Case: 83-Year-Old Woman
Dr. Watchmaker discussed an 83-year old patient, who had malar mounds and accentuation of the infraorbital hollowness resulting from changes in subcutaneous fat and ligament laxity. She also had uneven coloration from photo damage, wrinkles on the upper face, linear appearance of zygoma related to underlying bony changes and fat compartment descent, and nasolabial folds and jowls related to decreased bony compartments, ligament laxity, and shifting of fat. She was naive to any cosmetic procedure.
Despite her age, this patient had no wrinkling on the upper forehead. Dr. Watchmaker did not inject neuromodulator in the upper forehead, as this patient also had a slightly heavy eyelid. “If you inject too much, it can cause some drooping of the eyelid and eyebrow,” she said.
For filler, she used a combination of high G (firmness, support) hyaluronic acid filler, a medium G acid filler, and a low G filler. The result: The woman’s face became more balanced, the mid-face volumization lifted the lower face, and the glabellar and periocular lines were softer, although still present. “It’s important to counsel patients that neuromodulators won’t make the lines go away the first time, but they will be softened.”
It’s important to titrate neuromodulators to fit the patient, Dr. Watchmaker said. Ask: What are their goals: Reversal of static lines? Softening wrinkles? Maintaining current status? “There’s not one dosing regimen,” and both dosing and frequency of neuromodulators can be titrated to fit each patient’s aesthetic goals, she said. For older patients who want to soften or maintain appearance, she suggested treatment every 4-6 months. And some patients just want to maintain the status quo, she noted.
For neuromodulators and fillers, who is an ideal candidate? “I think it’s anyone who has realistic expectations,” she said. Patients need to know how many treatments are needed and how much it will cost. For patients with extensive wrinkling and sagging, she said, she does extensive counseling about what results to expect “because I don’t want them to feel like they wasted their time or their money.”
She also suggests a surgical consult, as some may opt for that route after learning about the options and expected results.
Both radiofrequency and microfocused ultrasound are noninvasive and additional options. Radiofrequency uses radio waves, with electromagnetic energy to stimulate heat. Ultrasound uses ultrasound waves to stimulate heat. Both approaches cause collagen contraction, neocollagenesis, and skin tightening.
These procedures do well for the lower face, Dr. Watchmaker said, but “I am relatively unimpressed for how well they do for the upper face.” Ideal candidates have mild to moderate skin laxity and want to avoid surgery. She also tells patients that collagen isn’t made overnight. “You won’t see much for 3-6 months after.” The good news? Usually the treatments need to be repeated only every 1.5-2 years, she said.
“There are so many lasers out there,” said Dr. Watchmaker, who groups them into three categories: those used for wrinkles, dyschromia, and erythema. Her picks: ablative lasers (CO2 and erbium) and erbium-doped YAG 1550 nm laser for rhytids. Thulium 1927 and QS and picosecond lasers are her picks for dyschromia, and for erythema, pulsed dye and KTP lasers.
Some laser treatments are not a “walk in the park,” as she warns patients. For example, after treatment with ablative lasers, there is pain, post-procedure redness, and crusting.
A combination of noninvasive and minimally invasive procedures can produce appearance-improving results. That’s more likely if dermatologists choose ideal candidates, personalize the treatment, and set realistic expectations. “We have a finite number of tools,” she said, but they can be used in a variety of ways.
At the interactive panel discussion following her presentation, Dr. Watchmaker was asked what she tells patients about sun protection. “I talk a lot about sunscreens,’’ she said, always urging patients to use them. While the options for rejuvenation are numerous, taking care of the skin is still crucial.
Dr. Watchmaker had no disclosures. MedscapeLive and this news organization are owned by the same parent company.