The nasal soft tissue envelope affects the final rhinoplasty result, and can limit the expected improvement. Currently, no dependable and objective test exists to measure the thickness of the nasal ...skin and underlying soft tissue.
This paper presents a simple, yet reliable method to determine the thickness of the soft tissue envelope. An algorithm is presented for treatment of the dermis and/or soft tissue apart from surgery of the underlying osseocartilaginous structures.
Seventy-five patients presenting for primary rhinoplasty underwent visual and ultrasound assessment of their nasal soft tissue envelope. At preoperative evaluation, the Obagi "skin pinch test" was used to assess the thickness of the nasolabial fold and whether or not the skin was oily. Patients were classified based on the pinch thickness. At time of surgery prior to injection of local anesthesia, ultrasonic assessment was done at the nasolabial fold, keystone junction, supratip, and tip to measure the thickness of the nasal dermis and underlying soft tissue.
Patients determined to have thin, normal, and thick skin by the "skin pinch test" were found to have a nasolabial fold dermal thickness with an average of 0.7 mm (0.4-1.2 mm), 1.1 mm (0.8-1.8 mm), and 1.4 mm (0.7-2.0 mm). Patients determined to have thin, normal, and thick skin were found to have a dermal thickness at the keystone junction with an average of 0.3 mm (0.2-0.4 mm), 0.5 mm (0.3-1.1 mm), and 0.9 mm (0.6-1.2 mm), respectively. This difference in thickness also translated to the supratip and tip areas measured. However, all areas were also affected by the oiliness of the skin. Soft tissue thickness (SMAS and muscle) underlying the dermis was variable. Patients of non-Caucasian background were more likely to have a thicker soft tissue layer.
The "skin pinch test" is an easy and reliable way for the surgeon to evaluate the thickness of the nasal soft tissue envelope. The rhinoplasty surgeon can make decisions pre- and postoperatively to treat patients with difficult soft tissue envelopes. LEVEL OF EVIDENCE 4.
We present a case of delayed-type hypersensitivity to hyaluronic acid (HA)-based filler on the face following the Pfizer booster in a Moderna-vaccinated individual. It is the first known case of ...treatment of the delayed-type hypersensitivity reaction with hyaluronidase following Covid vaccination. Hyaluronidase is a viable option to treat this reaction, particularly for patients who may not benefit from systemic treatment options. With an anticipated fourth round of vaccine boosters on the horizon, there may be an increased incidence of cutaneous adverse events, including the reaction discussed.
Background. Trichloroacetic acid (TCA) peels are popular, well known, and widely utilized to correct a variety of skin problems. Different methods exist, ranging from the use of plain TCA to ...augmented or modified TCA at concentrations ranging from 30% to 50%. However, peel results vary depending upon the physician skill level, patient selection, and patient management.
Objectives. The purpose of this article is to fill the gap for a peel that is deeper than superficial exfoliative procedures yet lighter than a medium‐depth peel, to simplify and standardize the TCA peel, to define depth properly based on intraoperative clinical signs, to implement a color guide that facilitates even application of TCA and avoids skip areas, and to identify and minimize variables that may contribute to inconsistent outcomes.
Methods. A coating system for TCA application is created by selecting a specific TCA concentration (15% or 20%), TCA volume (4 or 6 ml, respectively), and a standardized body surface area to be peeled (5%), taking into consideration skin thickness and fragility. Multiple coats of TCA are applied to reach the desired endpoints: papillary dermis (light Blue Peel) or the immediate upper reticular dermis (light/medium Blue Peel). Clinical signs guide the depth achieved (frost quality, even blue, pink sign, epidermal sliding) and correlate retrospectively with healing time (7–10 days).
Results. The TCA Blue Peel was found to be a simple and consistent treatment approach for problems related to the epidermis, papillary dermis, and immediate upper reticular dermis. An unexpected benefit was the appearance of skin tightening and a reduction of skin laxity in many cases. This suggests that the papillary dermis and the immediate upper reticular dermis play a significant role in skin tightness.
Conclusion. A simple coating system for achieving depth‐controlled TCA peels is presented with correlation to intraoperative clinical signs. This method makes it easier to peel skin of all racial backgrounds, including nonfacial skin. This is especially useful for many patients previously excluded from having procedures that penetrate beneath the papillary dermis. Commonly encountered variables in chemical peels are presented which may affect outcome.
