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JUMPHEAD medestheticsmagazine.com | JANUARY/FEBRUARY 2017 47 However, there was no clinical data available at that time to support or disprove pretreatment with skin lighteners, such as hydroquinone, to reduce the risk of PIH. Despite the lack of evidence, their survey revealed that many dermatolo- gists and plastic surgeons were prescribing skin lighteners prior to ablative laser resurfacing. Today, some cosmetic dermatologists, including Michael Gold, MD, founder of Gold Skin Care Center in Nashville, say it is always a good idea to have the skin prepped and primed for any cosmetic procedure, while others such as Tina Alster, MD, say they don't prescribe anything special before ablative laser resurfacing. Plastic surgeons including Elizabeth Morgan, MD, PhD, MPH, founder of Morgan Cosmetic Surgery, in Atlanta, sug- gest specifi c skincare treatments before cosmetic surgery for some but not all patients. James A. Heinrich, MD, founder of Coast Cosmetic & Laser Medical Center, Mission Viejo, California, and others do not prep the skin before facelifts or other facial surgery, but always prepare the skin before ablative laser resurfacing. Faster Healing Times In July 2016 Patrick J. Buchanan and Robert H. Gilman pub- lished a review of literature on the use of retinoids prior to facial resurfacing procedures (Journal of Cutaneous Aesthetic Surgery) concluding that, although much of the evidence published is anecdotal, "a regimen of tretinoin before facial resurfacing expedites epidermal healing." "We prescribe a course of Retin A (tretinoin, Valeant), at least three weeks—but six weeks is optimal—before laser resurfacing, especially if we are using a CO 2 laser," says Dr. Heinrich. "We fi nd patients heal more quickly with fewer problems. We have recently begun using Alastin, which has both a preprocedure kit and a postprocedure kit. We are getting good results with these kits, and none of our patients have experienced any sensitivity reactions to the products." Developed in 2015, Alastin (TriHex Technology) uses a proprietary blend of peptides to activate production of elas- tin and collagen. The results of a randomized, investigator- blinded study by Sabrina Fabi, MD, and Deanne Robinson, MD, presented at the 7th Annual Summit in Aesthetic Medi- cine in May 2017, showed faster healing times in patients who were pretreated with Alastin prior to fractional ablatve laser skin resurfacing. "If you ask skincare company representatives, each will tell you their company has the best before-and-after skin- care routines," says Dr. Gold. "We need to make sure we rely on clinical scientifi c studies and real world experience. This is how we determine what works best." He emphasizes an individualistic approach to pretreat- ment in his practice, opting for retinoids in combination with concern-specifi c topicals. "There is no preferred routine that we use with every procedure. Instead, we customize based on what is needed to give us the best results," says Dr. Gold. "If we are dealing with wrinkles, we want to use topi- cals with growth factors and antioxidants; if we are treating pigment, we want to add in a hydroquinone or one of the many great anti-pigment products without hydroquinone." Dr. Morgan prefers a six-week pretreatment kit based on tretinoin. "The most effective ingredients are tretinoin or related retinoids, glycolics (research shows that both tretinoin and glycolic acid work better when used together) and a skin lightener," she says. Based on their 2016 review of published studies, Drs. Buchanan and Gilman recommended a specifi c regimen for use before ablative laser resurfacing, consisting of "0.1% tretinoin cream applied nightly for three months prior to, and discontinuing 24 hours before, the planned procedure." They recommended that physicians start patients who are new to retinoids at lower concentrations or use slower- acting synthetic retinoids, such as adapalene or tazarotene, to minimize the risk of retinoid dermatitis. When considering a pretreatment skincare program de signed to speed healing and reduce the risk of complica- tions, Dr. Heinrich notes that physicians must also be aware of what patients are using on their own. Supplements and medications that increase the risk of bleeding and topicals that cause skin sensitivity can affect outcomes and increase the risk of complications. "This is extremely important be- cause when patients have problems after laser treatments, it is often because of the products they are using or taking," he says. "If we fi nd out what they are using beforehand, we can head off some of these problems." medestheticsmagazine.com | JULY/AUGUST 2017 47 "We found that patients who used preoperative bleaching or retinoic acid preparations did not have a lower risk of developing post-laser ablation hyperpigmentation."