THE COLLABORATION BETWEEN PLASTIC SURGEONS AND SKIN CARE
THERAPISTS
Dr. Desmond Fernandes, Plastic Surgeon, Cape Town, South Africa
Modern scientific skin care has created the need for greater collaboration between skin
care therapists and plastic, reconstructive and aesthetic surgeons. The surgeon generally
does not have the time or patience to be involved in working out a good skin care routine
for his patients even though this will make an important contribution towards the final
result. This is where skin care therapists can use their expertise to make sure that scars
heal better and the skin has a radiant healthy youthful character. But of course the
therapist must first understand how to influence skin and make it healthier and set the
stage for the skin to heal as well as possible. Unfortunately, many therapists are not
sufficiently educated in skin physiology, so I will give a brief outline of the physiology
underlying the growing and healing process of skin.
When a surgeon operates on skin, he needs the skin to:
1. Be as healthy as possible
2. Heal as rapidly as possible
3. Heal with minimal post-traumatic hyperpigmentation
No matter where the operation is to be, the skin can be prepared for the operation by a
knowledgeable therapist.
MAKING HEALTHY SKIN
Without doubt the most important nutrient for healthy skin is vitamin A. Most of us walk
around with varying degrees of deficiency of vitamin A in our skin because it is easily
destroyed by exposure to light. The major form of vitamin A in the skin is retinyl
palmitate and this is the most sun-susceptible version of the retinoids. Because this is the
version of vitamin A that is destroyed by the sun, I believe this exact molecule should be
replaced by daily skin care. Retinyl palmitate is converted continuously to retinol, and
then to retinyl aldehyde and finally to the various isomers (variations) of retinoic acid.
Retinoic acid controls the normal activity of cells through its effects on the DNA. It
directs the keratinocytes, those important basal cells of the epidermis, to grow to normal
size, with a healthy metabolism. Vitamin A speeds up the rate of growth of keratinocytes
and, as a result, wounds heal faster. Healthier collagen is produced, and in combination
with vitamin C, scars will heal better and stronger. Vitamin C is also damaged by
exposure to light and is used up in fighting free radicals induced by UV light. For that
reason we also need to restore the normal balance of vitamin C in the area of the
operation. The addition of other free radical scavengers, particularly vitamin E, and beta
carotene will boost the antioxidant status of the skin and preserve more vitamin A and C
in the skin. Both vitamin A and C act on the production of melanin. Vitamin C is a
tyrosinase inhibitor and also provides an antioxidant rich milieu in the cell that acts
against the production of melanin. Vitamin A also controls the production of melanin
and tends to even out the distribution of melanin in the skin as well as reduce the total
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melanin. For that reason both vitamin A and C needs to be in high levels to reduce the
chances of post-inflammatory hyperpigmentation. Added antioxidants means that the
vitamin C will be able to function better to control pigmentation.
HOW TO PREPARE THE SKIN
Most surgeons believe that only retinoic acid can be successfully used on skin. They also
believe that the primary function of retinoic acid is as a peeling agent. They mistakenly
believe that since retinoic acid is the actual functional form of vitamin A, that it should be
used for skin care. Unfortunately, retinoic acid irritates skin and most patients will not
use it as regularly as they should. Patients get a retinoid reaction in the beginning
because they do not have sufficient retinoid receptors on the cell walls and cannot absorb
the retinoic acid as fast as they should. Retinoic acid is an irritant to cell walls and that is
one reason for the peeling effect. The outermost layers of the stratum corneum also flake
off. The skin becomes pink and sensitive and it looks very much like the patient is
allergic to retinoic acid. However, contrary to a true allergy, the longer one uses the
retinoic acid, the less irritated the skin becomes because vitamin A stimulates the
production of retinoid receptors and retinoic acid is metabolised properly. The important
point is that the cell cannot handle all the retinoic acid and as a result the stores of
vitamin A as retinyl palmitate build up and that eventually is responsible for the
continuous increased supply of retinoic acid at physiological doses.
I believe that we should apply retinyl palmitate or some other ester form of vitamin A
(e.g. retinyl acetate or propionate), which is significantly less irritating and will produce
the same results because it works better with the physiology of the skin. The dose of
vitamin A should be as high as the patient can tolerate (up to about 10 to 50,000 i.u.g%)
Right now there is a marketing fashion to use retinol which is also an irritant, but less so
than retinoic acid. The fact is that virtually all the retinol will be converted to retinyl
palmitate! So use retinyl palmitate right from the beginning. The retinyl palmitate
molecule carries the energy that is required for the production of the various isomers of
retinoic acid. The main advantage is that the client will use this product regularly and
prime up the skin easily before the operation.
Vitamin C can be used either as the ascorbic acid form or a stabilised form (e.g. Sodium
or Magnesium ascorbyl phosphate.). The ascorbic acid can cause peeling of the skin due
to its acid activity, so should be used with caution in clients with sensitive skin. Ascorbic
acid is not stable and should preferably be used as a freshly made gel or solution. If the
solution has turned brown then the ascorbic acid is no longer worth using. The ascorbyl
phosphates are more neutral and can safely be used on sensitive skin. Their drawback is
that they are rather expensive. From a practical point of view, ascorbic acid is generally
used only on the face. You should advise the client also to take oral vitamin C. I prefer
that they use about 1000 mg per day.
Make sure that when using vitamin A and C that they are protected by their normal
accompanying antioxidants, vitamin E and beta-carotene. These four vital nutrients act in
concert with each other and should always be used together.
