FAQ

Q) What are the differences between the various hair removal methods and what are the indications?
A) The ideal patient for laser and pulsed light treatment has thick dark terminal hair, white skin and a normal hormonal status. Methods that use a light beam are not definitive and require multiple treatment sessions. Each technique has advantages and disadvantages in terms of effectiveness and adverse events. Hair removal with lasers and pulsed light is normally performed by non-medical personnel. Another technique once used by beauticians is hydrolysis, which creates a chemical lesion in the follicle. Electrolysis is slow and painful and has been abandoned. The most effective technique is the use of a programmed diathermic current. Using conical electrodes with triangular tips allows such precise selectivity of action that two hairs situated side by side must be treated individually. Laser and pulsed light techniques require particularly precise adjustment of the equipment, while little manual skill is needed. By contrast, the Timed technique of rapid definitive hair removal requires greater manual skill. Regarding indications, we carry out rapid definitive hair removal mainly on the face, where the deep terminal hairs can be reached with extreme precision by the electrode, and where no visible marks remain after the treatment. To remove groin hair, we carry out three or four sessions, so as to also eliminate hairs in the telogen phase. In the remaining regions of the body, our technique is uneconomical. We therefore send our patients for laser epilation of these regions.

Q) Is the result of timedsurgical mixed peeling permanent?
A) Yes, mixed peeling of the lip will no longer have to be repeated. If a wrinkle remains visible, is it possible to de-epithelialize 5 mm of skin and apply the resorcin solution, but this rarely happens.

Q) When can the patient expose the skin to the sun?
A) As soon as the redness disappears, the patient can expose the lip to the sun, to stimulate the melanocytes present in the hair follicles.

Q) Can there be hyperpigmentation problems?
A) No, there can’t.

Q) Can there be problems of hypopigmentation?
A) If the procedure is performed correctly, no. The saturated solution must be applied for the pre-established times to the skin of the lip where the wrinkles are, exactly where the terminal hairs are most numerous.

Q) Can timedsurgical mixed peeling be carried out on other regions of the face?
A) It can be used to treat the eyelids roughness and festoons and crows’ feet. In this case, the saturated solution of resorcin is diluted to 50% and application lasts only 20/40 seconds.

Q) Mixed peeling means physical-chemical peeling. Why do you prefer this?
A) The physical phase makes the skin amenable to treatment, thereby enabling the peeling solution to act; when applied to intact skin, it has no effect. In practice, the skin can be micro-perforated by means of Electroporo Cosmesis, permeabilized by means of 0.5 mixed peeling or, as in this case, de-epithelialized. De-epithelialization allows the resorcin solution to act effectively on all geometric points the surface of the skin. The result is an extremely effective, safe, and constant action. The physical phase eliminates the variable that is constituted by the thickness of the epidermis. When the resorcin solution makes direct contact with the dermis, it exerts its peeling, cross-linking and powerful depigmenting actions. Depigmentation also takes place through the reduction of the number of melanocytes in the treated area. In some cases of generalized vitiligo of the face, the natural pigmentation of the skin can be eliminated.

Q) Can de-epithelialization also be performed with a laser?
A) The use of a rectilinear form of energy, a light beam, is useless in most dermatological applications. If a skin formation is vaporized with a laser, deep lesions are created, which should be avoided. De-epithelialization cannot be performed by means of lasers, as it is not possible to keep the dermis intact. In mixed peeling, by contrast, the dermis remains perfectly intact and can adequately absorb the chemical solution.
To enable the Timed apparatus (Korpo) to detach the epidermis, we had to design a specific high-frequency current. This current travels at the speed of light, but returns to the electrode positioned on the surface of the patient’s body; thus, suitably modulated, it causes no damage in depth.

Q) Why use a cannula for anesthesia?
A) In patients who are prone to skin hyperpigmentation of the eyelids, we prefer to use a cannula for local anesthesia, so as to avoid possible bleeding and the associated inflammation of the tissues caused by the free iron ions that are released from hemoglobin.

Q) Why is it also necessary to de-epithelialize the crow’s feet?
A) Even if the crow’s feet are not very evident, it is always necessary to intervene in this area, in order to balance the reorganization of the connective fibers. If this region is not treated, only downward skin retraction will be achieved, while retraction should also be lateral.

Q) In which other procedures is Timed de-epithelialization used?
A) Mixed peeling by means of timedsurgical de-epithelialization is also used to eliminate lip wrinkles (about 1 minute and a half) and extensive dermal-epidermal skin spots in subjects with a uniform complexion (about 20-30 seconds). We have also used it in the treatment of large nevi of the scalp within the first 10 days of birth.
Timedsurgical de-epithelialization is used for the repigmentation of stable vitiligo, piebaldism and achromic scars. In these cases, the achromic epidermis is replaced with grafts of autologous keratinocytes and melanocytes obtained from the cultivation of a 1 cm2 fragment of normal-pigmented taken 20 days earlier. In Timedsurgery, the other two mixed peeling procedures are Electroporo Cosmesis and epidermal permeabilization or 0.5 mixed peeling.

Q) What is the role of Adipofilling in the eyelid region?
A) Adipofilling is a recent technique of lipoaspirate preparation. The Adipopimer creates a suspension of small lobular fragments consisting of 5-6 cells in 6 seconds. In 30-40 seconds, it creates a suspension of single adipose and stromal cells. In this region, we normally use both suspensions: to fill sunken dark circles, to fill the upper portion of the upper eyelids, to reduce the aperture of the eye, to enhance the volume of the malar regions, and to correct the forehead and temporal regions. The Adipofilling suspension is made up of living material which, once grafted, has a high survival index. Moreover, it can be stored at -31°C to -81°C, as separation by means of the suction vortex created by the Adipopimer makes it resistant to freezing. Its effects are volumetric and/or regenerative. Owing to its characteristics, Adipofilling is the ideal technique for facial rejuvenation, whether for the purpose of enhancing volume or symmetry or, when applied intradermally, to rejuvenate the skin (lip wrinkles and elastosis of the neck). The cathelicidin produced by the adipocytes prevents infectious complications.

Q) Normally, the lower line is drawn in a wrinkle that is already present in the eyelid. Is that wrong?
A) Yes, it’s wrong. The wrinkle indicates the site of folding of the aged eyelid, not that of the fold that will be formed after excision of the skin. Removing the skin flap creates upward traction and the scar could become visible. Moreover, the altered ratio between the inferior and superior portions of the eyelid may create a visual artifact. The proportions between these two small anatomical areas must for us follow the golden number. If fat is removed, the operator must carefully evaluate where the septum orbitae incision is made, with the golden proportion the cut must be very close to the upper skin margin.

Q) So most blepharoplasty procedures are wrong?
A) Some, yes. Surgeons have to assess their results. Upper blepharoplasty is not a simple operation.

Q) Some surgeons raise the incision laterally. What do you think of that?
A) In that case, the incision becomes visible. Therefore, it must not be done. In addition, we have to be careful not to extend the incision to the nasal skin, as this could lead to the formation of skin folds. The preoperative design must be drawn before anesthesia is carried out.

Q) To achieve the maximum rejuvenating effect, does all the aged skin have to be removed?
A) Yes, if very evident rejuvenation is desired. In the upper portion of the eyelid, at least 1 cm of skin must be preserved. Removing the palpebral skin lowers the eyebrows slightly. This is a desirable effect, as the eyebrows rise with aging.

Q) Is all the aged or wrinkled skin always removed?
A) Not always. In some patients, for example actresses, it may be more appropriate to perform partial removal of the skin, so as not to modify the patient’s look too much.

