April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Plastic and Reconstructive Surgery • January 2019

it. It is important to treat deeper wrinkles with a manual “island technique.” The shoulders of each wrinkle are manually ablated until the wrinkle is ablated (Fig. 2). Attention is directed to the next deep wrinkle, leaving small superficial islands of nonwrinkled tissue with skin appendages to aid in healing the adjacent aggressively treated deeper areas. The goal is to reach the depth need to treat the wrinkle while ensuring reepithelializa- tion within a maximum of 10 to 14 days. Healing within this time implies a second-degree midre- ticular dermis injury, which should heal without scarring. After each pass, the debris is wiped off to assess bleeding endpoints. The desired endpoint is either complete ablation of the wrinkle or a midreticular bleeding pattern. ( See Video, Sup- plemental Digital Content 5 , which demonstrates midreticular dermis bleeding, the maximum depth of treatment, available in the “Related Vid- eos” section of the full-text article on PRSJournal. com or, for Ovid users, available at http://links.lww. com/PRS/D150 .) If the wrinkle seems to be obliter- ated, it is confirmed by rehydrating the area with a wet gauze and waiting 1 to 2 minutes to ensure desiccation did not cause overestimation of the removal of the wrinkle. The more superficial pap- illary dermal endpoint is a fine, pinpoint, robust, bleeding pattern. The bleeding pattern within the deeper reticular dermis shows larger individual bleeding points that are less dense than the pap- illary dermal bleeding points. This is because of the larger, more sparsely scattered vessels that are encountered at this reticular dermis level. All patients received acyclovir as antiviral pro- phylaxis. For patients without a history of “cold sores” or perioral herpes, a dose of 500 mg two

rhytides, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http://links.lww.com/PRS/ D148 . See Video, Supplemental Digital Content 4 , which demonstrates the focused laser ablation of deep perioral rhytides, island technique, available in the “Related Videos” section of the full-text arti- cle on PRSJournal.com or, for Ovid users, avail- able at http://links.lww.com/PRS/D149 .) At this setting, a manual overlap of 50 percent is desir- able and carried out as precisely as possible at a frequency of 2 to 3 Hz to ensure adequate time for movement of the handpiece, and to avoid over- treatment in one area. The goal of this technique is to fully ablate the individual perioral wrinkle or maximally treat Video 4. Supplemental Digital Content 4 demonstrates the focused laser ablation of deep perioral rhytides, island tech- nique, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, available at http:// links.lww.com/PRS/D149 .

Fig. 2. Island technique showing complete ablation of wrinkles on right side with a midreticular dermis bleeding pattern. Compare the treated area next to the untreated wrinkles along the philtrum and contralateral lip with several areas of large scarcely populated ves- sels of the midreticular dermis.

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