1 Background

Familiarity with the skin-type characteristics is critical for successful cosmetic procedure outcome. Aiming this, detailed cutaneous examination, including degree of sebaceous activity (oily or dry skin), photoaging, presence of postinflammatory hyperpigmentation, infection, and preexisting inflammation, will be facilitated using Baumann’s skin-type classification [1,2,3].

The procedures discussed are as follows:

  • Skin surgery

  • Injectables (fillers, toxins, and fat reduction), microneedling, and ablative lasers

  • Nonablative lasers and light

  • Chemical peels

2 Classification

Performing cosmetic procedures in mixed and global skin types can be challenging. There are certain skin types that are at greater risk than others for development of one or more complications after these treatments. The emerging world phenotype continues to have far-reaching, important implications for patients and those involved in caring for the skin [1, 4,5,6,7].

There are several unfavorable reactions that may result in skin of any color that undergoes a cosmetic procedure. The observation that skin of any color has a unique response when under environmental or physical stress dates past antiquity to ancient civilizations, including Egyptian civilization [2,3,4, 8].

In the dawn of Western medicine, the predominant skin type was light/white in color, and procedures/treatments were geared toward that one phenotype. There was not a perceived need to classify the different types of Caucasian skin because there were little observed differences in clinical behavior among the European skin type of that time [1,2,3].

Modern-day globalization has had an impact on human phenotype. Mixing of ethnicities has led to the increased emergence of mixed genotypes resulting from interethnic marriages and progeny. This mixing of ethnicities leads to a significant change in the world demographics as we are developing new skin types.

We have all experienced the phenotypically blonde-haired, blue-eyed patient who develops scarring after cosmetic surgery and conversely the dark-complexioned patient who has no adverse sequelae from a deep trichloroacetic acid (TCA) peel. And whereas the skin care product market has undergone rapid innovation and exponential growth, the categories used to describe skin types have changed little over the last century.

Identifying and classifying the patient’s skin type can prevent some side effects and ameliorate the final cosmetic results. Skin care pre- and post-procedure can be used to improve the results [1,2,3,4,5,6,7,8].

There are many skin-type classifications. The Fitzpatrick skin phototype classification remains the gold standard. It is simple and user friendly. However, this system fails to accurately predict skin reactions. Baumann’s skin-type classification system is a tool to predict the skin’s response to injury and insult from cosmetic procedures and to identify the propensity of sequelae from inflammatory skin disorders. It can be a predictor of an impending complication, such as hyperpigmentation, which can then be avoided [1,2,3,4,5,6,7,8].

In early 1990, Helena Rubinstein identified four skin types: dry, oily, combination, and sensitive [1,2,3]. In 2005, Dr. Baumann developed a system of skin typing based on our modern understanding of four basic skin parameters: dry or oily, sensitive or resistant, pigmented or nonpigmented, and wrinkled or unwrinkled (tight) [1,2,3].

There are four basic dichotomies or parameters introduced in the Baumann Skin Type Indicator (BSTI) that more accurately characterize skin types. Evaluating skin according to these parameters—dry or oily, sensitive or resistant, pigmented or nonpigmented, and wrinkled or unwrinkled—and thus differentiating among the 16 permutations of possible skin types facilitate identifying the most suitable topical treatments for their skin (Tables 84.1 and 84.2).

Table 84.1 The 16 Baumann skin types [1,2,3, 9]
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Table 84.2 Using this nomenclature allows physicians to use a standardized methodology that takes into account all four of the skin parameters, each of which contributes to the patient’s skin phenotype and needs. Taking all four of the parameters into consideration when prescribing a skin care regimen will improve outcomes because all of the important variables are taken into account [1,2,3]
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Not only can Baumann’s classification permit classifying the skin type, but we can also plan the patient’s treatment according to the BSTI, and we can predict and anticipate some skin troubles that the patients can experience during the treatment. In other words, we have a dynamic and prognostic classification [1,2,3].

The four skin-type parameters are as follows.

The Baumann Skin Type Indicator (BSTI) is a validated questionnaire [3], which consists of a 3- to 5-min computer-based questionnaire assessing four main parameters of the skin:

  • Oily vs. dry

  • Sensitive vs. resistant

  • Pigmented vs. nonpigmented

  • Wrinkle prone vs. tight

Depending on the way the questions are answered, the patient is diagnosed as having a distinct skin phenotype known as the Baumann Skin Type®. There are 16 possible Baumann skin types based on these four parameters. The Baumann Skin Type is designated by four letters (Table 84.1).