Q) How important is symmetry?
A) Symmetry is always important in esthetic surgery. The Timed apparatus enables us to carry out millimetric skin excisions in order to achieve symmetry.

Q) Many operators remove some of the orbicular muscle. What you think of that?
A) We stopped removing orbicular muscle tissue years ago. With the Timed apparatus, it was extremely easy for us to remove orbicular muscle tissue. We even used to sculpt a flap in the outer portion of the muscle, which was then rolled like a cigarette, to enhance the volume of the eyelid. Today, however, the volume of the eyelid is provided by the orbicular muscle, which is compacted by the skin excision and, if this is not sufficient, by means of Adipofilling, which utilizes a suspension of adipose and stromal cells.

Q) Some surgeons carry out intradermal suturing. Why do you advise spiral suturing?
A) It is difficult to perform intradermal suturing in the thin palpebral skin. If all the aged skin is removed, the incision may widen. Spiral suturing is preferable.

Q) What can you say about epinephrine?
A) In this type of surgery, it is extraordinarily important. As well as the ½ mg of epinephrine that is added to the 10 ml of local anesthetic, it is advisable to keep some pure epinephrine handy, so as to stop any sudden bleeding. It should be borne in mind that hematomas are more serious in upper blepharoplasty than in transconjunctival blepharoplasty. Hematomas in this region can be emptied by means of epinephrine, cotton buds and an 18 G cannula.

Q) What else can be done to rejuvenate aged eyelids?
A) There are many possibilities. The first procedure I would do is transconjunctival blepharoplasty, eliminating all the adipose pouches from the lower eyelid. Then I would perform elastic canthopexy to correct drooping of the eyelids. Next, I would eliminate roughness of the lower eyelid by means of mixed peeling. Subsequently, I would enhance the volume of the malar region and correct any volume deficits by means of cellular Adipofilling. Finally, I would carry out upper blepharoplasty. After the elastic canthopexy, the lateral skin fold of the upper eyelid becomes more evident and has to be removed.

Q) As silicone oil is difficult to eliminate from the lips, does some of it remain?
A) Yes, some remains in the tissues. However, it is still possible to remodel the lips, reduce their volume and make them look more natural.

Q) Is there any alternative to silicone?
A) We perform Adipofilling, which involves injecting a suspension of tiny lobular fragments and adipocytes and stromal cells. The suspension is injected into the vermilion through a fine cannula. Adipofilling enhances the volume and exerts a trophic action. Volumetric enhancement of the vermilion by means of fat grafting is a natural biological procedure and gives aged lips a new lease of life. Moreover, as the Adipofilling suspension can be conserved at temperatures between -20°C and -81°C, it can be used for any minor adjustments that may be required.

Q) When do you recommend lip lifting?
A) If the vermilion borders are markedly reduced, the upper lip loses its support and tends to lengthen. For this reason, we perform lip lifting after a few months, in order to shorten the upper lip. In this procedure, we incise the skin by means of slow pulsed timedsurgical cutting; the incision does not extend beyond the nostrils even if the lip needs to be shortened considerably.

Q) Does this saturated solution of resorcin also act on the vessels?
A) Yes. We often use it in areas of permanently reddened skin, where no vessels are visible.

Q) What are the advantages of these mixed peeling techniques?
A) They enable us to use resorcin. This substance has no effect on intact skin, but acts efficaciously if the epidermis has been micropored, permeabilized or de-epithelialized. The physical action of the specific currents, followed by the application of resorcin solution, is the most versatile, efficacious and safe peeling technique available today.
If we wish to apply acids after the physical phase, they must be used at low concentrations, in order to reduce the risk of iatrogenic damage.
The three mixed peeling techniques (Electroporo Cosmesis, Epidermal Permeablization and De-epithelialisation) enable us to regulate the contact of the resorcin solution with the dermis. The times of application of the solution are also different in the different procedures. These techniques enable us to improve the skin of an 18-year-old who is going to a ball, for example, or to eliminate lip wrinkles and abdominal skin folds.

Q) In the procedure illustrated, you dissolved the resorcin in 3% hydrogen peroxide, while in most other procedures you dissolve it in water. Why?
A) We dissolve the resorcin in hydrogen peroxide when we want to increase its power. By means of Electroporo Cosmesis, we create micropores in the epidermis of large areas. We treat the neck, arms and abdomen. This technique is also used on skin that is visibly reddened by micro-ectatic capillaries, as in this patient. Melasmas also lighten and disappear. To treat these extensive hyperpigmentations, the operator needs to know that Electroporo Cosmesis is inflammatory at higher powers; by contrast, the application of resorcin in water for long times is not inflammatory. It is therefore necessary to increase the time during which the rotating electrode brushes the skin at a power of 14 Watt, 20 Watt or 27 Watt, and to increase the time of application of the resorcin.

Q) Mixed peeling solves the problems of normo-pigmented facial skin in patients with generalized vitiligo. What advantages does it have over other methods?
A) • No other methods can be compared with this extraordinary technique.
A) • No standardized methods are able to de-pigment the skin in one or two sessions, as timedsurgical mixed peeling does.
A) • No existing methods act specifically on the melanocytes, as timedsurgical mixed peeling does.
A) • No existing methods act on all the geometric points of the pigmented surface, as timedsurgical mixed peeling does.
A) • No other methods utilize a chemical substance that, when applied to intact skin, has no effect, as timedsurgical mixed peeling does.
A) • No other methods exist in which medications are not required, as in timedsurgical mixed peeling.
A) • No other methods have such little toxic effect, as timedsurgical mixed peeling does.
A) • No existing techniques or treatments are as safe and efficacious as timedsurgical mixed peeling.

Q) What can you say about re-pigmentation?
A) De-epithelialized achromic areas are re-pigmented by grafting cultivated autologous keratinocytes and melanocytes. Only patients with stable vitiligo, piebaldism and areas of scarring can be treated. However, we no longer perform this procedure, as we no longer have a cell-culture laboratory available.

Q) What happens if the areas treated with mixed peeling are medicated with ointments or creams?
A) Healing takes place underneath the crust. If we hinder the formation of the crust by applying creams, ointments or disinfectants, we will delay the healing process and probably cause problems of scarring. The crust forms within a few hours, facilitates healing and prevents infections and other complications.

Q) Are these results achieved in a single session?
Yes.

Q) Are there any other mixed peeling techniques and, if so, what applications do they have?
A) Pulsed timedsurgical de-epithelialization eliminates lip wrinkles, roughness and festoons from the lower eyelids, and extensive hyperpigmentations in subjects with a uniform complexion (This patient also underwent mixed peeling of the lips with de-epithelialization to eliminate wrinkles definitively).
Another indication for mixed peeling, which utilizes a specific pulsed function of the Timed Micropulse, is that of giant nevi of the scalp. In this case, we perform de-epithelialization, followed by the application of resorcin for 1 minute, within the first 10 days of life. In this case, too, we exploit the toxic effect of resorcin on the melanocytes. A further session of mixed peeling is then carried out after 6 or 12 months.

Q) Is Electroporo Cosmesis also used to treat melasma?
A) Yes. Low power (14 or 20 Watt) and a longer time (4 or 5 minutes) of application of the resorcin solution. The resorcin solution is also effective in treating reddening due to skin elastosis.

Q) Do you dissolve the resorcin in water?
A) Yes. When dissolved in water, it is not absorbed by the organism. If we wish to achieve greater penetration of the solution during Electroporo Cosmesis, the resorcin can be dissolved in H2O2. We use this solution to reduce roughness of the face, abdomen (also after liposuction) and arms, or to eliminate very superficial congenital angiomas.

