There are four relatively simple things that cosmetic surgeons can do in their daily practices to avoid complications and to improve outcomes of common cosmetic procedures, according to Joel L. Cohen, M.D., director of AboutSkin Dermatology and Dermsurgery in Greenwood Village and Lone Tree, Colo., associate clinical professor of dermatology, University of Colorado, and assistant clinical professor of dermatology at University of California, Irvine.
Dr. Cohen discussed complications with lasers and other energy-based devices and combination therapy with injectables during the 36th Annual Conference of the American Society for Laser Medicine & Surgery, Boston, Mass.
Tip 1: Re-evaluate each visit for recent sun-exposure and any hint of a tan
When using laser devices, physicians should re-evaluate patients for recent sun-exposure and any suggestion of a tan before every treatment, according to Dr. Cohen.
“It’s important to look at the skin color for that specific day, and not just reflexively use similar settings to what we did last time or at their baseline,” he says.
There’s a specific device available today that can help objectively do just that. It’s the Skintel Melanin Reader, which is part of Cynosure’s ICON system, according to Dr. Cohen.
“When using one of the ICON IPL handpieces, there is a blue tooth melanin reader that communicates with the ICON platform to use spectrophotomer readings that I use as a back-up to my clinical judgment. If someone looks tan and has evidence of recent significant sun-exposure, such as tan sparing the squint lines of the crow’s feet, then I tell them they need to reschedule and be more careful about sun-protection. And then I use the SkinTel exact reading to tell them where they were in the past and where they are today to objectively solidify that treatment today is just not a good idea,” Dr. Cohen says.
Dr. Cohen along with lead author Dr. Vic Ross have an article in the upcoming April issue of Journal of Drugs in Dermatology on the SkinTel system.
“The point is to always look for any subtleties of a recent tan or sun exposure. [Detecting those changes] may cause you to cancel a procedure or to back off a little bit,” Dr. Cohen says. “If you have something like Skintel available, it can help show patients, objectively, that their skin color has changed, and that you might not feel comfortable doing procedures [at that time].”
Tip 2: Consider looking at the literature before using antiviral prophylaxis
Physicians often prescribe antiviral prophylaxis prior to ablative resurfacing of the face. Dr. Cohen, was a co-author of a review of such prophylaxis treatments, published Feb. 2013 in the Journal of Drugs in Dermatology, and explains some anti-viral oral regimens are more effective than others.
“One things that’s clear is valacyclovir and famciclovir have better absorption and better bioavailability than acylovir. And now that valacyclovir is generic, it’s more affordable,” Dr. Cohen says. “Valacyclovir is my go-to antiviral as I have had at least a couple of patients over the years who have actually broken through and had [herpes simplex virus] HSV around their mouths after resurfacing even with acyclovir prophylactic doses.”
Tip 3: Take a look at post-procedure pustules before shrugging them off as non-inflammatory from occlusive ointments
Patients often have noninflammatory pustules, with no redness or swelling, after laser and other resurfacing procedures. The skin condition is probably related to the occlusive nature of some of the ointments physicians use, such as petrolatum. It’s still a good idea, however, to have these patients come in when this does occur and to specifically evaluate them to see the distribution and to see if there is erythema or swelling, or if there’s anything else going on, according to Dr. Cohen.
“Sometimes we can see infection, and, if there’s infection, most of the time it’s staph, but sometimes it’s yeast, so best to evaluate in the office and consider a culture or KOH evaluation,” he says.
Tip 4: Consider using pre-procedure botulinum toxin to improve filler, resurfacing and surgical outcomes
It’s common for aesthetic surgeons to use multiple modalities to rejuvenate the face. Dr. Cohen says studies and personal experience suggest botulinum toxin done in conjunction with fillers, resurfacing and even skin cancer surgery in some specific areas can help to improve outcomes.
“Before I do resurfacing around the mouth or around the eyes, I often use botulinum toxin a week or two before to help immobilize the area and improve results,” he says. “I also commonly do that before skin cancer surgery on an area where it may be tight and highly mobile with animation, like on the forehead. Some recent studies have shown that it’s not just chemo-immobilization but there are some very specific cytokine and chemokine pathways that are actually helping the healing process.
When I do fillers in some areas, my approach is very similar.” Dr. Cohen says using a neuromodulator a week or two before injecting a filler in certain specific areas like the glabella can markedly extend filler duration (as per Carruthers’ Derm Surg 2003 article) and also I feel like I end up using less filler many times, which is something that can be helpful to decrease the risk of vascular compromise in the glabella. I think it helps me keep my overall filler volume down, from a safety perspective,” he says.
Disclosure: Related to injectable aesthetic agents, Dr. Cohen consults with and does clinical trials for Allergan, Galderma, Merz. Related to the ICON and SkinTel, Dr. Cohen previously consulted and participated in clinical trials for Palomar before they were purchased a few years ago by Cynosure.