Ablative and Non Ablative Procedures Medical Rejuvenation Forehead lifts

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Ablative and Non Ablative Procedures Medical Rejuvenation  Forehead lifts Powered By Docstoc
					Ablative and Non-Ablative Procedures


         Obagi Systems
       Pre- and Post-treatments
              Objectives

• Review Ablative Aesthetic Procedures
• Review Non-Ablative Aesthetic Procedures
• Condition and Enhance the Procedures
• Benefits to incorporating the Obagi
  Systems with your Procedures
• Suggested Guidelines/Protocols (pre and
  post treatment)
              Ablative Procedures

Definition:
• Ablative procedures are techniques designed to
  remove the top layers of skin with the goal of
  regeneration of “fresh” skin that is more even
  and smooth
• Injury into the reticular dermis or surgeries
  which go deeper
• Or those procedures which require significant
  “down-time” in post-treatment recovery
            Ablative Procedures

• List of Procedures
  – Dermabrasion
     • Dermasanding
  – Ablative Lasers
     • CO2
     • Erbium Yag, Nd: Yag
  – Ablative Chemical Peels
     •   Phenol
     •   Baker-Gordon
     •   TCA 35% or higher
     •   Combinations
  – Facial Surgeries
    Procedure: Dermabrasion

• Indications/purpose
  – Resurfacing localized areas, skin planing or leveling,
    facial scars, perioral rhytides, rhinophyma (severe
    hyperplasia of the sebaceous gland results in bulbous
    contours and nodules) removal of benign neoplastic
    lesions, tattoos unresponsive to laser
  – Controlled mechanical planing of the epidermis and a
    variable portion of the upper dermis
  – Used in combination with laser or chemical peels to
    feather the transition between treated and non-
    treated skin
     Procedure: Dermabrasion


• Full face dermabrasion
  for acne scars
• A=Pre-op
• B=Immediate Post-op
• C=Three months
Procedure: Dermabrasion




 Reference: Facial Skin Resurfacing, Thomas J. Baker, et al.
    Procedure: Dermasanding

• Usually performed
  with other
  procedures to help
  reduce demarcation
  lines
• Photo - 320 grit to
  blend CO2 laser
• Into eyebrow area
                 Ablative Lasers

• Indication - Resurfacing the top layers of skin to
  improve skin texture, color and thickness
• Procedure:
   – High-energy pulses produce a controlled thermal
     injury that extends through the epidermis and into
     the papillary dermis and even upper reticular dermis
   – Goal is to stimulate a repair response
      • This tightens collagen fibers and stimulates fibroblast activity
   – With ablative lasers, there is generally “down-time”
     associated with them. The epidermis will need to re-
     epithelialize
                  Top Lasers

• Candela                 • CoolTouch (Nd:Yag)
  – Gentle Yag (Nd:Yag)   • Sharplan (CO2)
  – V-Beam (Pulse Dye)    • LaserScope (CO2 and
• Cutera                    Erbiums)

  – CoolGlide (Nd:Yag)
• Lumenis/Coherent
  – Ultra Pulse (CO2)
              CO2 Laser


• Resurfacing Laser
• Severe
  Photodamage
• Before and one
  year after
               Er:Yag Laser




                                         Three weeks after treatment




One day after treatment

                          Photo complements of American Academy of Dermatology
              Ablative Lasers

• Good results can be obtained with many lasers
  currently available
  – Research the market
  – Familiarize yourself with each machines’ attributes
    and your office’s needs
  – Get proper training of the laser you choose
  – Attend laser courses to ensure laser safety and
    predictability
  – Get referrals from associates/colleagues
  – Be conservative when first beginning
     Chemical Peels In General

There is a wide variety of peeling agents on the
  market to create a controlled skin injury
  – Chemical peels remain a popular choice
  – Long-standing safety and efficacy profile
  – Performed with ease, at a low cost and relatively
    quick recovery time
  – Each agent used has a unique chemical property and
    causes a specific pattern of injury on the skin
                 Chemical Peels

• The effect of the peel is dependent on:
   – The agent used
   – The concentration
   – Technique employed during and after its application
• Chemical Peels are classified as:
       • Superficial – injury at the epidermal level (considered non-ablative
          in this presentation)
        • Medium-depth – injury through the papillary dermis to the
          upper reticular dermis (considered ablative in this presentation)
        • Deep – injury to the mid-reticular dermis (considered ablative in
          this presentation)
      Ablative Chemical Peels

