Title: Current trends in the Art and Science of looking Young and BeautifulAbstractCosmetic and aesthetic dermatology is one of the fastest advancing fields of medicine, both in terms of patient (or “client” as the beneficiaries are now sometimes referred to) demand and the advent and proliferation of technology. Several fundamental dermatologic treatments are carried out as office strategies to treat trivial cosmetic issues in a speedy and non or minimally-invasive way. This includes treatment of scars, wrinkles, moles, facial volume loss, excessive fat, unwanted hair, and . Although these conditions may be physically harmless, the psychological impact cannot be overlooked. The major advantage in recent years is the significant new development in techniques and pharmacotherapy and other non-surgical approaches. Present day cosmetic skin treatments are safe and supported by scientific evidence. The discovery of a myriad of novel cosmetic applications for autologous platelet-rich products and botulinum toxin has further revolutionised this field. Some of these procedures are feasible in resource-limited settings while others might require an elaborate set-up with expensive equipment. However, the role of meticulous routine skin care, sun-protection, healthy life- style modifications and balanced diet along with avoidance of certain factors contributing to premature ageing remains undisputed. Cosmetic dermatology has led to significant emotional benefits in the form of increased self ‑ esteem and improvement in quality of life indices.This review highlights some popular and contemporary trends in this vast and fascinating field ranging from the quintessential chemical peels that have stood the test of time through state- of- the art lasers and other energy based devices.Key words : Cosmetic dermatology, technology, minimally-invasive "The practice of medicine is an art, not a trade; a calling, not a business; a calling in which Your heart will be exercised equally with your head." - Sir William OslerThe field of Dermatology has witnessed rapid advancements over the past few decades with “disease dermatology” paving the way for “desire dermatology”. Today, cosmetic dermatology is undoubtedly the fastest growing specialty, focusing on the improvement and enhancement of appearance of skin, hair and nails aesthetically, artistically and cosmetically. Since the latter part of last century, cosmetic procedures have witnessed approximately 500% rise. (1) Seldom considered a necessity, it can on occasion resolve medical dermatological concerns. With changing mind-set, attaining and maintaining healthy, youthful skin in addition to a healthy body and mind is now considered a priority. A daily regimen that integrates the use of dermatologist-approved anti-aging skin care products along with the regular use of can help diminish the unwanted effects of premature aging and sun damage. Several fundamental dermatologic treatments are carried out as office strategies to treat trivial cosmetic issues in a speedy and non-invasive way. This includes treatment of scars, wrinkles, moles, facial volume loss, excessive fat, unwanted hair, and . Moreover, even though these conditions may be physically harmless, the psychological impact cannot be dismissed. Studies have demonstrated the adverse impact of cosmetic impairment on the psyche of the affected individuals, which may range from depression to suicidal ideation in the worst case scenarios. (2)Cosmetic dermatology has led to significant emotional benefits in the form of increasedself ‑ esteem and improvement in quality of life indices. (3)Factors contributing to premature-aging or damaged skin that can be controlled include (4):Sun exposurePollutionSmokingUse of ineffective or harmful skin-care productsLack of hygiene Extreme weight loss/weight gainThe field of esthetic and cosmetic dermatology has gained remarkable momentum all over the world. The major advantage in recent years is the significant new development in techniques and pharmacotherapy and other non-surgical approaches. Present day cosmetic skin treatments are supported by scientific evidence. (5) This review highlights some of the popular and contemporary trends in this vast and fascinating field. Chemical peels Over the centuries numerous techniques have been employed to reverse the ravages of age and the effects of cutaneous disease. Among these methods, chemical peeling has withstood the test of time with superficial peels in particular remaining a popular tool in the dermatological therapeutic armamentarium. Chemical peels consist of the application of one or more chemical ablative agents to the skin surface in order to induce keratolysis or keratocoagulation. This process causes the controlled destruction of all or part of the epidermis or dermis, resulting in the subsequent exfoliation of these layers. (6) After wounding, regeneration and remodelling of the epidermis and dermis ensues, leading to the improved appearance and texture of the treated skin.Aesthetic indications include: Dilated pores, melasma, facial and non-facial melanosis photoageing, superficial fine rhytides, superficial scars.