_reactivation for laser depigmented areas激光白斑区色素再活化课件

Art of Facial SurgeryArt of Facial Surgery Facial Hyper-PigmentationFacial Hyper-Pigmentation Current Thoughts:Current Thoughts: David A.F. Ellis M.D. FRSCSDavid A.F. Ellis M.D. FRSCS Professor, University of TorontoProfessor, University of Toronto Medical Director, Art of Facial SurgeryMedical Director, Art of Facial Surgery Toronto, CanadaToronto, Canada 416 229.1050416 229.1050 drfaceArtofFacialSdrfaceArtofFacialS Art of Facial SurgeryArt of Facial Surgery Normal Skin ColorNormal Skin Color REDRED = Oxy- = Oxy-hemaglobinhemaglobin in red capillaries in red capillaries YELLOWYELLOW = = exogeneousexogeneous produced produced cartenoidscartenoids BROWN/BLACKBROWN/BLACK = melanin = melanin BLUEBLUE = reduced = reduced hemaglobinhemaglobin in blue capillaries in blue capillaries Art of Facial SurgeryArt of Facial Surgery PigmentationPigmentation & & Melanin SynthesisMelanin Synthesis Art of Facial SurgeryArt of Facial Surgery MelanocyteMelanocyte Formation Formation 1.1. They are the key to skin pigmentation They are the key to skin pigmentation 2.2. They are derived from the neural crest They are derived from the neural crest cells as the neural plate forms a tubecells as the neural plate forms a tube 3.3. They migrate along blood vessels They migrate along blood vessels through dermis to epidermisthrough dermis to epidermis 4.4. They become visible in 10 weeks under They become visible in 10 weeks under light microscopylight microscopy Art of Facial SurgeryArt of Facial Surgery Art of Facial SurgeryArt of Facial Surgery MelanocyteMelanocyte Location Location 1.1. Found at the tips of the Found at the tips of the reterete ridges at the ridges at the epidermal-dermal junctionepidermal-dermal junction 2.2. The Epidermal-Melanin Unit The Epidermal-Melanin Unit a)a) the the melanocytesmelanocytes dendrite process dendrite process forms a forms a melanosomemelanosome that is that is deposited in the deposited in the keratocytekeratocyte b)b) 1 1 melanocytemelanocyte feeds 36 keratocytes feeds 36 keratocytes c)c) the the melanosomemelanosome manufactures manufactures melanin melanin Art of Facial SurgeryArt of Facial Surgery Art of Facial SurgeryArt of Facial Surgery MelanocyteMelanocyte Location Location 3.3. Pigment Pigment IncontinanceIncontinance Pigment gets into the dermisPigment gets into the dermis 4.4. Density Density * * Ave: = Ave: = 1155 melanocytes/mm 1155 melanocytes/mm 2 2 * *Male Genitalia: = 1668 melanocytes/mmMale Genitalia: = 1668 melanocytes/mm 2 2 * *Remains the same for 3 decades + thenRemains the same for 3 decades + then declines 10% per year declines 10% per year Art of Facial SurgeryArt of Facial Surgery Bio-Chemistry of Bio-Chemistry of Melanin FormationMelanin Formation 1.1. Tyrosine DOPATyrosine DOPA 2.2. DOPA DOPA dopaquinonedopaquinone 3.3. 5,6-dihydroxyindole(DHI) to indole-5,6 5,6-dihydroxyindole(DHI) to indole-5,6 quinonequinone 4.4. all all indolesindoles polymerizes to form melanin polymerizes to form melanin tyrosinasetyrosinase tyrosinasetyrosinase Art of Facial SurgeryArt of Facial Surgery Types of MelaninTypes of Melanin Melanocytes actually produce two different Melanocytes actually produce two different pigments: pigments: 1.1. EumelaninEumelanin (brown-black) (brown-black) 2.2. PhaeomelaninPhaeomelanin (yellow and red). (yellow and red). Red heads happen to produce more Red heads happen to produce more phaeomelaninphaeomelanin and less and less eumelanineumelanin, which is why , which is why they dont tan very wellthey dont tan very well Art of Facial SurgeryArt of Facial Surgery Regulation of Regulation of Human PigmentationHuman Pigmentation 1.1. Baseline color Baseline color 2.2. Genetic Effects Genetic Effects 3.3. Solar Effects Solar Effects 4.4. Biologic Modifiers Biologic Modifiers 5.5. Hormones Hormones Art of Facial SurgeryArt of Facial Surgery Regulation of Regulation of Human PigmentationHuman Pigmentation 1.1. Baseline color Baseline color * * genetically determined basal genetically determined basal melanin synthesis melanin synthesis * * LysosomalLysosomal hydrolasehydrolase degrades degrades pigment and is desquamated