Q) Does 0.5 mixed peeling ever fail?
A) In rare cases, inflammatory pigmentation may persist; however, this disappears spontaneously after a few months. In a few cases, small hyperpigmented areas have remained after epidermal permeabilization. If this happens, the treatment is completed by means of 0.5 mixed peeling. If, however, the patches are very dark, we adopt a different technique; we de-epithelialize and apply the resorcin solution for about 10 seconds. This is a rare occurrence but needs to be considered in patients who have displayed resistance to de-pigmenting treatments.

Q) Can Electroporo Cosmesis be used as a peeling to improve the skin?
A) Yes. It can be an exclusively aesthetic peeling, a medium-light peeling or, by dissolving the resorcinol in H2O2, a medium peeling that also works on superficial skin angiomas.

Q) A lot of doctors don’t use strong peeling techniques on the eyelids because they think they’re risky. What do you think?
A) They are right. Peeling techniques that use strong acids risk penetrating through the epidermis. Our peeling technique, which combines physical and chemical methods, is extremely efficacious and safe. Instead of acids, we use a substance that produces no effect if applied to intact skin. In practice, our peeling procedures are both the safest and the most efficacious.

Q) What other indications are there for timedsurgical mixed peeling with de-epithelialization?
A) One of the most frequent is hyperpigmentation of the lower eyelids (dark circles). This problem is solved in a single treatment session. Mixed peeling with de-epithelialization is the only technique in the world that can achieve this result.
Another common application is the elimination of wrinkles and festoons from the eyelids after transconjunctival blepharoplasty. If lower blepharoplasty is performed by means of a skin incision, it changes the shape of the eyes. For this reason, we abandoned this approach about 25 years ago. Instead, we use the Timed apparatus to remove all the adipose pouches through two 8 mm incisions in the conjunctiva. Other uses of mixed peeling with de-epithelialization are: the elimination of lip wrinkles; the elimination of large skin patches; the treatment of giant nevi of the scalp, which we treat within the first 10 days of life; depigmentation of the skin in patients with generalized vitiligo, etc…

Q) Some surgeons say that adipose pouches of the lower eyelids should not be completely removed.
A) We disagree. These adipose pouches are where they should not be. The anatomical structure of the pouches has the property of retaining water; the pouches therefore swell if the patient eats salty food. It should also be borne in mind that the complete removal of adipose pouches creates a concave area, which distends the overlying skin. For this reason, it is rarely necessary to remove any skin (only in the case of asymmetry). Unfortunately, many surgeons continue to perform lower blepharoplasty by means of skin incision; this is because they lack the skill and/or the technology needed in order to perform this procedure through the conjunctiva. Transconjunctival blepharoplasty does not change the shape of the eye!

Q) What other method can be used to rejuvenate the patient’s look?
A) If necessary, we use cellular Adipofilling. The adipose and stromal cells in this suspension rejuvenate the upper eyelids; in the lower eyelids, they enhance the volume of the malar region and eliminate sunken eye-rings and the lacrimal sulcus. Elastic canthopexy is another recent minimally invasive procedure; it elongates the eyes and corrects the appearance of eyes that are too close together.
In addition, we advise thorough cleansing of the eyelashes, cleansing of the skin in the morning and evening, and the application of bionic serums to the face and eyelids; these serums act on the energy centers of the cells, perfecting and maintaining the results of our procedures.

Q) What are these bionic serums?
A) They are serums (Korpocare) which combine the principles of advanced physics with cosmeceutics. We use Oro&Seta, Orizzonte, Contorno Occhi, Mito Gold C, Combi and R, to perfect and maintain our results.

Q) Are the results of mixed peeling excellent in all patients?
A) Yes. However, it should be avoided in patients who are sun-lovers, those with dark skin, depressed subjects, etc…

Q) Can hyperpigmentation occur?
A) No. Rather, slight hypopigmentation may ensue, but this will resolve over time and with exposure to sunlight. The upper lip is always a little darker than the surrounding skin.

Q) What advantages does timedsurgical mixed peeling have over other techniques?
A) The result is marvelous: wrinkles disappear, the texture of the skin is rejuvenated, the white portion of the upper lip shortens and the effect is lifelong. In addition, the pulsed de-epithelialization procedure is simple and risk-free.

Q) What can you say about Adipofilling?
A) Adipofilling is a revolutionary technique which has great possibilities in esthetic surgery. Not only does it have a splendid volumetric effect, it also exerts a potent regenerative action if the cell suspension is injected intradermally. Moreover, the fact that different Adipofilling suspensions can be conserved for use as a filler in subsequent months is extraordinary. Naturally, we only use this technique to treat wrinkles that are less deep.

Q) Is it correct to say that the more the canthus is raised during elastic canthopexy, the more evident the excess skin of the upper eyelid becomes?
A) Yes. The traction and lifting of the external angle of the eyelid make the excess skin of the upper eyelid more visible. This must be explained to the patient before elastic canthopexy is performed and the shape of the eyes is modified. It can easily be corrected by means of upper blepharoplasty.

Q) Do traditional canthopexy procedures also increase drooping of the palpebral skin?
A) Of course. For this reason, traditional canthopexy is performed together with blepharoplasty. In the case of elastic canthopexy, we prefer to perform blepharoplasty later, not only exerts traction and lifts the external canthus of the eye, but also has the same effect on all the tissues contained within the Isosceles triangle, the base of which is situated at the hairline in the temporal region.

Q) After blepharoplasty, the patient’s esthetic appearance can be improved by eliminating wrinkles from the lower eyelids. Is this peeling safe?
A) Timedsurgical mixed peeling is a physical/chemical treatment that is extremely safe. The chemical solution that is applied after pulsed de-epithelialization of the area is neither acidic nor alkaline. If applied to intact skin, it has no effect; it acts exclusively in the area from which the epidermis has been removed, and causes no damage to the dermis. The only important thing to know is that no ointments, creams or other products must be applied to the treated area. After the procedure, a crust forms in a few hours. Any exudate must simply be dried.

Q) In which regions is mixed peeling carried out?
A) There are three types of mixed peeling. The mildest is Electroporo-Cosmesis, followed by permeabilization of the epidermis, and then pulsed timedsurgical de-epithelialization. This last technique also finds application in the treatment of the lips, from which it permanently eliminates wrinkles. The mixed peeling procedures are indicated for cleansing and firming up the facial skin and reducing blemishes, and for treating melasma and lateral erythrosis of the neck. On the abdomen or arms, Electroporo-Cosmesis reduces wrinkles and makes the skin more compact. Permeablization is used in non-ablative blepharoplasty and the treatment of patches (face, body and hands).

Q) Eliminating wrinkles from the lower eyelid is important. What other methods can be used to achieve this goal?
A) The only standardized and consistently efficacious technique that can rejuvenate the skin by eliminating wrinkles is mixed peeling; no other technique can do this.
The result of mixed peeling can be further improved through volume enhancement, which is achieved by means of injecting adipose and stromal cells (Cellular Adipofilling).

Q) What is the difference between mixed peeling of lip wrinkles and mixed peeling of the lower eyelid?
A) The de-epithelialization is the same. To eliminate lip wrinkles, a saturated solution of resorcin is applied to the de-epithelialized skin. To treat the eyelid, the resorcin solution is not saturated; it is diluted to 50%. The application times are also different: from 1 to 2 minutes on the lips, and about 20 – 30 seconds on the eyelids. The operator has to judge by the frosting effect.

Q) Why is no type of medication used?
A) The resorcin solution exerts a coagulating effect. Within a few hours, a crust forms, which prevents infection. The patient must dry the area repeatedly during the first few hours, in order to keep the crust thin. Applying creams or other products to areas of resorcin mixed peeling is very risky and must be avoided.

