WEBVTT 00:00.000 --> 00:30.000 position:50% align:top line:0% *This machine-generated transcript may have errors. If remediation or a manually-generated transcript is needed, please contact NLM Support at https://support.nlm.nih.gov.* 00:20.129 --> 00:20.659 Good morning. 00:20.670 --> 00:21.459 I'm Norm Hugo. 00:21.469 --> 00:24.020 You're probably all reasonably tired having 00:24.030 --> 00:26.620 watched the symposium for two 00:26.629 --> 00:27.139 days. 00:28.739 --> 00:31.510 The previous tapes that we viewed 00:31.709 --> 00:34.349 have been on extensive surgical procedures. 00:34.360 --> 00:36.970 This is a brief tape on derm abrasion 00:38.259 --> 00:40.659 to explain to you how this 00:40.669 --> 00:43.520 adjunctive procedure enhances these 00:43.529 --> 00:45.610 other more formidable procedures. 00:46.430 --> 00:46.740 Now, 00:46.750 --> 00:49.330 dermabrasion itself is nothing 00:49.340 --> 00:51.569 more than the controlled removal of the 00:51.580 --> 00:54.259 epidermis down to the upper 00:54.270 --> 00:57.200 levels of the dermis by an abrasive substance. 00:58.360 --> 01:00.880 It's been used in a highly effective 01:00.889 --> 01:03.549 fashion for acne pits, 01:03.560 --> 01:06.040 hypertrophic scars and to feather the 01:06.050 --> 01:08.889 junction between a graft and its recipient 01:08.900 --> 01:09.260 area. 01:10.300 --> 01:13.230 It has also been used to diminish 01:13.239 --> 01:16.139 the wrinkles associated with the aging 01:16.150 --> 01:17.059 process, 01:17.470 --> 01:20.199 especially in areas of excessive 01:20.209 --> 01:22.919 muscular activity in an otherwise 01:22.930 --> 01:24.819 very expressive face. 01:24.830 --> 01:27.639 This is the lady who's on the beach, 01:27.650 --> 01:28.639 very social, 01:28.650 --> 01:29.660 smiling, 01:29.669 --> 01:31.050 enjoying life, 01:31.300 --> 01:33.760 but who adds to the wrinkles in the glabella 01:33.769 --> 01:36.599 lateral cantal and perioral areas. 01:37.790 --> 01:38.449 Now, 01:39.440 --> 01:41.910 the success of failure of any 01:41.919 --> 01:43.209 surgical procedure 01:44.529 --> 01:47.139 depends on patient selection. 01:48.349 --> 01:49.760 The key question 01:51.190 --> 01:53.940 that we must ask is who is the best 01:53.949 --> 01:56.319 candidate for this type of procedure? 01:57.279 --> 01:57.809 Now, 01:58.099 --> 02:00.410 if a patient is left with 02:00.419 --> 02:03.139 widespread and deep wrinkles over the facial 02:03.150 --> 02:05.209 area after Riady and 02:05.220 --> 02:06.269 blepharoplasty, 02:06.410 --> 02:09.250 a chemical peel is 02:09.259 --> 02:12.100 probably the best modality 02:12.440 --> 02:14.080 to enhance her result. 02:15.020 --> 02:15.309 Now, 02:15.320 --> 02:17.710 let's take a look at a cross section 02:18.979 --> 02:19.869 of skin 02:21.839 --> 02:22.940 for review. 02:23.429 --> 02:26.220 The epidermis which we 02:26.229 --> 02:28.820 see here is 1/10 of a 02:28.830 --> 02:29.899 millimeter thick. 02:30.960 --> 02:33.929 The dermis itself ranges 02:34.610 --> 02:37.199 in the area of one millimeter thick. 02:39.139 --> 02:40.740 The chemical peel 02:42.259 --> 02:44.070 takes the collagen 02:45.080 --> 02:46.910 and homogenizes it. 02:47.570 --> 02:50.460 It gives it a more parallel type 02:50.470 --> 02:51.320 structuring. 