Treatment of Perioral Rhytids

Many techniques exist for treatment of the perioral region. Injectable fillers, Botox, implants, lip lifts and lip advancements are all useful techniques to attain lasting results. Resurfacing procedures allow the surgeon another tool to rejuvenate the area. Chemical peels, dermabrasion and laser resurfacing alone or in combination can be used to reduce fine rhytids, and vertical rhytids of the upper and lower lips, as well as superficial scarring in the perioral region. We have found that the best outcomes are often achieved by using a combination of these modalities tailored to each individual patients needs.

Patient Selection

Proper planning begins with a thorough history and physical exam. Attention must be directed to determining any prior procedures performed, previous use of retinoids (iso-tretinoin [Accutane]), prior radiation therapy, and presence of herpes simplex virus infection or previous outbreak. It is imperative to accurately attain any history of cardiac disease, hepatic or renal insufficiency, abnormal scarring, medication use, skin sensitivities, allergy history, and collagen vascular diseases.

Patients taking isotretinoin are at increased risk for scarring [1]. It is therefore recommended to wait 6 months after use of isotretinoin before undergoing chemical peels. This allows for regrowth of epithelial appendages, which are essential for post-peel re-epithelialization [2].

For patients with a known history of herpes labialis, we recommend pretreatment with acyclovir (Zovirax) 800 mg orally three times a day for three to four days before and up to two weeks after the resurfacing. Patients without a herpetic history are also treated with valacyclovir (Valtrex), 500mg orally twice daily for the same time frame or until re-epithelialization has occurred. Prophylaxis in patients with no previous herpetic history is controversial [4]. Some authors advocate prophylaxis only for medium to deep chemical peels [5,6]. However, previous studies have demonstrated a 6.6% HSV infection rate in chemical peels patients with no history of infection (8/121 patients) [3]. (Figure 1)

As with all facial cosmetic surgery, expectation of the patient must be realistic. Patients must understand the nature of complications and the recovery period. Patients requesting deeper resurfacing procedures must understand the increased risks that come with the procedure.

Patients must understand their level of involvement in their recovery period. Patients are required to apply Aquaphor to the treated areas 6 times per day after rinsing and cleaning the resurfaced areas. Patients must accept the requirements of postoperative sunscreen (SPF 30 or higher) and the possibility of blending coloration variabilities with make-up.

Choosing which resurfacing techniques are best used for each individual patient relies heavily on the classification of the patient’s skin type. Fitzpatrick type I and II patients are at low risk for complications of hypopigmentation and hyperpigmentation [5] Bernstein notes that Fitzpatrick skin types III and IV, although at higher risk, are still appropriate for chemical peeling. These patients may regularly develop up to 3 months of hyperpigmentation in the post-operative period. Skin types V and VI should be limited to only superficial chemical peels [6].

Glogau further classifies the skin according to clinical photodamage. Group 1 is best suited for medical (retinoid) skin care and superficial peeling agents. Groups II and III are also good candidates for medical skin care. Most agree that group II and II patients are treated appropriately with superficial and medium peels, although deep resurfacing techniques may be applicable in select patients desiring a dramatic result. Group IV patients (Figure 2) are best treated with medium and deep peeling agents or CO2 laser resurfacing [7].

Pre-operative Preparation

All patients are prophylactically treated to prevent HSV infection. For all chemical peels, dermabrasion and laser resurfacing, tretinoin (Retin-A, Renova) is used topically for 2 to 4 weeks before the procedure. This exfoliates keratinocytes, thins the stratum corneum and activates fibroblasts. This series of events facilitates the depth of the peeing agents and results in a more uniform result [2]. Retinoid use is stopped for three months after the procedure to allow uniform re-epithelialization and maturation of the skin [11]. For patients with Fitzpatrick type II or IV skin, hydroquinone gel 4% is also used in the pretreatment regimen. This reduces melanin precursors by blocking the enzyme tyrosinase and can be used both preoperatively and post-operatively [5, 8].

Chemical Peels

Superficial Peels

Superficial peeling agents target the level from the stratum granulosum to the upper papillary dermis. Agents include low concentration glycolic acid, 10% to 20% trichloroacetic acid (TCA), Jessner’s solution (14g resorcinol, 14g salicylic acid, 14ml lactic acid, and 100ml ethanol) tretinoin, 5-Flourouracil (5-FU) and salicylic acid [9]. These peels are most useful for mild conditions such as post-inflammatory erythema, mild photoaging or comedonal acne in the perioral region. During application patients experience a mild stinging sensation and level 1 frosting (erythema and streaky whitening) [10]. Recovery time depends on the number of applications and strength of agent but commonly ranges from 1 to 4 days. Maximal results are obtained with weekly or twice monthly sessions. Often the most superficial agents are too superficial to treat vertical rhytids of the upper and lower lips.