Q) What are the indications for this timedsurgical procedure?
A) Roughness of the lower eyelid, palpebral folds, crow’s feet and dark circles under the eyes. Mixed peeling can also be performed after transconjunctival blepharoplasty. This association is advantageous because it eliminates the roughness of the eyelids without changing the patient’s look.

Q) Does mixed peeling eliminate pigmentation?
A) The technique used to treat the lower eyelids also eliminates dermal pigmentation. The reduction in the number of melanocytes stabilizes the result.

Q) Is de-epithelialization also carried out on the upper eyelids?
A) On the upper eyelids, we prefer to use 0.5 mixed peeling, which perfects surgical upper blepharoplasty and can, in many cases, replace it.

Q) Can the look be further improved?
A) Adipofilling can restore the correct volume to the eyelids. The elastic lifting of the lateral canthus can lengthen the eye avoiding risky interventions on singing. I remember that eye elongation is essential to restore a young and fascinating appearance.

Q) Is it necessary to mark on the eyelid where the nasal skin begins?
A) Yes. A peeling on two different skins can cause retractions. After local anesthesia it is difficult to identify where the skin of the nose begins.

Q) Should the application of the saturated resorcinol solution be continuous?
A) Yes, during the minutes of application the resorcinol must never dry out, if it dries it creates an impermeable layer.

Q) Is the correction of surgical blepharoplasty frequent with mixed timedurgical peeling 0.5?
A) Yes, mixed peeling 0.5 simply corrects the asymmetries that occur easily in this operation.

Q) I noticed that the sclera becomes whiter after the mixed peeling, how come?
A) Resorcinol applied to the eyelid narrows the ectatic capillaries of the sclera. It is a side effect that has an aesthetic and functional value.

Q) Is mixed peeling the technique of choice in patients with sagging skin and large orbits?
A) Yes, if we want to restore a youthful appearance.

Q) Is the 0.5 timedsurgical mixed peeling used also to remove skin blemishes when is indicated? It is indicated in patients with non-uniform complexion. With this technique of Timedsurgery there is no risk of white spots. Can the look be further improved?
A) Adipofilling can restore the correct volume to the eyelids. The elastic lifting of the lateral canthus can lengthen the eye avoiding risky interventions on singing. I remember that eye elongation is essential to restore a young and fascinating appearance.

Q) Is it necessary to mark on the eyelid where the nasal skin begins?
A) Yes. A peeling on two different skins can cause retractions. After local anesthesia it is difficult to identify where the skin of the nose begins.

Q) Should the application of the saturated resorcinol solution be continuous?
A) Yes, during the minutes of application the resorcinol must never dry out, if it dries it creates an impermeable layer.

Q) Is the correction of surgical blepharoplasty frequent with mixed timedurgical peeling 0.5?
A) Yes, mixed peeling 0.5 simply corrects the asymmetries that occur easily in this operation.

Q) I noticed that the sclera becomes whiter after the mixed peeling, how come?
A) Resorcinol applied to the eyelid narrows the ectatic capillaries of the sclera. It is a side effect that has an aesthetic and functional value.

Q) Is mixed peeling the technique of choice in patients with sagging skin and large orbits?
A) Yes, if we want to restore a youthful appearance.

Q) Is the 0.5 timedsurgical mixed peeling used also to remove skin blemishes when is indicated?
A) It is indicated in patients with non-uniform complexion. With this technique of Timedsurgery there is no risk of white spots.

Q) By reducing the number of melanocytes, can timedsurgical mixed peeling with resorcin eliminate dark circles definitively?
A) Yes, this treatment is highly efficacious and very safe. Moreover, the results are permanent. Mixed peeling corrects hyperpigmentation and rejuvenates the lower eyelids. Removing the epidermis enables the resorcin to act on all the geometric points of the treated surface, without any risk. Let’s remember that resorcin in an aqueous solution does not have any effect on intact skin.

Q) What other indications for mixed peeling are there in this region?
A) There are two types of mixed peeling. In the upper eyelid, we use mixed peeling 0.5 with permeabilization of the epidermis. This technique is used to perform nonsurgical upper blepharoplasty; mixed peeling with de-epithelialization, by contrast, is used on the lower eyelid in patients with pigmented or wrinkled skin, palpebral festoons that are difficult to correct surgically, and evident crows’ feet. This latter problem can also be treated with intradermal cellular Adipofilling. Mixed peeling to rejuvenate the skin of the lower eyelid is preferably performed in patients with a uniform complexion. If the complexion is not uniform, mixed peeling 0.5 with permeabilization is carried out. This type of peeling is less efficacious but leaves the complexion identical to that of the surrounding area.

Q) We know that cellular Adipofilling can be injected under the fine palpebral skin to restore the correct volume of this region. When is it performed?
A) The Adipofilling suspension of living adipose and stromal cells can be injected into the dermis, in which case it has no volumetric effect, but exerts a potent regenerative action. Alternatively, it can be injected immediately beneath the skin, in which case it has a delicate volumetric effect. In the palpebral region, it corrects sunken eye-rings and distances the skin from the orbicular muscle, making the palpebral skin look brighter. After eliminating palpebral roughness by means of mixed peeling, we advise patients to undergo subcutaneous cellular Adipofilling in order to complete the rejuvenation of the region. In the treatment of the periocular region, in addition to surgical, transconjunctival and upper blepharoplasty procedures, and to mixed peeling with de-epithelialization and epidermal permeabilization, Adipofilling also has an important role to play.
Another procedure, which we are now refining for the treatment of this region, is canthopexy by means of the elastic thread. This restores the youthful elongated look of the eyes in a few minutes, without intervening directly on the canthus.

Q) Are the program data of the Timed apparatus suitable for all patients?
A) Of course. These program data are based on real values and are used to perform over 70 standardized applications. The programmable Timed apparatus has been specially designed for the innovative procedures of Timedsurgery (Technique for the Implementation of Measured Electrosurgery Data). The high-frequency current used travels over surfaces at the speed of light. By contrast, light travels in a straight line. This is the main disadvantage of using laser beams in dermatology.

Q) The operation we’ve just seen is simple and yields a very natural result. What other pathologies is this technique used for?
A) Although lip shaving dates back to the 1950s, it is little-known but very useful. As well as for treating “precancerous” lesions of the vermilion border of the lip (leukoplakia, keratoses, chronic solar or actinic cheilitis, radiation ulcers, cutaneous horns, chronic fissures, cheilitis glandularis, etc.) lip shave is used to remove superficial or multicentric malignant tumors and in situ or non-invasive carcinomas of the vermilion, and to treat congenital hypertrophy of the lower lip (“Hapsburg lip or negroid lip”), macrocheilia of either lip and diffuse pigmentation of the lip (lentigo). Today, however, most of our lip-shaving procedures are performed to correct the unsightly results of the injection of silicone and permanent fillers into the vermilion border of the upper and lower lips.

Q) With rapid pulsed timedsurgical cutting, are the scars always so good, practically invisible?
A) The scars are hardly visible. This means that we can even reshape lips that have been deformed by the injection of silicone or other permanent fillers; to do this, we use multiple micro-excisions until we achieve the result that the patient wants.

Q) Do many patients request reduction of the lips?
A) Yes. A lot of patients want to have natural lips again – with the right proportion between the upper and lower lip and the right harmony of the vermilion. However, reduction is not indiscriminate; it is carried out where it is necessary. If the previous volume increase is esthetically advantageous, we leave it.

Q) When lip shaving is performed in men, are facial hairs a hindrance? If so, what do you do?
A) We eliminate these hairs by means of definitive rapid epilation. Pulsed timedsurgical epilation enables us to selectively and definitively eliminate all the hair terminals present.

