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TREATMENT GUIDE | treatment guide


Skin tightening and rejuvenation


Ines Verner provides an overview of the treatment modalities available for skin rejuvenation and tightening, drawing on the available evidence


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URING THE LAST DECADE, great advances have been made in understanding skin ageing, which is characterised by thinner skin, dyspigmentation,


wrinkles, teleangiectasia, rough skin surface, and sagging. The changes that accompany these


clinical alterations are mainly found in the epidermis and upper dermis. One might see a loss of epidermal polarity and orderly maturation of keratinocytes, keratinocyte atypia, and flattening of the dermoÐ epidermal junction, which contribute to a rough and uneven skin surface and dyspigmentation. Skin laxity is mainly a result of changes


in the extracellular matrix (ECM) molecules of the dermis. Fragmented and disorganised collagen molecules are seen, elastin fibres are degraded and accumulate (i.e. solar elastosis), and hyaluronic acid molecules are broken1 Skin tightening and rejuvenation can be


.


achieved through skin resurfacing, which can be ablative, non-ablative, or fractional (ablative and non-ablative). All forms of skin resurfacing create a wound in the skin and induce different forms and degrees of cutaneous injury. Directly after the injury, a series of interlinked molecular and cellular reactions characterise the wound healing process for tissue repair. This process begins with an inflammatory


March 2012 | prime-journal.com


phase (days 1–3), enters the proliferative phase (days 4–21), and continues with the remodelling phase (day 21–1 year), in which new ECM molecules are formed, creating renewed and rejuvenated skin2


.


Chemical peels In recent years new and better chemical peeling agents have been developed. A superficial chemical peel will peel part of the epidermis (up to 60 m ), a medium depth peel will create a wound that includes the upper reticular dermis (450–600 m ), and a deep peel will wound the mid-reticular dermis (600–800 m ). While superficial peels improve mild


dyspigmentaion and some surface irregularities, medium depth peels will improve solar lentigines and fine wrinkles. A deep chemical peel gives remarkable results on wrinkles and induces tissue tightening and lifting. While superficial chemical peels are still commonly used, deep chemical peels are in decline. This is owing to the vigorous wound healing process with a 1-week downtime, as well as the possible permanent side-effects (e.g. hypopigmentation and scarring).


Light sources Lasers and light sources for skin rejuvenation have become


extremely


popular in recent years. Many new technologies emerge each year and enter into the skin rejuvenation market. Light emitted from a light source can be a single wavelength (laser) or be a part of the visible and infrared spectrum (IPL or LED). The emitted light energy is absorbed in the skin by melanin, haemoglobin or water, after which the light energy is converted into heat inducing a thermal injury. This thermal injury can induce tissue vaporisation and be ablative or only heat up the tissue and not cause vaporisation being non-ablative. Ablative resurfacing by CO2


or Er: YAG


induces bulk heating and can thus lead to a remarkable improvement of wrinkles and some tissue tightening. But as with the deep chemical peels, this treatment has become less popular as it is associated with a strong wound healing response with downtime and a risk for permanent complications (e.g. hypopigmentation and scarring). In the search for efficient and safe


technologies with less downtime and side-effects, fractional photothermolysis has been developed in which microscopic thermal wounds are created and the surrounding tissue is spared3


. Here the


columns of thermal zones (microscopic treatment zones; MTZs) can be coagulative and ablative (ablative fractional) or coagulative only (non-ablative fractional).


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