• Indications:
  – Improves severe photodamaged skin by
    production of new collagen and ground
    substance
  – Removes fine and coarse facial wrinkling and
    irregular pigmentation localized in the dermis
  – Acne scarring, neoplastic lesions (actinic
    keratoses), pigmentary disorders (non-
    responsive tattoos to lasers) and smoothening
    of the surface
        Ablative Chemical Peels


•   Moderate Photodamage
•   A=Pre-op
•   B=Application of 35% TCA
•   C=Frosting
•   D=4 days after
•   E=6 Month post
Obagi Blue Peel
                  Ablative Chemical Peels

                                                              • Six months following a
                                                                full-face phenol peel this
                                                                patient’s coarse facial
                                                                wrinkles have been totally
                                                                eliminated
                                                              • Observe the resulting
                                                                hypopigmentation
                                                                following full-face phenol
Reference: Facial Skin Resurfacing, Thomas J. Baker, et al.     application
     Other Ablative Procedures

• Surgical procedures:
  – Face Lifts – Browlift, blepharoplasty, rhinoplasty,
    rhytidectomy
  – Implants
  – Liposuction
  – Contour Thread Lift
• No skin epithelialization occurs so skin texture,
  tone and/or color are not improved
• Systems/products to condition and enhance the
  skin are essential
Non-Ablative Procedures
      Non-Ablative Procedures

Definition:
• Non-ablative procedures smooth and repair
  lines, wrinkles, and other defects, where the
  intent is not to remove the epidermal layer of
  skin
• Epidermis is left intact and injury occurs in upper
  papillary dermis
   – Or only minimal injury to the epidermis
• These procedures generally have minimal
  “down-time” in post-treatment recovery phase
     Non-Ablative Procedures

                   List of Procedures:
• IPL (Intense Pulse Light)      •   Dermaplaning
        • Hair
        • Vascular               •   Microdermabrasion
        • Skin Tightening
• Fraxel                         •   Botox
• Non-ablative peels             •   Fillers
        • Obagi Blue Peel
              – Epidermis        •   Thermage
        •
        •
            TCA (30% or less)
            Jessner’s
                                 •   Photodynamic
        •   Alpha Hydroxy Acid       Therapy
        •   Beta Hydroxy Acid
                Non-Ablative: IPL

• IPL’s for hair reduction:
   – Thermal injury is restricted to hair follicles as the targeted
     chromophore is melanin
   – When melanin absorbs the laser energy, the hair follicle is
     heated and then destroyed
• IPL’s for Vascular Lesions
   – Same concept except the targeted chromophore is hemoglobin
   – The vein is coagulated and blood does not flow through it any
     longer
• IPL’s for Skin Tightening
   – Same concept except the targeted chromophore is water in the
     dermis
   – Through this injury it stimulates fibroblasts and collagen
     synthesis
   – Better suited for patients with mild to moderate vs. moderate to
     severe photodamage
                        Top IPL’s

• Palomar                         • Lumenis
  – Starlux                         – Light Sheer
     • Lots of heads to make it     – Clear Light
       more versatile
                                  • Syneron
  – Estelux
                                    – Aurora
  – Medilux
                                    – Polaris
• Candela
                                  • Alma
  – Ellispe (name changing at
    AAD)                            – Harmony
• Cutera
  – Genesis
  – Titan
        Non-Ablative Lasers


• Port Wine Stain
   – Before
   – Immediately after
   – And at six weeks
Before & After - Ellipse IPL
        Fraxel           (Reliant Technology/Diode Laser)




•   Fractional laser resurfacing technology
•   Gentler approach to the ablative properties of CO2 and Er:Yags
•   Tiny pinpoints of coagulated tissue within the skin
•   Number, size and depth of these microthermal zones can be
    varied to individual treatments
• Claims:
    – Leaves surrounding tissue unaffected and intact
    – Rejuvenates the skin, fine lines and wrinkles, stretch marks,
      age spots, blotchy discoloration, acne scars and melasma
    – Some swelling may appear for 2-3 days after the procedure


    (Photo complements of Fraxel Treatment)
Fraxel Laser Treatment
Other “Fraxel” like technologies

