MIAMI – In his practice, Joel L. Cohen, MD, spends a good part of his day doing Mohs surgery, “with the goal of cancer removal, and after surgery, having the patient look good,” he said at the Orlando Dermatology Aesthetic and Clinical Conference.
“Having resurfacing in my practice has allowed me to treat not only wrinkles and etched lines, but also help skin cancer patients by blending and minimizing their skin cancer scars,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in Denver.
Dr. Joel L. Cohen
Resurfacing in his practice using a variety of lasers is very helpful, Dr. Cohen said. He published a study in November that compared pulse dye laser, CO2 ablative fractional lasers, or a combination of both for modification of scars following Mohs surgery (J Drugs Dermatol. 2016 Nov 1;15[11]:1315-9).
The prospective, multicenter study revealed that although both monotherapy approaches were safe and effective, the combination of pulse dye laser and fractional ablative laser offered some synergy that was preferred by patients.
Reprinted with permission from J Drugs Dermatol. 2013.12:10;1172.
A 48-year-old woman: a) 2 days after excision of melanoma in situ; b) 2 days after undergoing a large rotation flap repair; c) 2 months later, before laser treatment; d) 4 months after surgery and 5 weeks after a second laser treatment; e) about 7 months after the first surgery and 6 weeks after a third laser treatment.
Perioral resurfacing possible
Beyond the world of treating scars, a typical cosmetic patient in Dr. Cohen’s practice presents with numerous lines around the perioral area. “When people think about rejuvenation of the lips, they only think of fillers. But fillers are not the only way to rejuvenate this area, and it is really about choosing the right tool for the right job – where resurfacing lasers are needed.”
Reprinted with permission from Journal of Drugs in Dermatology, 2016, 15:1, 112. Photo credit: Joel Cohen, Colorado Springs, CO
Before and after perioral fillers and erbium full-field laser resurfacing.
Set realistic expectations
Setting the right expectations for people is extremely important, Dr. Cohen said. “You can educate the patient that if you’re putting the needle into the lines, you’re only treating the larger lines that you can get a 30-g needle into, but there are often a host of other lines in that area – many of which are too small to get a needle into.”
As a starting point, neuromodulators can have a role in trying to prevent or delay etched-in lines from forming around the mouth in the first place. “These are the lines between the musculature, the ones you see when you ask the patient to purse their lips,” Dr. Cohen said. He typically injects a medium dose of one of three neuromodulators – such as 6-10 U of onabotulinumtoxinA (Botox), 6-10 U of incobotulinumtoxinA (Xeomin) or 14-18 U of abobotulinumtoxinA (Dysport). “Then somewhere between week 8 and 10, there is an attenuation of the effect, and I often will see patients back then for additional treatment with a neuromodulator,” he added.
“For our every day patient complaining of lots of etched perioral lines, we have laser resurfacing,” Dr. Cohen noted. He is a bigger proponent of full-field erbium treatment versus fractional ablative laser resurfacing for these prominent upper cutaneous lip lines because the results are much more impressive with a single treatment. He added that dermatologists could do fractional treatment around the rest of the face, and reserve the erbium resurfacing to improve the appearance of lines around the mouth and prominent creping skin around the eyes.
Realistic postprocedure expectations are especially essential in the days after erbium laser resurfacing – as it is a tough downtime procedure for patients, often taking 7-9 days to re-epithelialize. “Having photos to show patients what they will look like is really helpful,” Dr. Cohen said. He suggested showing patients a chronologic set of photos of the downtime period as well as the results – so they realize improvement occurs slowly over time. “Getting people to understand they are gong to look terrible for 1.5-2 weeks is superimportant.”
“I like to have them back in the office for a postprocedure check a few days after the bigger laser resurfacing procedures are done, just to check on them,” Dr. Cohen said. “A lot of hand holding is often needed, as there is significantly more healing time with the full-field ablative resurfacing than there is with fractional. Full-field resurfacing patients will experience postprocedure erythema for a few weeks or even months,” Dr. Cohen said. A prescription of topical steroids, and sometimes some brimonidine topical gel (Mirvaso) as well can help reduce the redness.
Toxin injection then laser resurfacing
For some patients, injection of a neuromodulator a week or 2 before laser resurfacing treatment can decrease some of the movement and contraction of the muscle, “and hopefully give them better results,” Dr. Cohen said.
Timing is important. “You don’t want to use neuromodulators on the same day of treatment,” he advised. “The thinking is swelling could potentially cause the neuromodulators to spread to unwanted adjacent muscles.”
Safety first
Another tip for the postprocedure period is to supply patients with very specific written instructions. “I wish they would follow them. Patients don’t always listen to what we advise, demonstrate, and also have written down for them,” he commented. For example, one patient had resurfacing several weeks before leaving on an undisclosed kayaking trip. Despite instructions to use sunscreen, she said she wore a hat for sun protection and developed postinflammatory hyperpigmentation around the mouth that lasted for several months, Dr. Cohen said.*
With heavy resurfacing and ablative resurfacing in general, it is advised to always give patients an antiviral prophylaxis course such as valacyclovir, but it is unfortunate that not all patients will adhere to the recommended regimen, he added.
Another patient had an adverse reaction after resurfacing because she did not follow instructions to apply white petrolatum to her chest following laser resurfacing, Dr. Cohen said. She used Neosporin, “even though in all our paperwork we say never use Neosporin and just use the petrolatum. She had a big contact dermatitis reaction to the Neosporin.”
“So you really need to caution people about the importance of following instructions very carefully,” he emphasized.
Dr. Cohen is a consultant for Sciton and for companies that manufacture injectables, including Allergan, Galderma, and Merz.
Correction 2/24/17: An earlier version of this article mischaracterized the type of pigmentation disorder that the patient developed.