Dermatology World October 2011 SUPPLEMENT : Page 14

BY LISETTE HILTON , CONTRIBUTING WRITER COMBINING IDEAS Dermatologists share their experience with therapies that they nd yield optimal results. 14 SUPPLEMENT TO DERMATOLOGY WORLD // October 2011



Dermatologists are combining minimally invasive procedures to more completely address patients’ multiple cosmetic concerns. Experienced practitioners have learned that combination approaches are convenient for patients, don’t generally increase downtime, and result in higher patient satisfaction.

When expert dermatologists were asked about how they were using combination therapies in their practice, they offered varying and sometimes differing approaches to areas that they address most commonly.


“Combination techniques are often based on dermatologists’ experiences in using the noninvasive approaches, along with the science behind the individual techniques,” said Chicago dermatologist Carolyn Jacob, M.D.

Dr. Jacob treats a young patient population. Many are experiencing only the first signs of aging in their faces — predominantly around the eyes — and Dr. Jacob finds that a combination approach helps them retain an overall youthful look.

“A lot of my patients complain about loss of volume under the eyes,” said Dr. Jacob, an associate instructor in dermatology at Northwestern Memorial Feinberg School of Medicine in Chicago. She uses a combination of fillers, a neuromodulator, and, sometimes, lasers to address the issue. She also uses a hyaluronic acid under the eyes to build volume.

“However, in a lot of these cases, patients also have loss of volume in the mid-cheek, temples, lower-lateral cheeks and, sometimes, marionette area,” Dr. Jacob said. “For those areas, volume is what I think is needed. I use a poly-L-lactic acid filler throughout the cheeks and temples and marionette area because it gives a natural production of your own collagen, and softens the facial appearance without looking ‘done.’” She combines the fillers initially, following up with a series of poly- L-lactic acid treatments and hyaluronic acid touchups every six to 12 months.

In some cases, Dr. Jacob also adds treatment with a neuromodulator, such as abobotulinumtoxinA, to address the glabellar area.

“I do the injectable wrinkle relaxer, first; a hyaluronic acid, second; and a poly-L-lactic acid, third. That’s just because the poly-L-lactic acid can distort the area under the eyes,” she said. “I use abobotulinumtoxinA in the majority of my patients because I find that it sets in faster, and in some patients lasts longer than botulinum toxin. Studies have shown that it lasts longer in the forehead, and works better in the crow’s feet [both off-label treatment areas].”

For patients also bothered by the red blood vessels on their nose and cheeks, Dr. Jacob will add treatment with a potassiumtitanyl- phosphate (KTP) laser, prior to the neuromodulator and hyaluronic acid.

For some cases, Dr. Jacob also recommends resurfacing with a fractionated CO2 laser, although this is a treatment she reserves for second visits.

“I don’t do the resurfacing on the same day as the fillers or neuromodulators. Sometimes you get a little bit of swelling, which would distort how much filler I need to use. And I don’t want to put in the line filler and then laser over it with the fractionated laser because it could destroy a fraction of the product, depending on how superficially the product was placed,” she said.


Bruce Katz, M.D., clinical professor at Mount Sinai School of Medicine in New York City, agrees with Dr. Jacob’s assessment that combination techniques are based on personal experience, but that each technique has had scientific studies behind them individually. His own experience with combination therapies for eyes had led him to a different method he finds effective for rejuvenating the area around the eyes.

When addressing eye area wrinkles, eyelid laxity, crows’ feet, and deep tear troughs, Dr. Katz combines treatment with a fractional C02 laser, botulinum toxin, and fillers.

“We do fractional C02 resurfacing of the eyelids. The nice thing about that is we can usually do just three or four treatments, so there’s minimal downtime,” Dr. Katz said. “Then, we do onabotulinumtoxinA or botulinum toxin for the crow’s feet to prevent them from coming back after the laser. But that doesn’t take care of the deep tear troughs. For those, we use non-animal stabilized hyaluronic acid or hyaluronic acid gel.”

Dr. Katz explained he uses those particular fillers because other non-hyaluronic acid fillers are too heavy to inject under the thin, delicate eyelid skin and may be visible.

This combination approach results in a major cosmetic improvement in the eyelids, he said.

The hands are another area of the body where Dr. Katz has observed benefits from combination therapies, and he has found that using a combination of laser and filler treatments is an ideal combination for rejuvenating aging hands, which are often one of the earliest spots to show signs of aging.

“A lot of men and women have dark spots or sun spots on the backs of the hands and their hands start to become bony looking. The tendons and the veins become a lot more prominent,” he said. “What we do is use the laser to remove the sun spots. Then, we use a volumizing filler to fill in the hands to make the tendons and veins less noticeable.”

He offers this final pearl for a successful outcome: Make sure to massage the filler into the hand so that it doesn’t look lumpy.


Fillers have long been a part of the aesthetic dermatologist’s armamentarium and a variety of products have entered the market. Now dermatologists are discovering innovative ways to use them in various combinations for optimal results.

Dermatologist Richard Glogau, M.D., uses a single filler but in a combination of different concentrations to address midface volume loss. According to Dr. Glogau, clinical professor of dermatology at University of California, San Francisco, the trend is away from using fillers simply as wrinkle treatments and toward using hyaluronic fillers for deep tissue volume reconstruction.

“Building up the area that’s lost to aging in front of the malar cheekbones and in the midface has a lot more importance than trying to attack lines in the dermis or skin folds,” he said. “The paradox is that we’re using the hyaluronic fillers in lower concentrations. We’re actually diluting them to food just underneath the skin and stimulate collagen production.”

Dr. Glogau also offered some recommendations for his approach to other areas, like the upper lip and around the eyes, suggesting a diluted hyaluronic filler to enhance volume. He added that he uses a concentration hyaluronic filler to add volume in deeper areas of the midface.

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