via pigment and is desquamated via the stratum the stratum corneumcorneum Art of Facial SurgeryArt of Facial Surgery Regulation of Regulation of Human PigmentationHuman Pigmentation 2.2. Genetic Effects Genetic Effects * * Genes not yet identified Genes not yet identified * * Genetic conditions Genetic conditions i.e. Albinism,i.e. Albinism, PKU, Freckling, Familial PKU, Freckling, Familial DyplasticDyplastic Art of Facial SurgeryArt of Facial Surgery Regulation of Regulation of Human PigmentationHuman Pigmentation 3.3. Solar Effects Solar Effects * *Continuous UVA: Continuous UVA: Immediate darkening Immediate darkening Can last for days blending Can last for days blending with melanin from UVB with melanin from UVB * *Continuous UVBContinuous UVB 72 hr delay of darkening 72 hr delay of darkening Darker than UVADarker than UVA Art of Facial SurgeryArt of Facial Surgery Regulation of Regulation of Human PigmentationHuman Pigmentation 4.4. Biologic Modifiers Biologic Modifiers * * Prostaglandins produced by Prostaglandins produced by keratocytes stimulate melanin keratocytes stimulate melanin synthesis synthesis * * PostinflammatoryPostinflammatory Hyperpigmentation Hyperpigmentation induced by prostaglandins E induced by prostaglandins E1 1 + E + E 2 2 Art of Facial SurgeryArt of Facial Surgery Regulation of Regulation of Human PigmentationHuman Pigmentation 5.5. Hormones Hormones * * MSH darkens the skin by binding MSH darkens the skin by binding to melanocortin-1 receptors to melanocortin-1 receptors in the in the melanocytesmelanocytes stimulating stimulating tyrosinasetyrosinase Art of Facial SurgeryArt of Facial Surgery Racial DifferencesRacial Differences 1. Color depend on the size, number, and distribution of the melanosomes in the melanocytes and keratocytes and is more efficient in dark skinned individuals 2. Dark skinned individuals have a large single melanosome in the keratocyte 3. Light skin individuals have smaller grouped melanosomes in the keratocyte 4. The strength of the melanocyte is not dependant on race but autosomal dominance Art of Facial SurgeryArt of Facial Surgery Causes of Causes of HyperpigmentationHyperpigmentation 1.1. rate of rate of melanosomemelanosome production production 2.2. # of melanosomes transfer to# of melanosomes transfer to keratocytekeratocyte 3.3. in size and in size and melaninizationmelaninization of of melanosomes melanosomes Art of Facial SurgeryArt of Facial Surgery Causes of Causes of HypopigmentationHypopigmentation 1.1. TryrosinaseTryrosinase Activity i.e. Phenol Activity i.e. Phenol 2.2. Loss of Loss of melanocytesmelanocytes caused by caused by a)a) inflammation inflammation b)b) immunologically diseases immunologically diseases i.e. i.e. VitilagoVitilago c)c) laser resurfacing laser resurfacing Art of Facial SurgeryArt of Facial Surgery Art of Facial SurgeryArt of Facial Surgery Art of Facial SurgeryArt of Facial Surgery MelanogenesisMelanogenesis in Aging in Aging 1.1. Decrease in Decrease in melanocytesmelanocytes in UV unexposed in UV unexposed skinskin 2.2. Increase in Increase in melanocytesmelanocytes + + melanogenesismelanogenesis in UV exposed skinin UV exposed skin 3.3. Leads to formation of Leads to formation of lentigineslentigines Tan-brown-black 2-20mm spots Tan-brown-black 2-20mm spots melanogenesismelanogenesis Hyperplasia of highly active Hyperplasia of highly active melanocytesmelanocytes Focal hyperpigmentation of keratocytes Focal hyperpigmentation of keratocytes Art of Facial SurgeryArt of Facial Surgery LentiginesLentigines Art of Facial SurgeryArt of Facial Surgery Afghan Girls 18 years apartAfghan Girls 18 years apart Age 14 Age 32 Art of Facial SurgeryArt of Facial Surgery TranscutaneousTranscutaneous MesodermicMesodermic Therapy (TMT)Therapy (TMT) 1.1. 