Algorithms for the joint work of a surgeon and a cosmetologist

Modern aesthetic medicine is based on the principles of individualization, personalization of the approach to the patient, to his problems and expectations. Today, many tools have appeared that allow the patient to choose exactly what he needs (injections, RF, cellular technologies, and much more). How can a patient understand all this diversity?

The rejuvenation program is feasible only with the coordinated work of doctors of different specialties. A person comes to the clinic not for an injection and not for an operation. He comes for results. And such a result  is possible only in a team game.

The patient should receive not what you, as a doctor, can do, but what he needs. And in order to optimally and quickly determine how to give it to him, it is necessary to make a correct diagnosis, on the basis of which to develop an individual treatment algorithm.

 

Vladimir Aleksandrovich Tsepkolenko

MD, Professor, General Director of the Institute of Plastic Surgery and Aesthetic Medicine "Virtus"

Comprehensive approach to facial rejuvenation

Unfortunately, as such, there is no specialty  doctor of aesthetic medicine today. When  we talk about gastroenterology, we remember  – there is a gastrosurgeon and a gastrotherapist, in cardiology there is a cardiotherapist and a cardiac surgeon, and in our specialty there is a plastic surgeon representing the surgical part of our specialty, and a dermatologist – as a specialist in the therapeutic part, and if necessary, gynecologists, endocrinologists and doctors of other specialties are involved.

An integrated approach that takes into account the individual characteristics of age-related changes and general somatic health should become the basis of an algorithm for successful work. This approach is the essence of modern aesthetic medicine,  whose slogan is the harmony of beauty and health.

Classification of age-related changes in the skin as an important component of the diagnosis

Until now, there is no unified classification of age-related skin changes that would allow standardizing the actions of a doctor of aesthetic medicine.

Wonderful classification by I.I.Kolgunenko, which  our colleagues still use it today, it was created in 1974, but actually even earlier. It is based on the division into primary and secondary signs of aging.

External signs of aging (according to I. I. Kolgunenko, 1974)
Main	Minor
Lower soft tissue elasticity Dryness, thinning of the skin Wrinkling (wrinkling of the skin) senile deformity	Swelling and swelling around the eyes Porosity Telangiectasias, rosacea, stellate angiomas (ruby bodies) Hypertrichosis, hirsutism Hyperpigmentation Seborrheic keratosis (papillomas, warts, spots) Xanthelasma

 It is very important, when classifying the level of skin aging, to take into account  not only its elasticity, but also  edema, pastosity, density, telangiectasia, pigmentation, porosity, skin neoplasms.

A patient who comes to the clinic and complains of hirsutism also wants to look younger, but sees it in getting rid of unwanted hair that has appeared with age.

The same applies to age-related pigmentation: it is not necessary for everyone to undergo braces or injections, sometimes it is enough to save the patient from such secondary age-related skin changes to make him look younger. Thus, the concept of rejuvenation is much broader than just getting rid of wrinkles.

In 2000, Dr. O.S. Panova presented the classification of facial wrinkles used today.  It is based on the division into three classes of wrinkles, each of which is divided into three subclasses depending on the severity. So, for example, superficial mimic wrinkles belong to class I A, and to class III A – deep mimic, static medium and deep wrinkles, pronounced skin changes.

Class	View  wrinkle
I class	A. Superficial mimic wrinkles
	B. Mimic and superficial static wrinkles
	S. Mimic and superficial static wrinkles, initial changes in skin texture
II class	A. Mimic and static moderate severity; initial skin texture changes
	B. Deep mimic, static moderate severity against the background of changes in skin texture
III grade	A. Deep mimic, static medium and deep wrinkles; pronounced changes in skin texture
	B. Deep mimic, static medium, pronounced changes in skin texture, slight excess skin
	C. Deep mimic, static deep wrinkles; significant excess skin, gross changes in skin texture

 The variety of age-related changes requires individualization of the approach. I sincerely hope that the use of the classification of skin types, taking into account the characteristics of somatic health, developed by me in 2005, can help to understand this.

It was made taking into account the functional diagnostics of the skin and allows you to more accurately choose the tactics of correcting age-related changes for each of the skin types – vascular, atopic, hyperplastic and hypoestrogen.

 

 

Vascular skin type
Histological  features Mononuclear infiltration Tissue swelling Fragmented disorganized collagen Vascular dilatation	Appearances Matte color Shine Vasodilation high humidity Increased sensitivity Mimic wrinkles prevail

 

Atopic skin type
Histological  features Severe edema        fabrics Enlargement of the sebaceous glands Dilatation and deformation of the excretory ducts    sebaceous glands Fragmented disorganized collagen	Appearances Matte color Shine Acne, post-acne Prevail  mimic wrinkles Increased skin moisture

 

Hyperplastic skin type
Histological  features Thickening of the epidermal layer Mononuclear infiltration Disorganization of collagen fiber bundles Atrophy of the sebaceous glands	Appearances Pronounced matte color Lack of shine Declamation of the epithelium Dry skin Reduced sensitivity Gravity wrinkles prevail

 

Hypoestrogenic skin type
Histological  features Thinning of the epidermis Thinning of collagen fibers Smoothing of skin papillae Vasodilation, perivascular edema	Appearances Pronounced pigmentation High porosity Sagging Post Acne Dry skin Statically and gravitational wrinkles prevail

Stages of age-related changes in the skin and necessary interventions

Most often, patients come to the doctor and complain about the appearance of wrinkles. Wrinkles are mimic, static and gravitational. Accordingly, if facial expressions prevail and the skin texture is not changed, then in terms of the class of wrinkles, this is just the first stage of age-related changes that do not require correction, it is more difficult than high-quality skin care.