02:51.729 --> 02:54.350 It reaches down deep into the dermis. 02:55.779 --> 02:58.649 One sees permanent swelling following a 02:58.660 --> 03:01.110 chemical peel and also 03:02.440 --> 03:05.320 elastically degenerated collagen fibers. 03:05.330 --> 03:07.600 These are collagen fibers which have been 03:07.610 --> 03:10.300 denatured and now take up an elastic 03:10.309 --> 03:10.880 stain. 03:11.720 --> 03:14.289 It also takes away 03:14.520 --> 03:16.850 the pigment cells up near 03:17.529 --> 03:20.479 the base basal 03:20.720 --> 03:21.399 layer. 03:21.770 --> 03:24.369 And this unfortunately is a drawback 03:24.380 --> 03:26.289 because it bleaches the area. 03:26.660 --> 03:26.880 Now, 03:26.889 --> 03:28.190 by contrast, 03:28.839 --> 03:30.929 derma abrasion does cause some 03:30.940 --> 03:33.919 parallelism in the dermal collagen, 03:34.649 --> 03:36.990 but essentially it 03:37.000 --> 03:39.580 heals as a donor 03:39.630 --> 03:40.130 site. 03:41.610 --> 03:42.800 Consequently, 03:42.809 --> 03:45.470 these changes are much 03:45.479 --> 03:47.600 less than a chemical peel. 03:48.610 --> 03:49.759 Consequently, 03:50.589 --> 03:53.050 the patient who is best served 03:53.369 --> 03:56.350 by the derma abrasion procedure is 03:56.360 --> 03:59.300 one who has fine wrinkles in the 03:59.820 --> 04:00.199 perioral, 04:00.580 --> 04:03.020 the lateral canal and the glabella 04:03.029 --> 04:03.679 areas. 04:04.589 --> 04:05.110 Again, 04:05.119 --> 04:07.449 let us stress that this is only an 04:07.460 --> 04:09.240 adjunctive procedure. 04:10.809 --> 04:12.979 It is less liable however, 04:13.039 --> 04:15.490 to cause the frosted bleached 04:15.500 --> 04:18.209 look than an isolated peel night. 04:18.730 --> 04:19.209 Now, 04:19.369 --> 04:20.459 with this in mind, 04:20.950 --> 04:23.410 let's examine a few patients who have met these 04:23.420 --> 04:25.549 criteria for patient selection 04:25.910 --> 04:28.279 and who have had derm abrasion. 04:29.329 --> 04:31.420 This is a older woman 04:32.980 --> 04:35.709 who has aged and does have the 04:35.720 --> 04:38.709 glabella fine wrinkles and 04:38.720 --> 04:40.510 the perioral wrinkles. 04:42.109 --> 04:44.750 On the first post operative day one can 04:44.760 --> 04:47.410 see that she's had a ectomy and 04:47.420 --> 04:50.160 also the above mentioned areas 04:50.299 --> 04:52.779 MIB she's healing nicely without any 04:52.790 --> 04:53.679 difficulty. 04:53.769 --> 04:56.760 Her final result shows a very 04:56.769 --> 04:58.720 smooth perioral area 05:00.540 --> 05:03.109 and a smoother 05:03.119 --> 05:04.279 glabella area, 05:05.230 --> 05:07.839 but it does not take out the deeper 05:07.850 --> 05:08.500 wrinkles. 05:09.559 --> 05:12.309 Another lady who had her perioral 05:12.320 --> 05:13.190 area MIB 05:16.170 --> 05:19.049 with a reasonably satisfactory result 05:19.059 --> 05:21.299 and an improvement in the color texture, 05:25.459 --> 05:28.429 heavy perry oil wrinkles in another middle 05:28.440 --> 05:29.380 aged woman, 05:30.140 --> 05:32.540 lateral view also reveals a 05:32.549 --> 05:34.390 similar picture 05:35.170 --> 05:36.329 post operatively. 