50% 50% MandelicMandelic Peel for a maximum of ten Peel for a maximum of ten minutes immediately prior to mask minutes immediately prior to mask application application 2.2. Dermamelan Mask Treatment for 12 hours both sides Dermamelan Mask Treatment for 12 hours both sides 3.3. Dermamelan Cream Dermamelan Cream tidtid on face bilaterally on face bilaterally 4.4. TMT ( TMT (TranscutaneousTranscutaneous MesodermicMesodermic Therapy) system weekly Therapy) system weekly for 12 weeks for 12 weeks 5.5. Random face study Random face study 6.6. N = 10 patients N = 10 patients Art of Facial SurgeryArt of Facial Surgery INGREDIENTSINGREDIENTS TYROSINASE TYROSINASE INHIBITORINHIBITOR OTHER OTHER EFFECTSEFFECTS CUTANEOUS CUTANEOUS PERMEABILITYPERMEABILITY SKIN PENETRATION ENHANCER SKIN BLEACHING ACCELERATOR AZELAICAZELAIC ACIDACID KOJICKOJIC ACIDACID ALPHA ARBUTINALPHA ARBUTIN RUMEX LANARUMEX LANA TYROSINOL COMPLEXTYROSINOL COMPLEX ALOE VERAALOE VERA LIQUORICE EXTRACTLIQUORICE EXTRACT ASCORBYL ASCORBYL PHOSPHATEPHOSPHATE NICOTINAMIDENICOTINAMIDE Ingredients in DermamelanDermamelan Part 1Part 1 Art of Facial SurgeryArt of Facial Surgery Ingredients inIngredients in DermamelanDermamelan Part 2Part 2 AMINOETHYLPHOS-AMINOETHYLPHOS- PHINIC ACIDPHINIC ACID PEPTIDE-1PEPTIDE-1 RETINOLRETINOL TOCOPHEROLTOCOPHEROL ASCORBIC ACIDASCORBIC ACID BISABOLOLBISABOLOL ETHOXYDIGLYCOLETHOXYDIGLYCOL SALICYLIC ACIDSALICYLIC ACID AMINOEAMINOE THYLPHTHYLPH OS-OS- PHINIC PHINIC ACIDACID PEPTIDE-PEPTIDE- 1 1 RETINOLRETINOL TOCOPHTOCOPH EROLEROL ASCORBIASCORBI C ACIDC ACID BISABOLBISABOL OLOL ETHOXYETHOXY DIGLYCDIGLYC OLOL SALICYLSALICYL IC ACIDIC ACID INGREDIENTSINGREDIENTS TYROSINASE TYROSINASE INHIBITORINHIBITOR OTHER OTHER EFFECTSEFFECTS CUTANEOUS CUTANEOUS PERMEABILITYPERMEABILITY SKIN PENETRATION ENHANCER SKIN BLEACHING ACCELERATOR AMINOETHYLPHOS-AMINOETHYLPHOS- PHINIC ACIDPHINIC ACID PEPTIDE-1PEPTIDE-1 RETINOLRETINOL TOCOPHEROLTOCOPHEROL ASCORBIC ACIDASCORBIC ACID BISABOLOLBISABOLOL ETHOXYDIGLYCOLETHOXYDIGLYCOL SALICYLIC ACIDSALICYLIC ACID Art of Facial SurgeryArt of Facial Surgery INGREDIENTSTYROSINASE INHIB.OTHER EFFECTS INCREASE PERMEABILITY SKIN EMBELLISHMENT ACELERATES EXFOLIATION AZELAIC ACID KOJIC ACID ALFA ARBUTINE RUMEX LANA TIROSINOL COMPLEX ALOE BARBADENSIS LICORICE EXTRACT ASCORBIC PHOSPHATE NIACINAMIDE AMINOETILPHOSPHINIC NONAPEPTIDE-1 RETINOL TOCOFEROL ASCORBIC ACID BISABOLOL ETHOXIDIGLYCOL SALICYLIC ACID Art of Facial SurgeryArt of Facial Surgery Dermamelan MaskDermamelan Mask 12 hours Art of Facial SurgeryArt of Facial Surgery TranscutaneousTranscutaneous MesodermicMesodermic Therapy (TMT)Therapy (TMT) Art of Facial SurgeryArt of Facial Surgery Stratum CorneumStratum Corneum The Major SkinThe Major Skin BarrierBarrier 1. This lipid structure represents approximately 5% to 30% of the principle obstruction to trans-dermal skin crossing 2. It is the skins principal barrier to substance permeation. 3. Pore size and sweat glands 10-40 m 15-20 cells deep Art of Facial SurgeryArt of Facial Surgery Electrophoresis (Electrophoresis (electrorepulsion) Electrophoresis represents the transportation of substances through the skin in ionic form by means of a direct current. The entrance channels are basically the sweat glands and hair follicles (low efficiency because Is only the 0.1% of the cutaneous area and as the Stratum Corneum is not very permeable to ionic (cationic) substances Art of Facial SurgeryArt of Facial Surgery Electroporation Electroporation consists of the application of brief voltage impulses on the cells and tissues that act on the cell membranes and the lipidic intercellular spaces, causing molecular changes leading to the forming of ultramicropores which increase the permeability of the skin, particularly on the stratum corneum Art of Facial SurgeryArt of Facial Surgery ResultsResults 1.600% greater penetration of the active substance in the corneous stratum. 2.1200 % greater penetration of the active substance in the epidermis. 3. 4000% greater penetration of the active substance in the dermis. Art of Facial SurgeryArt of Facial Surgery TMT TreatmentsTMT Treatments Polarity: negativePolarity: negative Energy Level: 95%Energy Level: 95% System #7: System #7: Face Cleanser Mix ingredients After care skin moisturizer Art of Facial SurgeryArt of Facial Surgery TMT TreatmentsTMT Treatments 1.1. Weekly interval X 12 weeks Weekly interval X 12 weeks 2.2. 20-30 minutes 20-30 minutes 3.3. face only face only Art of Facial SurgeryArt of Facial Surgery AssessmentAssessment MASI Scale:MASI Scale: MelasmaMelasma Area + Severity Index