34 practical dermatology february 2005

34 Practical Dermatology February 2005

W

hen a patient visits a dermatology clin-

ic for facial rejuvenation these days, it is

unlikely he or she will undergo a major

operative procedure. The approach to these

patients is much different today than it was

just a few years ago. Carbon dioxide laser resur-

facing, while still performed, is not always the most desired pro-

cedure for facial rejuvenation. Standards for recovery time have

changed, more options are available, and each patient’s treatment

can be individualized to meet his or her specific needs.

With recent advances in cosmetic dermatology, we have a vari-

ety of non-invasive procedures at our fingertips that allow us to

help patients achieve the results they desire without facing down

time or significant side effects. Let’s review our range of current-

ly available options, and then we’ll share how we combine these

options to help rejuvenate patients’ faces from the top down.

February 2005 Practical Dermatology 35

WBy Sarah M

. Boyce, MD

and Conway C. H

uang, MD

Our ArmamentariumSkin Care Regimens. Cosmetic patients almost always want todiscuss what they can do on a day-to-day basis to enhance whatwe decide to do in the clinic. We certainly cannot argue theimportant role of sunscreens, and most physicians have theirfavorites to which they tend to direct patients. Sun-blockingtitanium dioxide and zinc oxide are now common ingredientsin moisturizers and make-up; this can save a step in the morn-ing regimen. Make sure patients understand that post-proce-dure sun protection is mandatory for obtaining and sustainingoptimum results. Also, emphasize to patients the potential forpost-inflammatory pigmentation problems and show themphotos to ensure they understand and avoid ultraviolet light.

Retinoids are also a mainstay of skin care regimens. Thereare many to choose from, ranging from over-the-counter toprescription, and if patients can tolerate them, retinoids aretruly beneficial scientifically and clinically.1 Keep in mind,however, that starting a retinoid during winter can be quite achallenge, so be prepared to make adjustments accordingly.

Hydroquinones also augment the process when hyperpig-mentation is a factor. Used alone, results vary greatly, but onewould be remiss to omit a bleaching agent from a patient withsolar lentigos, melasma, or other hyperpigmented skin disorder

even when one or more procedures are performed. I person-ally have seen much success with patients using retinoids inconjunction with hydroquinones.

There are thousands of other products sold over thecounter that claim to have anti-aging properties. Thegrowth factor serums have swept the media and the cosmet-ic counters. While we know that some growth factorsenhance the growth of epithelial cells, we are not yet certainexactly how that translates to our aging faces. We may gainmore knowledge in the future and be able to confidentlyadd these products to our patients’ regimens.

Botulinum Toxin. The use of botulinum toxin for cos-metic purposes has, without question, revolutionized thefield of aesthetic medicine. With Botox (Allergan), we canoffer and achieve solid, predictable results with little to norisk for the patient. The glabella and periorbital areas areboth satisfying places to begin injections. Resting creasescan begin to occur in these regions, caused by repetitivedynamic movement, and Botox can immobilize the musclesof facial expression that produce those creases. For this rea-son, Botox use can be “preventative” in addition to elimi-nating dynamic rhytides that are already present. Foreheadcreases can also be unpleasant for patients and can give acynical, frustrated appearance. These lines can be softenedor eliminated with Botox injections, as well. A hypertrophicorbicularis oculi can cause a pucker of skin just beneath thelower lid margins. Injecting a couple of units into this area

(off-label use) allows the skin to be redraped in this area.Another more advanced use of Botox is to chemically lift thebrow by immobilizing the brow depressors.

Botulinum toxin injections must be repeated every threemonths initially, but over a series of injections most patientsnotice an ability to lengthen the time between injections.Headaches and mild purpura following injections are the mostcommon side effects, but brow or lid ptosis can also occur.

Soft Tissue Fillers. Over time, the human face loses vol-ume, and the lost volume produces a tired, hollow appearance.For patients who come in distraught over accentuated nasolabi-al folds, thinning lips, and hollow cheeks, we have many softtissue fillers from which we can choose, most of which are tem-porary. Bovine collagen has been the most commonly usedfiller, but we are constantly hearing about new products in thisarena. Restylane (Medicis) and Hylaform (Genzyme/Inamed)are hyaluronic acid products that have seen a large increase inuse over the past year. Radiesse (Bioform Medical), a calciumhydroxylapatite gel, and Sculptra (Dermik), which is aninjectable poly-L-lactic acid, also appear to be promisingoptions for treating contour deficiencies.

The duration of these fillers is variable, but in general twoto three months is a good estimation for the duration of colla-gen. Restylane can last up to nine months, but only in rare


Targeting the Sagging Face

Before

Soft Tissue Filler

After

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cases; Sculptra and Radiesse can be present for two to threeyears.

