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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.