The Baumann Skin Type (BST) can vary with seasons, hormone fluctuation, lifestyle changes, pregnancy, medications, move to a new geographic location, and other factors. Patients should retake the questionnaire if they have experienced any of these changes so that their skin care regimen can be properly adjusted.

3 Procedure Types

3.1 Skin Surgery

Whether patients are having a biopsy, surgical excision, or Mohs surgery, the outcome will be improved when proper skin care is used before and after the procedure.

3.1.1 Presurgery Skin Care and Supplements (Table 84.3)

The goal is to speed healing and minimize infection, scarring, and hyperpigmentation. For 2 weeks prior to surgery, use products that have been shown to speed wound healing by increasing keratinization and/or collagen production.

Table 84.3 Pretreatment skin care for surgeries
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Ingredients that should be used prior to wounding include retinoids such as tretinoin and retinol. Several other studies have convincingly shown that pretreatment with tretinoin speeds wound healing.

Kligman evaluated healing after punch biopsy and found that the wounds on arms pretreated with tretinoin cream 0.05–0.1% were significantly smaller by 35–37% on days 1 and 4 and 47–50% smaller on days 6, 8, and 11 than the untreated arms.

Most studies suggest a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment. That way, the skin will have recovered from any retinoid dermatitis prior to surgery.

Adapalene should be started 5–6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.

Although wound healing studies have not been done, pretreating skin with topical ascorbic acid and hydroxy acids might help speed wound healing by increasing collagen synthesis.

3.1.2 Ingredients and Activities to Avoid Presurgery (Table 84.3)

Avoid ingredients that could promote skin tumor growth. Although there are no studies evaluating the effects of growth factors on promoting the growth of skin cancer, caution is prudent.

To reduce bruising, patients should avoid aspirin, ibuprofen, naproxen, St. John’s wort, vitamin E, omega-3 fatty acid supplements, flaxseed oil, ginseng, salmon, and alcohol. Most physicians agree that these should be avoided for 10 days prior to the procedure. Smoking should be avoided 4 weeks prior to the procedure.

3.1.3 Postsurgery Skin Care and Supplements (Tables 84.4, 84.5, and 84.6)

Oral vitamin C and zinc supplements were shown to speed wound healing in rats when taken immediately post-procedure. Oral arnica tablets and tinctures are often used prior to and after surgery to reduce bruising and inflammation. There is much anecdotal support for the use of arnica but few trials to substantiate its efficacy to prevent bruising and reduce swelling.

Table 84.4 Posttreatment skin care for surgeries
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Table 84.5 Pretreatment skin care for surgeries
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Topical products used after surgery play an important role in healing. The combination of topical Arnica montana and Rhododendron tomentosum (Ledum palustre) in a gel pad was shown to reduce postoperative ecchymosis and edema after oculofacial surgery. Topical curcumin speeds wound healing in animals. Another study showed that an occlusive ointment containing a triad of antioxidants sped wound healing.

Defensin, a protein important in wound repair, is available in a topical formulation. Defensin has been shown to activate the leucine-rich repeat-containing G-protein-coupled receptors 5 and 6 (also known as LGR 5 and LGR 6) stem cells. Defensin speeds wound healing by increasing LGR stem cell migration into wound beds.

Wounds should be covered to protect from sun exposure until they are reepithelized. Once epithelized, zinc oxide sunscreens can be used. These have been shown to be safe with minimal penetration into the skin.

3.1.4 Ingredients to Avoid Postsurgery (Table 84.4)

Topical retinoids should not be used post skin cancer surgery until epithelialization is complete. A study by Hung et al. in a porcine model that used 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding demonstrated that use of tretinoin 10 days prior to wounding sped reepithelialization, while use after the procedure slowed wound healing.

Table 84.6 Posttreatment skin care for surgeries
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Acidic products will sting wounded skin. For this reason, benzoic acid, hydroxy acids, and ascorbic acid should be avoided until the skin has completely reepithelialized. Products with preservatives and fragrance should be avoided if possible. Vitamin E derived from oral supplement capsules slowed healing after skin cancer surgery and had a high rate of contact dermatitis.

