Invasion of noninvasive treatments

May 1, 2007

Cosmetic dermatologists use several methods to achieve skin rejuvenation in patients. Many physicians prefer to use noninvasive therapies in aesthetic procedures, as they achieve good cosmetic results with a significantly decreased risk of adverse events and no downtime. One expert offers a review of the special techniques he uses, including combination therapies.

Key Points

Scottsdale, Ariz. - Noninvasive procedures clearly are more popular with cosmetic patients than invasive aesthetic procedures, as noninvasive procedures can offer a patient a "quick fix" with no downtime, as well as little to no risk of adverse events if done properly, according to one expert.

"There are certain cosmetic procedures that really get rid of wrinkles and, in the long term, will keep the cosmetic patient happy following an aesthetic procedure. The ones I prefer to do include Botox (Allergan Medical), fillers, chemical peels - TCA and combinations - CO2 laser resurfacing and dermabrasion," says Henry H. Roenigk Jr., M.D., Arizona Advanced Dermatology, Scottsdale, Ariz.

"Other procedures may work, such as superficial peels, microdermabrasion, Thermacooly™ radiofrequency, Fraxel (Reliant), Portrait (Rhytec), as well as noninvasive lasers such as pulsed dye, erbium and photodynamic rejuvenation, but the evidence for their long-term benefits is lacking," he says.

According to Dr. Roenigk, the popularity and use of laser resurfacing procedures, however effective they may be, are decreasing, because other less-invasive procedures can offer a better safety profile, boasting lower risks, fewer complications and little to no downtime.

Botox is easy to administer and very effective in getting rid of wrinkles, as are fillers - which also are available in a multitude of products, allowing the physician to customize treatments for cosmetic patients.

When performing a Botox procedure, Dr. Roenigk often likes to use the Arnold Klein technique, for which the dilution is 2.5 cc. For the glabella, he does three to five injection sites, injecting 0.18 cc per site. For the forehead, Dr. Roenigk does six to eight injection sites, injecting 0.08 cc per site, and for crow's feet, he does three injection sites, also using 0.08 cc per site. According to Dr. Roenigk, the cosmetic effect of Botox usually can be seen anywhere from two to three days and up to two weeks following the procedure. If necessary, touch-ups can be done every two to four weeks.

Procedural complications include swelling at the treated site, ecchymosis, and ptosis in 1 percent to 2 percent of patients. Dr. Roenigk tells Dermatology Times that these unwanted side effects can be decreased if higher dilutions are used.

"The basic goals of combined procedures are to achieve an improved appearance, to reduce the risk of post-procedural complications, and to ensure patients are happy six months after the procedure and are not mad about the money they spent with less than expected cosmetic results," Dr. Roenigk says.

He says that Botox treatment can be combined with everything, such as chemical peels, CO2 laser and derm-abrasion.

Dr. Roenigk favors the chemical peel because it is a single treatment. If done right, a single chemical peel can achieve the same positive cosmetic result as four laser therapy treatments.

One of Dr. Roenigk's favorite resurfacing combination procedures is combining a CO2 laser with a TCA 35 percent peel. Here, he lasers the lips, chin, jowls, periorbital region and glabella and then does a TCA peel for the remainder of the face.

"The CO2 laser is very effective and needed to treat the deeper wrinkles. TCA works very well, as it quickens the healing time, and therefore there is less post-op care and less persistent erythema. Furthermore, TCA and CO2 laser blend very well and complement each other, showing no lines of demarcation following the procedure," Dr. Roenigk explains.

He says that the Fraxel device is used in skin resurfacing and can treat cosmetic thorns such as dyschromias and acne scars, as well as melasma, but there are recurrences. The new SR-1500 device penetrates more deeply, and according to Dr. Roenigk, the procedure is not completely "noninvasive."

"A typical patient may require four to five treatments, and can have a downtime for several days, and pain. The lip lines do not do so well with Fraxel, and tightening is minimal," Dr. Roenigk says.

He says, though, that Fraxel does have good results for nonfacial areas, such as the chest and neck areas. According to Dr. Roenigk, the Fraxel results are encouraging, but not as good as those seen with CO2 laser treatments.

Disclosure: Dr. Roenigk reports no personal experience with Fraxel laser.