A change of complexion in the face is very important to first diagnose the internal organs imbalance, may be said ‘ Aging’ most of the time but can be coupled up with many other reasons like decrease in kidney function, or dryness with wrinkles, fat loss of face, hair loss, pale complexion, premature greying, tanning of skin even facial asymmetry where that can be related to myofascial tightening or facial nerve palsy or TMj disorder, if you go on listing, there are many more conditions found on face.

So its very important to diagnose with the detailed history of a patient where we can find out the cause of underlying condition with the energy loss or deficiency or energy excess in the body and treat with an acupuncture along with Aesthetic treatments like botox injections or fillers or chemical peels to treat s well as to look radiant with coupling both the treatments together for a better results.

It helps us to treat the cause from the root, and also to take care of side effects if any, and also to accerelate the effects of the treatment.

Cosmetic acupuncture is always done with Meditation in my Acu- Slim wellness Clinic, so that it helps patient to calm your mind and skin too. It helps to reduce stress, to get better sleep and to improve skin texture.

Our chromosomes (genes) are made up of Telomeres at the end; which get shorter with Aging. Studies have shown that stem cells count of blood and increased telomere activity may delay Aging process, which happens with meditation.

For this study together, we need to know our SKIN in depth with the muscles of face and neck, also the blood supply to the face and neck. Same time to learn the intrinsic factors like anatomical variations or lipid composition or skin rigidity, also hormonal changes, And same time extrinsic factors which can be another cause of Aging like sunlight exposure, smoking, high temperature.

With Aging, we lose Hyluronic acid which is a moisturizing substance helps to retain collagen and provide flexibility and elasticity of skin.

collagen fibres is a building block of skin, it makes 70% of proteins to keep its volume, here acupuncture helps to rebuild collagen fibres in ligaments and tendons. 

Equally to know the bones and their position and 3 types of muscles, 1st skeletal like masseters, 2nd group of expression muscles, for emotions and speech, last is postural sustaining a certain amount of tension against gravity, around neck are very important part of this study and practice. 

Facial muscles are unique structure as one side they are attached to bones, as an anchor, it contracts pulls skin towards anchor manipulating expression and speech, other side to the skin of face.

Same time, we can correct our smile, by correcting the symmetry of face where some muscles are overused, adjusting Muscle tensegrity of facial musles .

For eg. When one side of masseter bigger than other, can release tightened one with additional effect like less teeth grinding, better sleep and  a symmetrical face.

Three principles of Cosmetic Acupuncture:

St 4 acupuncture point can be used for all this 3 purposes.(lateral to the corner of mouth, below the pupil of eye. ).5 cun towards st 6.

 There are 15 the most used local points on face , stomach meridian covers the most part of face,gall bladder, large intestine and triple burner channel also covers each part of face.

With this cosmetic acupuncture on face coupling with local beneficial acupuncture points on our body, can correct the underlying problems and to boost it aesthetically, we can do other treatments to sustain the look without having dynamic or static wrinkles , or dryness on face.

There are fillers treatment, chemical peels, botox injections , laser treatments for rejuvenation of face.

During aging process, the face starts losing fat and volume while the skin loses collagen and elasticity. 

Accentuated by full cheeks and curves in youth, the aging face becomes framed by bony countours wrapped with thin skin, lending a deflated and fallen appearance. The older face has 

loss of cheek, temporal volume

Sharpening of curves, square face

Wrinkled loose skin

Drying and atrophy of skin.

In addition, there are intrinsic factors like Genetic, Hormonal and biological causes and Extrinsic but controllable like Photodamage by UV rays of Sun, Stress, crash diets and unhealthy lifestyle, smoking and pollution.

This can be corrected by all these tretments and can achieve following goals of rejuvenation.

 

At epidermal level: 

Improve quality and function of keratinocytes

Control irregular pigmentation

Smooth , radiant glow to the skin

Optimize cell turnover.

At dermal level;

Improve collagen formation by fibroblasts.

Restore lost volume in the face.

Corrects wrinkles.

Improve skin hydration.

INDICATIONS OF BOTULINUM TOXIN. (BOTOX)

1.Cosmetic & Anti-Ageing. 

2.Dental. 

3.Chronic Pain & Muscle spasticity. 

4.Hyperhidrosis. 

5.Psychiatric  

Indications-Mood disorders and depression. 

 

COSMETIC INDICATIONS. 

1. Dynamic Wrinkles- Frown lines, forehead lines, Crows feet. 
2. Nefertiti Lift- Platysma Injections  
3. Masseter Shaping 
4. Jawline Shaping. 
5. Marionette lines & Chin Rejuvenation.
6. Microbotox for Skin Radiance. 