(7)Chemical peels are classified according to their depth of penetration of the skin into superficial, medium‐depth and deep subtypes. The depth of penetration is determined by the concentration, pH and type of peeling agent used.(8,9)Anatomical location, epidermal integrity, adnexal structure density and skin thickness also influence the depth of the peel.(10) Agents: Alpha hydroxy acids (glycolic acid), Beta hydroxyl acids (salicylic acid), trichloroacetic acid, pyruvic acid, mandelic acid, lactic acid, resorcinol etc.(11) Boutique or pamper peels have become increasingly popular in recent years. These products consist of conventional peeling agents (e.g., AHA, beta hydroxy acid and TCA) in combination with various botanical extracts, vitamins and other adjunctive ingredients, which may be incorporated in a proprietary topical delivery vehicle. While there is no significant evidence favouring boutique peels over conventional peels, superior marketing, cobranding with cosmeceutical ranges and a greater emphasis on enhancing the patient's experience have increased the presence of boutique peels in the chemical peel sphere.Periocular peelsThe eyes are one of the earliest and most prominent regions of the face to show signs of ageing. The periocular skin is thin, translucent and sensitive. Chemical peels can improve skin color, texture and fine lines to some extent, but they cannot improve eyebags, tear trough and ptosis. Hence to be effective a combination of treatments is required. Before attempting treatment it is essential to assess and investigate the patient to detect co-morbidities such as atopic dermatitis, allergic contact dermatitis, pigmentary demarcation lines, facial acanthosis nigricans, photoageing etc. (12) These should be simultaneously treated. Periocular peels combined with fractional CO2 lasers or microneedling can address many of the problems such as pigmentation and fine superficial wrinkling. For enhanced results they can be combined with botulinum toxin and periocular fillers. For advanced cases of skin laxity, blepharoplasty may be required, if the patient is unsatisfied with these minimally invasive techniques. Jessner’s peel, Retinol peel, lactic acid, TCA 10-15% and glycolic acid 35-70% are the peels of choice. (13) The peels should be done carefully to avoid complications. Chemical peels are versatile, offer significant benefit with minimum downtime and can be combined with other procedures.Microdermabrasion : Chemical peeling may be combined with microdermabrasion for the treatment of photoageing, moderately deep rhytides and acne scars. This involves the mechanical exfoliation of skin by the application of microcrystals. A specialised closed‐circuit device containing a vacuum propels aluminium oxide, sodium bicarbonate or salt crystals of varying velocities against the skin. This action abrades the stratum corneum allowing for increased penetration of the chemical peel. (14)Microneedling: (also known as percutaneous collagen induction ) involves the penetration of the stratum corneum into the papillary dermis with needles. This results in the formation of microchannels and a demarcation current that stimulates the release of growth factors involved in neo-collagenesis and neo-angiogenesis. It may be used alone or in combination with glycolic acid or platelet-rich plasma to manage wrinkles and acne scars. (15) Mesotherapy Derived from the Greek words "mesos" that means " middle" and "therapeia" that means to treat medically, it is a form of treatment that involves injection of very little amount of substances into mesoderm, which is the embryonic middle layer located between the ectoderm and endoderm. (16) Different cocktails of concentrated vitamins, amino-acids, antioxidants, hyaluronic acid, coenzymes are injected to improve, nourish and rejuvenate the skin, promote production of collagen and elastin and stimulate metabolism. (17) Different protocols and preparations are used for varied indications like anti-ageing, facial melanosis, hair loss etc.