Preparing the skin for injectable treatments
Prof Beth Briden explains why there’s a lot more to preparing for aesthetic injections than an alcohol swab
Proper skin preparation not only enhances the outcome of a treatment and minimises the complications, it helps to prolong the effects of the treatment, meaning a much happier patient.
Injectables are among the most popular anti-ageing procedures. The American Society of Plastic Surgeons report for 2014 showed a marked increase in injectable procedures, particularly toxins and fillers—up 6% and 3% respectively—with the total number reaching almost nine million procedures. Injections give immediate results, they’re minimally invasive, they have minimal risks of complications, and they are cost effective for the patient—no wonder they are so popular. With anything so popular, it’s vital that we know how to administer the injectables to get the best possible results; and since the effects aren’t permanent, it is the overall effect of the injectable along with the technique that keep patients coming back.
Why prepare the skin?
Using a little alcohol pad before inserting a needle really isn’t adequate preparation for an aesthetic injection.
The most popular injectable procedures, such as toxins, fillers, lipodissolver, even liposuction and surgical procedures, such as the cosmetic surgery and non-ablative or tightening lasers, really don’t have any effect on the skin surface. So no matter how well wrinkles, nasal labial folds and jowls are filled, if there is still dispigmentation and sallowness a rejuvenation effect won’t be apparent.
Whether injecting a neurotoxin into the muscular layer, placing fillers in the dermal layer, or fat dissolvers into the fat layer, there is no effect on the epidermal layer. It’s this epidermal layer which is like the skin’s palette, so effect won’t be as great if that isn’t addressed. Significant improvements in skin rejuvenation can be achieved with injectables. Virtually all wrinkles can be filled in and volume redistributed, but still there are limitations, which require adding additional procedures. Proper skin preparation can provide epidermal improvements that aren’t provided with injectable treatments. Skin can be smoothed, pigmentation evened, pore size reduced, and barrier function improved, so that the skin is more tolerant and less irritable and has a good, healthy glow. The risks of complications such as bruising and infections can also be reduced with proper skin preparation, and augment and even help maintain the effect of injectables.
Step by step skin prep
1. The first step of skin preparation is to take a good medical history, and from this introduce patients to a good skincare regimen, because good, science based therapeutic skincare can greatly improve the epidermis and dermal matrix and maintain the effects of injectables.
Once they are on a good skin care regimen, additional procedures can be performed to deliver surface change, such as a superficial chemical peel, microdermabrasion, or perhaps lasers. IPL can be used on pigmentation in light skinned individuals and fractional lasering for large numbers of wrinkles that can’t be filled. Also, specific treatments can be used to help minimise bruising that can occur with injectables, such as applying topical arnica cream, recommending pineapple consumption for the bromelain effect, stopping use of any blood thinners, and sometimes even vitamin K, although that is not approved in the EU.
In the medical history and consultation ensure that the patient does not have any allergies to substances that could be present in the injectable. Look at their medications carefully, have them stop any of the blood thinners, aspirin, fish oil, vitamin E, NSAIDs, if it’s medically appropriate in attempts to minimise bruising.
Find out if clients are on any immunosuppressive agents, which could make them more prone to infections. Sometimes with injectables, biofilms can develop leading to chronic infections, and immunosuppression can make infections more likely to occur. Thus, you need to be extra careful in your skin prep to ensure a sterile procedure. Chemotherapy agents can also impede healing and increase the risk of infection.
Nutritive supplements and vitamins should not be forgotten. Vitamin E and fish oil can make the patient more prone to bruising and you want to make them aware of that.
Also, take a good history for any systemic diseases. Ensure they don’t have myasthenia gravis if you’re going to be injecting a neurotoxin, or collagen vascular disease, if you’re going to be doing the dermal fillers. If they have a history of cold sores or herpes simplex, you should premedicate with acyclovir, just to make sure that the trauma of the injection doesn’t precipitate an outbreak.
Other important questions to ask in the history include if they smoke and their sun exposure. Smoking impedes healing and could impede the vasculature, so smokers could be more likely to have vascular occlusion with an injectable treatment. Always ask about levels of sun exposure, but most importantly their expectations—because you’ve got to have realistic expectations and try to fulfil what the patient wants, to get the best results.
2. After taking an initial history, take series of photos and perform a consultation so you have a baseline to discuss what the patient would like to see improved and what improvements you can provide. Show your patient what they can expect to see improved on the photo to ensure realistic expectations of the treatment. I use a photography system called Visia which takes standardised photographs along with a computerised analysis comparing the patient’s scores to others their age.
