EXPERT ANALYSIS FROM THE AACS ANNUAL MEETING
NEW ORLEANS (FRONTLINE MEDICAL NEWS) – Knowledge of skin anatomy and methods of proper pretreatment will enhance and extend the results of skin-resurfacing modalities, according to Dr. Suzan Obagi.
Skin resurfacing procedures continue to grow in popularity, and newer resurfacing modalities with less recovery time are regularly being introduced, Dr. Obagi said at the annual meeting of the American Academy of Cosmetic Surgery.
“Managing the skin properly by appropriately evaluating and treating it before, during, and after a skin resurfacing procedure will allow us to expand the base of patients we can treat safely, improve and maximize their results, and reduce complications,” she added.
The most common patient concerns are acne, wrinkles, pores, rosacea, facial redness, sensitive skin, and discoloration, said Dr. Obagi of the University of Pittsburgh.
“We hear about these issues all the time, so we need to know how to properly address them,” she noted. Discuss a range of procedures and the downtime associated with each modality when advising patients. “What patients do at home is equally – if not more – important than what is done in the office,” she stressed. “This puts some of the responsibility on them [patients]; we can only fix so much, but they have to be partners with us in this process.”
Aesthetic skin concerns can be treated with chemical peels, lasers, fillers, and skin-tightening procedures, but anyone performing surgery without first preparing the patient’s skin is doing the patient a disservice, Dr. Obagi stated.
Topical agents should be considered prior to other treatments, she advised. “A patient with excessive wrinkles will not achieve the desired result through a face-lift alone; I want to fix their skin first, and then do the face-lift if needed,” she noted. Similarly, skin problems such as rosacea and acne must be addressed before considering resurfacing modalities, as resurfacing skin that is actively inflamed will only exacerbate the issue, she said.
To maximize results from a skin-resurfacing modality, skin must be healthy before it is treated. “If you laser away just one brown spot, you’ll have a healthy spot of skin surrounded by a sea of sun damage,” said Dr. Obagi. Healthy skin heals faster and scars are less noticeable when sun damage is primarily addressed. This process serves as a test of patient compliance with instructions, she added.
The importance of topical agents in a preoperative skin care regimen cannot be overstated, she said. A retinoid should always be used to activate and stimulate keratinocytes and fibroblasts, and hydroquinone should be used to stimulate melanocytes. The use of hydroquinone is controversial, but claims regarding its carcinogenic properties have not been supported in the literature, said Dr. Obagi. “If you want to see results, become comfortable speaking to the safety of hydroquinone and using it properly in your patients,” she added. Mineral-based sunblock should take the place of a daily moisturizer, and a product containing zinc or titanium is recommended. “Many of us work under fluorescent light; even the visible spectrum of light interacts with tissue and causes some of the aging we’re seeing, and chemical sunscreens don’t touch that spectrum,” she stated. Finally, supportive topical agents such as AHAs, benzoyl peroxide, and astringents can be added as needed to a topical skin care regimen depending on a patient’s skin concerns.
Pre-resurfacing goals include controlling acne and rosacea, testing compliance, enhancing wound healing, and controlling pigment production. When all of these issues are addressed prior to resurfacing, results are enhanced. “Always do a skin conditioning treatment, as this makes results more dramatic,” said Dr. Obagi. “I usually do a pre-resurfacing regimen for 6 weeks on a lighter-skinned patient; on a patient with darker skin I continue the regimen for about 12 weeks before I feel I can safely treat them,” she said.
Resurfacing treatments must be tailored to differing levels of the skin for different conditions, Dr. Obagi noted. Sun damage resides very superficially in the epidermis, wrinkles and scars can reside superficially or deeper, and acne and rosacea involve deeper layers of the skin. Some treatments will not go deep enough in the skin to address certain problems, so it is crucial to address treatment depths to where the problem actually resides. “Although new lasers are constantly introduced, one thing that has remained stable is skin cells; we know we can only target certain ones,” she added.
Cellular targets for skin health restoration in the keratinocytes involve normalizing turnover and improving atypia; in the melanocytes, the targets involve decreasing pigment production and enhancing melanin distribution. Deeper in the dermis, cellular targets for skin health in the fibroblasts include increasing collagen, elastin and glycosaminoglycans (GAGs). “We want to take these cells and really stimulate and control them at every level, so we can make patients heal the way we want them to post procedurally,” explained Dr. Obagi.
For best results, postresurfacing goals should involve resuming control of acne and rosacea, monitoring for complications such as infections, and enhancing wound healing through such modalities as steroids, antibiotics, or low-level lasers when appropriate. “However, the most crucial postresurfacing goal is controlling pigmentation. Don’t wait for hyperpigmentation to occur; it is much harder to treat than it is to prevent,” Dr. Obagi emphasized.
Establishing a proper skin care regimen prior to a procedure is vital in combating aging, and will in turn produce better and longer-lasting procedure results with fewer complications, said Dr. Obagi. Further, communicating with patients and involving them in their own skin care establishes trust and confidence. These patients will be happier with their surgical results, will report for regular follow-ups, and will serve as sources of referral. “If you deliver results before you even get to the procedure, the patient will trust you implicitly,” Dr. Obagi said.
Dr. Obagi reported serving on the scientific advisory board for Valeant Pharmaceuticals.