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Lucian Fodor (editor) - Aesthetic Applications of Intense Pulsed Light

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Lucian Fodor (editor) Aesthetic Applications of Intense Pulsed Light

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The book is structured into eight chapters:1. Skin anatomy. This chapter is intended to describe the pertinent anatomy related to IPL applications. In addition to the described main structural elements of the skin, the chapter has important points about skin aging and histological aspects which gives the reader a better understanding of the etiology of skin lesions and the need for Intense Pulsed Light (IPL) treatment.2. Light-tissue interaction. This chapter describes the interaction between IPL and different skin structures. Target skin structures (chromophores) are described in detail. The results of this interaction are detailed as being important to understanding the goals and principles of IPL treatment. 3. IPL safety and legal issues. This chapter describes the needs of the environment for a safe treatment. The necessary equipment and things to avoid pitfalls which may lead to lawsuits are detailed. Several aspects of IPL legal issues are also described: how to avoid medical liabilities and how to manage them are also included in this chapter.4. Patient selection. This chapter describes the pearls and pitfalls in selecting patients for IPL treatment. This is not an easy task and proper patient selection is extremely important to have satisfied patients. Problematic patient types are also described here.5. Skin rejuvenation. This chapter starts with a description of skin aging. Intrinsic and extrinsic mechanisms are detailed. The most common skin lesions related to aging that can benefit from IPL treatment for rejuvenation are detailed. The chapter continues with treatment protocols which describe strategies for achieving optimal results. A review of the literature is included, presenting the treatment parameters of different studies and their results.6. Hair removal. This chapter starts with a description of the hair follicle cycle, hair types and important structures for treatment. Treatment strategies are emphasized and detailed, starting from choosing the right parameters to post-treatment recommendations. A literature review is presented regarding treatment parameters and results according to different authors.7. Vascular lesions treatment. This chapter describes the types of vascular lesions that can benefit from IPL treatment. The treatment protocol is emphasized and all the steps for performing this application are described in detail. A literature review is presented and different results are compared regarding treatment parameters.8. Complications. It is inevitable that any medical treatment can end with complications. The possible complications of the most common IPL applications (skin rejuvenation, hair removal, pigmented and vascular lesion treatment) are detailed. The way to avoid them and how to handle them is also described.At the end of each chapter, there is a section on the practical points highlighting the most important points of the chapter. An extensive literature review of this technology is presented alongside numerous illustrations, tables and color pictures. The book will benefit any doctor or healthcare professional who uses IPL for cosmetic purposes, such as plastic surgeons, dermatologists, ophthalmologists, maxillofacial surgeons and otolaryngologists dealing with aesthetics of the face, as well as residents interested in learning the subject.

