Photorejuvenation requires personal touch from physicians
"One of the frustrations we have as dermatologic surgeons is that there are a plethora of options available to patients, and patients come in with preconceived ideas of what may work for them," says Sandy Sharon Tsao, M.D., instructor in dermatology, Harvard Medical School, and a dermatologic surgeon at Massachusetts General Hospital in Boston.
However, she says, "There isn't just one hammer, or one treatment that would match each patient." Dermatologists must individualize treatment plans according to the patient's desires, clinical findings, history (including prior treatments and their outcomes), lifestyle, expectations and the risks and benefits of a possible procedure.
Moreover, "One of the main factors to consider when planning any treatment option for photoaging is that any time you do a facial treatment, how will it affect nonfacial regions?" she says. A patient who has a significant amount of facial lentigines and brown spots frequently will have similar findings on the hands. Therefore, if a physician erases these discolorations from the patient's face and neck but leaves the arms, legs and hands untreated, the patient's skin will have a mismatched appearance.
Similarly, she says that for patients with solar lentigines or melasma, dermatologists can taper treatment to help blend the edges of treated areas into the surrounding skin tone if areas are to be left untreated.
Fighting wrinkles and more
Determining through a clinical examination whether wrinkles are static or dynamic helps to determine whether they're likely to respond best to botulinum toxin injections; to fillers and lasers; or to a combination of toxins, fillers and lasers, Dr. Tsao says.
"Many people are very knowledgeable about the use of Botox Cosmetic (onabotulinumtoxinA, Allergan) for softening of wrinkles around the face. However, once you've softened those lines on the face, then the neck lines can become more prominent," she says.
Although many physicians almost inevitably think of platysmal bands as an indication for surgery, she says dermatologists can inject these, and horizontal neck bands, with toxins — as long as they use great care to avoid injecting too deeply.
"Botox injected too deeply into the neck muscles can present a great deal of concern regarding swallowing or voice changes," Dr. Tsao says. "It's not for the inexperienced physician. But for a patient interested in softening lines around the neck, Botox, injected very conservatively, works beautifully."
Static wrinkles represent the most significant learning curve for patients and physicians, Dr. Tsao says, adding that "there are a multitude of devices available, including lasers, chemical peels and filling agents."
Choosing the most appropriate treatment or combination of treatments requires listening closely to the patient's desires, she says. "Are they trying to get rid of brown spots and wrinkles? Are they amenable to having one or two days of downtime, or can they manage a week to 10 days? Do they understand the limitations of the different devices? These factors significantly impact which devices you would offer patients. And if you feel that a procedure you don't offer would be better for a patient, absolutely refer the patient to someone who can provide it," she says.