28. Elimination of roughness and festoons of the lower eyelid by means of mixed timedsurgical peeling
KEYWORDS: eyelid wrinkles, mixed timedsurgical peeling, timedsurgical de-epithelialization, Timed, resorcin
Mixed timedsurgical peeling with de-epithelialization is the only technique capable of eliminating roughness and festoons from the lower eyelids by means of a standardized, safe treatment. Mixed peeling rejuvenates the patient’s look in a single session by eliminating wrinkles and hyperpigmentation. It is called mixed because it combines physical and chemical processes.
The area to be rejuvenated is marked out with a dermographic pen. The design extends to the crow's feet.
A local anesthetic is administered through a 25 G cannula. Before local anesthesia is performed, a saturated solution of resorcin is prepared. Resorcin powder is placed in a container, to which a small amount of water is added.
The Timed apparatus (Korpo) is programmed with the specific data for pulsed timedsurgical de-epithelialization: Direct Pulsed 4/9 hundredths of a second, Coag, 2 Watt. An EM10 Yellow electromaniple is used, the electrode of which is bent at an angle.
The edge of the corner of the electromaniple skims the surface of the skin inside the design in small circular movements.
The specific pulsed current of the Timed apparatus (Korpo) lifts the epidermis from the dermis. Brushing the surface concentrates the current at the point of contact. To ensure optimum conductivity, the operator cleans the electrode repeatedly with his glove. If the skin is dry, it is moistened with saline to improve its conductivity. The epidermis is lifted in an area that extends from immediately below the eyelashes to just beyond the preoperatively drawn line. The physical action of the current of the Timed also extends to the lower crow's feet. Even if the crow's feet are not very evident, it is always necessary to intervene in this area in order to balance the reorganization of the connective fibers. If this region is not treated, only downward skin retraction will be achieved, while retraction should also be lateral. Once the activated electromaniple has been brushed over the entire skin surface to be rejuvenated, the epidermis is removed with the same non-activated EM 10 Yellow electrode. If any fragments of epidermis fail to detach, the operator brushes them with the edge of the corner of the activated electromaniple and then removes them. When the electrode is activated, it must not come into contact with the dermis. The integrity of the dermal papillae ensures uniform absorption of the resorcin.
The de-epithelialized area is washed and dried.
Preparation of the resorcin is completed.
A syringe is used to aspirate 1 ml of physiological solution and 1 ml of saturated resorcin solution; in this way, a saturated solution diluted to 50% is produced.
The chemical phase of the procedure now begins. The resorcin solution is applied to the de-epithelialized skin with a cotton-wool stick.
On contact with the dermis, the resorcin causes immediate "frosting". As is known, resorcin in an aqueous solution has no effect on intact skin. However, if it is applied to de-epithelialized areas, it acts effectively, constantly and uniformly.
The solution is applied for 30 to 40 seconds, according to the depth of the wrinkles and the characteristics of the skin. The resorcin is removed with saline solution.
The 50% diluted saturated solution is applied to the lower eyelids for a maximum time of 40 seconds. By contrast, to eliminate crow's feet, it has to be applied for a longer time, for example 1 minute. However, the removal of crow's feet is rarely requested.
Once mixed peeling has been carried out on one eyelid, the contralateral eyelid is treated.
In the first few hours, the patient dries the eyelids with a paper tissue. Resorcin has a coagulative action and exerts its healing effect under the crust. No creams, lotions, serums etc. must be applied to the treated area. After a few hours, a thin crust forms, which thickens over time. After 7 -12 days, the crust drops off spontaneously. Once it has dropped off, the patient waits one day, to allow keratinization of the epidermis. Subsequently, color correctors and zinc oxide creams are applied.
After a month, a slight redness can still be seen; this will disappear within a short time.
Timedsurgical mixed peeling eliminates eyelid wrinkles and festoons. The skin is firmer and its texture is improved. A single treatment session also eliminates dark circles.
Rejuvenation of the lower eyelids can be completed by correcting sunken dark circles by means of Adipofilling; this involves injecting a suspension of small fragments of adipose lobules, a suspension of single adipose and stromal cells, or a combination of both suspensions.
We have not performed lower blepharoplasty by means of skin excision for more than 25 years. Indeed, we only perform transconjunctival blepharoplasty, which requires only two incisions of approximately 1 cm in the conjunctiva. Fat pouches are removed by means of the rapid pulsed cutting mode of the Timed apparatus. All the pouches are removed. Once the pouches have been removed, no excision of the eyelid skin is required, as the skin adapts to the concavity that is created by the complete removal of the pouches. In patients with aged eyelid skin, we rejuvenate the skin by means of timedsurgical mixed peeling after a few months.