Medium-depth Peels

Medium depth peeling agents extend the level of tissue injury to the mid and lower papillary dermis. Commonly used agents include 35% TCA with Jessner’s solution, 35% TCA with 70% glycolic acid, 35% TCA with carbon dioxide (CO2) laser treatment or phenol 88%. These agents may also be successfully utilized as a blending agent through the rest of the face when other resurfacing modalities are used in the perioral region. Dermabrasion, CO2 laser resurfacing or deep chemical peels may leave behind areas of skin color tone demarcation if used in the perioral region alone (Figure 3). By blending the face and neck with Jessner’s solution and 35% TCA we have been able to achieve a more uniform skin tone result.

Regional anesthesia with 0.25% Marcaine (Bupivacaine) with 1:200,000 epinephrine is used to provide prolonged comfort. The procedure is to be done under IV or sedation. The skin is thoroughly cleansed with acetone. Jessner’s solution is applied in a uniform matter. Erythema and a faint frosting appear within one minute. After the Jessner’s solution has dried, 35% TCA is applied evenly with cotton swabs. The amount of TCA delivered depends on the number of applications, the amount of pressure applied to the skin, and the contact time with the peel solution. A white frost appears in 30 to 120 seconds after application (Figure 4). Before retreating an area, one should wait 3-4 minutes to ensure frosting has peaked. Frosting indicates keratocoagulation. An appropriate endpoint for medium peeling is a uniform white frost.

Cool saline gauze is placed over the areas of peeling for comfort. The face becomes erythematous 12 hours after the peel and will continue to develop edema for the first 48-72 hours. The edema slowly resolves and new erythematous epithelium appears on postpeel day 5-7. Completion of the epithelialization process occurs on day 10, at which point it is safe for the patient to apply appropriate makeup. A mild 2.5% non-fluorinated topical steroid is prescribed to use under makeup and moisturizer to reduce redness and inflammation. Lingering areas of non-epithelialized skin may be covered with Duoderm (Bristol-Myers Squibb, Princeton, New Jersey) covering to allow the epithelialization process to conclude. A consultation with an Esthetician at postpeel day 10 will help educate the patient on the safest products to use and how to best camouflage resolving erythema. Sunscreens are started as necessary and the patient is instructed to avoid services such as superficial peels and microdermabrasion for 3 months. Another medium-depth peel should be avoided for at least one year [11].

Deep Peels

Deep chemical peel agents create an injury to the level of the upper to mid-reticular dermis. This is most commonly performed using the classic Baker-Gordon solution [12]. This consists of: 3ml phenol 88%, 8 drops Septisol, 3 drops croton oil, and 2mL distilled water. This type of peel is best suited for the Glogau group II and IV patients. In contrast to the keratocoagulation seen with phenol peels in higher concentration, the Baker peel results in denaturation of the keratin when applied to the skin. As the sulfur bridges between the keratin molecules are disrupted, the chemical peel penetrates deeper. The depth is augmented by croton oil, which acts as a skin irritant, and Septisol, which lowers the surface tension of the skin. By reducing the number of drops of croton oil, one may reduce the depth of the peel.

Ideal candidates for a deep peel are a fair complexion, with fine or course rhytids, and are not averse to mild hypopigmentation [13]. Patients must also accept the significant risk of complication and increased potential morbidity associated with deeper peels. These include potential scarring, hypopigmentation, textural changes, and cardiotoxicity [10].

Application of the peel solution is done with a cotton tip applicator. Prior to painting the solution over the entire perioral area, the tip of a broken wooden applicator may be used to apply the solution to the depth of the prominent perioral rhytids [14,15]. The peel should extend 2 to 3 mm beyond the vermilion border [16].

Patients are placed on a methylprednisolone taper to reduce swelling. Patients are given a seven-day course of antibiotics and are encouraged to take 1 to 2 grams of vitamin C per day. The day after the peel patients are instructed to wash their face with warm water only, five to six times per day, with subsequent reapplication of petrolatum or Aquaphor in thick frosting-like layers.

The patient is seen on postoperative day 1, and complete wound care instructions are demonstrated, and then followed closely on postoperative days 3, 7 and 10. If one observes an adherent yellow-green crust, which is characteristic of pseudomonal infection, it should be treated with wet-to-dry acetic acid soaks and oral Ciprofloxacin [4,17]. All patients are put on hydrocortisone cream at day 10 or when epithelialization is complete. Patients are counseled on the use of sunscreens for 6 months post-peel, with no direct sunlight exposure for at least 6 weeks after the procedure [17]. Post-inflammatory hyperpigmentation is usually transitory and can be treated with 4% hydroquinone bleaching agents.