Chemical sunscreens are more likely to cause an allergic contact dermatitis and should be avoided for 4 weeks after skin surgery.

Organic products with essential oils and botanical ingredients may present a higher risk of contact dermatitis because of allergen exposure.

Although there are no studies evaluating the effects on promoting skin cancer, caution is prudent.

3.2 Injectables (Fillers, Toxins, and Fat Reductor), Microneedling, and Ablative Lasers

3.2.1 Pretreatment Skin Care and Supplements

Prior to any of these procedures, patients can use a high-quality vitamin C serum and retinol for 2–4 weeks to help increase collagen production.

3.2.2 Ingredients and Activities to Avoid Pretreatments

With fillers, bruising may be more of a concern than with other cosmetic treatment options. Measures can be taken prior to injections and needling to help reduce the likelihood and severity of bruising once the procedure is over.

Temporarily discontinue use of vitamins, supplements, and medications that can interfere with the blood’s ability to clot, unless otherwise directed by a physician. These include aspirin, ibuprofen, naproxen, St. John’s wort, vitamin E, omega-3 fatty acids, ginseng, and others.

If pain medication is needed, use acetaminophen instead of nonsteroidal anti-inflammatory drugs (NSAIDS). Avoid drinking alcohol 1–2 days prior to injections. Stop smoking for several weeks before and after treatment to maximize the body’s natural healing process. Take arnica supplements. Although some bruising, swelling, or redness can be expected after each of these treatments, taking a little extra time to prepare can help minimize these common side effects.

Standard photography and informed consent should always be obtained before the procedure.

3.2.3 Ingredients and Cosmetc Skin Care Post Filler Injections

To help alleviate these symptoms and maximize their results, the provider should apply skin-soothing products like arnica pads immediately after injections and leave on for 6 h.

Oral arnica supplements should be taken for 2 days post-procedure, or until bruising and swelling has resolved.

Within the first 24 h after injections, cold compresses or ice packs can be applied to help reduce swelling.

Patient can put a wet washcloth in the freezer for 5–10 min. It can then be applied on the face. The washcloth is stiff at first, but then it molds nicely around the face and is not cold enough to burn the skin.

Patients should avoid alcohol, strenuous physical activities, and heat such as hot showers for 48 h after getting dermal fillers to prevent bruising.

3.2.4 Ingredients and Cosmetc Skin Care Post Microneedling

Granulomatous reactions and/or acne can be seen after having had microneedling. This may be due to what is applied to the skin after the procedure.

It is recommended not to use any topical products including sunscreen for 24 h after this treatment until these reactions are better understood. One study showed that the channels stay open for 12–18 h, depending on the length of the needles, and that pore closure can be delayed significantly under occluded conditions [16]. For this reason, avoid placing anything on the skin for 24 h post microneedling.

3.3 Nonablative Laser, IPL (Intense Pulsed Light), and Tightening Devices

Intense pulsed light (IPL) and hair removal laser are some of the more commonly performed cosmetic procedures that have produced untoward complications [13,14,15].

With nonablative lasers and nonsurgical skin-tightening devices like Ultherapy, Thermage, and IPL, some immediate results may be visible, but most patients see the most results unfold over the next several weeks.

Standard photography and informed consent should always be obtained before the procedure.

During this time, it is very important to boost collagen production in every way possible. Using a topical vitamin C and high-potency retinol is critical to improve results. Other options such as heparan sulfate and defensin may also help increase cellular response and increase collagen production [7].

Postoperative treatment with ascorbic acid containing serum following laser resurfacing reduced duration of redness post-procedure. Another study showed that an occlusive ointment containing a triad of antioxidants sped wound healing [7].

3.4 Chemical Peels

Chemical peels have widespread acceptance in the facial cosmetic treatment of aging faces (aging and photoaging), acne (comedones, pustules, and superficial scarring), pigmentary abnormalities, and more.

Many chemicals are available for facial peeling, including phenol, trichloroacetic acid (TCA), alpha hydroxy acids, and retinoic acid. All act by varying degrees of cellular destruction of the epidermis and papillary dermis, producing consistent histologic changes.