Q) Why is upper blepharoplasty with skin excision particularly suitable for patients with small orbits?
A) In patients with medium-sized, and especially large, orbits, removing the skin makes the eye look sunken, like a doll’s eye; this often does not correspond to the patient’s appearance when young. In these patients, I frequently carry out non-surgical blepharoplasty by means of 0.5 mixed peeling; this technique of strong peeling does not involve any risk and rejuvenates the patient’s look without leaving scars or surgical artifacts. Even in patients with sunken eyes and excess skin, this timedsurgical peeling technique restores the patient’s youthful look, maintaining the volumes of the eyelid and the palpebral fold that is typical of youth.

Q) How do you make the preoperative design?
A) A dermographic pen is used. With the patient in the supine position, the eyelid is pulled upwards; the patient opens the eyes slightly, and the line of the design is traced immediately below the angle that is formed in the eyelid. The lower line starts from the vicinity of the internal canthus, reaches the extremity of the eyelid and extends to the wrinkle, if present. The upper line starts from the medial end of the lower line and continues along the border between the skin that has been worn by the opening of the eyelid over time and the intact skin below the eyebrow. The upper line stops at the level of the external canthus. At this point, the patient is placed in a sitting position in order to complete the design of the diamond-shaped skin flap that encompasses the lateral skin excess that is visible only under the effect of gravity.

Q) If a patient with small orbits wants to undergo blepharoplasty, do you perform non-surgical blepharoplasty with 0.5 mixed peeling?
A) Generally, yes, but you have to consider what the eyelids were like when the patient was young; if the eyelids were sunken, surgical blepharoplasty can be performed. If the eyelids had a fold, it is advisable to carry out 0.5 mixed peeling.

Q) Why do you use rapid pulsed timedsurgical cutting for upper blepharoplasty? What advantages does it have?
A) This particular type of cutting, which uses the specific 0.3/5.3 pulsed current generated by the Timed apparatus, has several advantages: it allows perfect visibility, ensures hemostasis of the capillaries, and, unlike all cutting by means of high-frequency currents, does not burn the tissues; moreover, scarring is excellent and never hypertrophic – much better than that of the traditional surgical scalpel or the diamond scalpel. If a new EM10 White electromaniple is used, the scar is practically invisible, as in this case. Even on the mucosae, such as the vermilion border for example, the scars are practically invisible.

Q) What device is the TIMED?
A) The TIMED (Technique for the Implementation of Measured Electrosurgical Data) is a programmable electrosurgical device (Patent USA, Sergio Capurro) suitable to perform more than 70 standardized interventions in the field of plastic, aesthetic and dermatological surgery. Timed has unique and exclusive operating possibilities that have been implemented and tested for around 40 years.

Q) What do you think of the Colorado needle?
A) The Colorado needle has an evocative name which fascinates those colleagues who do not know Timedsurgery, who are unfamiliar with high-frequency currents, and who are unwilling to learn new techniques. To me, it is just a pointed piece of iron, like many other electrodes that we used to use at one time.

Q) What do you prescribe in the post-operative period following upper blepharoplasty?
A) The patient continues antibiotic therapy and applies swabs of cold chamomile, which is prepared before the procedure.

Q) If the patient wants to modify the shape of the eyes, what can be done?
A) In the patient shown here, we lifted the eyebrows and the temporal region by implanting elastic threads (Elasticum, Korpo, Italy) a few weeks later. Elastic lifting was performed through an incision of a few millimeters at the hairline. This lifting technique enables several elastic threads to be implanted through the same incision. Lifting the tail of the eyebrow makes the eye almand-shaped, modifying the patient’s look.

Q) Why do you knot the two sutures above the nose?
A) We prefer to avoid knotting the spiral suture in the medial corner because, if we want to remove the stitches after three days, the palpebral edema could make it more difficult.

Q) How should the patient prepare for the blepharoplasty procedure?
A) Two weeks before the procedure, the patient must suspend any treatment with aspirin, anti-inflammatories, vitamin E or phytotherapy, and refrain from drinking alcoholic beverages. If the patient is a coagulation defect, this must be corrected.

Q) The benefits of upper blepharoplasty are immediately visible, but how stable are they?
A) For a year, the appearance of the eyelids improves; in the following years, gravitational ptosis continues to exert its effect. However, this can be corrected by means of Adipofilling of the forehead and eyelids. Conceptually, we never operate twice on the upper eyelids, except in the rare and unforeseen event of herniation of fat. Repeat procedures are more frequent in blepharoplasty of the lower eyelids, in which we always remove all the visible fat through the conjunctiva.

Q) What advantages does rapid pulsed timedsurgical cutting have over laser therapy or the scalpel?
A) A laser beam burns the tissues and is difficult to control. Palpebral surgery can certainly be performed with the scalpel and scissors, but we prefer rapid pulsed cutting. This type of cutting does not burn the tissues, is hemostatic, does not deform the tissues, allows extreme precision, and offers perfect visibility; in addition, in comparison with incisions made with a scalpel, healing times are halved. Moreover, when used on the mucosa, for example on the vermilion border, pulsed timedsurgical cutting does not leave visible scars. However, the greatest advantage of performing transconjunctival blepharoplasty by means of rapid pulsed timedsurgical cutting is that it is extremely selective and scantly invasive. For us, preserving the integrity of the tissues is very important in every procedure! Indeed, it is irrational to perform transconjunctival blepharoplasty by dissecting the whole area, as is done in blepharoplasty through an external incision, an approach that we abandoned decades ago! In the procedure demonstrated here, the adipose pouches were isolated and removed selectively, without damaging the surrounding tissues.

Q) What are the features of the electromaniples used?
A) The EM10 electromaniples have a flexible tip, which is conical in shape and has a triangular cross-section. These electromaniples come in different sizes (EM10 White 0.08 mm, EM10 Green 0.10 mm, EM10 Gray 0.15 mm, EM10 Yellow 0.20 mm, EM10 Black 0.30 mm; the EM15 has a 1.5 mm cylindrical tip) and are used in the numerous (over 70) standardized Timedsurgery procedures.

Q) In the lower eyelid, are the adipose pouches completely removed?
A) Yes. A feature of the adipose pouches of the eyelids is that they retain water and swell in response to the amount of sodium in the diet or to dietary intolerance. If there is little subcutaneous tissue in the region, we can perform Adipofilling, which is able to correct the lachrymal sulcus and rings under the eyes and enhance the malar region.

Q) Some surgeons say that adipose pouches of the lower eyelid should not be completely removed. What is your view?
A) Congenital weakness of the orbital septum allows the retrobulbar adipose tissue to herniate through to the surface. The adipose pouches therefore occupy an anatomically anomalous position. This is a sufficient reason to remove them. Moreover, the complete removal of the adipose pouches, in addition to eliminating the swelling of the eyelids, creates a hollow that distends the skin. This is very useful in transconjunctival blepharoplasty, in which the skin is almost never removed. If we wished to be a bit malicious, we might say that removing all the pouches during lower blepharoplasty requires a degree of patience that not everyone has.

Q) We know that you remove adipose pouches from the lower eyelids only by means of transconjunctival blepharoplasty. Why is this?
A) I believe it is important to remove these pouches completely, without causing scarring of the skin or muscles. In this way, we avoid those frequent surgical artefacts, rounded eyes and an altered appearance. Very rarely, and mainly in cases of asymmetry, we remove a small strip of skin a few months after transconjunctival blepharoplasty. Complete removal of the pouches restores the natural introflexion of the eyelids that is typical of youth and distends the skin. If the patient has unsightly festoons, we carry out timedsurgical mixed peeling, which smooths the skin and eliminates crow’s feet, even if they are deep.
Finally, it should be borne in mind that transconjunctival blepharoplasty should be performed at a young age, as adipose pouches of the lower eyelids are congenital and familial.