05:36.339 --> 05:37.540 Several months later, 05:38.649 --> 05:41.380 good smooth looking appearance with 05:41.390 --> 05:44.179 no persistent ero thema or 05:44.190 --> 05:45.179 pigmentation, 05:48.179 --> 05:50.429 lateral view revealing a similar 05:50.440 --> 05:51.190 change. 05:53.190 --> 05:53.929 And finally, 05:53.940 --> 05:55.760 a lady with slightly more 05:55.769 --> 05:56.959 extensive 05:58.429 --> 06:01.230 wrinkling around the perioral area. 06:01.239 --> 06:03.369 This is a lady who loves the sun. 06:03.380 --> 06:05.600 She's very social and gregarious 06:06.480 --> 06:08.910 is uh recently 06:08.920 --> 06:11.739 widowed and wishes to have not only her 06:11.750 --> 06:14.640 face lifted but something done with all of 06:14.649 --> 06:15.529 this wrinkling. 06:15.660 --> 06:16.890 Consequently, 06:16.910 --> 06:19.500 a more full derm abrasion was done. 06:19.510 --> 06:21.799 This is her lateral preoperative view 06:22.790 --> 06:25.649 and then post operatively and 06:25.660 --> 06:27.410 this germ abrasion was carried out, 06:27.420 --> 06:30.410 not just in the perioral area but out into the cheek 06:30.420 --> 06:33.160 areas where a 06:33.170 --> 06:36.010 better result was obtained by doing so. 06:36.880 --> 06:39.750 And the last view showing a very 06:39.760 --> 06:40.890 nice result. 06:41.339 --> 06:41.850 Now, 06:42.790 --> 06:45.529 these are some static patients that we've shown. 06:46.269 --> 06:49.089 Let us go now to the operating 06:49.100 --> 06:51.369 room and show you the 06:51.380 --> 06:53.359 technique which is a quite 06:53.369 --> 06:56.279 simple and straightforward procedure 06:57.420 --> 07:00.309 marking is done with methylene blue to establish the 07:00.320 --> 07:03.320 lateral margins of whatever area is 07:03.329 --> 07:06.070 to be migrated to perioral and lateral cantal 07:06.079 --> 07:06.630 areas. 07:10.250 --> 07:12.649 After marking the local 07:12.660 --> 07:14.989 anesthetic 1% silica is 07:15.000 --> 07:17.690 injected slowly and gently with a fine 07:17.700 --> 07:19.440 gauge number 27 needle, 07:21.920 --> 07:24.739 the injection of the local not only serves 07:24.750 --> 07:26.440 to anesthetize the area, 07:27.089 --> 07:29.779 but it also swells the area 07:30.459 --> 07:32.470 and thereby gives it tissue. 07:34.089 --> 07:37.089 This is important in order to have a surface 07:37.100 --> 07:38.320 against which to mirate. 07:40.149 --> 07:42.670 Let's take a look at a couple of the instruments 07:42.679 --> 07:44.549 used presently for Derm Abra. 07:46.619 --> 07:49.070 One of the units is a hand held battery 07:49.079 --> 07:51.779 powered Derr which I do not often 07:51.790 --> 07:54.239 use since it doesn't have the power which I 07:54.250 --> 07:55.070 require. 07:55.119 --> 07:55.690 Also, 07:55.700 --> 07:58.690 the wire wheel attachment has a 07:58.700 --> 08:01.179 tendency to splay 08:01.190 --> 08:02.880 out in rotation, 08:02.890 --> 08:04.720 giving a slightly uneven cut. 08:08.290 --> 08:11.000 The unit which I do prefer is the 08:11.010 --> 08:12.279 strike of Dermata. 08:12.589 --> 08:15.510 Now let's cut back to the operating room so we can 08:15.519 --> 08:17.670 see how that works and explain it to you, 08:17.679 --> 08:18.140 please. 