In terms of managing expectations, you just can’t assume what you think needs to be corrected is what the patient wants corrected. Some people like their moles, or a particular mark or spot, or they want to keep their crow’s feet, so you want to make sure that you know their expectations. What’s obvious to you may not be what the patient wants.
3. Outline their plan and create a timeline of procedures—because often it’s unwise to combine multiple procedures on the same day. Certain procedures can cause swelling of the dermis, for example tissue tightening lasers can cause marked dermal oedema, which may cause some of the neurotoxin to migrate and cause adverse reactions. With the IPL and perhaps a filler, if there is redness or irritation you might not be sure what it’s from, so I recommend minimising any risks of complications by doing those treatments perhaps a week apart, or at least a day apart.
Why bother with skincare?
Creating a good skincare regimen is a simple thing for the patient to do and skincare products can provide a very uniform skin surface if they enhance cell turnover and disperse pigmentation to even out the skin tone. They can improve barrier function and reduce inflammation, and also help minimise the risks of bruising by plumping the epidermis from an atrophic skin to a nice, plump, firm skin.
They can also help prevent and reverse signs of photo ageing. Using a sunscreen with some of the active ingredients will also help protect from further photo-induced ageing changes. With scientifically tested and proven skincare products we can achieve nice rejuvenating results—enhancing cell turnover and stimulating new skin in the epidermis and the dermal compartments.
A recent study by Mintel showed that 94% of consumers are using some type of skincare regimen, so it’s our job as physicians and skincare experts to try to direct them to the best products to help reverse their ageing or address their concerns, and there are some decent products out there that can help.
Number one on my skincare regimen list is a sunscreen to help prevent hyperpigmentation from additional sun and prevent further photo ageing.
For stimulating new skin growth and repair and for moisturisation, I prefer the alpha poly and bionic acids as they can be used by everyone. I will also add a retinoid if the skin is not too irritated, or barrier function is not compromised. There are some very effective dermal plumping agents, and antioxidants that can help decrease inflammation and the MMPs that degrade the collagen and elastic fibres, helping to prolong the life of the treatment. Adding a pigment-lightening agent can also reduce the risk of post inflammatory pigmentation.
The trauma from injections has been shown to help stimulate some new skin growth and repair, so we want to try to help enhance the growth by providing some of the substrates to enhance the skin repair.
Where to start
Resurfacing the skin is my starting point—helping to remove the excess dead stratum corneum, increase moisturisation, enhance cell turnover and disperse the pigmentation. Good skin care products for this are the alpha, poly and bionic acids, and a non-acid N-acetylglucosamine. Retinoids are also very effective, if the patient can tolerate these and not be too irritated. Chemical peels, microdermabrasion and fractional resurfacing are also other good treatments to help with this.
Several compounds have been shown to really help improve barrier function. There has been a big buzz in the past couple of years about the need to improve the skin barrier. The alpha, poly and bionic acids have been shown to improve the barrier function for over 20 years. Thus, the AHAs, PHAs and bionic acids are my mainstay for resurfacing and improving the barrier function.
In a 1997 study from the British Journal of Dermatology, Dr Berardesca measured transepidermal water loss as a measure of epidermal barrier function. In this study he took areas of the skin where he applied four different alpha hydroxy acids, glycolic acid, lactic acid, tartaric acid and gluconolactone, a second-generation polyhydroxy acid. There was an untreated site and a vehicle control site. Dr Berardesca treated these areas twice daily for four weeks and then applied sodium lauryl sulphate—a known irritant that disrupts the barrier, under occlusion for six hours. After removing that, transepidermal water loss was measured and all of the alpha and the polyhydroxy acid had improved barrier function. When colourimetry for the erythema and the transepidermal water loss was measured, compared to the non-treated and vehicle site there was no redness.
The study showed the alpha, poly and bionic acids, can all improve the barrier function and sun damage, making a normal basketweave stratum corneum that becomes thinned out and more normal. They can also enhance epidermal proliferation and normalisation with a return of the rete ridges from the atrophic flattened epidermis. Thickening that gives us a little bit more play to apply our dermal fillers down in the dermis without having them show through with the Tyndall effect, and that will also help reduce some of the solar elastosis.
The dermal matrix of the skin is important in providing plumpness and firmness to the skin. Ingredients available in skincare that build the skin’s matrix include: Aminofil, NeoGlucosamine, the polyhydroxy acids, multibionic and lactobionic, and some of the matrixyl peptides. The dermal matrix is comprised of acid mucopolysaccharides such as hyaluronic acid that bathe the collagen and elastic fibres.
