MIAMI BEACH Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.
Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.
There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.
There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.
Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.
Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.
Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.
Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.
As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."
Assess each patient at baseline to determine the optimal drug and device combination.
The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor
Cosmetic Procedures: Pros and Cons
Ablative Laser Resurfacing
Pros: Best results on deep rhytidsSignificant tightening Long-term results
Cons: PainfulLengthy healing phaseRisksHypopigmentation
Photodynamic Skin Rejuvenation
Pros: Excellent results on red and brown pigmentation
Better tightening and remodeling
Minimal downtime
Superb for actinic keratosis and damage
Acne and other applications
Long-term results
Can be used for skin types I-IV
Cons: Photosensitivity
Some downtime
Radiofrequency Toning and Tightening
Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques
Cons: PainVariability
Intense Pulsed Light Photorejuvenation
Pros: Best results on brown and red pigmentation
Slight tightening and remodeling
No downtime
Long-term results
Cons: No effect on actinic keratosisSlight effect on rhytids