Q) What advice would you give to someone who wants to begin performing these procedures?
A) Thorough anamnesis and careful preparation. Measure the patient’s pressure before the procedure and reduce it if necessary. Use the doses of epinephrine indicated and inject the adipose pouches as the operation proceeds. Epinephrine can also be used to control more persistent bleeding. You need to be resolute in order to remove all the adipose pouches, which is the aim of the procedure.
Finally, you must avoid the ample dissection used in traditional transconjunctival blepharoplasty procedures, as this needlessly damages the tissues.

Q) Is the post-operative course painful?
A) No, there is no pain.

Q) What do you think of the Colorado needle?
A) A piece of iron.

Q) What are the indications for mixed peeling 0.5?
A) Mixed peeling 0.5 is particularly indicated for patients whose palpebral skin is aged, thin and drooping; for patients with asymmetrical eyelids; for young women with a slight defect of the eyelid; for those whose eyelids lack volume; for patients with aged skin who have already undergone surgical blepharoplasty; for those who do not want to risk having an artificial appearance after surgical blepharoplasty, and for those who do not wish to undergo a surgical procedure. Mixed peeling 0.5 is also indicated for upper blepharoplasty in patients with large or medium-sized orbits. If these patients have already undergone traditional surgical blepharoplasty, the shape of the eyelids will have changed, taking on a “withered”, sunken and too sharply outlined appearance. If the patient had a palpebral fold when young, our aim is to restore the youthful shape of the eyelids without giving them a sunken appearance, as happens when skin is removed. It should be borne in mind that sunken eyelids, if they are not familial, are characteristic of aged eyes and always appear artificial. As a general rule, I recommend surgical blepharoplasty when the orbits are small; in medium-sized/large orbits, mixed timedsurgical peeling 0.5 certainly yields more natural results.

Q) When is mixed peeling contraindicated?
A) Mixed peeling 0.5 can always be carried out in the above-mentioned conditions. It must be borne in mind that mixed peeling 0.5 is an esthetic treatment. Surgical blepharoplasty, in addition to improving the esthetic appearance, is also a functional operation; when adipose pouches are removed, the eyelids can be opened more easily and the eye appears larger. Of course, surgical blepharoplasty does not rejuvenate aged skin. The two techniques, however, can be joined. For instance, adipose pouches can be removed without removing any skin, and mixed peeling 0.5 can be carried out later; alternatively, this order can be reversed.

Q) What do you need to be particularly careful about in mixed peeling 0.5?
A) You have to perform local anesthesia with a 2% anesthetic solution. You have to be careful to remain within the palpebral area and not touch the skin of the nose. Frosting must be intense and uniform. The entire surface of the eyelid must be treated. It is advisable to keep a distance of 1 mm from the eyelashes. For what concerns “crows’ feet”, mixed peeling 0.5 is not as effective in this area as mixed peeling with de-epithelialization; unless the patient expressly asks otherwise, it is preferable to limit the area of action to the eyelids. In this way, the patient can soon return to her normal activities.

Q) What happens if the saturated solution of resorcin comes into contact with the eyes?
A) We wash it out with a little physiological solution. Brief contact does not damage the tissues of the eye.

Q) What happens in the post-operative period?
A) After treatment, the patient dries the area several times with a paper tissue. Edema will persist for two or three days. The patient cleans the eyelashes with chamomile and uses decongestant eyedrops. Subsequently, she can apply a non-cortisone anti-inflammatory cream. After 10-12 days, only slight redness will remain. A protective sun-cream should be used in the first few months.

Q) How is the epidermis made permeable?
A) To make the epidermis permeable, we have to apply a high power (50 Watt or 38 Watt) while in the coagulation function. Emission of the current is extremely short (0.5 hundredths of a second) and powerful, creating an arc that renders the epidermis permeable to the resorcin solution. The brevity of the pulsed emission prevents the arc from reaching the dermis, as this would cause dehydration and desiccation. If the dermis were subjected to vaporization, as would happen if the emissions were more prolonged, it would no longer be able to absorb the saturated solution of resorcin. The operator’s technique also plays a role; the electrode must approach the surface through vertical movements until the arc is triggered. It is important to keep the EM 15 electromaniple clean. The return electrode must remain in contact with the skin of the chest, as close as possible to the face. If there are problems of conductivity, this area can be slightly moistened.

Q) Why must frosting be complete?
A) Frosting must be complete because the rejuvenating action is exerted exclusively by chemical means – in this case, by the saturated solution of resorcin. Physical treatments are not efficacious and are also risky. To improve the action of retraction and reorganization of the connective fibers of the palpebral skin, the physical-chemical action must be exerted over the entire surface of the eyelid, from the eyebrow to a millimeter from the eyelashes.

Q) Given that timedsurgical de-epithelialization works so well on the lower eyelid, why don’t you use it on the upper eyelid, too?
A) Because the upper eyelid is much more mobile, the skin is difficult to de-epithelialize. Moreover, we do not want to exert the same action at all points of the surface of the skin of the upper eyelid. For this reason, frosting is made to occur through the epidermis, which has been rendered permeable by the micro-arc. This mixed peeling is powerful (up to 4 minutes of application!), but absorption of the solution is not uniform. This ensures rapid healing and the absence of problems. We also use mixed peeling 0.5 to remove skin blemishes – even deep ones – in patients with an irregular complexion. While pulsed timedsurgical de-epithelialization, followed by the application of a saturated solution of resorcin for 20 seconds, is able to remove a dermal-epidermal patch in a single session, mixed peeling 0.5 often requires two sessions. However, following mixed peeling carried out by means of de-epithelialization, the skin presents no blemishes and not even slight redness. In a non-homogeneous complexion, this is likely to be noticeable, which is not desirable.

Q) What do you think of those physical methods that create a series of punctiform burns on the palpebral skin?
A) I think the best apparatus that can create punctiform lesions of uniform depth at stepped power settings is the Timed, which is, by the way, the only apparatus designed to be programmable. However, as I have already said, I believe that physics alone is much less efficacious than physics and chemistry combined. This is why I created these mixed peeling procedures. The result seen in this video was achieved by means of a single treatment session.

Q) You cite power levels of 50 Watt or 38 Watt. What criterion do you use in order to choose one or the other of these two power values?
A) When performing permeablization of the epidermis, it is always preferable to use the lower power setting. Contrary to what one might think, this enables mixed peeling to be more efficacious. Emissions of 38 Watt for 0.5 hundredths of a second permeabilize the epidermis without drying the dermis. This allows better absorption of the saturated resorcin solution, making mixed peeling more effective. If the skin of the eyelids is particularly aged, it can be useful to apply a urea cream on the days before the peeling procedure, in order to improve the conductivity of the skin. Pulsed emissions at 38 Watt require good conductivity of the skin, a light hand and a magnifying lens. If the operator experiences any difficulty, the 50 Watt setting can be used.

Q) This video clearly illustrates the importance of rejuvenating the palpebral skin. What other techniques are able to do this?
A) Rejuvenating the skin of the upper and lower eyelids is of great importance to rejuvenating the overall appearance of the face. I believe that mixed peeling procedures will be widely used once the importance of skin rejuvenation has been fully grasped. The only technique that is able to retract and thicken the skin is mixed peeling, which is a standardised and consistently efficacious procedure; no other technique can do this. The result of mixed peeling can be further improved through volume enhancement, which is achieved by means of injecting adipose and stromal cells (Adipofilling).