(18,19) Besides the traditional needle-syringe combination, more sophisticated and expensive instruments may be used, such as the mesotherapy gun. These guns electronically inject multiple points and allow a controlled amount and depth of application. (20)Botulinum toxinThe botulinum neurotoxin (BoNT) is produced by Clostridium botulinum bacteria. Seven toxin isoforms can be distinguished (BoNT A–G) (1), with BoNT-A and B being commercially available for clinical applications. In 1989, BoNT, onabotulinumtoxin A, was initially approved for the treatment of strabismus and blepharospasm by the US Food and Drug Administration (FDA).The most recognized mechanism of action of BoNTs is the inhibition of neurotransmitters (acetylcholine, norepinephrine, substance P, calcitonin gene-related peptide [CGRP], and glutamate) release at the presynaptic neuromuscular junction. However, BoNTs can affect both sympathetic and parasympathetic functionality since acetylcholine is also a neurotransmitter of the autonomic nervous system. (22) Furthermore, recent evidence shows the effect of BoNTs on different human cell types, both neuronal and non-neuronal cells. These latter include epidermal keratinocytes, mesenchymal stem cells from subcutaneous adipose, neutrophils and macrophages, dermal fibroblasts, mast cells, sebocytes and vascular endothelial cells. Thus, several clinical applications are emerging in dermatology.(23) The clinical effects of botulinum toxin injections last for 2-6 months after which, the inactivated terminals slowly recover function in an average period of four months. Then, the new nerve terminal sprouts and their end plates regress. Recovery of inactivated terminals appears to be the basis of the loss of clinical effects several months after the injection. The dermatologic use of botulinum toxin requires an in-depth knowledge of the anatomy and function of the areas treated (eg, in the case of the face, facial muscles, and their relations with the orbit). Common uses of botulinum toxin A include the treatment of wrinkles caused by contraction of the muscles of the face, particularly glabellar frown lines, transverse forehead lines, lateral canthal wrinkles (ie, crow's feet), and medial and lateral brow lifts. For cosmetic purposes, BT is commonly used on the upper half of the face to target horizontal forehead lines, glabellar frown lines and lateral canthal lines (Crow's Feet). It is also used for temporal brow lift, bunny lines (Levator labia superioris) and nasal flare. (24) Other uses of BT include achalasia, blepharospasm, cervical dystonia, detrusor hyperreflexia, essential tremor, hemifacial spasm, hyperhidrosis, migraine and headache, myofascial pain syndrome, occupational dystonia, pain due to muscle spasm, rectal fissure, sialorrhea, spasmodic dysphonia, strabismus, spasticity, thoracic outlet syndrome and oily skin. (25) Autologous Platelet rich plasma (PRP)PRP has revolutionized cosmetic and aesthetic dermatology. Activated platelets release many bioactive proteins responsible for attracting macrophages and mesenchymal stem cells. Platelets contain alpha granules which release various growth factors: platelet-derived growth factor, transforming growth factor, fibroblast growth factor, insulin-like growth factor 1, insulin like growth factor 2, vascular endothelial growth factor, epidermal growth factor, interleukin 8, keratinocyte growth factor, and connective tissue growth factor. (26) When PRP is injected into the damaged area, it stimulates the tissue, causing mild inflammation that triggers the healing cascade. As a result, new collagen begins to develop. As this collagen matures, it begins to shrink and tightens and strengthens the skin. Improvement in skin texture and tone is noticeable within 3 weeks. Full collagen regeneration requires 3 months. (27, 28) The PRP treatments can be used on all skin types and tones. Minimal swelling, bruising, and redness for the initial 12 to 24 hours are expected. A bruise at the needle stick site may be visible for 2 to 3 days. Over the subsequent several weeks, the platelets continue to stimulate growth factors, which assist in more collagen re-modelling. (29) Treatment results vary but last up to 18 months in most patients. Advantages of using PRP for aesthetic medicine include: tissue regeneration and rejuvenation, induction of cell differentiation, extracellular matrix formation, recruitment of other cells to the site of injury, and an increase in collagen production, which can increase skin thickness and overall skin health. (30) In addition, PRP is non-allergenic, is an autologous physiological product, eliminates donor transmissible infections, and is a biological glue for tissue adhesion, especially in skin flaps, bone grafts etc. (31)There are various uses of PRP in aesthetic medicine:PRP has made the most significant progress in the facial area. Platelet Rich