 

DENTAL INDICATIONS. 

1.Masseter Hypertrophy 

2.Bruxism 

3.TMJ Pain 

4.Re-training of muscles during denture trials. 

5.Jawline Shaping. 6.Gummy Smile. 

 

CHRONIC PAIN INDICATIONS. 

1.Migraines. 

2.Cervical Dystonia. 

3.TMJ Pain 

4.Muscle spasticity.

This is commonly done for Eyebrow lift,forehead lines, crow’’s feet,frown line, square jaw, nasal bunny lines, smile lifts, dimpled chin, neck lines.

CONTRAINDICATIONS TO BOTOX.

 

 

• Pregnancy & Lactation 

 

• Multiple sclerosis 
• Myasthenia gravis, Eaton-Lambert Syndrome
• Hypersensitivity to any of the components (Albumin).

 

Caution –Aminoglycoside antibiotics,Aminoquinolines. 

Unrealistic Expectations 

 

PRE-TREATMENT INSTRUCTIONS 

• Caution with aspirin, blood thinning agents 
• Stop Vit C,Vit E,ginseng,green tea,ayurvedic medicines.  
• Amla preparations  
• Topical anaesthesia 

 

  POST TREAT  MENT INSTRUCTIONS.        

• No lying flat -4 hours 
• No strenuous exercise/ no heat exposure-48 hours. 
• Clean face gently- No vigorous rubbing! 
• Avoid make -up & alcohol for 24 hours. 
• No facials  ,parlour procedures or any other cosmetic treatments for 1 week. 
• No steam /sauna for 1 week 
• Follow –up after 10 days. 
• Avoid touch-up and additional doses before 10 days

FILLERS

Hydrates the skin by holding in water, gives volume and countering to the face.

HA dermal fillers:

These  are polysaccharides derived from fermentation of bacteria.This Hyluronic acid therapy is most popular choice for temporary filler for facial augmentation.

This is safe non surgical procedure that conveniently softens facial lines and furrows.

Pre-Procedure Instructions

• Stop green tea,Vit E ,Vit C,ginseng preparations 72 hours prior. 
• Aspirin & anticoagulants to be continued. 
• Wash  face thoroughly. 
• Photograph & Consent 
• Sterile precautions 
• Local anaesthetic cream may be used to numb the treatment area. 
• Nerve Blocks 
• Ice packs –prevent bruising 
• Injection Method-Operator dependant.

Post Treatment Instructions.

• Ice packs.
• No make-up for 12 hours.
• No heavy exercise.
• No Steam/sauna/massage for 3 days.
• Follow-up after 1 week

 

Post Treatment Instructions.

• Ice packs.
• No make-up for 12 hours.
• No heavy exercise.
• No Steam/sauna/massage for 3 days.
• Follow-up after 1 week.

 

CHEMICAL PEELS:

SKIN

The skin is the largest organ in the body. The surface area of the skin on an adult human body is 1.5 -2.0 square metres and the thickness varies on different parts of the body.The skin on an adult skeleton weighs approximately7% of total body weight. Generally the skin is between 1-2 mm all over the body.  It is thinnest over the eyelids (0.5 mm) and thickest (4mm)over the soles. The skin is divided into 3 layers. The epidermis,the dermis and the subcutaneous layer.Each layer has unique features and distinctive skin functions. The epidermis is the outermost layer of the skin and is composed of four types of cells. Keratinocytes, melanocytes, Langerhan’s cells, and Merkel cells. 

 

Functions of the skin.

 1.Protection from external aggression of all kinds. 

2.Sensation. 

3.Temperature Regulation. 

4.Giving shape to various body parts. 

5.Excretion of small amount of salts and organic compounds.

 6.Immune function. 

7.Synthesis of VIt D. 

 

Clinical Signs of Photoageing.

 Textural Changes:

Wrinkles Dilated Pores, Dry and rough skin, Solar elastosis, Sagging and laxity. 

Pigmentary Changes

Hyperpigmentation and mottled pigmentation. Freckles Hypopigmentation Sallow discolouration.

 Vascular Changes. 

Telangiectasis Erythema ,Degenerative changes. 

Glogau Classification of Photoageing.

Skin Resurfacing with chemical peels also known as Epidermal exfoliation or dermal peeling. The popularity of  chemical peels lies in the simplicity ,efficacy and versatility of the procedure.

It is inexpensive and has good results with minimal downtime.

The regenerated skin is smoother ,less wrinkled and less pigmented  than the original skin.