With transconjunctival blepharoplasty, the eyes do not become round, as often happens after blepharoplasty by means of skin incision; rather, they remain natural and young-looking.
If the patient has already undergone blepharoplasty with skin incision and has rounded eyes, any residual fat pouches can be removed and elastic canthopexy can be performed; this is a new procedure that does not leave any skin scars.
Capurro S. (2023). Elimination of roughness and festoons of the lower eyelid by means of mixed timedsurgical peeling. CRPUB Medical Video Journal. Elastic Plastic Surgery section. https://www.crpub.org
Mixed peeling means physical-chemical peeling. Why do you prefer this?
The physical phase makes the skin amenable to treatment, thereby enabling the peeling solution to act; when applied to intact skin, it has no effect. In practice, the skin can be micro-perforated by means of Electroporo Cosmesis, permeabilized by means of 0.5 mixed peeling or, as in this case, de-epithelialized. De-epithelialization allows the resorcin solution to act effectively on all geometric points the surface of the skin. The result is an extremely effective, safe, and constant action. The physical phase eliminates the variable that is constituted by the thickness of the epidermis. When the resorcin solution makes direct contact with the dermis, it exerts its peeling, cross-linking and powerful depigmenting actions. Depigmentation also takes place through the reduction of the number of melanocytes in the treated area. In some cases of generalized vitiligo of the face, the natural pigmentation of the skin can be eliminated.
Can de-epithelialization also be performed with a laser?
The use of a rectilinear form of energy, a light beam, is useless in most dermatological applications. If a skin formation is vaporized with a laser, deep lesions are created, which should be avoided. De-epithelialization cannot be performed by means of lasers, as it is not possible to keep the dermis intact. In mixed peeling, by contrast, the dermis remains perfectly intact and can adequately absorb the chemical solution.
To enable the Timed apparatus (Korpo) to detach the epidermis, we had to design a specific high-frequency current. This current travels at the speed of light, but returns to the electrode positioned on the surface of the patient's body; thus, suitably modulated, it causes no damage in depth.
Why use a cannula for anesthesia?
In patients who are prone to skin hyperpigmentation of the eyelids, we prefer to use a cannula for local anesthesia, so as to avoid possible bleeding and the associated inflammation of the tissues caused by the free iron ions that are released from hemoglobin.
Why is it also necessary to de-epithelialize the crow's feet?
Even if the crow's feet are not very evident, it is always necessary to intervene in this area, in order to balance the reorganization of the connective fibers. If this region is not treated, only downward skin retraction will be achieved, while retraction should also be lateral.
In which other procedures is Timed de-epithelialization used?
Mixed peeling by means of timedsurgical de-epithelialization is also used to eliminate lip wrinkles (about 1 minute and a half) and extensive dermal-epidermal skin spots in subjects with a uniform complexion (about 20-30 seconds). We have also used it in the treatment of large nevi of the scalp within the first 10 days of birth.
Timedsurgical de-epithelialization is used for the repigmentation of stable vitiligo, piebaldism and achromic scars. In these cases, the achromic epidermis is replaced with grafts of autologous keratinocytes and melanocytes obtained from the cultivation of a 1 cm2 fragment of normal-pigmented taken 20 days earlier. In Timedsurgery, the other two mixed peeling procedures are Electroporo Cosmesis and epidermal permeabilization or 0.5 mixed peeling.
What is the role of Adipofilling in the eyelid region?
Adipofilling is a recent technique of lipoaspirate preparation. The Adipopimer creates a suspension of small lobular fragments consisting of 5-6 cells in 6 seconds. In 30-40 seconds, it creates a suspension of single adipose and stromal cells. In this region, we normally use both suspensions: to fill sunken dark circles, to fill the upper portion of the upper eyelids, to reduce the aperture of the eye, to enhance the volume of the malar regions, and to correct the forehead and temporal regions. The Adipofilling suspension is made up of living material which, once grafted, has a high survival index. Moreover, it can be stored at -31°C to -81°C, as separation by means of the suction vortex created by the Adipopimer makes it resistant to freezing. Its effects are volumetric and/or regenerative. Owing to its characteristics, Adipofilling is the ideal technique for facial rejuvenation, whether for the purpose of enhancing volume or symmetry or, when applied intradermally, to rejuvenate the skin (lip wrinkles and elastosis of the neck). The cathelicidin produced by the adipocytes prevents infectious complications.
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