Q) What is the difference between mixed peeling of lip wrinkles and mixed peeling of the lower eyelid? ?
A) The de-epithelialisation is the same. To eliminate lip wrinkles, a saturated solution of resorcin is applied to the de-epithelialised skin. To treat the eyelid, the resorcin solution is not saturated; it is diluted to 50%. The application times are also different: from 1 to 2 minutes on the lips, and about 20 or 30 seconds on the eyelids. The operator has to judge by the frosting effect.

Q) Why is no type of medication used?
A) The resorcin solution exerts a coagulating effect. Within a few hours, a crust forms, which prevents infection. The patient has to dry the area repeatedly during the first few hours, in order to keep the crust thin.

Q) In this video, while the resorcin solution is being washed off, a little resorcin gets into the patient’s eye…
A) Yes. We always keep a vial of physiological solution handy so that the eye can be washed if this happens. But resorcin is very safe. When applied to intact skin, it has no effect; on the mucosa, it can cause discomfort, but not damage.

Q) What are the indications for this timedsurgical procedure?
A) Roughness of the lower eyelid, palpebral folds, crow’s feet and pigmentation of rings under the eyes.

Q) Does mixed peeling eliminate pigmentations?
A) The technique used to treat the lower eyelids also eliminates dermal pigmentations.

Q) Is de-epithelialisation also carried out on the upper eyelids?
A) We have never done it. In the upper eyelids, we prefer to use another mixed peeling technique (0.5), which perfects surgical blepharoplasty and, in many cases, replaces it. This technique will be published in 2016.

Q) Can slow pulsed timedsurgical cutting be used in other regions?
A) Electroshaving by means of slow pulsed timedsurgical cutting is the method of choice for the removal of neoformations of the edge of the eyelid. It enables the neoformation to be exercised precisely while maintaining the integrity of the residual tissues. We apply the concept of self-regeneration of the organism that underlies electroshaving to all benign neoformations of the face and body. Surgical excision and suturing would cause evident scarring. Electroshaving does not produce surgical artefacts and, if correctly performed, leaves no visible signs.

Q) Why is it so important to achieve good local anaesthesia?
A) The haemostatic action of the epinephrine contained in the anaesthetic solution allows the operator to distinguish the plane of cleavage between the neoformation and the healthy tissues.

Q) Does electroshaving presuppose the maintenance of an underlying dermal layer?
A) Generally speaking, yes. If the neoformation is deep, we sometimes see some small areas of adipose tissue. If the neoformation occupies the entire thickness of the skin, for example in the case of syringomas of the eyelid, the micro-excisions made by means of slow pulsed timedsurgical cutting may be sutured. Let us remember that slow pulsed timedsurgical cutting is able to cut out a 1 mm flap between two lines.

Q) Is medication important?
A) Yes, medication after electroshaving is important. The edge of the eyelid has a great regenerative capacity and requires the application of a collagenase cream until a crust forms. After electroshaving in other areas of the face and body, a collagenase cream must be applied every day for a week. Before the cream is reapplied, the previously applied cream must be removed by means of a moist cotton wool bud. After a week, an antiseptic powder can be applied. Immediately after applying the powder, the patient must use cotton wool to remove any powder that does not adhere to the site of substance loss.

Q) What advantages does rapid pulsed timedsurgical cutting have over scalpels and lasers?
A) Lasers burn the tissues and are difficult to control. A scalpel can certainly be used, but for palpebral surgery we prefer to use rapid pulsed cutting because it is hemostatic, does not deform the tissues, enables the skin and muscles to be incised with great precision, allows perfect visibility and halves the healing times required for scalpel incisions. Moreover, when pulsed timedsurgical cutting is used on the mucosa, for example on the vermilion border, it does not leave any visible scars.

Q) What are the characteristics of the electromaniples?
A) The electromaniples are used to carry out the numerous (more than 70) standardized techniques of Timedsurgery. The EM10 electromaniples have flexible, conical tips with a triangular cross-section; they come in different sizes for use in the various applications (EM10 White 0.08 mm, EM10 Green 0.10 mm, EM10 Grey 0.15 mm, EM10 Yellow 0.20 mm, EM10 Black 0.30 mm. The EM15 has a 1.5 mm cylindrical tip).

Q) In the lower eyelid, are the adipose pouches completely removed?
A) Yes, completely. The adipose pouches of the eyelids retain water and swell according to the amount of sodium in the diet or as a result of dietary intolerance. If the region has little subcutaneous tissue, we can also perform Adipofilling, which can correct the lachrymal sulcus and bags under the eyes or enhance the volume of the malar region.

Q) Some surgeons say that adipose pouches in the lower eyelid should not be removed completely. What do you think of that view?
A) Congenital weakness of the septum orbitae allows the retrobulbar adipose tissue to herniate through to the surface. Adipose pouches therefore occupy an anatomically anomalous position. This alone is sufficient reason to remove them. Moreover, in addition to eliminating swelling of the eyelids, the complete removal of adipose pouches creates a recess that distends the skin. This is very useful in trans-conjunctival blepharoplasty, in which the skin is almost never removed. If we wanted to be a little malicious, we could say that removing all the pouches in lower blepharoplasty requires a degree of patience that not all operators have.

Q) During vaporization of the tissues of a malar pouch, what can be felt with a fingertip when the electrode is superficial?
A) Heat. This heat also provides an indication of the depth of the electrode.

Q) Do you have any other advice concerning this procedure?
A) I advise extending vaporization to the margins of the malar pouch in order to exploit the retraction of the tissues.

Q) What can be done to prevent malar pouches from recurring?
A) The patient should undergo elastic lifting of the eyebrows and temporal regions. The lachrymal sulcus and the malar region can be corrected by means of Adipofilling. Naturally, an elastic MACS and Neck lift would have a further rejuvenating effect.

Q) Is there any fibrosis of the subcutaneous tissue after Timedsurgical Adipolysis?
A) There is no visible fibrosis; Adipolysis specifically eliminates the adipose cells, and the micro-tunnels, though numerous, are too narrow to give rise to permanent hardening of the tissues; they do, however, have an effect on the retraction of the skin.

Q) Upper blepharoplasty is the first esthetic surgery procedure used to counteract aging. Is that right?
A) Yes, but upper blepharoplasty is not only an esthetic procedure; it also has a functional effect. Removing the herniated fat enables the eyelids to be opened wider and more easily.

Q) When timedsurgical resurfacing is carried out in the coagulation mode, is there any risk of causing a greater than necessary destructive effect?
A) Timedsurgical resurfacing exerts a potent effect, but this effect is superficial. It does not heat the healthy underlying tissues, which would cause damage. Let us remember that resurfacing is also used for hemostasis during electroshaving, a procedure in which regeneration of the skin begins immediately after the removal of the neoformation, thanks to the absence of necrosis.

Q) Why are two sessions necessary?
A) As xanthelasma is due to a familial metabolic predisposition, we cannot guarantee that the lesion will disappear definitively. The operator must tell the patient that xanthelasma is due to a metabolic alteration and that its treatment will require two sessions.

Q) In timedsurgery, are there really over 70 techniques, each with its own program data?
A) Timedsurgery (Technique for the Implementation of Measured Electrosurgical Data) utilises the Timed TD 50 Micropulse apparatus, which is specifically designed to be programmable. This means that we can control all the parameters that condition the effect of a high-frequency current. The high-frequency current is not influenced by the colour of the skin, but by its electrical conductivity, which is very similar from one individual to another. Each of the more than 70 applications has its own precise program data and uses a specific electromaniple. Specially designed currents have been created in order to perform operations that were previously impossible, such as de-epithelialisation of the skin, rapid or slow timedsurgical cutting, resurfacing, etc.