Introduction:
There is a great deal of concern when it comes to resurfacing the skin of patients who have recently taken or are taking isotretinoin. Much of the concern arises from reports of ...abnormal and keloidal scarring postdermabrasion, Argon laser, and pulsed dye laser. This study was designed to retrospectively evaluate the complication rate of patients undergoing chemical resurfacing within 2 years of taking isotretinoin and to see if timing of the medication and depth of peel correlated.
Materials and Methods:
This is a retrospective chart review of 91 patients (14 men, 77 women) who had 123 peels documented. Patients were assigned to 1 of the following 4 groups based on the timing of isotretinoin use to the chemical peel: prepeel, perioperative, pre- and postpeel, and postoperative. Complications, isotretinoin dose, patient age and race, peel depth, and presence of keloids before surgery were recorded.
Results:
A total of 123 peels were documented in 91 patients: 51 prepeel, 13 perioperative, 22 pre- and postpeel, and 37 postoperative. The complications recorded were prolonged erythema (0.8%), atrophic scarring (0.8%), altered texture (0.8%), delayed healing (3.25%), and hypertrophic scarring (2.44%). Delayed healing was observed only in patients taking isotretinoin before or at the time of surgery. Two of 3 patients who developed hypertrophic scarring had taken isotretinoin during the postoperative stage.
Discussion:
Although previous case reports suggest a correlation between isotretinoin use and abnormal or keloidal scarring after dermabrasion, Argon laser, and pulsed dye laser, the occurrence of hypertrophic scarring remained low in the chemical-peel group of patients. We suggest avoiding isotretinoin for 3 months preoperatively and delaying postoperative use of isotretinoin until dermal regeneration is complete (3 months). Further studies are needed to determine if the use of refrigerants in dermabrasion and the heat generated by lasers cause temperature alterations that predispose to scarring in patients taking isotretinoin.
Current treatments to correct and reverse diseased or aged skin yield widely divergent results. Judging the outcome of such treatments is done in an arbitrary and subjective fashion that is often ...limited to a patient's feedback or the physician's opinion. This makes it difficult for inter-physician or physician-patient agreement as to the degree of improvement achieved. In an age where skin rejuvenation is being widely practiced, a tremendous void needs to be filled by a system that appropriately evaluates and scores treatment outcomes. Such a system will help physicians communicate better in lectures, help them to better assess the results of various treatment modalities, and facilitate patient-doctor communication. The objective of this paper is to present a standardized scoring system against which skin rejuvenation results can be judged. This system is based on a model of healthy skin that can be defined by practical criteria against which patients can be judged pre- and post-skin rejuvenation procedures. A gold standard for healthy skin (baby skin) is established from a clinical, functional, and histologic perspective. Each patient's skin is compared with the healthy skin model and graded before and after treatment by implementing our scoring system which encompasses objective and subjective criteria. Objective criteria include the following skin characteristics: smoothness, firmness, even coloration, normal texture, and absence of any clinically evident disease. Subjective criteria include proper hydration and normal tolerance, and are not considered in the final scoring. Grading of each element in the scoring system minimal (1), average (2), maximal (3), and subsequently the final score excellent (12 to 15), average (7 to 11), poor (<7) are done with reference to the healthy skin model defined. The scoring system is novel and easy to use, and can be implemented to help improve communication between physicians and patients as well as during the dissemination of knowledge during medical conferences. In conclusion, treatment end-results can be consistently and more accurately assessed when the scoring system (based on objective criteria and a model of healthy skin) is used. Adopting this protocol will also help in directing our treatment to achieve the best possible results.
Currently, no documentation correlates histological changes with clinical signs of depth of the trichloroacetic acid peel. Obagi identified clinical signs of depth of injury following topical ...trichloroacetic acid application, employing prepeel conditioning and a method for slowing trichloroacetic acid action. A three-part study of 20 patients was undertaken to determine whether Obagi's visual and palpatory signs of depth correlated histologically with depth of peel. Also analyzed were physiological mechanisms associated with these signs. Patients were pretreated and biopsy specimens were harvested before and after modified trichloroacetic acid peeling. The results largely confirmed the validity of Obagi's observations regarding the method of trichloroacetic acid peel described. These clinical signs are verified by histology and correlated with some findings by electron microscopy. Differentiation of papillary from upper reticular dermal penetration is particularly useful. Physiological explanations for the phenomena observed are proposed. The specificity and safety of peels may be improved with these criteria.
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