Good morning.
I'm Norm Hugo.
You're probably all reasonably tired having
watched the symposium for two
days.
The previous tapes that we viewed
have been on extensive surgical procedures.
This is a brief tape on derm abrasion
to explain to you how this
adjunctive procedure enhances these
other more formidable procedures.
Now,
dermabrasion itself is nothing
more than the controlled removal of the
epidermis down to the upper
levels of the dermis by an abrasive substance.
It's been used in a highly effective
fashion for acne pits,
hypertrophic scars and to feather the
junction between a graft and its recipient
area.
It has also been used to diminish
the wrinkles associated with the aging
process,
especially in areas of excessive
muscular activity in an otherwise
very expressive face.
This is the lady who's on the beach,
very social,
smiling,
enjoying life,
but who adds to the wrinkles in the glabella
lateral cantal and perioral areas.
Now,
the success of failure of any
surgical procedure
depends on patient selection.
The key question
that we must ask is who is the best
candidate for this type of procedure?
Now,
if a patient is left with
widespread and deep wrinkles over the facial
area after Riady and
blepharoplasty,
a chemical peel is
probably the best modality
to enhance her result.
Now,
let's take a look at a cross section
of skin
for review.
The epidermis which we
see here is 1/10 of a
millimeter thick.
The dermis itself ranges
in the area of one millimeter thick.
The chemical peel
takes the collagen
and homogenizes it.
It gives it a more parallel type
structuring.
It reaches down deep into the dermis.
One sees permanent swelling following a
chemical peel and also
elastically degenerated collagen fibers.
These are collagen fibers which have been
denatured and now take up an elastic
stain.
It also takes away
the pigment cells up near
the base basal
layer.
And this unfortunately is a drawback
because it bleaches the area.
Now,
by contrast,
derma abrasion does cause some
parallelism in the dermal collagen,
but essentially it
heals as a donor
site.
Consequently,
these changes are much
less than a chemical peel.
Consequently,
the patient who is best served
by the derma abrasion procedure is
one who has fine wrinkles in the
perioral,
the lateral canal and the glabella
areas.
Again,
let us stress that this is only an
adjunctive procedure.
It is less liable however,
to cause the frosted bleached
look than an isolated peel night.
Now,
with this in mind,
let's examine a few patients who have met these
criteria for patient selection
and who have had derm abrasion.
This is a older woman
who has aged and does have the
glabella fine wrinkles and
the perioral wrinkles.
On the first post operative day one can
see that she's had a ectomy and
also the above mentioned areas
MIB she's healing nicely without any
difficulty.
Her final result shows a very
smooth perioral area
and a smoother
glabella area,
but it does not take out the deeper
wrinkles.
Another lady who had her perioral
area MIB
with a reasonably satisfactory result
and an improvement in the color texture,
heavy perry oil wrinkles in another middle
aged woman,
lateral view also reveals a
similar picture
post operatively.
Several months later,
good smooth looking appearance with
no persistent ero thema or
pigmentation,
lateral view revealing a similar
change.
And finally,
a lady with slightly more
extensive
wrinkling around the perioral area.
This is a lady who loves the sun.
She's very social and gregarious
is uh recently
widowed and wishes to have not only her
face lifted but something done with all of
this wrinkling.
Consequently,
a more full derm abrasion was done.
This is her lateral preoperative view
and then post operatively and
this germ abrasion was carried out,
not just in the perioral area but out into the cheek
areas where a
better result was obtained by doing so.
And the last view showing a very
nice result.
Now,
these are some static patients that we've shown.
Let us go now to the operating
room and show you the
technique which is a quite
simple and straightforward procedure
marking is done with methylene blue to establish the
lateral margins of whatever area is
to be migrated to perioral and lateral cantal
areas.
After marking the local
anesthetic 1% silica is
injected slowly and gently with a fine
gauge number 27 needle,
the injection of the local not only serves
to anesthetize the area,
but it also swells the area
and thereby gives it tissue.
This is important in order to have a surface
against which to mirate.
Let's take a look at a couple of the instruments
used presently for Derm Abra.
One of the units is a hand held battery
powered Derr which I do not often
use since it doesn't have the power which I
require.
Also,
the wire wheel attachment has a
tendency to splay
out in rotation,
giving a slightly uneven cut.
The unit which I do prefer is the
strike of Dermata.
Now let's cut back to the operating room so we can
see how that works and explain it to you,
please.