Most fillers are placed in the dermis, and the effect isnoticeable immediately. Typically at least some swelling willoccur, and the patient must understand that the swellingcan make the treated area look overdone for a short time fol-lowing the procedure. Collagen or hyaluronic acid fillers arereasonable options with which to begin. The use of fillersinvolves a learning curve, and melolabial folds are a satisfy-ing area to treat when the physician is just beginning to usethese products. Soft tissue fillers may successfully treat otherareas, such as the lips and perioral rhytides, glabellar creas-es, cheeks, earlobes, and small scars.

Chemical Peels. Chemical peels are a quick, straightfor-ward option for removing part or all of the epidermis. Thiscan be very beneficial for epidermal hyperpigmentation ofany kind. A series of superficial chemical peels can slowlyfade unwanted lentigos, mild melasma, or post-inflammato-ry hyperpigmentation (PIHP). If a patient is willing toundergo several days to a week of healing time, a mediumdepth chemical peel may be more appropriate. However,the patient is undertaking more risk with a medium depthpeel, especially if the patient has darker or ethnic skin. Wecan dial in the depth of the peel by choosing the concentra-tion of acid and the number of layers of application, whichallows for a custom-made treatment for each patient.

Light Sources. Intense pulsed light (IPL) for non-invasivecosmetic procedures is a concept that has been in the forefrontfor several years. IPL involves a broad band of pulsed light,involving all wavelengths typically from 500-650nm to around1100nm, and offers treatment for photodamage, rosacea,melasma, and PIHP. Different filters can be used depending onthe targeted chromophore. The ideal patient for this procedurehas a face full of solar lentigines and/or telangiectasias androsacea, as this device can target both simultaneously. Whenused properly, this device can offer significant cosmeticimprovement, usually with very little down time and risk.Multiple treatments are typically needed to achieve the desiredresult.

In addition, photodynamic therapy has also carved a nichein the treatment of photodamage. Photosensitizers used in con-junction with photodynamic therapy can produce impressiveresults in as few as one or two treatments.

Lasers. Without doubt a full array of lasers exists that tar-gets many of our patients’ cosmetic concerns. Pulsed dye, KTP,alexandrite, and Nd:YAG lasers are all being used not only totarget vascular lesions but also for overall photorejuvenation.Non-ablative resurfacing lasers are also very popular for treat-ing mild to moderate rhytides. For the most part, a combina-tion of these lasers is the best option, and we have significant

evidence suggesting that today’s laser devices are capable ofinducing collagen remodeling and stimulation.2

Radiofrequency treatments have also gained popularity fornon-surgical tightening of sagging skin, and these treatmentsoffer a wonderful option for the patient who wants to avoidgoing under the knife. Occasionally, radiofrequency treatmentscan produce results that rival those of invasive surgical proce-dures.

The ConsultOf course, each patient’s experience begins with a consult.Many patients, because of the ever-present media, know exact-ly what they would like to discuss. They’ve heard aboutRestylane (Medicis) or Thermalift (Thermage) and want toknow if these procedures could benefit them. Discussionensues, and the final decisions are then made. However, it isnot always straightforward, and often a patient wants thephysician to decide what would be the most appropriate cos-metic procedure for him or her. This can be a pitfall, and oftenthe physician finds himself or herself backpedaling after mak-ing a statement about an imperfection that was never noticedby the patient. Each physician must handle situations like thisaccording to his or her practice style, but in general I try to

Before

Pulsed Light

After

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tickle out specifically what bothers the patient about his or herappearance.

It is also important to have a general idea of the healingtime that a patient is willing to tolerate. It varies greatly frompatient to patient, but it can be futile to discuss, for instance,laser resurfacing if the patient does not want to undergo a pro-cedure that involves missing any work or social activities or heor she does not want friends to notice that a procedure has beenperformed. When asked to evaluate a patient’s appearance forthe purpose of recommending a cosmetic procedure, a “topdown” approach can work well.

The Upper Face. Aging in the upper face can manifest itselfvia both dynamic and resting rhytides, loss of elasticity of theskin and connective tissue around the eyes, and lentigines ofthe forehead and upper cheeks. The upper face changes we canmake include eliminating dynamic rhytides of the forehead,glabella, and periorbital areas; tightening skin and eliminatingfine lines around the eyes; chemically lifting the brow; andeliminating dyschromias.

The Lower Face. The lower face typically shows age with asagging of the cheeks and jowls, perioral rhytides, thinning lips,deepened anatomical lines like the melolabial grooves, and dys-

pigmentation. With non-invasive procedures, we can offersome tightening of the sagging cheeks and jowls, softeningof rhytides, and elimination of dyschromias. Lip enhance-ment can also help tremendously when trying to retain orachieve a more youthful appearance.