08:18.970 --> 08:20.880 I prefer the striker 08:22.200 --> 08:24.119 and just let me illustrate the many 08:24.519 --> 08:26.959 heads that are included with it. 08:27.559 --> 08:30.220 I use this head almost exclusively. 08:30.230 --> 08:31.320 This is too big. 08:31.329 --> 08:32.400 It drags too much. 08:32.409 --> 08:34.700 This is too hard for me to use. 08:34.710 --> 08:37.169 I don't use the guards at 08:37.179 --> 08:37.739 all. 08:37.750 --> 08:40.159 I find I have got a control over the Derra 08:40.760 --> 08:41.460 without it. 08:41.950 --> 08:42.700 Now, 08:42.770 --> 08:44.979 we've already injected the patient. 08:45.369 --> 08:46.940 I usually start naturally. 08:46.950 --> 08:48.719 And if you'll look it, 08:48.729 --> 08:51.349 you will see that this is rotating this 08:51.359 --> 08:51.909 way. 08:51.919 --> 08:54.729 So you take that towards the 08:54.739 --> 08:57.719 part that is movable 08:57.729 --> 09:00.140 and it will constantly push that part away. 09:00.150 --> 09:02.349 We will do the same up here in the lateral camp 09:02.510 --> 09:04.929 areas and in so doing you 09:04.940 --> 09:06.960 protect any vulnerable part. 09:06.969 --> 09:09.539 Now we'll start here and you'll also notice I 09:09.549 --> 09:12.479 make occasional sweeping motions, 09:17.450 --> 09:19.869 it's reasonably comfortable for the patient. 09:41.820 --> 09:43.340 And as you can see, 09:43.349 --> 09:46.000 the Xylocaine that's 09:46.010 --> 09:48.969 injected serves in a very good 09:50.710 --> 09:53.409 method of giving this tissue 09:53.419 --> 09:55.289 turn so that we can break 09:56.349 --> 09:56.700 right now. 09:56.710 --> 09:59.659 Can you see that the type of the depth 09:59.669 --> 10:02.400 you can estimate by just 10:02.409 --> 10:05.380 peeling off the epidermis until it gets down into 10:05.390 --> 10:07.010 the mid dum area. 10:07.419 --> 10:10.289 And I always make sure that I get a 10:10.299 --> 10:11.030 little bit of. 10:12.539 --> 10:12.849 Now, 10:12.859 --> 10:15.619 I want to interrupt here to make this point 10:15.630 --> 10:16.250 clear, 10:16.580 --> 10:18.950 you must mirate up 10:19.099 --> 10:20.359 over the vermilion. 10:20.369 --> 10:20.919 Otherwise, 10:20.929 --> 10:22.500 in the postoperative period, 10:22.650 --> 10:25.590 you'll be left with a white line around the perioral 10:25.599 --> 10:26.190 area, 10:26.200 --> 10:28.940 which first of all hasn't been mirate and 10:28.950 --> 10:29.750 secondly, 10:29.760 --> 10:32.590 retains all those fine writs that you think 10:32.599 --> 10:35.559 you've gotten rid of and the patient and you will be 10:35.570 --> 10:36.690 most unhappy. 10:38.369 --> 10:38.760 Now, 10:38.770 --> 10:40.809 finishing with the in the 10:41.349 --> 10:41.900 area, 10:42.099 --> 10:43.630 we go up to the 10:44.590 --> 10:46.960 previously outlined methylene glue 10:47.270 --> 10:49.859 and just feather it slightly beyond 10:49.869 --> 10:50.380 very, 10:50.390 --> 10:53.059 very gently and easily so that it 10:53.070 --> 10:54.400 blends a little better. 