Chronicle of Cosmetic Medicine + Surgery, Autumn 2014
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Chronicle of Cosmetic Medicine + Surgery, Autumn 2014

Lower extremity rejuvenation

By Dr. Lisa Kellett, TORONTO DERMATOLOGIST

Lower extremity rejuvenation is interesting in that, although often not directly requested by patients, it is often an area that can have considerable improvement with high patient satisfaction rates.

Conditions that can be treated on the legs include cellulite, skin laxity, seborrheic keratosis, photoaging, rhytides, lentigines, dyschromia, telangiectasia and unwanted hair.  The other issue to be concerned about is the presence of pre-malignant and malignant disease.

With respect to treatments, for both medical and cosmetic reasons the most important preventative treatment for the skin on the legs is sun protection.

The calves in women are a common site of Malignant Melanoma likely secondary to unprotected sun exposure.  Other common precancerous and cancerous lesions on the legs are actinic keratoses, basal cell carcinomas and squamous cell carcinomas including keratoacanthomas. Thus, when legs are exposed to the sun, even when wearing stockings, the skin should be protected with a broad spectrum sunscreen of SPF 30 with UVA and UVB wavelength blocking agents. In addition, sun-protective pants of UPF 50 or higher should be worn when out for prolonged periods of time.

I also instruct my patients to examine their skin once a month looking for any new moles or brown spots or any change in these lesions.

Any lesions suspected of being basal cell carcinoma, squamous cell carcinoma, keratoacanthoma or malignant melanoma should be excised with the appropriate margins and sent for histopathological examination with a request to check the pathological margins of the lesion.

Ultraviolet light exposure also causes photo aging, namely rhytides, lentigines, telangiectasia and dyschromia.  Because the legs are often sun exposed without protection, the legs are a common area for these lesions.  Lentigines are benign pigmented lesions common on the lower legs. The optimal treatment for these is either Lumenis One Intense Pulsed Light treatment or Q switched ruby 694 nm laser treatment both of which target pigmented lesions and can effectively remove lentigines. Generalized dyschromia and telangiectasia can be treated with multiple sessions of Intense Pulsed Light.

Rhytides on the legs can be treated with ablative lasers including erbium and CO2 lasers in a fractionated mode to limit downtime. Multiple treatments are usually required and patients see an effacement of rhytides. For some superficial rhytides around the knees, Botulinum toxin (Botox) can be used to minimize these.

Skin laxity on the legs is quite common with advancing age, especially around the knee. Thermage body treatment is helpful in treating this area.

One common leg complaint has nothing to do with the sun and everything to do with nature.  Cellulite affects up to 90 percent of women and is characterized by an irregular, dimpled appearance of the skin. Histologically, the fat is normal. There are many topical cosmetic creams that propose to banish cellulite however there is no permanent cure. Synergy treatments and deep lymphatic massage can improve the appearance of cellulite but it is not permanent.

Keratosis Pilaris is a common skin condition in both men and women characterized by small perifollicular papules on the back of the thighs and buttocks.  For many patients its appearance is quite disturbing as it can become quite erythematous and irritated. There is no cure, however, an effective treatment is a diamond peel which removes the keratin plugs resulting in a smoother skin appearance.

One self-imposed concern of many patients is professional tattoos on the legs.  In women these are often found on the lower legs and might affect their choice of clothing. The gold standard for tattoo removal is the Q-switched Ruby laser which removes the most common pigments of black, blue, purple and green. Multiple treatments are necessary but tattoos can be removed safely without scarring.

No discussion of lower extremity rejuvenation would be complete without mentioning laser hair reduction. I inform my patients that there is no good treatment for grey hair so it is best to remove hair while it is still pigmented. Laser hair reduction lasers are now sophisticated enough with sufficient contact cooling to ensure a more comfortable, effective treatment .

Dermatofibromas are firm papules found mainly on the legs and are a result of trauma commonly being ingrown hairs or insect bites. These are found in both men and women and can be treated with surgery such as shave excisions or fusiform excisions.

Seborrhoeic keratoses and stucco keratoses are common benign pigmented lesions on the legs after the age of 35 and can be easily removed by electrodessication or liquid nitrogen.

In summary, there are many common conditions on the lower extremity that can be treated in a straight forward manner which are often not addressed.  Furthermore, remember during a skin exam to examine the legs to rule out the presence of skin cancer or pre-malignant lesions.

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