Erythema and hypersensitivity 2 to 3 weeks after re-epithelialization is treated with Hytone (Dermik Laboratories, Collegeville Pennsylvania) cream 2.5%. We prefer to wait at least 3-6 months before starting Retin-A (Tretinoin, Ortho Biotech Inc., San Bruno, California). (Figure 5)

Dermabrasion

Dermabrasion is another resurfacing modality with great utility in the perioral region. In our experience, dermabrasion remains the best single modality for treatment of deep perioral and lip rhytids. Even the deep Baker’s solution chemical peel tends to leave more residual rhytids than dermabrasion. General indications for dermabrasion include acne scarring, and grade III and IV perioral rhytids. The mechanism of dermabrasion is mechanical injury of the skin to the level of the papillary and reticular dermis. After treatment, types I and III collagen deposition and re-epithelialization ensue, covering a more refined dermal landscape [18]. Total eradication of every scar or rhytid is not expected. [19]. As with other resurfacing techniques, the patient must commit to an intensive postoperative wound care regimen. Healing times range from 10 to 14 days.

Dermabrasion hand pieces commonly offer revolutions per minute (rpm’s) in the 1500 to 35,000 range with reversible rotation to accommodate both left and right-handed surgeons. Drill bits include a diamond fraise, wire brush, or a serrated wheel. The diamond fraise tips are slowest at abrading the skin but allow for a more controlled injury, whereas the wire brush and serrated wheel are more aggressive. After adequate anesthesia including regional blocks (0.25% bupivacaine with 1:200,000 epinephrine) refrigerant spray is applied to the area. Areas are blocked off with gauze to prevent inhalational injury of the refrigerant spray. Dermabrasion is performed with each cooling of the skin. Slow and even pressure is applied at right angles to the skin in the direction of the relaxed skin tension lines. Extreme care must be taken to make sure the diamond fraise tip is rotating away from the vermillion border, i.e., in reverse mode for the upper lip and forward mode for the lower lip. Firm counter traction is maintained with an assistant. When using the diamond fraise tip, one can follow the removal of the epidermal layer, then the small capillary loops in the papillary dermis, which disappear as the openings of the sebaceous glands in the upper reticular dermis become evident [15, 20]. Care must be taken to avoid crossing the mandibular border. Be extremely cautious over the chin and upper lip areas. Untreated areas may be blended with medium depth chemical peeling.

In the perioral region, Xeroform dressing is applied to the area in the immediate postoperative time period. Great care is taken to assure flat adherence of the Xeroform to the treated perioral region, to allow bonding of the dressing. The Xeroform dressing dries to the treated area over the first postoperative day, and acts as a protective and analgesic buffer to allow proper scrubbing and cleansing of the area in the postoperative period. Warm water is used to remove serum and crusting from the face, and a thick coat of Aquaphor or petrolatum is applied six times daily. Postoperative care follows the same guidelines of medium to deep chemical peels. Complications are similar to that of chemical peels, and postoperative infections are handled in the same manner as described for chemical peels. (Figure 6)

Laser Resurfacing

CO2 Laser

Co2 laser is the most common resurfacing tool in our patient population. Developed in the 1960’s, the 10,600-nm wavelength CO2 laser is absorbed primarily by water, hence its mechanism of action for selective tissue destruction. CO2 laser is effective in treating fine and medium depth perioral rhytids, scars and photo damaged skin [21]. Healing is faster than a Baker’s solution phenol peel, although the post-laser erythema may last for up to 3 months [22].

Today’s CO2 lasers are used with sophisticated pattern generators that are adjustable to accommodate practically any area of facial skin. Energy settings are selected to determine the fluence (Joules/cm2), which in turn determines the depth of tissue injury with each firing of the laser. First passes usually reach the upper papillary dermis (Figure 7). This can be confirmed visually as the dermis appears pink. Second passes over resurfaced areas are reduced in their fluence and achieve a tissue injury at the level of the reticular dermis. This results in a distinctive yellow or chamois color. This is a sufficient endpoint for most resurfacing needs. Repeated passes transfers heat to the reticular dermis layer with the risk of postoperative scarring [11, 23]. Emphasis is placed on feathering the laser ablation at the periphery of the treatment areas to avoid sharp demarcation. In particular, blending across the jaw line onto the neck is an effective way to camouflage the transition from treated to untreated skin. (Figure 8)

Combination

Chemical peel resurfacing, dermabrasion and laser resurfacing have been used successfully in treating of the perioral region. Although each modality can be used successfully on its own, our experience has determined that combining these applications, and tailoring treatment for each individual patient's needs leads to superior results. An important caveat of combination resurfacing is to avoid abrasion of the skin before chemical peeling. For example, we recommend a chemical peel to be performed first, and then use the CO2 laser and finally, dermabrasion to complete the deepest resurfacing treatment.