Aminofil is a new product that has been on the market as a targeted treatment for over a year and recently introduced for use all over the skin instead of a targeted product for deep lines. Aminofil is an acetylated amino acid derivative of tyrosine, called N-acetyl Tyrosinamide. This has been shown to have marked plumping ability and to generate increased production of glycosaminoglycans, especially hyaluronic acid in the dermal layer. It increases the hyaluronic acid synthesis in fibroblasts and cell culture, also collagen expression of those fibroblasts, and it’s non-irritating and non-stinging.
Clinical studies presented at the 2012 AAD meeting showed that the application of Aminofil twice daily for eight weeks, created an almost a four to fivefold increase in skin thickness just after 12 weeks. It has almost an immediate effect, plumping the skin dramatically, so this will help augment and maintain the effects of later treatments.
NeoGlucosamine is a novel agent that has multiple benefits. It is a natural component of our hyaluronic acid. If you combine NeoGlucosamine with the polyhydroxy acid D-Glucoronic acid or gluconolactone, you have hyaluronic acid.
Hyaluronic acid in itself has not been able to penetrate through the epidermis to reach the dermal compartment where it’s needed, whereas the N-acetylglucosamine has been shown to penetrate through that epidermal barrier to place itself in the dermis where it’s needed. So it binds the water, helps plump the skin. It will help increase the formation and the volume and firmness of the skin.
NeoGlucosamine also has some benefits from being a non-acid exfoliator, meaning it can be combined with retinols. Retinols, in formulation, cannot be in an acidic base, or they degrade and they lose their bioactivity. This product that can be combined with retinols or Retin-A and create a synergistic effect in terms of plumping the dermal glycosaminoglycans and collagen formation.
It also inhibits the enzyme tyrosinase, so creates a pigment lightening effect by causing exfoliation, and by inhibiting new pigment production. Clinical studies show that there is a marked lightening and uniformisation of the pigment in the skin.
Third generation AHAs
Another matrix building ingredient is poly and bionic acids, multibionic and lactobionic acid. These are the third generation alpha hydroxy acids, which apply many benefits to the skin. They’re very strong humectants to hydrate the skin. They’re very potent antioxidants to help prevent the breakdown of MMPs, matrix metalloproteinase, and also lipid peroxidase and heavy metal chelation—so they help preserve the skin. They have also been shown to help prevent ultraviolet induced pigmentation, and are very good anti-ageing ingredients. They will increase the plumpness of the epidermis and the dermal compartment by increasing collagen, hyaluronic acid and in new elastic tissue formation and are also very non-irritating.
Multibionic acid is derived from corn sugar. Lactobionic acid is a natural component of the body. It’s used in organ perfusion baths because it is such a potent antioxidant and humectant. A study done at the AAD in Chicago, which showed the effects in studies on the multibionic and lactobionic acid over twelve weeks showed their plumping ability. Twice-daily application of multibionic acid, showing a marked 50% increase in thickness of the skin.
The multibionic acid and lactobionic acid in a second generation alpha hydroxy gluconolactone has been shown to inhibit MMPs to inhibit the breakdown. A good skincare regimen will help prevent the breakdown with the use of collagenase and the hyaluronidase to help preserve that dermal matrix and the plumpness and firmness of our injectables.
Matrix peptides these help improve collagen formation. They can be combined with retinol and alpha hydroxy acid to get a synergistic effect. They also help increase fibronectin and collagen to again give structural firmness to the dermal compartment.
Necks are another area that we need to address, sometimes, with neurotoxins, and certainly fat dissolvers; there’s citric acid cream that has shown a very nice improvement in tightening and plumping the skin. Plus citric acid has been shown to increase collagen production and the glycosaminoglycans, so I like to use this in conjunction with the lipodissolver, the newer fat dissolvers.
In addition to your little alcohol pads I would strongly recommend using a surgical scrub and using a sterile procedure on this with sterile gloves, because, especially with the injectables, you can get a biofilm developing and there have been some incidences of infections and chronic infections occurring. Ensure that they don’t have any active, open sores and that they’re not a nasal staph carrier. You want to premedicate with Acyclovir if they have a history of herpes simplex, and, if possible, stop their blood thinners and nutritional supplements that can lead to additional bruising.
A good pre-treatment skin regimen is an essential part to my treatment protocol. My advice is to keep things simple—use just a couple of products, but include the hydroxy acids, the retinoids, peptides, antioxidants, and then a sun block, to try to improve that barrier function and thicken the epidermis and dermis. You must prepare the skin prior to the injection. Cosmeceutical peels are a good way to do this to enhance the results and the healing and minimise complications and help prolong the results.
Professor Beth Briden MD is the founder, medical director and CEO of Advanced Dermatology & Cosmetic Institute in Edina, Minnesota. She is an international expert on skin rejuvenation.