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Lucian Fodor , Yehuda Ullman and Monica Elman Aesthetic Applications of Intense Pulsed Light 10.1007/978-1-84996-456-2_1 Springer-Verlag London Limited 2011
1. Skin Anatomy
Lucian Fodor 1, Yehuda Ullmann 1 and Monica Elman 2
(1)
Department of Plastic Surgery, Rambam Health Care Campus, Haifa, Israel
(2)
Maccabbi Insurance, Tel Aviv, Israel
1.1
1.1.1
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1.1.3
1.2
1.3
1.3.1
1.3.2
1.3.3
1.4
1.4.1
1.4.2
1.4.3
1.4.4
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Abstract
The skin is composed of three layers: epidermis, dermis and subcutaneous tissue. The thickness of the layers varies with different anatomical regions. The epidermis is thickest on the palm and soles, and very thin on the eyelids, while the dermis is thickest on the back. Keratinocytes are the main component of the epidermis. Melanocytes are the cells located in the epidermis whose function it is to produce pigment. The ratio is about one in every ten basal keratinocytes. Differences in skin color according to race are explained by the number of melanosomes. Langerhans cells represent 35% of the cells of the stratum spinosum where they are situated between the keratinocytes. The dermis consists of a supporting matrix (ground substances) in which polysaccharides and proteins act to produce proteoglycans. The protein fibers inside the dermis are represented by collagen, elastin and other components, such as fibrillin and microfibril proteins. The blood supply to the skin comes from the deep plexuses located at the fascia and subcutaneous level. With aging, there is a decrease in total collagen content in the skin, an increased amount of type III collagen, decreased number and diameter of elastin fibers, and a lack of interaction between water and surrounding molecules which contribute to the dry and wrinkled aspect.
The skin is composed of three layers: epidermis, dermis and subcutaneous tissue. The epidermis is the outer layer and is formed mainly by keratinocytes whose main function is to synthesize keratin. The dermis is the middle layer and its main component is collagen. This layer lies on lobules of lipocytes. The thickness of the layers varies with different anatomical regions. The epidermis is thickest on the palm and soles, and very thin on the eyelids, while the dermis is thickest on the back.
1.1 Epidermis
The epidermis is the outer part of the skin and is composed of three basic cell types: keratinocytes, melanocytes and Langerhans cells. Merkel cells can be found on the palms and soles and are located directly above the basal membrane.
1.1.1 Keratinocytes
Keratinocytes are the main component of the epidermis. Their function is to produce keratin, a complex filamentous protein that forms the stratum corneum of the epidermis.
The epidermis is composed of several layers, beginning with the innermost as follows: basal layer, malpighian layer, granular layer and horny layers (stratum corneum). The palms and soles have also a clear layer called stratum lucidum (above the granular layer). The horny layer and granular layer are the thickest on the palms and soles and are almost absent on the flexor aspect of the forearms. Cycling stem cells, located at the basal layer, provide a pool for epidermal regeneration. As the basal cells divide, they flatten and move upward (Wolff and Wolff-Schreiner ). The process of desquamation implies degradation of the lamellated lipid from the intercellular space and loss of desmosomal interconnections. The keratinocytes play an important role in the immune function of the skin.
1.1.2 Melanocytes
Melanocytes are the cells located in the epidermis whose function it is to produce pigment. The ratio is about one in every ten basal keratinocytes. The face and genitalia have a greater amount of these cells. The melanocyte cell is a dendritic type, extending for long distances within the epidermis and in close contact with the keratinocytes. Together they form the epidermal melanin unit. Melanin is synthetized by melanocytes in the basal layer of the epidermis and transferred to surrounding keratinocytes in melanosomes. Differences in skin color according to race is explained by the number of melanosomes. People with fair skin have fewer melanosomes which are smaller and packaged within membrane complexes. People with darker skin have more melanosomes which are larger and not packed. Sun exposure (Fig ).
Fig 11 a Significant photoaging and numerous lentigines prior to - photo 1
Fig. 1.1
( a ) Significant photoaging and numerous lentigines prior to treatment. ( b ) Eight weeks after a single IPL treatment
1.1.3 Langerhans Cells
Langerhans cells represent 35% of the cells of the stratum spinosum where they are situated between the keratinocytes. They are responsible for the immunological response of the skin.
1.2 Dermoepidermal Junction
The dermoepidermal junction represents the junction between the epidermis and the dermis. It is located at the basement membrane zone and resembles a semi-permeable filter which allows cells and fluids to travel between epidermis and dermis (Briggaman and Wheeler ). It also serves as a structural support for the epidermis.
1.3 Epidermal Appendages
The eccrine and appocrine glands, ducts and pilosebaceous units constitute the skin adnexa. All have a role in epidermis regeneration (reepithelization). When an injury occurs, the keratinocytes from the adnexa migrate to the skin surface (Kollar ).
1.3.1 Eccrine Sweat Glands
These glands have three main components:
  • The intraepidermal spinal ducts which open directly onto the skin surface
  • The straight dermal portion of the duct composed of cuboidal epithelial cells
  • The secretory zone located in the superficial panniculus. In the back region, this zone is situated in the deep dermis
The role of these glands is also to produce sweat which is similar in composition to plasma with regard to the electrolytes. They are important in thermoregulatory function and are present in great amounts in the palms, soles and axillae. Some eccrine glands from the axillae have widely dilated secretory coils in patients with hyperhidrosis.
1.3.2 Appocrine Glands
Appocrine glands develop on the infundibular upper portion of the hair follicle. They are intimally related to the pilar units. The coiled secretory gland is present at the junction of the dermis and subcutaneous fat. Appocrine secretion is odorless and episodic. The appocrine units of the human body are generally confined to the axillae, areolae, genital region, ear canal and eyelids. The glands start to function after puberty.
1.3.3 Hair Follicles
Hair follicles develop in rows of three. Primary follicles are surrounded by the appearance of two secondary follicles. The amount of pilosebaceous units decreases throughout life mainly because of poor formation of secondary follicles. The hair follicle has three main components:
  • The lower part beginning at the base of the follicle and extending to the insertion of the arrector pili muscle
  • The middle portion, also called the isthmus, from the arrector pili to the entrance of the sebaceous duct
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