Conclusion

Many treatment options exist for rejuvenating the perioral region. We have found that appropriate patient selection, counseling and technique have yielded a consistent result with high patient satisfaction. The astute surgeon will customize and individualize his or her treatment to the needs of each patient. The ability to employ all modalities gives one greater flexibility in combining treatments and achieving maximal results.

REFERENCES

Bernstein EF. Chemical Peels. Semin Cutan Med Surg March 2002; 21(1): 27-45.
Revis DR, Seagel MB. Skin Resurfacing: Chemical Peels. Emedicine. http://www.emedicine.com/ent/topic625.htm
Perkins SW, Sklarew EC. Prevention of facial herpetic infections after chemical peel and dermabrasion. Plast Reconstr Surg 1996; 98(3): 427-33.
Alt TH. Occluded Baker-Gordon chemical peel. J Dermatol Surg Oncol 1989; 15(9): 980-93.
Monheit GD, Chastain MA. Chemical peels. Facial Plast Surg Clin North Am 2001; 9(2): 239-55.
Brody HJ, Hailey CW. Medium depth chemical peeling. J Dermatol Surg Oncol 1989; 12:1268-75.
Glogau RG, Matarasso SL. Chemical facial peeling; patient peeling and patient selection. Facial Plast Surg 1995; 11(1): 1-8.
Gladstone HA, Nguyen SL, et al. Efficacy of hydroquinone cream (USP 4%) used alone or in combination with salicylic acid peels in improving photodamage on the neck ad upper chest. Dermatol Surg 2000; 26(4): 333-7.
Cuce LC, Bertino MCM et al. Tretinoin peeling. Dermatol Surg 2001; 27(1): 12-14.
Monheit GD. Chemical peeling vs laser resurfacing. Dermatol Surg 2001; 27(2): 213-14.
Perkins SW, Gillum TG. Management of aging skin. In: Cummings C et al Otolaryngology head and neck surgery. Philadelphia. Elsevier.
Baker TJ, Gordon HL. The ablation of rhytids by chemical means: a preliminary report. J Fla Med Assoc 1961; 48:451.
Asken S. Unoccluded Baker Gordon phenol peels. J Dermatol Surg Oncol 1989; 15(9): 998-1008.
Branhan GH, Thomas JR. Rejuvenation of the skin surface: chemical peel and dermabrasion. Facial Plast Surgery 1996; 12(2): 125-33.
McCollough EG, Langsdon PR. Dermabrasion and chemical peel: a guide for the facial plastic surgeon. In: McCollough EG, Langsdon PR, editors. Chemical Peel. New York: Thieme; 1988.
McCollough EG, Hillman RA. Chemical Face Peel. Otolaryngol Clin North Am 1980; 13(2): 353-65.
Perkins SW. Complications of chemical face peeling: prevention and management. Facial Plast Surgery 1995; 11(1): 39-46.
Harmon CB, Hanke CW. In: Coleman WP, Lawrence N, editors. Skin Resurfacing. Baltimore, MD: Williams and Wilkins; 1998. p. 89-96.
Fulton JE. Dermabrasion, chemabrasion, and laser abrasion. Dermatol Surg 1996; 22:619-28.
Yarborough JB, Coleman WP, Lawrence N. Wire brush dermabrasion. In: Coleman WP, Lawrence N, editors. Skin Resurfacing. Baltimore MD: Williams and Wilkins: 1998. p 97-110.
Trimas SJ, Bordeaux CE et al. Carbon dioxide laser. Archives of Fac Plast Surg 2000; 2:137-40.
Kauver ANB, Dover JS. Facial skin rejuvenation. Dermatol Surg 2001; 27(2): 209-12.
Alster TS, Lupton JR. An overview of cutaneous laser resurfacing. Clin Plast Surg 2001; 28(1): 37-52.
Wheeland RG. The future of laser resurfacing. In: Coleman WP, Lawrence N, editors. Skin Resurfacing. Baltimore, MD: Williams and Wilkins; 1998. p. 195-204.
Kock BB, Perkins SW. Simultaneous rhytidectomy and full face carbon dioxide laser resurfacing. Arch Facial Plas Surg 2002; 4:227-33.
Price CR, Carniol PJ et al. Skin resurfacing with the erbium: YAG laser. Facial Plast Surg Clin North Am 2001; 9(2): 291-302.