In the second class, static wrinkles predominate, and involutional changes have led to a change in the texture of the skin, and against the background of these changes, facial ptosis appears, which also has different degrees - initial, medium and more pronounced ptosis. In this case, there is a need for surface treatment, and the beautician decides, depending on the texture of the skin, which combination of technologies to solve the problem.

If we are talking about the third class of wrinkles, gravitational ptosis - this is the competence of a plastic surgeon. However, the third grade A– these are pronounced structural changes in the skin, ptosis that has begun, where you can still do without braces, but with the help of cosmetology. For example, laser technology will significantly improve the appearance of the patient.

Third Class B– ptosis of the middle zone, pronounced changes in the upper  parts of the face, initial changes in the lower part of the face, here the optimal combination of surgery and dermatological procedures, in particular laser

Even in the third grade C, when there is pronounced ptosis, gravitational, static and mimic wrinkles – this does not mean that the beautician will have nothing to do. The surgeon tightens muscles and removes excess skin, but this skin needs to be restored, so the beautician and surgeon have a lot to do together to get the best result.

Peculiarities of diagnosing age-related skin changes

And another important thing to consider when talking about age, skin texture. Today, ultrasound diagnostics has appeared, which allows you to individualize a cosmetology approach based on  evidence-based medicine. That is, suppose the patient has external skin changes that  belong to a certain class of wrinkles.

But we are launching additional research methods, in particular ultrasound diagnostics, and we can really assess the structural changes in his skin, correctly diagnose problems – this belongs to the competence of the beautician.

So  if we are talking about mimic wrinkles of the first class, which disturb the patient, this is an occasion to give him recommendations on skin care.

If superficial static wrinkles appear, this means that in the summer the person had a good rest, did not use sun protection, a lot  smiled, but it is unlikely that involutionary changes occurred in the skin. This only means that the person did not look after himself, and easy care allows you to solve the problem, and ultrasound diagnostics makes it possible  to make sure that there are no structural changes and there is no problem requiring aggressive intervention.

Real dermatological cosmetology begins  where there are changes in the skin structure, for example, hyperkeratosis. In this case, care will no longer be enough, it will not solve the problem.

The patient must receive objective information about the condition of his skin and consciously choose the type of intervention that seems most acceptable to him. He must know that it is possible to restore  the tone and structure of the skin not only by surgery, but also without incisions – for example, you can use botulinum toxin, eliminating the frown and wrinkles, or you can do an endoscopic operation, notching these muscles.

And you can get great results by using your own skin cells – fibroblasts, as well as the method of laser resurfacing, in which the normal structure of the skin is restored and its relief is smoothed.

The need for a comprehensive approach to solving age-related skin problems

It is possible to improve the appearance of patients at any age and with any class of wrinkles. But this is a joint work of surgeons, dermatologists and cosmetologists, when the individual characteristics of the patient's skin are taken into account and a personalized approach to its treatment is chosen.

When choosing the tactics of treating age-related skin changes, it is necessary to take into account the morphology of the skin and the patient's history.

For example, a patient atopic skin. This means that there is a history of autoimmune diseases, and the patient received hormonal therapy, which leads to dystrophic changes in the skin.

If we consider hypoestrogenic skin type, then we must remember: both premature and natural changes in this case can occur due to gynecological and hormonal problems.  The skin is dry, finely wrinkled.

Hyperplastic skin is a genetically determined oriental type of appearance. This is thick skin, which, as a rule, does not have fine wrinkles, but with age, pronounced ptosis is noted.

We have developed an integrated approach – these are  general therapy, cosmetology care, laser technologies, which can significantly rejuvenate the appearance of the skin, tone it, improve its structure and thus avoid the need for surgery, restoring its natural appearance.

Today, this becomes possible thanks to the emergence of new technologies that allow the use of own growth factors, own skin cells - fibroblasts or the patient's own stem cells – that is, those elements that are in an optimal relationship created by nature, both quantitatively and qualitatively. It is these technologies that make it possible to really rejuvenate the appearance of the patient, and not to carry out  short-lived injectable make-up. We will certainly tell you about all this.

We all need to learn, to improve our knowledge. Today it is no longer possible to take aesthetics lightly - & nbsp; this is fraught with a huge number of complications. A collaboration  cosmetologists, dermatologists and plastic surgeons  will enhance real aesthetic results.

To be continued