Plasma (PRP) with fat transfer is the surgical combination of injecting a patient’s own plasma containing growth factors along with their own purified fat to augment areas of lost volume, wrinkles or atrophic scars (acne, post-traumatic, post-varicella etc) on the face. Patients who do not want or need fillers can benefit from PRP. The activated PRP serum can be injected just under the skin surface to stimulate the body to make a small amount of its own ‘filler’. Although this will not approximate the same results as one gets from a gel filler, some improvement in textural changes can be seen.PRP in combination with fractional ablative lasers (carbon dioxide) for deep wrinkles and severe photodamaged skin, has also been shown to reduce commonly encountered, transient adverse effects and decrease the downtime. ‘PRP Facial’ popularly known as “Vampire facial”: consists of PRP applied to skin that has been pre-treated by an automatic microneedle. The micro-needling makes tiny “wounds” in the skin which accept the PRP serum and begins the process of collagen creation along with the tissue enhancement from platelet-derived growth factors. (28) The latest facial rejuvenation procedure is the face lift which combines the power of new PRP technology and facial fillers to minimize the signs of facial aging. This non-surgical procedure promotes new tissue growth to improve overall facial skin tone for a more youthful appearance. The PRP is combined with a facial filler and then re- injected into areas of concern around the face. [32]Patients benefit from this procedure as there is minimal downtime and results can last for over a year. The true “lift” effect is achievable with a combination of fillers, layered with the PRP serum. The fillers provide an instant fill or volume correction and the PRP – injected above the filler – immediately initiates a skin regeneration process. Patients can see and feel the effects within minutes as their skin becomes tauter and smoother. The use of PRP with fillers not only enhances the skin tone and texture, but prolongs the effective filler correction for 3 to 6 months longer than when fillers are used alone. Monthly intradermal injections of PRP in 3 sessions have shown satisfactory results in face and neck rejuvenation and scar attenuation.Method of Preparation (PRP): A small amount of blood drawn from the patient is placed in a centrifuge that spins at high speed and separates the platelets from the rest of the blood components. The typical baseline blood platelet count is approximately 200 000 per microliter; therapeutic PRP centrifuges concentrate the platelets by roughly 5-fold. However, broad variability exists in the production of PRP by various concentrating equipment and techniques (single/double spin). Recent modifications (second generation platelet derived products) are Platelet rich fibrin matrix (PRFM) and injectable Platelet rich fibrin (i-PRF).High Intensity Focused Ultrasound (HIFU) is a safe non-surgical ultrasound treatment that uses the body’s own regenerative response to gently and gradually lift the skin thereby counteracting the effects of ageing. (33) This technology has been adapted specifically for skin tightening, lifting and body contouring (cellulite and fat reduction) with minimal or no downtime. HIFU deposits focused ultrasound energy deep beneath the skin at the optimal temperature for collagen regeneration. The treatment stimulates neo-collagenesis to strengthen existing collagen and produce fresh new collagen. A clinically visible lifting effect is seen almost immediately which improves over a period of 2 to 3 months. Depending on the age group and degree of skin laxity one may require 1 to 2 sessions at the interval of 3 to 6 months. (34)Non-surgical fat reduction and body sculpting: “Lunch-time” slimming solutionsCryo-Lipolysis is an FDA-approved non-surgical fat reduction procedure that uses precisely controlled cooling to destroy fat cells. Although not a treatment for obesity or weight loss on the scale, it is designed for spot treatment of "problem" areas such as back fat, breast and stomach bulge, belly fat, thigh bulge etc that have not reduced despite diet and exercise.A typical session lasts 60 minutes. During the procedure, the fatty area between the applicator arms is gently pinched. The applicator then cools the area to a temperature that causes the fat cells to crystallize and die, without damaging the surrounding tissue. The initial 5 minutes are uncomfortable due to the cold sensation following which the whole area goes numb. The redness and swelling that occurs immediately after the treatment is transient and settles in few hours. Principle: The technology is