I prefer the striker
and just let me illustrate the many
heads that are included with it.
I use this head almost exclusively.
This is too big.
It drags too much.
This is too hard for me to use.
I don't use the guards at
all.
I find I have got a control over the Derra
without it.
Now,
we've already injected the patient.
I usually start naturally.
And if you'll look it,
you will see that this is rotating this
way.
So you take that towards the
part that is movable
and it will constantly push that part away.
We will do the same up here in the lateral camp
areas and in so doing you
protect any vulnerable part.
Now we'll start here and you'll also notice I
make occasional sweeping motions,
it's reasonably comfortable for the patient.
And as you can see,
the Xylocaine that's
injected serves in a very good
method of giving this tissue
turn so that we can break
right now.
Can you see that the type of the depth
you can estimate by just
peeling off the epidermis until it gets down into
the mid dum area.
And I always make sure that I get a
little bit of.
Now,
I want to interrupt here to make this point
clear,
you must mirate up
over the vermilion.
Otherwise,
in the postoperative period,
you'll be left with a white line around the perioral
area,
which first of all hasn't been mirate and
secondly,
retains all those fine writs that you think
you've gotten rid of and the patient and you will be
most unhappy.
Now,
finishing with the in the
area,
we go up to the
previously outlined methylene glue
and just feather it slightly beyond
very,
very gently and easily so that it
blends a little better.
We're we're just feathering this so it will blend
in
complete the oral area.
And now we'll start on the
area where some small crow's feet have troubled
her.
And again,
we make sure in which
direction the
rotation occurs and then go
towards the movable and vulnerable
area.
This is very thin skin
and it very carefully approach it.
So a slightly circular motion.
Now,
let's have,
we've got two dates.
We can always come back again,
protective of our list and
globe and
very slowly and gently.
This is much different than the skin around the
mouth,
not nearly as tough or as stretch.
So we have to be very careful
and a blended chi
and in light fashion,
we go to the other side.
OK.
OK.
Time and make sure again that it rotates in the direction
we wish
just me,
I'm trying to finish
everything and paid
and they just gently cut,
it
completes the procedure.
Alternatively,
what we do next is to just the
areas and by a very thin film of concentration
and we put in no dressings,
you can see we've come up just a little over
the all the way around so that we'll be able to
have confidence we've done the areas we want.
Again,
as I point out you did not use dressing.
Was that reasonably comfortable you up?
And how much premeditation did you have?
None?
And what will you do?
Now,
this is being done as an outpatient procedure.
Had she had a face lift today,
we would have done it at the conclusion of the facelift,
but this is as an adjunct
to a previous facelift and
you will be able to go off this afternoon back to
your room.
Now we finished the procedure and these
always go well when they're videotaped.
But let's for a moment,
spend a brief second,
considering some of the complications which may occur
following derm abra,
the most common,
but the least difficult to manage is
milia,
I have never known these to be
permanent.
They are troublesome to the patient.
They appear as tiny white spots over the area of
derm abrasion,
but they can be removed either by having the patient
use a somewhat abrasive soap if the area is
healed well enough or simply by pricking with a number
18 gauge needle or a number
11 blade.
And there's very little difficulty from these.
However,
a more troublesome but
less common complication is persistent
erma.
Now,
this can be seen by looking at this middle
aged lady who had a face lift and
perry oral and glabella derma abrasion
and yet several months later still
remains with an area of persistent
erma.
There's very little that can be done for this
except to practice tincture of
time in this regard.
One need only advise the patient to continue to
use covering cosmetics while the area
of persistent ero thema vanishes
slightly more troublesome
complication,
which is again,
less frequent is persistent
pigmentation in this
patient who's quite old.
We did a perioral germ
abrasion from which she got a very nice
result as regards the
removal of the writ heads.
However,
a year later,
she still has this persistent
pigmentation which is very troublesome
to her and it can be perhaps even
appreciated more on the lateral view,
this persistent perioral
pigmentation.
Now,
one can either cover that with cosmetics
or could add hydroquinone to the area
until it's bleached to an a level that
satisfies both the patient and her physician.
I would like again to reiterate if I might the
timing of these procedures,
they almost invariably are done with a
face lift.
Although the video tape today was done
after a face that had been previously performed,
but it adds very little time to the procedure and
very little discomfort.
We've enjoyed bringing you this
very brief video tape exploring derm
abrasion and we hope that you too
have profited from it.
Thank you.