Management of Complications of Cosmetic Procedures Antonella Tosti (cid:129) Kenneth Beer Maria Pia De Padova Editors Management of Complications of Cosmetic Procedures Handling Common and More Uncommon Problems Editors Prof. Dr. Antonella Tosti Prof. Kenneth Beer, M.D., FAAD Department of Dermatology PA- General and Cutaneous Surgery Surgical and Esthetic Dermatology Miller School of Medicine West Palm Beach, FL University of Miami USA Miami, FL USA Dr. Maria Pia De Padova Department of Dermatology Nigrisoli Hospital Bologna Bologna Italy ISBN 978-3-642-28414-4 ISBN 978-3-642-28415-1 (eBook) DOI 10.1007/978-3-642-28415-1 Springer Heidelberg New York Dordrecht London Library of Congress Control Number: 2012942342 © Springer-Verlag Berlin Heidelberg 2012 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illus- trations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its cur- rent version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibil- ity for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Contents 1 Complications of Superficial and Medium Chemical Peels. . . . 1 Maria Pia De Padova and Antonella Tosti 2 Nonpermanent Fillers and Permanent Fillers. . . . . . . . . . . . . . . 9 Murad Alam and Nowell Solish 3 Complications of Fractional Lasers (Ablative and Nonablative). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Robert Anolik and Roy G. Geronemus 4 Complications of Vascular Lasers . . . . . . . . . . . . . . . . . . . . . . . . 37 Norma Cameli, Giovanni Cannarozzo, Paolo Bonan, Nicola Bruscino, and Piero Campolmi 5 Complications of Removal Lasers . . . . . . . . . . . . . . . . . . . . . . . . 47 Remington 6 Intense Pulsed Light Complications. . . . . . . . . . . . . . . . . . . . . . . 57 Hillary Julius 7 Complications of Photodynamic Therapy. . . . . . . . . . . . . . . . . . 65 Martin Zaiac, Adriana Abuchar, and Mercedes Florez 8 Complication of Biorivitalization. . . . . . . . . . . . . . . . . . . . . . . . . 73 Maria Pia De Padova and Antonella Tosti 9 Complications of Mesotherapy. . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Doris M. Hexsel and Juliana Dumêt Fernandes 10 Complications in Radiofrequency (RF). . . . . . . . . . . . . . . . . . . . 83 Suveena Bhutani and Neil S. Sadick 11 Complications of Botulinum Toxins. . . . . . . . . . . . . . . . . . . . . . . 97 Kenneth R. Beer and Jacob Beer 12 Management of Complications of Microdermabrasion and Dermabrasion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Meghan Dubina and Rebecca Tung 13 Complications of Needling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Gabriella Fabbrocini Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 v 1 Complications of Super fi cial and Medium Chemical Peels Maria Pia De Padova and Antonella Tosti Since their potency is mild, repea ted treatment is Key Features required to obtain the desired effects. Choice of • Super fi cial and medium chemical peels peel depends on skin type and indication. usually cause mild and transitory side Super fi cial and medium chemical peels usu- effects. ally cause mild and transitory side effects. The • Most side effects resolve spontaneously most common complication is the development even if several months may be needed. of pigmentary changes, which are especially seen • Topical steroids and topical and sys- in patients with dark phototypes. Development of temic antibiotics are useful for treatment this complication may be due to utilization of a of most complications. peeling which is too strong for the patient’s pho- totype or to inadequate photoprotection in the postpeeling period. 1.1 Introduction 1.2 Technology Super fi cial and medium peelings include sali- cylic acid 25–30%, glycolic acid 70%, pyruvic 1.2.1 Glycolic Acid 30–70%/Pyruvic acid 40–60%, trichloroacetic acid 20–35%, and Acid 40–60% [1 – 3 ] combination of salicylic acid or Jessner peel with trichloroacetic acid. Glycolic and pyruvic acid peelings are utilized Super fi cial and medium peelings are utilized to for the treatment of photoaging, melasma and induce a damage limited to the epidermis and pap- postin fl ammatory pigmentation, and acne scars. illary dermis. This results in epidermal regenera- Pyruvic acid can also be used for active acnes. tion and postin fl ammatory collagen neoformation. Advantages • Mild desquamation • Short postoperative period M. P. De Padova ((cid:2)) Disadvantages Department of Dermatology , Nigrisoli Hospital Bologna , • Penetration often not uniform for glycolic Bologna , Italy acid e-mail: [email protected] • Pyruvic acid causes intense stinging and burn- A. Tosti ing sensation during the application and pro- Department of Dermatology and Cutaneous Surgery , duces pungent and irritating vapors for the Miller School of Medicine, University of Miami , Miami , FL , USA upper respiratory mucosa A. Tosti et al. (eds.), Management of Complications of Cosmetic Procedures, 1 DOI 10.1007/978-3-642-28415-1_1, © Springer-Verlag Berlin Heidelberg 2012 2 M.P. De Padova and A. Tosti • Require neutralization can be utilized for the treatment of melasma and • High risk of overpeel if time of application is postin fl ammatory pigmentation. too long or the skin is in fl amed Advantages • Low cost • Uniformity of application 1.2.2 Jessner’s Solution • Penetration can be easily evaluated by the color of frost Jessner’s solution is utilized for the treatment of Disadvantages photoaging, melasma and postin fl ammatory pig- • Stinging and burning sensation during the mentation, and active acne. application Advantages • High concentrations are not recommended in • Excellent safety pro fi le