10:55.530 --> 10:58.380 We're we're just feathering this so it will blend 10:58.390 --> 10:58.719 in 11:01.450 --> 11:03.989 complete the oral area. 11:04.000 --> 11:06.349 And now we'll start on the 11:07.239 --> 11:09.820 area where some small crow's feet have troubled 11:09.830 --> 11:10.260 her. 11:10.700 --> 11:11.770 And again, 11:11.780 --> 11:14.250 we make sure in which 11:14.260 --> 11:15.880 direction the 11:17.969 --> 11:20.429 rotation occurs and then go 11:20.440 --> 11:23.020 towards the movable and vulnerable 11:23.030 --> 11:23.799 area. 11:24.630 --> 11:26.840 This is very thin skin 11:27.619 --> 11:30.419 and it very carefully approach it. 11:31.770 --> 11:34.039 So a slightly circular motion. 11:35.559 --> 11:35.859 Now, 11:35.869 --> 11:36.229 let's have, 11:36.390 --> 11:37.570 we've got two dates. 11:39.070 --> 11:41.119 We can always come back again, 11:46.280 --> 11:49.070 protective of our list and 11:49.080 --> 11:50.010 globe and 11:52.260 --> 11:54.450 very slowly and gently. 11:55.469 --> 11:58.369 This is much different than the skin around the 11:58.380 --> 11:58.880 mouth, 11:59.159 --> 12:01.669 not nearly as tough or as stretch. 12:02.450 --> 12:04.719 So we have to be very careful 12:05.580 --> 12:06.969 and a blended chi 12:11.250 --> 12:12.770 and in light fashion, 12:12.780 --> 12:14.359 we go to the other side. 12:15.059 --> 12:15.090 OK. 12:15.219 --> 12:15.820 OK. 12:19.359 --> 12:22.250 Time and make sure again that it rotates in the direction 12:22.260 --> 12:23.000 we wish 12:30.469 --> 12:31.229 just me, 12:34.359 --> 12:35.849 I'm trying to finish 12:36.799 --> 12:39.590 everything and paid 12:46.049 --> 12:47.719 and they just gently cut, 12:47.729 --> 12:48.039 it 12:50.349 --> 12:51.919 completes the procedure. 12:52.580 --> 12:53.500 Alternatively, 12:54.289 --> 12:57.280 what we do next is to just the 12:57.289 --> 13:00.210 areas and by a very thin film of concentration 13:00.530 --> 13:02.559 and we put in no dressings, 13:03.710 --> 13:06.580 you can see we've come up just a little over 13:06.590 --> 13:09.479 the all the way around so that we'll be able to 13:10.320 --> 13:13.070 have confidence we've done the areas we want. 13:14.989 --> 13:15.570 Again, 13:15.580 --> 13:18.020 as I point out you did not use dressing. 13:18.030 --> 13:20.460 Was that reasonably comfortable you up? 13:21.070 --> 13:23.890 And how much premeditation did you have? 13:24.400 --> 13:24.950 None? 13:25.340 --> 13:26.270 And what will you do? 13:26.280 --> 13:26.650 Now, 13:26.659 --> 13:29.340 this is being done as an outpatient procedure. 13:29.679 --> 13:32.340 Had she had a face lift today, 13:32.349 --> 13:34.830 we would have done it at the conclusion of the facelift, 13:34.840 --> 13:37.840 but this is as an adjunct 13:37.849 --> 13:40.700 to a previous facelift and 13:41.250 --> 13:44.179 you will be able to go off this afternoon back to 13:44.200 --> 13:44.549 your room. 13:47.219 --> 13:50.080 Now we finished the procedure and these 13:50.090 --> 13:52.349 always go well when they're videotaped. 13:52.359 --> 13:53.809 But let's for a moment, 13:53.820 --> 13:55.700 spend a brief second, 13:55.710 --> 13:58.390 considering some of the complications which may occur 13:58.400 --> 13:59.679 following derm abra, 14:00.719 --> 14:01.820 the most common, 14:02.070 --> 14:04.789 but the least difficult to manage is 14:04.799 --> 14:05.429 milia, 14:05.830 --> 14:08.299 I have never known these to be 14:08.309 --> 14:09.280 permanent. 14:09.520 --> 14:11.650 They are troublesome to the patient. 