• Palamar has a fractionated laser
• Almar has a pixeled laser
              Thermage

Thermage Non-Surgical Face Lift
  – Radio-Frequency rejuvenation
    • Tightening and dermal collagen remodeling
    • Selective heating and tightening of the fibrous
      “threads” that run through the subcutaneous
    • Benefits seen usually 4 to 6 weeks after
      procedure
    • Non-invasive without downtime and short
      recovery compared to more invasive procedure
                   Thermage




Tightening of the neck, jaw line and the skin folds by her mouth after Thermage
              Thermage® photos: Camelback Dermatology
                Blu-Light

• High intensity ultraviolet light
• The response is a creation of oxygen
  molecules inside the sebaceous gland that
  destroy the bacteria (called P.Acnes) and
  help the healing process
           Photodynamic Therapy

• Step 1: Application of the light-absorbing agent Levulan.
    – This liquid is left on skin for 45-60 minutes while it very selectively sinks
      into pimples, acne cysts and the overactive sebaceous glands that feed
      acne bacteria.
    – The absorption of the Levulan essentially turns the acne and oil glands
      into "targets" for the next step - light.
• Step 2:  Patients are placed under a special blue light. This light is
  drawn to the "targets", strong oxygen radicals are formed and the
  bacteria responsible for the acne is killed.
• NOTE: Levulan is only absorbed by abnormal cells such as those in
  acne conditions, pre-cancerous actinic keratoses, and sun
  damage.
• It is the selectivity of this solution in targeting only bad cells that
  allows such quick success in restoring skin back to a healthy normal
  condition
   Non-Ablative Chemical Peels

• Indication:
  – Skin rejuvenation of primarily the epidermis and very
    top layer of the dermis
     • Mild pigmentation
     • Smoothening of the surface layer of skin
     • Helps reduce the appearance of fine lines by exfoliating off
       the top layer of skin
  – Generally a series of peels are provided with 6 to 8
    week intervals depending on chemical agent selected
  – May be more frequent if agent does not penetrate to
    basal layer
  – Patient in usually offered a home skin care procedure
    to condition and enhance results
           Salicylic Acid (BHA)

• Treatment of Acne
• Salicylic Acid Peel
• Note: perifollicular
  frosting
                Dermaplaning

• Indication:
  – Same as non-ablative chemical peels
• Procedure:
  – Combines a mechanical removal of the outer
    most keratin layer with non-ablative chemical
    agent
  – Most common peeling agent = AHA
  – Generally a series of treatments every
    2-weeks
                 Dermaplaning

• Outer layer of keratin
  is dermaplaned away
• Usually a 30% glycolic
  acid is applied to the
  skin
• Then the skin is held
  under slight tension as
  blade moves across
  the skin
• Thin sheets of skin roll
  off blade’s edge           Reference: Facial Skin Resurfacing, Thomas J. Baker, et al.
          Microdermabrasion

• Indication:
  – Facial rejuvenation
  – Smooth skin texture
  – Lighten dark spots/freckles
  – Help minimize the appearance of fine wrinkles
  – Claim: increase epidermal and dermal
    thickness which is believed to be caused by
    the “sucking” of the machine
     • No scientific study supporting this claim
           Botox Cosmetics

Uses:
  – Crow’s feet, horizontal forehead lines, nasal
    flares, upper gum show, mouth frown, vertical
    upper lip lines, brow lift, etc.
        Botox Cosmetics

• Horizontal Forehead Lines
• Before and one month after
                 Botox cont.

Glabellar Lines
• A=At rest
• B=During frowning
• C=After inject attempting
        to frown
• D=One week after
 Fillers (Soft tissue augmentation)

Indication:
• Filler substances are used to smooth and even out
  superficial wrinkles and deep folds of the face
• Agents include: autologous (self) or xenografts (other
  source such as bovine) fat or collagen, allografts
  (from human tissue) hyaluronic acid and synthetic
  materials
• Agents are injected into the dermis or subcutaneous
  by a series of punctures or single entry
• Fillers can be used as monotherapy or adjunct to
  other procedures
                           Fillers