Basic mechanism of action of a peel.

 A chemical peel creates a controlled injury of specific skin depth with the goal of stimulating new skin growth and improving surface texture and appearance. Classification of peels and depth of action.

1. 1. Very Superficial – Penetrates upto the stratum spinosum, improving skin texture in dull skin.
2. Superficial Peels – Penetrate only the epidermis can be used to enhance treatment for acne, tanning, melasma and skin dyschromia. 
3. Medium/Depth Peels – Penetrate to the papillary dermis can be used for dyschromia,pigmentation and superficial acne scars    .
4. Deep Peels – Penetrate upto reticular dermis.Choosing the right peel with clinical correlation is important for success of procedure.  

 

Factors affecting depth of peel.

• Chemical Peeling agent. 
• Concentration and pH of agent. 
• Application time and quantity and number of layers applied . 
• Pre peel skin preparation and skin characteristics. 

 

Mechanism of Action

 1.Peels with metabolic activity. Glycolic acid Lactic acid Tartaric acid Malic acid 

Citric acid. Retinoic acid and Azel

 2.Peels with Mainly Caustic Activity. Trichloroacetic acid peels. 

 3.Peels with Mainly Toxic Activity.

 Phenol Peel

 Resorcinol Peel.

 Salicylic acid.

 Peels based on Chemical Composition.

1. Alpha hydroxy acids. Glycolic, lactic ,malic ,citric mandelic and pyruvic acids.
2. Beta hydroxy acids.  

  salicylic acid, essners Peel and Retinoic acid peel.

Contraindications of Peels.

• Pregnancy and lactation
• Active infection at site of proposed peel
• Recent sunburn
• Fever or systemic illness
• Use of oral retinoids in last 3 months
• Tendency to keloids. 
• Recent face -lift procedure or surgery
• Hypersensitivity to any of the ingredients
• Unrealistic expectations
• Uncooperative patient not willing to follow post peel protocol especially regarding UV protection.

 

 

Role of priming the skin for peels.

The mainstay of a successful peel treatment is skin preparation.

This can start in the weeks leading up to the peel . 

Advantages of adequate priming are 

• Even distribution and penetration of the peel 
• Minimal discomfort
• Rapid healing and repair and less chances of post inflammatory hypo/hyper pigmentation

Priming should begin 3-4 weeks prior to the peel and agents used are 0.05% tretinoin cream hydroquinone 2% cream or 6% glycolic acid cream. These agents should be discontinued 48-72 hours prior to the peel. Sunscreens should also be added to the regime prior to the peel. 

 

Peel Procedure

• Consent to be taken
• History taking should be meticulous-general medical history and history of keloid tendency ,unusual scarring tendencies, herpes infection.
• Photographs -Frontal and lateral views. 
• Bowl of ice -cold water to be kept ready prior to starting the procedure. Patient to be in sitting or 45  degree upright position.
• Cleansing and degreasing the face with a cleanser or acetone or alcohol swab. 
• Application of Vaseline cream in alar grooves, medial and lateral canthi of the eyes and the angles of the mouth. This will prevent pooling of the acidic solution in these areas.
• Application of the peel with a specially provided brush rapidly and evenly
• Application should be complete in 45 seconds ideally. 
• Start with forehead, one cheek, second  cheek ,chin, jawline, nose and peri-oral, upper neck area. 

Peels can be applied to any area of the body – Chest, neck ,back, arms or legs too.

Follow contact time as prescribed by manufacturer and judge according to skin type, usually 3-8 minutes. 

Neutralise after the contact time is completed.

Observe carefully for  persistent erythema, itching, burning or skin edema.

Never leave a peel patient unattended during the procedure.

Meticulous observation is required during the peel application.

 

GENERAL  POST PEEL PROTOCOL.

1.Use of pH balanced face wash for at least 7 days.

2.Use of pH balanced moisturiser 2-3 times a day. 

3.Use of a broad spectrum sunscreen with a SPF of 30 2-3 times a day.

4.No topical applications for 4-7 days depending on depth of the peel.Mineral make up may be applied after 48 hours for superficial peels and after 4-5 days after medium -depth peels.

5.No parlour treatments for at least one week

6.No swimming/intense sun exposure/ steam /sauna for 3-4 days. 

7.During healing and repair of skin instruct the patient to avoid picking,scrubbing,exfoliating or abrading the skin.This may increase the chances of pigmentation and scarring.

 

Commonly used AHA peels are-

 1.Glycolic-Derived from sugar cane. 