Classification of Peels According to the Histological Depth of Necrosis (Fig. 84.1)

  1. A.

    Very superficial light peels: necrosis up to the level of stratum corneum. Agents used: TCA 10%, glycolic acid (GA) 30–50%, salicylic acid 20–30%, Jessner’s solution 1–3 coats, tretinoin 1–5%

  2. B.

    Superficial light peels: necrosis through the entire epidermis up to basal layer. Agents used: TCA 10–30%, GA 50–70%, Jessner’s solution 4–7 coats

  3. C.

    Medium depth peels: necrosis up to upper reticular dermis. Agents used: TCA 35–50%, GA 70% plus TCA 35%, 88% phenol unoccluded, Jessner’s solution plus TCA 35%, solid CO2 plus TCA 35%

  4. D.

    Deep peels: necrosis up to mid-reticular dermis. Agents used: Baker-Gordon phenol peel

Fig. 84.1
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The goal of a chemical peel is to cause the outer layer of skin to peel and flake, revealing the fresh, smooth layer underneath

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3.4.1 Prepeeling Preparation (Table 84.7)

For optimal results, preparation of the skin in the weeks before the procedure is very important.

Table 84.7 Pre- and post-chemical peel recommendations [5,8,7, 14, 15]
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Topical retinoic acid preparations used daily for 3–6 weeks prior to the procedure may create better and more even penetration of the peeling solution in sebaceous and hyperkeratotic skins.

Standard photography and informed consent should always be obtained before the procedure for all types of peelings.

In patients with a history of recurrent herpes simplex, it is necessary to prescribe prophylaxis with systemic antivirals from the day before the procedure until full reepithelialization. Generally, it is not necessary to discontinue use of any of the patient’s medications including anticoagulants, aspirin, or nonsteroidal anti-inflammatory or antihypertension drugs.

A new consensus statement says it is not necessary to postpone elective skin procedures for patients with concurrent or recent systemic isotretinoin therapy [17]. According to our experience with superficial peeling, smoking does not have any adverse effect on postpeel healing or on the extent of the results.

3.4.2 Postpeeling Recommendations (Table 84.7)

The goal of a chemical peel is to cause the outer layer of skin to peel and flake, revealing the fresh, smooth layer underneath.

Patients will experience some level of dryness and flaking for 2–5 days after treatment. During this time of dryness and flaking, their skin is more sensitive (more redness and stinging), and they cannot use vitamin C, retinol, avobenzone, glycolic acid, and lactic acid.

In this 2–5-day period, using a soothing gel or mask helps calm and soothe the skin. Other great options to use in this post-procedure time period are heparan sulfate and hyaluronic acid.

Patients should be advised to stay out of the sun and to avoid picking at dry, flaking skin. Exfoliating scrubs and other facial brushes and other forms of friction, including microdermabrasion, should be avoided during the healing process. Avoid any products with hydroxy acids and retinol until the skin barrier has been restored. Use calming skin care products with anti-inflammatory ingredients such as green tea, argan oil, and chamomile to help alleviate any stinging or redness while the skin recovers.

Tip Box

  • To ensure the best outcome from surgical treatments, patient education is crucial.

  • The Baumann skin typing system assigns patients to one of 16 skin types based on their answers to a validated questionnaire [18] known as the Baumann Skin Type Indicator [19, 20].

  • Using the Baumann Skin Type nomenclature improves communication between physicians, scientists, researchers, aestheticians, and patients about skin care regimen efficacy and adverse events [10, 18,17,20].

  • Because studies have demonstrated that patients cannot properly self-diagnose their skin type, the Baumann Skin Type should be diagnosed using a validated questionnaire for that purpose [18,17,20].

  • The more that patients know and understand about the ways in which they can prepare for their procedure and treat the skin after the procedure, the better the outcomes will be.

  • Retinoids should be used 2–3 days prior to procedures to speed healing.

  • Retinoids should not be used after the procedure until reepithelialization has occurred.

  • Vitamin C and zinc supplements taken post-procedure might speed wound healing.

  • Standard photography and informed consent should always be obtained before the cosmetic procedures.

  • A new consensus statement says it is not necessary to postpone elective skin procedures for patients with concurrent or recent systemic isotretinoin therapy [17].

4 Conclusions

It is up to the physician to fully understand the nature of skin and sun damage, protective techniques available, and active agents that work as cosmeceutical preparations. Having available multiple procedures to solve these problems will make his patients better candidates for the right treatment to restore and rehabilitate their skin. The aim of this chapter is optimizing outcome from facial surgical and cosmetic procedures and improving the outcomes.