Ageless CombinationsMost patients require more than one procedure to rejuve-nate the face. Although any of the non-invasive procedurescan be combined, there are some common effective combi-nations.

The 30-Year-Old Patient. A very typical approach to apatient in his or her upper 30s who does not have much inthe way of rhytides or sagging is to combine intense pulsedlight or a chemical peel with botulinum toxin injections fordynamic rhytides. These procedures can typically be per-formed on the same day and can work to fade dyschromiasand eliminate unwanted lines in the upper face.

Periorbital Area. Patients often point to the periorbitalareas when describing the desired treatment areas. Lines andherniation of periorbital fat pads can give the eyes, and forthat matter, the entire face, an older appearance. Whileablative laser resurfacing and blepharoplasty remain thegold standard for elimination of these problems, non-abla-tive laser resurfacing in the periorbital areas and careful useof retinoids and/or hydroquinones around the eyes can pro-

duce impressive results.Mouth Area. Around the mouth, vertical lines seem to be

the most commonly mentioned complaint. A combination ofa soft tissue filler, such as collagen and/or hyaluronic acid, andsmall aliquots of botulinum toxin carefully placed can enhancethe body of the lip and immobilize the muscles that producethe unwanted lines.

Lower Face. Sagging jowls and lines in the lower face candrag the appearance south. Today’s radiofrequency tighteningdevices can tighten sagging skin, and soft tissue fillers can treatindividual lines. Combine this with Botox in the upper faceand a few IPL treatments for dyschromias—a new look is cre-ated with no down time.

Dyschromias and Telangiectasias. Any of several lasers,including KTP, alexandrite, Nd:YAG and pulsed dye lasers,can be used in combination to treat dyschromias and telang-iectasias as well as fine rhytides with no down time and verylittle risk.

Rhytides and Rosacea. Not only are combination treat-ments available; combinations of problems can also occur. Apatient with rosacea may have rhytides, as well, and an abla-tive laser resurfacing procedure or deep chemical peel willleave the rosacea patient very red for quite some time. A vas-


Before

Botox for the Glabella

After

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. Boy

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D


cular laser combined with a non-ablative resurfacing laser,however, can offer treatment for both problems in the samesession.

Photodamage and AKs. A patient who has photodamagemay also have actinic keratoses. For these patients, photody-namic therapy with aminolevulinic acid or a medium-depthchemical peel can reduce the risk for skin cancer and brightena patient’s look at the same time.

Acne and Acne Scarring. Acne and acne scarring can alsobe present in the same patient. A non-ablative resurfacing lasercan be useful for both problems, since this device can bothshrink sebaceous glands and remodel collagen.

Seeing Beyond RealityIt seems that our options are limited only by our imaginationswhen we look at the different ways patients can reach theirgoals for looking and feeling rejuvenated. As dermatologists, weare on the forefront of this movement to help patients realizewhat is available to them. No doubt in the coming days addi-tional options that are even more safe and effective will becomeavailable, and as dermatologists, it will remain our privilege toprovide this service to cosmetic patients.

1.Varani J, Warner RL, Gharaee-Kermani M, Phan SH, Kang S, Chung JH,Wang ZQ, Datta SC, Fisher GJ, Voorhees JJ. Vitamin A antagonizes decreasedcell growth and elevated collagen-degrading matrix metalloproteinases andstimulates collagen accumulation in naturally aged human skin. InvestDermatol. 2000 Mar;114(3):480-6.

2.Weiss RA, McDaniel DH, Geronemus RG. Review of nonablative photoreju-venation: reversal of the aging effects of the sun and environmental damageusing laser and light sources. Semin Cutan Med Surg. 2003 Jun;22(2):93-106.

New in Your Practice

Premier Care. Financial support and medical care is now available for allpatients who have experienced an allergic reaction to permanent cosmetic

and tattoo pigments through Premier Pigments. The company is extending thishelp to clients of other pigment suppliers as well. To assist physicians, PremierPigments also announced the launch of a comprehensive educational plan tonetwork and train physicians to help them successfully treat these allergic reac-tions. A training seminar is planned for early this year.

Picture Perfect. A hyaluronic acid-based dermal filler formulated with lido-caine may soon be in the picture for patients, according to Mentor

Corporation. Mentor points out that Hyalite is the first dermal filler to focus onpatient comfort by adding lidocaine to the formulation and will also be the firstdermal filler to seek FDA approval for lip augmentation in addition to facialwrinkles. Hyalite is currently undergoing clinical trials to determine its efficacyand safety compared to Restylane (hyaluronic acid, Medicis).


34 practical dermatology february 2005

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