14:11.659 --> 14:14.450 They appear as tiny white spots over the area of 14:14.460 --> 14:15.309 derm abrasion, 14:15.659 --> 14:18.580 but they can be removed either by having the patient 14:18.590 --> 14:21.590 use a somewhat abrasive soap if the area is 14:21.599 --> 14:24.369 healed well enough or simply by pricking with a number 14:24.380 --> 14:27.359 18 gauge needle or a number 14:27.369 --> 14:28.340 11 blade. 14:28.460 --> 14:31.030 And there's very little difficulty from these. 14:31.369 --> 14:32.250 However, 14:32.849 --> 14:35.640 a more troublesome but 14:35.650 --> 14:38.150 less common complication is persistent 14:38.609 --> 14:38.849 erma. 14:39.679 --> 14:39.890 Now, 14:39.900 --> 14:42.900 this can be seen by looking at this middle 14:42.909 --> 14:45.580 aged lady who had a face lift and 14:45.590 --> 14:47.989 perry oral and glabella derma abrasion 14:48.440 --> 14:51.390 and yet several months later still 14:52.710 --> 14:55.500 remains with an area of persistent 14:55.900 --> 14:56.250 erma. 14:56.669 --> 14:58.799 There's very little that can be done for this 14:58.809 --> 15:01.500 except to practice tincture of 15:01.510 --> 15:04.320 time in this regard. 15:04.520 --> 15:07.169 One need only advise the patient to continue to 15:07.179 --> 15:10.159 use covering cosmetics while the area 15:10.169 --> 15:12.150 of persistent ero thema vanishes 15:13.030 --> 15:14.809 slightly more troublesome 15:15.809 --> 15:17.280 complication, 15:17.289 --> 15:18.400 which is again, 15:18.409 --> 15:21.409 less frequent is persistent 15:21.419 --> 15:24.020 pigmentation in this 15:24.030 --> 15:26.739 patient who's quite old. 15:27.210 --> 15:30.059 We did a perioral germ 15:30.070 --> 15:32.900 abrasion from which she got a very nice 15:32.909 --> 15:35.729 result as regards the 15:35.739 --> 15:37.359 removal of the writ heads. 15:37.369 --> 15:38.130 However, 15:39.190 --> 15:40.320 a year later, 15:40.549 --> 15:42.609 she still has this persistent 15:42.619 --> 15:45.559 pigmentation which is very troublesome 15:45.570 --> 15:48.349 to her and it can be perhaps even 15:48.359 --> 15:51.320 appreciated more on the lateral view, 15:51.750 --> 15:54.119 this persistent perioral 15:56.119 --> 15:57.090 pigmentation. 15:57.099 --> 15:57.479 Now, 15:57.630 --> 16:00.369 one can either cover that with cosmetics 16:00.840 --> 16:03.580 or could add hydroquinone to the area 16:03.590 --> 16:06.510 until it's bleached to an a level that 16:06.520 --> 16:09.070 satisfies both the patient and her physician. 16:12.020 --> 16:14.940 I would like again to reiterate if I might the 16:14.950 --> 16:16.510 timing of these procedures, 16:16.520 --> 16:19.280 they almost invariably are done with a 16:19.289 --> 16:19.950 face lift. 16:19.960 --> 16:22.309 Although the video tape today was done 16:23.349 --> 16:26.020 after a face that had been previously performed, 16:26.250 --> 16:29.030 but it adds very little time to the procedure and 16:29.039 --> 16:30.299 very little discomfort. 16:31.400 --> 16:33.510 We've enjoyed bringing you this 16:33.520 --> 16:36.469 very brief video tape exploring derm 16:36.479 --> 16:39.130 abrasion and we hope that you too 16:39.359 --> 16:40.979 have profited from it. 16:40.989 --> 16:41.609 Thank you.