sunscreen is recommended as part of the moisturizing routine. Sun avoidance is essential before epithelialization. Persistent postoperative erythema can be a sign of early hypertrophic scarring, requiring a topical corticosteroid or intralesional injection if the scar begins to mature. Postinflammatory hyperpigmentation is usually transient but can be treated with bleaching agents such as hydroquinone (3%–4%).
Peeling agents are often used in combination with laser resurfacing to diminish lines demarcating the site for laser treatment. Superficial peeling agents used before laser resurfacing can reduce complications such as hyperpigmentation and may reduce the healing time.
Laser hair removal
Traditional methods of hair removal include shaving, bleaching, plucking, waxing, use of chemical depilatories, and electrolysis. These techniques are limited by the pain, inconvenience, and poor long-term efficacy. Only electrolysis has offered the potential for permanent hair removal, but is tedious. Several lasers and other light sources have been developed specifically to target hair follicles and rapidly treat large areas with long-term results.
Light can potentially destroy hair follicles by photothermal (by local heating), mechanical (by shockwaves or violent cavitation), and photochemical mechanisms (by generation of toxic mediators such as singlet oxygen or free radicals). Some individual laser systems are mentioned below but not discussed in detail.
Photothermal lasers include 694-nm normal-mode ruby lasers (RubyStar [Aesculap-Meditec GmBH, Jena, Germany], Sinon [WaveLight Laser Technologie AG, Erlangen, Germany]), 755-nm normal-mode alexandrite lasers (Elite [Cynosure, Chelmsford, MA, USA], GentleLASE [Candela Corporation, Wayland, MA, USA], Ultrawave II–III [Adept Medical, Rancho Santa Margarita, CA, USA], Epicare [Light Age Inc, Somerset, NJ, USA]), 800-nm pulsed diode lasers (LightSheer [Lumenis Inc, Santa Clara, CA, USA]), 1064-nm long-pulsed Nd:YAG lasers (CoolGlide [Cutera Inc, Brisbane, CA, USA], Profile [Sciton, Palo Alto, CA, USA], Cynergy [Cynosure, Chelmsford, MA, USA], Dualis [Fotona, Ljubljana, Slowenie; Petrakis Holdings Ltd, Limassol, Cyprus], Varia [CoolTouch Laser Corp, Auburn, LA, USA], Mydon [Quantel Derma GmbH, Erlangen, Germany], GentleYAG [Candela Corporation]), and 590- to 1200-nm intense-pulsed light (IPL) source lasers (Lumenis One [Lumenis, Santa Clara, CA, USA], Cynergy PL [Cynosure Inc, Westford, MA, USA], Quadra Q4 [DermaMed International Inc, Lenni, PA, USA], Estelux [Palomar, Burlington, MA, USA]). Photothermal destruction is based on the principle of selective photothermolysis. This principle predicts that selective thermal damage of a pigmented target structure will result when sufficient fluence is delivered at a specific wavelength for a required thermal relaxation time. In the visible to near infrared region, melanin is the natural chromophore for targeting hair follicles. Lasers of this wavelength are selectively absorbed by melanin in the dermis, permitting deep heating of the hair shaft, hair follicle epithelium, and heavily pigmented matrix. However, epidermal melanin competes for absorption, and epidermal injury must be minimized by selectively cooling the epidermis with various methods including cooling gels, a cooled glass chamber or sapphire window, or a pulsed cryogen spray. Ruby lasers are best indicated in light-skinned individuals with dark hairs because of the high melanin absorption at 684 nm. Higher-wavelength (755 nm) alexandrite lasers penetrate the dermis deeper and deposit more energy in the dermis than ruby lasers. The risk for epidermal damage in darker skin types is thus reduced. The pulsed 800-nm diode laser is effective for removal of dark terminal hair, seen in darker skin types. The long-pulsed Nd:YAG lasers have reduced melanin absorption at their emitted wavelength of 1064 nm, requiring high fluencies to adequately damage hair. However, the poor melanin absorption is safer for darker skin types. This laser is also used for treatment of pseudofolliculitis barbae, a skin condition commonly seen in people with darker skin types. Intense-pulsed nonlaser light sources used for hair reduction emit multiwavelength light and can be adjusted to specific pulse durations and delay intervals, effective for a wide range of skin types.
Photomechanical lasers include carbon-suspension Q-switched Nd:YAG lasers and Q-switched Nd:YAG lasers. Photomechanical destruction due to small local explosions results from Q-switched laser pulses. These higher-powered short pulse width lasers target hair follicles and rapidly heat melanin. The generated photoacoustic shock waves mechanically disrupt the melanocytes in the bulb but cause incomplete follicular disruption, ineffective for long-term hair removal.
Photochemical lasers include those used in photodynamic therapy, which use light and a photosensitizer to produce a targeted photochemical reaction and therapeutic effect. Primarily used for malignant skin tumors, long-term data for their efficacy in hair removal are still needed.
An evidence-based review of laser and light sources for hair removal demonstrated partial short-term hair removal efficacy up to 6 months after treatment with the ruby, alexandrite, diode, and Nd:YAG lasers and IPL. Alexandrite and diode lasers demonstrated long-term hair removal beyond 6 months. Repeated treatments improved efficacy, and there were few side effects.
Nonablative rejuvenation
Nonablative rejuvenation refers to the ability of a laser or light energy source to selectively create thermal injury to the underlying dermis with minimal effect on the epidermis. Many patients prefer the minimal recovery associated with nonablative treatments, even though the final result may not be as dramatic as that obtained with laser resurfacing or a deep chemical peel. Of these devices, many cool the overlying epidermis to protect the skin from emitted energy. This effect is achieved with a cold handpiece or dynamic cryogen device delivering a cooling spray. These devices include the 532-nm laser (Versapulse [Coherent Medical Group, Palo Alto, CA, USA], Diolite [Iridex Inc, Mountain View, CA, USA]), the 585-nm pulsed dye laser, the 1064-nm Q-switched Nd:YAG laser, the 1320-nm long-pulsed Nd:YAG with coolant spray (CoolTouch Varia, CoolTouch Inc, Roseville, CA, USA), the 1450-nm diode with a coolant spray (Smoothbeam, Candela Corporation), the 1540-nm erbium (Er):glass laser (Aramis, Quantel Derma GmbH), and a broadband IPL, which emits a continuous spectrum from 515 nm to 1200 nm.
Selective absorption by chomophores including hemoglobin, collagen, and melanin, can induce neocollagenesis. Light-tissue interactions can induce collagen remodeling and other molecular events to culminate in improvement of rough texture, red and brown discoloration, and fine lines.
Related posts:
Cosmetic Medicine and Surgery: A Shift in Perspective
An Overview of Botulinum Toxins: Past, Present, and Future
Principles and Practice of Cutaneous Laser and Light Therapy
Injectable Therapies for Localized Fat Loss: State of the Art
Noninvasive Body Contouring with Radiofrequency, Ultrasound, Cryolipolysis, and Low-Level Laser Therapy
Lifting and Wound Closure with Barbed Sutures
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