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HOW TO FIND THE RIGHT PRODUCT FOR YOUR CLIENT
The product containing vitamin A and C, E and beta-carotene should come either in a
compressible aluminium foiled tube, thick oil or in an airless dispenser. If the product is
supplied from the manufacturer in a typical cosmetic jar then the antioxidants and
vitamin A will be destroyed by exposure to light and air and rendered useless. Make sure
that the product is as fresh as possible to get the most activity out of these unstable
vitamins.
TREAT THE AREA OF THE PROPOSED SCAR
The minimum preparation period should be about three weeks. The area where the scars
are to be made must be treated at least twice a day.
1. For facelifts, then take care that the client should rub the preparation on the skin
in front of, and behind, the ear.
2. For augmentation mammaplasty, then apply the cream either into the armpit or
around the nipple or in the breast crease, according to the surgeon’s operative
plans.
3. Reduction mammaplasty and abdominoplasty will also heal faster and the scars
will be better if the whole breast or abdomen is treated pre-operatively for a
protracted period. So if you know that your client wishes to have an operation
like this, suggest that he/she prepares the skin for as long as possible. In
combination with a lactate containing product, you will also get tightening of the
skin that will help to create a more aesthetic result.
4. People with stretch marks will require intensive treatment with both vitamin A
and C in the salon as well as at home. I have found that intensive treatments with
a special pulsed iontophoresis machine, that has been recently patented, we can
more effectively treat stretch marks. Under ideal condition, the skin should be
treated for a minimum of three months before the operation. I found the best
results when we did iontophoresis (and even sonophoresis) to the stretch marks
once or twice a week for 20 minutes using both vitamin A and C, for a minimum
of 16 treatments. Because the skin will be smooth, the final result after abdominal
surgery will be better. For people with loose inelastic abdominal or thigh skin,
treatments like this have no equal.
5. For the best results from liposuction the skin has to be as elastic as possible so
that it can retract into the new shape. This is where high dose vitamin A (about
10,000 i.u. g%) is absolutely essential. Again I combine it with sodium or
ammonium lactate to get the tightest skin.
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6. If your client has rough thick facial skin, then it is appropriate to do a mild
peeling treatment prior to any facial surgery (provided that the peeling is done in
the cooler months!). One or two peels should be enough to make the skin more
permeable so that the vitamins can take their effects. This is especially useful if
your client is to have a dermabrasion or laser treatment.
7. While I personally do not believe in laser resurfacing, I know that the skin
benefits enormously by being pre-treated with vitamin A. People with thick skin
will be easier for their surgeon to treat if their facial skin has been peeled at least a
month prior to surgery. I prefer to treat people with intensive vitamin A and C
treatments with iontophoresis and sonophoresis.
8. If the client is to have a skin graft done then you can treat both the area that is to
be excised, and also the donor area of the skin graft. This will ensure rapid
healing and a healthier donor site.
One of the real benefits for clients who have sun-sensitive skin, is that if you have put
them on vitamin A restorative skin care at an early stage, then you will most likely have
significantly reduced their chances of getting a skin cancer. Clients with solar keratoses
will also benefit and may easily develop smooth skin within eight to twelve months.
POSTOPERATIVE CARE
1. Facelift surgery: As soon as the surgeon permits, then start using the routine day
creams to maintain healthy doses of vitamin A and the antioxidants in the skin.
Iontophoresis will also stimulate lymphatic drainage so this may be started within
a week of surgery. Special delicate massages also promote lymphatic drainage
and should be recommended. However, bear in mind that after facial surgery the
lymph will drain towards the nose rather than towards the ears.
2. For augmentation mammaplasty, reduction mammaplasty and abdominoplasty I
prefer to support the scars with micropore® for a prolonged period (in some
cases, even three months!) after the operation. The vitamin A and/or vitamin C
preparation can be applied to the surface of the micropore® and some will
permeate through to the surface of the skin. The tapes should be removed and
replaced when they become loose.
3. After liposuction the skin has to retract into the new shape. Start using the vitamin
A and sodium or ammonium lactate as soon as the bandages have been removed.
4. After laser resurfacing, or dermabrasion I soothe the skin with a vitamin A based
gel, which cools the skin as well as promotes rapid healing and an earlier return to
normal skin colour. Start iontophoresis and sonophoresis as soon as the skin is
fully healed.
Lymphatic drainage has an important role in many cases and should be encouraged.
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THE SAFETY OF VITAMIN A
I need to say something about the safety of topical vitamin A and particularly for
pregnant mothers. Many people are worried that if they apply vitamin A to their skin that
they could get vitamin A poisoning. Nothing could be further from the truth. The levels
of vitamin A in the skin are generally higher than the levels in the blood so that means
that there must be an active transport mechanism removing vitamin A from the blood and
depositing it in the skin. The mechanism to take vitamin A from the skin and introduce it
into the blood stream does not seem to exist in humans. Therefore, vitamin A that has
been applied to skin is virtually trapped there and has to be used up by the skin cells. If
the vitamin A could get into the blood stream, then the dose would be so tiny that it
would be insignificant compared to the vitamin A that is readily absorbed from the diet.
As far as pregnancy is concerned I personally believe that there is no risk at all in using
retinyl esters (e.g. palmitate and acetate) on the skin to avoid the development of stretch
marks. The esters of vitamin A cannot pass the placental barrier whereas retinol and
retinoic acid can. However, after more than 35 years of using retinoic acid for the
treatment of acne in young people, clinicians do not believe that the treatment is contraindicated in pregnancy. In order to avoid the mistaken attribution of a congenital
abnormality to vitamin A, many manufacturers advise pregnant mothers not to use their
preparation during the first trimester.
Vitamins A and C, light peeling and scientific iontophoresis with sonophoresis are
important tools to use in strengthening the bond between skin care therapists and plastic,
cosmetic surgeons.
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