based on the scientific principle that fat cells are more sensitive to cold than the overlying skin and surrounding tissues. In the weeks and months to follow, the body naturally processes and permanently eliminates the treated fat cells. (35) On the other hand, studies (36-38) have shown that, with alternating cycles of low temperatures and heating, the lipids in the adipocytes crystallize more easily, and this process may improve the clinical outcome of the treatment. This method is known as contrast lipocryolysis. Based on both models (cryolipolysis and contrast lipocryolysis), a novel technology was conceived: contrast cryolipolysis. This technology differs from conventional cryolipolysis because it uses heating and cooling periods, and it differs from contrast lipocryolysis because it uses lower temperatures during cooling. (39) Injection lipolysis chemically reduces the number of fat cells around the injection site. The chemicals (phosphatidyl choline and deoxycholic acid) result in fat cell disruption and death. (40) Currently, it is FDA-approved for treatment of the area underneath the chin to eliminate what is known as a "double chin." Patients with loose skin or poor tone may not be suitable candidates for the procedure. This procedure can be done under local anesthesia.Injection lipolysis procedure: Under local anesthesia, a precise amount of chemical is injected in a grid pattern that has been pre-marked on the skin beneath the chin. Complications are uncommon and include nerve injury that can result in an uneven smile. In rare instances, patients have also reported difficulty swallowing after the procedure. There is no downtime, but patients may experience swelling, bruising, pain, redness and feel areas of hardness that soften with time. Fat reduction is typically visible by eight weeks. Most patients require at least two treatment sessions spaced 4 to 6 weeks apart for upto six sessions. Results are visible by 6 to 8 weeks. Unless weight gain occurs, the results are generally long-lasting.Laser lipolysis (adipocytolysis) : It is a state-of-the-art, controlled light-based technology,that utilizes an FDA approved 1060 nm wavelength laser technology for non- surgical lipolysis of the flanks and abdomen. 1060 nm wavelength’s specific affinity for adipose tissue, coupled with minimal absorption in the dermis, allows it to efficiently treat areas of recalcitrant fat. Other effective wavelengths are 920 nm, 980 nm, 1320 nm, 1064nm and 1440 nm. Over time, the body naturally eliminates the disrupted fat cells with clinically obvious results in 6 weeks and optimal results in 12 weeks. It has a flat contact non- suction applicator which elevates the adipose tissue temperature to 42-47 degree with contact cooling to increase patient comfort. This body contouring technology is designed to permanently destroy up to 24% of treated fat in a 25 minute procedure. There is no downtime hence patients can return to normal activities immediately. (41)Radiofrequency lipolysis is a procedure which uses radiofrequency energy to heat the fat without an instrument making physical contact with the patient. The applicator heats from a distance of one centimeter from the skin. Thus fat cells are preferentially heated without impacting other types of cells in the skin or other structures. A single session takes approximately thirty minutes and is repeated once a week for four weeks or as determined during the assessment. Mild erythema has been reported. There are no activity restrictions and no downtime. Patients with treatment to the abdomen have averaged a reduction of two inches, though not all patients have a measurable, perceptible reduction. (42)In conclusion, esthetic and cosmetic dermatology has become a scientific-based sub-specialty of dermatology with evidence-based treatments and a vast variety of high-tech approaches to provide more effective, more selective, and safer therapeutic options.ReferencesSandhu JK. Cosmetic Dermatology: an integral part of current dermatology curriculum. Indian J Dermatol Venereol Leprol. 2019; 85:1-2Picardi A, Mazzotti E, Pasquini P. Prevalence and correlates of suicidal ideation among patients with skin disease. J Am Acad Dermatol 2006; 54:420-6.Al-Shobaili HA. Treatment of vitiligo patients by excimer laser improves patients' quality of life. J Cutan Med Surg 2015; 19: 50-6.Zhang S, Duan E. Fighting against Skin Aging: The Way from Bench to Bedside. Cell Transplant. 2018; 27(5):729–738. doi:10.1177/0963689717725755 5. , , , . Esthetic and cosmetic dermatology. 2008 Mar-Apr; 21(2):118-30. doi: 10.1111/j.15298019.2008.00179.x. 6. Wollina U, Brzezinski P. 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