skin types V to VI • Can be used in all skin types • Can cause hypo/hyperpigmentation • Substantial effi cacy with minimal “down time” • Utilized for combination peels as it enhances 1.2.5 Combination Peeling: Salicylic the penetration of other agents Acid 25% + TCA 15–30% [4 , 5 ] Disadvantages • Concerns regarding resorcinol toxicity, includ- Pretreatment with salicylic acid permits to obtain ing thyroid dysfunction a medium peeling with low TCA concentrations • Manufacturing variations and therefore avoids pigmentary complications • Instability with exposure to light and air especially in dark phototypes. • Excessive exfoliation in some patients Combination peeling with salicylic acid + TCA is utilized for the treatment of photoag- ing and acne scars. Combination peeling with 1.2.3 Salicylic Acid 20–30% low concentrations of TCA can be utilized for the treatment of melasma and postin fl ammatory Salicylic acid peeling is utilized for the treatment pigmentation. of melasma and postin fl ammatory pigmentation, Advantages and comedonic and active acne. • Can be used in all skin types Advantages Disadvantages • Established safety pro fi le in all skin types • Risk of overpeeling • Formation of white precipitate allows to verify • Can cause hypo/hyperpigmentation if application is homogeneous • Salicylic acid has an anesthetic effect that is useful in combination peelings 1.2.6 Contraindications to Super fi cial Disadvantages and Medium Peelings • Causes intense stinging and burning sensation during the application Contraindications to super fi cial and medium • Minimal ef fi cacy in patients with signi fi cant peelings include: photodamage • History of hypertrophic scars • Connective tissue disorders • Active skin disorders on the treatment sites 1.2.4 Trichloroacetic Acid 15–35% • History of treatment with systemic retinoids in the previous 4 months Trichloroacetic acid is utilized for the treatment of • Oral anticoagulant treatment photoaging and acne scars. Low concentrations • Pregnancy 1 Complications of Super fi cial and Medium Chemical Peels 3 1.2.7 Prepeeling Care The patient should regularly wear a total sun block between peeling sessions and up to 6 This is essential to obtain uniform penetration and months after the last session. avoid postinfl a mmatory hyperpigmentation. Pres- cribe topical products containing 1–2% salicylic acid, 2–3% pyruvic acid, or 0.05% retinoic acid to 1.3 Epidemiology be applied three times a week for 1 month. Prescribe of Complications 4% topical hydroquinone three times a week for 1 month. Application of these topicals should be Super fi cial and medium peels are widely utilized interrupted 4 days before the procedure to avoid worldwide in both women and men. The relative excessive penetration of the peeling agent. safety of these peelings in dark phototypes Treatment with oral antivirals should be started explains their utilization in different races. 2 days before the procedure in patients with his- tory of recurrent herpes simplex infections. A detailed informed consent should be given to 1.4 Clinical Features the patient at this time to give her/him the possi- bility of understanding the procedure and asking 1.4.1 Minor Local Adverse Reactions possible questions before treatment. We always also provide written information about the proce- • Intense swelling. dure. It is very important to explain clearly to the • Eye irritation due to vapors of the peeling patient that super fi cial and medium peels require solution (e.g., pyruvic acid and TCA). multiple sessions and can improve but not com- • Transitory nose and oral irritation is common pletely resolve photoaging, pigmentary disorders, with pyruvic acid. and acne scars to avoid excessive expectations. • Irritative contact dermatitis: this may be It is mandatory to obtain good quality pictures caused by application of inadequate topical before starting the procedure. This is an essential products (scrubs, exfoliating agents) before documentation for follow-up and for possible complete reepithelization. medicolegal issues. • Exudative erosions: this is due to premature removal of scales and crust and is most com- monly seen after medium-deep peelings. It is 1.2.8 Postpeeling Care very important to instruct the patient to not manipulate the skin after peeling. It is very important to explain the patient to abso- • Prolonged erythema: in some patients, ery- lutely avoid sun exposure and prescribe a sun thema persists after 3 weeks from the proce- block to be applied several times a day. dure (Fig. 1.1 ). These patients require a close For the immediate postpeeling period, the follow-up as they are at risk of developing patient should also apply a moisturizing cream postin fl ammatory hyperpigmentation. If the three to four times a day. The patient should also patient complains of itching, consider contact be instructed to avoid scratching or peeling the dermatitis. Exclude other skin disorders inclu- skin. A mild skin cleanser can be utilized without ding lupus erythematosus. rubbing. • Dishomogeneous skin color: this is due to When reepithelization is complete, which usu- irregular penetration of the peeling agent (Fig. ally takes 7–10 days, the patient can resume 1.2 ). This occurs more frequently in patients application of topical products containing 1–2% with mixed skin as penetration is higher in salicylic acid, 2–3% pyruvic acid or 0.05% retin- greasy as compared with dry skin areas. oic acid, and 4% topical hydroquinone to prepare Possible causes include inadequate prepara- the skin for the next procedure. tion of the skin to the procedure, incorrect