Q) Is the result of timedsurgical mixed peeling permanent?
A) Yes, mixed peeling of the lip will not have to be repeated. If a wrinkle should remain visible, a 5 mm area of skin may be de-epithelialised and the resorcin solution reapplied. However, this is rarely necessary.

Q) When can the skin be exposed to the sun?
A) As soon as the reddening disappears, the lip can be exposed to the sun; this will actually stimulate the melanocytes present at the bottom of the hair follicles.

Q) Might there be problems of hyperpigmentation?
A) No, absolutely not.

Q) Might there be problems of hypopigmentation?
A) No, not if the procedure is carried out properly. The saturated solution must be applied for the set times to the skin of the lip where the wrinkles are present, exactly where the terminal hairs are most numerous.

Q) How does the resorcin solution act?
A) The saturated solution of resorcin in water is not efficacious on intact skin; it can only act on de-epithelialised skin. Elimination of the epidermis enables the resorcin to act uniformly on the whole area. During frosting, the saturated solution of resorcin has a toxic effect on the melanocytes. This reduction in the number of melanocytes makes resorcin an extremely interesting de-pigmenting agent.

Q) How is the patient medicated?
A) After washing the resorcin solution off, the operator applies a cortisol solution, for example a vial of Betamethasone. Over the next few hours, the patient repeatedly dries the area with a paper tissue until a thin crust forms; the crust will be left to drop off on its own. When the crust drops off, slight reddening will remain; this will disappear completely within a few months. During this period, the patient will apply a zinc oxide cream every morning and evening.

Q) How is the saturated solution of resorcin made?
A) A small amount of resorcin powder is dissolved in a few drops of water. When a few granules of resorcin remain on the bottom of the vessel, the solution is saturated.

Q) In this procedure, the achromic epidermidis is replaced by cultivated epidermis endowed with melanocytes. What is the advantage of this procedure?
A) Timedsurgical de-epithelialisation leaves the dermis intact. If the dermis is intact, the graft takes root 100%. After this procedure, the re-pigmented skin will have the appearance of the patient’s normal skin and no scarring or surgical artefacts will remain.

Q) Can this technique be used in all forms of vitiligo?
A) No, only in stable vitiligo and piebaldism.

Q) Can scars be re-pigmented, too?
A) Yes. We have successfully carried out this procedure on numerous large achromic scars.

Q) Do you use this technique to treat small achromic scars?
A) No, it is too costly. If the scars are small, we only apply Timed micro-evaporation at 50 Watts for 1/3 of a hundredth of a second. Once the achromic epidermidis at the edges and above the scar has been removed, the scar will be re-epithelialised from the adjacent epidermis of the healthy skin and normal pigmentation will be restored.

Q) What sort of achromic areas are treated with timedsurgical micro-evaporation?
A) We treat small iatrogenic achromic lesions and solar lesions in this way. Achromic surgical scars of the face and body also disappear from view after this treatment.

Q) For which other procedures can pulsed timedsurgical de-epithelialisation be used?
A) To eliminate deep lip wrinkles and crows’ feet; to de-pigment dermal-epidermal patches; to treat recurrent plane warts, and to treat epidermolysis bullosa. In this last procedure, the pathological epidermis is replaced by epidermis modified by genetic engineering.

Q) How is the antiseptic powder applied?
A) The powder is sprinkled on a wad of cotton-wool and applied like a face powder; the excess powder is then removed with the cotton-wool. The crust must remain thin.

Q) How do you generate the micro-arc?
A) The micro-arc is generated through the air. The tip of the electrode touches the tissue and is then withdrawn; this triggers a micro-arc, which ionises the air. The ionised air is conductive and maintains the micro-arcs when the electrode passes very close to the surface of the skin.

Q) How much time must elapse between one session and the next?
A) On the face, at least two months.

Q) Are keratoses on the body treated differently?
A) Keratosis on the body require much greater delicacy; timedsurgical resurfacing or timed emissions at 50 Watt for 1, 2 or 3 hundredths of a second are used.

Q) Which of these two options is preferable?
A) We are evaluating the second one, which has the advantage of being very well tolerated without anaesthesia and does not leave any residual areas of hypopigmentation.

Q) What about small facial keratoses?
A) At present, we use resurfacing in the Coag function at 27 or 38 Watts with the EM15 electromaniple; this is the same treatment that we use for small senile lentigines of the face. These latter lesions can also be treated by means of Electroporo-cosmesis, after which 45% citric acid or 25% TCA saturated with resorcin is dabbed on. Another option is to apply 50 Watts for 1 or 2 hundredths of a second. Alternatively, a more delicate approach can be adopted; this involves using the resurfacing function at 50 Watts and setting the time to 1 or 6 hundredths of a second. In the first case, an emission of 1/3 of one-hundredth of a second is obtained; in the second case, the emission time is 2/3 of one-hundredth of a second.

Q) Electroshaving by means of slow pulsed timedsurgical cutting enables small benign neoformations of the face and body to be removed and yields an aesthetic result. What precautions need to be taken?
A) Magnifying lens must be used; only the neoformation is removed, without burning the edges. In this way, healing can begin immediately. The patient has to apply a small amount of collagenase and chloamphenicol gel (Iruxol) every two days until the crust forms. If there is a lot of exudation and a crust has not formed after 3 or 4 days, an antiseptic powder (Ektogan) is applied. Once the crust has formed, it must be allowed to detach spontaneously; the patient must take care not to rub it off. When the crust is about to drop off, the patient should cover it with a sticking plaster before going to bed, so as to avoid rubbing against the pillow or sheets. When electroshaving is carried out on the body, it is advisable to add a drop of triamcinolone acetate (Kenacort A) to the anaesthetic solution in order to reduce the risk of slightly hypertrophic scarring, especially in young patients.

Q) How much triamcinolone acetate should be added?
A) Small amount of triamcinolone acetate is drawn up into the syringe and then emptied back into the vial; immediately afterwards, the anaesthetic solution is drawn into the syringe. The small amount of triamcinolone that remains in the extremity of the syringe and in the needle is enough to prevent hypertrophic scarring.

Q) How is the antiseptic powder applied?
A) Wad of cotton-wool is used to dab a small amount of powder onto the wound, in the same way as face powder is applied. After a minute, the same wad is used to remove all excess powder that does not adhere to the wound. In this way, the wound “breathes” and does not become infected.

Q) Should the powder be applied several times a day?
A) It is advisable to do so.

Q) Why is it called mixed peeling?
A) Because it mixes a physical technique (pulsed timedsurgical de-epithelialisation) with a chemical technique (peeling).

Q) Are the results of mixed peeling excellent in all patients?
A) Yes. However, the procedure should not be carried out on patients who habitually expose their skin to the sun, those with dark skin, those who are depressed etc.

Q) Can hyperpigmentation occur?
A) No. Slight hypopigmentation is more likely; this disappears with time and exposure to the sun. The upper lip is always a little patchy and slightly darker than the surrounding skin.

Q) What advantages does timedsurgical mixed peeling have over other techniques?
A) The result is marvellous; wrinkles disappear, the texture of the skin is rejuvenated, the white portion of the lip is shortened and the result is life-long. This pulsed de-epithelialisation procedure is simple and practically risk-free.

Q) Is anti-herpes prevention required?
A) No. Anti-herpes prevention is only carried out in predisposed patients.

Q) Is no medication needed?
A) The patient repeatedly dries the area with a paper tissue. The crust must be thin. When the crust drops off, the patient must not apply creams for 48 hours, in order to allow epidermal keratinisation; subsequently, an emollient cream is applied.

 

Korpo thanks the open-access Medical Video Journal CRPUB.ORG for the material provided.