 2.Lactic -Derived from sour milk.Famous as the beauty regime of Egyptian queen Cleopatra.

 3.Malic Acid- Derived from Apples.

 4.Citric Acid-   Derived from citrus fruits .

 5.Tartaric Acid -Derived from grapes. 

Bioavailabilty is the most important factor in determining the products ability to penetrate through the skin. Glycolic acid ,having,the smallest molecular size has greatest penetrating capacity and therefore shows good consistent results. Effects of AHA peels at the Skin Level. Epidermal Level-AHAs have profound effect on keratinization,which is clinically detectable by the formation of a new stratum corneum.AHAs modulate this formulation by decreasing the cohesion between corneocytes  and thereby promote even exfoliation at the stratum corneum level. Dermal Level-AHA acids with greater bioavailabilty have deeper penetration and deeper dermal effects. These, when applied to ageing or UV damaged skin stimulate the production of mucopolysaccharides and collagen and improve skin texture and thickness without detectable inflammation.

Glycolic Acid Peel–

 Most commonly used AHA peel in clinical practice. 

High safety index. 

Concentrations vary from 30% to 70%. 

Humectant properties, causes even distribution of melanin in regeneration phase and offers some skin lightening properties. 

Accelerates the cell turnover process and works as skin rejuvenating agent. Can be used for all skin types. 

 

Lactic Acid Peel 

Lactic acid peel is one the gentler acids and inherently hydrating. 

After application to the skin lactic acid forms lactate which is a component of  the skins NMF. 

It enhances desquamation at stratum corneum level. 

Improves skin texture,skin hydration and signs of ageing due to dry skin. Can be used for dry,photodamaged skin. 

Lactic acid can be used in concentrations of 50% Beta Hydroxy Acids-  

 

Salicylic Acid–

This is derived from willow bark,wintergreen oil and sweet birch as a biosynthetic product. Alternatively, it can be prepared by hydrolysis of Aspirin or Oil of Wintergreen with a strong acid or base. Salicylic acid is highly lipid soluble and therefore a peel of choice for oily and acne prone skin.Results are excellent for all grades of acne. 

Effects of salicylic acid at the skin level.  It works both as a keratolytic and comedolytic agent by causing the cells of the epidermis to shed more readily,opening clogged pores ,constricting pore diameter and also has a bacteriostatic action within the skin. Since it has anti-inflammatory properties it is suitable for sensitive skin conditions like rosacea. It is also a key ingredient in several shampoos used to treat dandruff.  Jessner peel. This is known as a blended peel since it combines multiple acids in a single formula. By combining multiple acids each can be used at a lower concentration maximising outcomes and minimizing the sideeffects and complications associated with high percentages.. It is a combination of 14% salicylic acid,14 % lactic acid and 14% resorcinol in an ethanol base. It works by breaking intracellular bridges between keratinocytes. diied essners eel is aailale where resorcinol is replaced by citric acid. 

 Other Commonly Used Peels in Clinical practice. TCA-Trichloroacetic acid peel. This product is obtained from the distillation of nitric acid steam on chloral acid. It is found as anhydrous ,white crystals.The molecular structure is close to glycolic acid. 

TCA can be used in its pure form from 20-50% or as a blended pel with TCA 20% with Lactic acid 10% or TCA 15% with Salicylic acid 15%. The Obagi  Blue Peel ,a commercially available peel,contains TCA 20%,glycerine and saponins which cause slow penetration and release TCA in the skin. It causes coagulation of skin proteins ,seen as whitish frosting on the skin. The degree of frosting depends on the depth of penetration in the skin.

 Level 1 Frosting-Faint skin whitening with patchy erythema.This is the desired clinical end -point.

 Level 2 Frosting- Visible skin whitening with erythema.Patient may complain of stinging and burning sensation.

 Level 3 Frosting-Opaque skin whitening.  It is a self- neutralising peel and does not need a neutralising solution.But sometimes the reaction can be exothermic,so some form of cooling may be needed on the skin.  Depth of penetration increases as concentration increases and 50% TCA can penetrate upto reticular dermis.

 Clinical and Practical Tips for TCA use

1.Should be stored in opaque glass bottles.

2.TCA action is directly linked to concentration of solution, the contact time, the pressure of application,the number of coats and the neutralisation.

3.hugh neuralisain is n needed hereically as “rue rsing ccurssecial creams called frosting stoppers are used to avoid a cold burn due to the exothermic reaction that ensues. 

4.UV protection after a TCA peel has to be extremely stringent to prevent post inflammatory hyperpigmentation.

Post peel care:

To apply sun screen lotion and moisturizer daily.