Types and Brands:
• Human Collagen (allograft) = Fascian (collagen from donor thigh muscle),
  Cosmoderm/plast, autologen (from skin of patient)
• Bovine Collagen (Xenografts) = Zyderm and Zyplast
• Hyaluronic Acid (a natural polysaccharide produced in many cell type
  membranes) = Restylane, Hylaform, Perlane, Captique
• Synthetic = Goretex, Sculptra (synthetic polylactic acid in microspheres)
• Lipotransfer (autologous fat) = Transferring your own fat to another
  location in the body
• Combination materials = Artecol (collagen and polymer), Radiance
  (calcium hydroxylapatite in aqueous gel), Artefill (bovine suspended in
  polymethlymethacrylate microspheres-pending FDA approval)
               Fillers


• Lip Augmentation
• Bovine Collagen
• Zyplast = 1cc
                  Fillers


•   Side Effect
•   Vascular injury
•   Bovine Collagen
•   Zyplast
  Obagi Systems

 Condition and Enhance
          your
Patients and your Practice
 Obagi Systems –            Condition and Enhance


How does Obagi Systems condition your patients
for the procedures?
• Prepares the skin prior to procedure
  – Thins the stratum corneum for better penetration of
    the products and procedure
  – Promotes cellular transformation prior to procedures
    to enhance healing time and reduce complications
  – Helps reduce risk of PIH through use of hydroquinone
• Starts a habit at patient’s home so when post-
  procedure home care is started, the patient is
  more compliant
 Obagi Systems –              Condition and Enhance


How does Obagi Systems enhance your patients
for the procedures?
• Faster healing with better overall results
• Proper home care hygiene will help to reduce possible
  infections
• Proper home care hygiene will help to reduce possible
  complications such as:
   – PIH
   – Acne flare-ups post treatment
• Changing habits in the patient’s home to properly take
  care of their skin to maintain procedure results
 Obagi Systems –                      Condition and Enhance


How does Obagi Systems help condition and
enhance practice goals?
   – Systems for all skin types
   – Builds office trust and credibility
       • By maintaining and enhancing results of office procedures
   – Offers opportunities for your patients to come back to the
     practice
       • Procedures, products and/or solutions for the aging process
       • Helps the patient return to the office - every 3 months
   – Helps crossover to other Cornerstones of your practice
       •   Product
       •   Non-Ablative
       •   Ablative
       •   Surgical/Trauma
Obagi Systems –
Condition and Enhance

System I                                      System II
•   Primarily for use with pre-conditioning   •   Primarily for use with post-conditioning
•   Can be used interchangeably; offers       •   Can be used interchangeably; offers
    flexibility to tailor a regimen to the        flexibility to tailor a regimen to the
    patients’ needs                               patients’ needs
•   Products included:                        •   Products included:
      – 2oz. Foaming Gel                            – 6.7oz. Foaming Gel
      – 2oz. Toner                                  – 6.7oz. Toner
      – 2oz. Clear                                  – 2oz. Clear (two of these per
      – 1oz. Exfoderm Forte                            system)
      – 1oz. Blender                                – 2oz. Exfoderm
      – 1oz. Healthy Skin Protection SPF            – 2oz. Blender
         35                                         – 1oz. Healthy Skin Protection SPF
      – Nu-Derm System Patient Guide                   35
                                                    – Nu-Derm System Patient Guide
                                                    – PLUS FREE! Physical UV Block SPF
                                                       32
Without Condition and Enhance
          Botox only
Without Condition and Enhance
          Fraxel only
Without Condition and Enhance
           IPL only
With Condition and Enhance
     Botox and Obagi
 Obagi Systems –       Condition and Enhance



Basic Guidelines/Protocols:
• Controlled injury in the epidermis and
  dermis
• Controlled injury in the epidermis only
• Controlled injury in the dermis or deeper
  leaving epidermis intact
 Determining the Right Protocol

What should you consider when setting
 protocols for conditioning and/or enhancing:
  – Treatment or procedure
  – Device/machine to be used
     • Always check with vender for their recommended
       protocol
  – Patient Skin Type (condition & concern)
  – Patient Compliance (commitment)
   Guidelines: Controlled injury in the epidermis and dermis



Conditioning the skin for ablative procedures:
  – Procedures: Er:Yag, TCA 35%, dermabrasion, Obagi Blue Peel


Pretreatment:
  – Pre-treatment will depend on procedure
     • Generally 4 to 6 weeks pre-treatment is recommended
  – Products:
     • Obagi Condition and Enhance Systems (Obagi Nu-Derm)
     • Stop “active” products 3 to 4 days prior to the procedure
     • Patient should continue to cleanse/tone and protect with Healthy
       Skin Protection SPF 35 up to day of procedure
Guidelines: Controlled injury in the epidermis and dermis



