Medesthetics

NOV-DEC 2016

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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44 NOVEMBER/DECEMBER 2016 | Med Esthetics BACKGROUND: NICHOLAS VEASEY © GETTY BACKGROUND: NICHOLAS VEASEY © GETTY IMAGES; TOP: IMAGE SOURCE © GETTY IMAGES SELECTIVE ABLATION macular seborrheic keratosis and scars). "In general, I like to perform erbium in multiple passes to achieve I like to perform erbium in multiple passes to achieve the precise depth of ablation with a low number of CO O the precise depth of ablation with a low number of CO 2 passes to achieve ablation plus coagulation," he says. ys passes to achieve ablation plus coagulation," he says. Dr. Narurkar varies his settings based on the severity Dr. Narurkar varies his settings based on the severity he Dr. Narurkar varies his settings based on the severity of photodamage and the areas of the face being treated. ce of photodamage and the areas of the face being treated. "I use the most aggressive settings around the perioral "I use the most aggressive settings around the perioral ar "I use the most aggressive settings around the perioral area and for thick hypertrophic scars," he says. "I generally area and for thick hypertrophic scars," he says. "I generally hic area and for thick hypertrophic scars," he says. "I generally avoid treating non-facial skin, such as the neck and chest, ski avoid treating non-facial skin, such as the neck and chest, due to the higher risk of scarring." isk due to the higher risk of scarring." Areas of Concern Some areas of the face and body carry a higher risk me Some areas of the face and body carry a higher risk of scarring and adverse events than others and should be treated more cautiously, both with decreased en- ergy settings and limitations on the number of passes. "The vermilion border and periorbital area may be restricted to one pass due to their delicate nature," says Dr. Nazarian. "Non-facial rhytides, including those on Dr. Nazarian. "Non-facial rhytides, including those on the neck and chest, should be treated with great care or avoided completely as decreased adnexal structures and vascularity increase the risk for scarring and pig- mentary alteration as compared to facial skin." The neck and chest are hot spots for adverse events, such as hypertrophic scarring. "If this occurs, fl uences that were too high and too many passes were em- ployed," says Dr. Alexiades, adding that she has safely and effectively treated these areas by adjusting the density so that the collateral columns of thermal injury do not overlap between microthermal columns. She also employs conservative fl uences when working off o also employs conservative fl uences when working off e also employs conservative fl uences when working off th the face. For Dr. Munavalli, being careful around the eyes, most notably the upper and lower eyelids, is critical. "I prefer lower densities and lower energies in these areas; I ap- proach the endpoint slowly and deliberately," he says. "The nose tends to be more forgiving." Furthermore, "The nose tends to be more forgiving." Furthermore, don't forget to treat the ears, he says, as they also get sun damaged, and feather the ablation into the hairline and jawline to give a blended, professional look. Pain Control Due to the ablative nature of these procedures, all pa- tients will require some form of pain management during treatment. Dr. Nazarian recommends a Zimmer chiller to keep the skin cool during treatment. For multi-pass CO 2 treatments, she may employ a nerve block using treatments, she may employ a nerve block using 1% lidocaine with 1:100,000 epinephrine, administered for supraorbital, supratrochlear, infraorbital or mental blocks. "Radially spacing subcutaneous injections of lidocaine from a single entry site, called 'fanning,' helps to deliver greater anesthesia to areas not suffi ciently covered by nerve blocks, including the lateral cheeks and lateral forehead," she says. For less aggressive treatments, topical anesthetic may be adequate. Dr. Alexiades' typical protocol is one hour of topical anesthetic, such as EMLA (lidocaine/ prilocaine), prior to treatment. "Once I treat each quadrant of the face, I apply cool compresses consisting of ice-water-soaked gauze immediately after each pass," "Non-facial rhytides, including those on the neck and chest, should be treated with great care or avoided completely."

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