Miami Beach — Combining cosmetic laser treatments together — and sometimes with injectable fillers, wrinkle relaxers or radiofrequency technologies — often provides more benefits than any modality does by itself, says Mark S. Nestor, M.D., Ph.D.
"When it comes to cosmetic laser treatments, the new devices such as Fraxel (Reliant Technologies), Titan (Cutera) and the new algorithms for ThermaCool™ (Thermage®) yield some excellent results. Fraxel does not yield much in the way of downtime, other than some redness and slight peeling. And when you use multiple treatments there are some significant improvements that can be obtained," says Dr. Nestor, director, Center for Cosmetic Enhancement and clinical associate professor of dermatology and cutaneous surgery at the University of Miami School of Medicine.
Recent refinements in using the ThermaCool™ amount to performing three or four passes (300 to 400 pulses) at lower fluences."Generally what we're talking about is in the 12 to 12.5 range on the slow tip and approximately 72 on the faster tip. The result is less pain and more consistent results. In patients with deep lines and wrinkles and significant skin laxity, using this algorithm along with a deeper erbium laser (Sciton) yields some amazing results, which heal rather quickly. The long pulse of the erbium laser allows us to achieve good hemostasis," Dr. Nestor says, who has treated approximately 50 or 60 patients in this fashion.
Physicians also are refining their approaches to treating other body areas.
For treating sun damage on the chest and hands, photodynamic therapy (PDT) provides excellent results. Sun-damaged hands also can benefit from superficial erbium lasers such as a MicroLaser peel (Sciton) and Fraxel.
Combining any of these nonablative lasers with botulinum toxin (Botox, Allergan) particularly in the upper face, improves overall results. The same can be said of selected lower-face areas such as the lips.
"The idea is to combine (lasers) in most cases with botulinum toxin, because laser use with Botox has been shown to give a better overall clinical improvement, and with fillers when necessary."
Exercise caution One must exercise caution, however, when using lasers or RF devices in combination with certain fillers.
Dr. Nestor says, "The more permanent fillers such as Radiesse (formerly Radiance, BioForm Medical), Sculptra (Dermik/Aventis) and silicone can yield some problems like bumps and lumps when we use the deeper devices such as the ThermaCool™, as well as deeper lasers. Even with some of the infrared lasers like CoolTouch (CoolTouch) and SmoothBeam (Candela Corp.), there can be an increased risk of granuloma formation.
Maximize results To maximize one's results, Dr. Nestor recommends keeping deeper lasers and devices away from the longer-lasting fillers, or administering the fillers after laser or other treatments. He takes a similar approach with botulinum toxin to avoid problems created by diffusion.
"For most of the treatments like photorejuvenation," he says, "you don't really have to wait. You're not going to have a problem. But the deeper procedures, including some of the deeper tightening procedures and lasers, one must wait a little while or treat those patients earlier."
Conversely, older fillers like collagen tend to last somewhat longer if one performs photorejuvenation over them. Dr. Nestor thinks this is due to a fibrotic response around the fillers.
Regarding combinations of lasers and filler substances, Dr. Nestor concludes, "One must look at the individual patient as an entire unit. In other words, one is looking at lines and wrinkles, as well as dark and brown (discolorations) all at the same time and saying, 'how can I best improve the overall cosmetic appearance of this patient?'
"If a patient comes in with scarring on their cheeks, for example, when they have red and brown associated with it, it actually outlines the scarring and makes it look worse. So even if you fix 50 percent to 70 percent of the scarring, the outline is still going to remain. These patients may benefit even more from the removal of the brown and red in addition to the scarring."