Enhancing the skin for ablative procedures:
  Procedures: Er:Yag, TCA 35%, dermabrasion, Obagi Blue Peel

Post Treatment:
• Immediately following procedure
   – Home care should be based on recommendations from vendor of
     device/agent used
• Return to skin care regimen
   – After skin has re-epithelialized
   – Begin cleansing/toning and using appropriate sunscreen as soon as
     skin permits (Physical UV Sunblock, SPF 32)
   – Slowly re-introducing actives – one by one
       • Skin Types IV, V, VI, = HQ’s back into protocol as soon as skin permits
Guidelines: Controlled injury in the epidermis only


Conditioning the skin for non-ablative procedures:
   – Procedures: Obagi Blue Peel (epidermal), dermaplaning,
                        AHA’s/BHA’s, microdermabrasion


Pretreatment:
   – Pre-treatment will depend on procedure
       • 2 week pre-treatment when exfoliation occurs
       • Obagi Blue Peel 4 to 6 weeks
   – Products:
       • Obagi Condition and Enhance Systems (Nu-Derm)
       • Stop “active” products 2 to 3 days prior to the procedure
       • Patient should continue to cleanse/tone and protect with HSP up to
         day of procedure
Guidelines: Controlled injury in the epidermis only


Enhancing the skin for non-ablative procedures:
   – Procedures: Obagi Blue Peel (epidermal), dermaplaning,
                         AHA’s/BHA’s, microdermabrasion


Post Treatment:
• Immediately following procedure
   – Home care should be based on recommendations from vendor
     of device/agent used
• Return to skin care regimen
   – After skin has re-epithelialized
   – Begin cleansing/toning and using the sunscreens as soon as skin
     permits
   – Slowly re-introducing actives – one by one
       • Skin Types IV, V, VI, = HQ’s back into protocol as soon as skin
         permits
Guidelines: Controlled injury in dermis/deeper – epidermis remains intact




  Conditioning the skin for non-ablative procedures:
      – Procedures: Botox, fillers, Thermage, IPL’s, Fraxel

  Pretreatment:
  • On-set of home care program will depend on procedure
      – Pre-treatment is not required for Botox and/or fillers
      – Usually conditioning can begin day of procedure or shortly
        thereafter
      – 4 weeks pre-treatment for skin rejuvenation is ideal for IPL’s,
        Fraxel and Thermage
  • Products:
          • Obagi Condition and Enhance Systems (Nu-Derm)
          • Stop “active” products 3 to 4 days prior to the procedure
          • Patient should continue to cleanse/tone and protect with HSP up to
            day of procedure
Guidelines: Controlled injury in dermis/deeper – epidermis remains intact




  Enhancing the skin for non-ablative procedures:
     – Procedures: Botox, fillers, Thermage, IPL’s, Fraxel

  Post Treatment:
  • Immediately following procedure
      – Home care should be based on recommendations from vendor of
        device/agent used
  • Skin care regimen:
      – After skin sensitivity to injury has resolved, products may be introduced
      – Usually day or two after procedure (IPL’s maybe a little longer)
      – Begin cleansing/toning and using appropriate sunscreen as soon as skin
        permits
      – Skin Types IV, V, VI, introduce HQ’s into protocol as soon as skin
        permits
          • Especially with Thermage and IPL’s
               In Summary
           Benefits for the Patient


• Restore skin health prior to procedure
• Minimize risk of post-procedural complications
     • PIH (post-inflammatory hyperpigmentation)
     • Infection
     • Acne flare-up
• Enhance healing time
• Helps establish compliancy with home care
  products prior to procedure
• Enhance cosmetic result and prevent future
  damage
               In Summary
          Benefits for the Practice


• Maximize and enhance outcome
• Minimize risk of post-procedural complications
  – Familiarizes patient with home care products and
    usage for recovery period
  – Helps you determine compliancy
• Expands your Cornerstones
• Keeps your patient in your practice long-term
  – Generates loyal patients who will refer friends
Obagi Condition and Enhance Systems

				
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Description: Ablative and Non Ablative Procedures Medical Rejuvenation Forehead lifts