In your practice, you might already combine energy-based devices and injectables when treating patients. But, to date, there’s also a chance you haven’t received much guidance on how best to use these strategies together.
During this year’s annual American Society of Laser Medicine & Surgery conference, industry experts provided insights on how dermatologists can pair these modalities to offer the highest quality patient care for clients. The “Optimizing Combination Therapies with Energy-Based Devices and Injectables” session was important, said Jeremy Green, M.D., voluntary assistant professor of dermatology at the University of Miami and Jackson Memorial Hospital, because it broached the use of combination therapies in a more public way.
“We don’t have a lot of good data at this point on the safety and efficacy of combining these modalities,” he said. “A lot of our knowledge, we learn from each other from experience, from trial and error and from what we can and can’t do safely.”
Together with other industry leaders, Dr. Green, who presented on how to put combination therapies to work, highlighted strategies to combine therapies most effectively, as well as the positives and negatives of this approach and stumbling blocks you should avoid.
What you should know
According to Vic Narurkar, M.D., founder of Bay Area Laser Institute in San Francisco, combining energy-based devices and injectables provides optimal outcomes for patients. It’s important to remember, though, that while some treatments are safe to provide same-day, others must be staggered for safety and efficacy.
For example, fillers, neuromodulators, and light-based technologies or energy-based technologies, fillers, and neuromodulators can be implemented in the same session, said E. Victor Ross, M.D., skin laser surgery specialist at Scripps Clinic Carmel Valley in San Diego. The long-held belief that introducing lasers could destabilize or damage fillers has been largely debunked, he said. You can use both modalities in the same session without problems.
Dr. Green also emphasized the role botulinum toxin can play with scars and wound care. If a patient has scars from MOHS surgery or an accident, use a laser on the area within two-to-three weeks. Alongside that therapy, he said, inject botulinum toxin into the muscle around the wound to prompt a molecular effect that promotes healing.
Most importantly, though, said Dr. Narurkar, who discussed optimizing combination therapies, you must remember that you, as the provider, play a significant role in a patient’s satisfaction level. Talk with them before any procedure to ensure they understand all possible results.
“It is important to educate patients on realistic outcomes with each modality and develop a treatment plan that is sensitive to both outcomes and the patient’s budget,” he said.
In fact, he said, his practice published the HARMONY study, the first prospective, multi-center study concentrating on outcomes when patients receive Botox, mid-face and upper-face fillers, and bimatoprost. Based on patient- and investigator-reported assessments, patient satisfaction with combination therapy is very high.
These satisfaction rates also underscore whether combination therapy is a feasible option both for dermatologists to provide and for patients to receive.
“These techniques are very practical, and we use them on a daily basis,” Dr. Narurkar said. “The majority of our patients receive combination therapies.”
In his practice, all patients undergoing any laser resurfacing are first prepared with a skin care regimen. The preferred facial combination is fraxel for photodamage, Botox for dynamic rhytids, and panfacial fillers for facial shaping. For the neck, the favorite combination is thermage for laxity, kybella and/or coolmini for submental fat, Botox for platysmal bands, and fraxel for photodamage.
Pros and Cons
As with any treatment option, combination therapy has its positives and negatives. Overall, the biggest benefit of combining energy-based device treatments and injectables is time saving for the patient, Dr. Green said.
“Rather than have the patient return for multiple office visits, in one or two sessions you can accomplish many things,” he said. “With injectables and different devices, the goal is to try to make one-plus-one equal three.”
But, there is a downside associated with this combination approach, he said. To date, there’s a lack of evidence-based medicine to guide providers on how best to use the combination approach. The research base is growing, and an increasing number of dermatologists are sharing their grassroots experiences, but there’s still much to learn.
Price can also be a deterrent, Dr. Narurkar said. In some instances, the price tag for completing more treatments during one or two sessions can be too high for patients.
Stumbling blocks to avoid
According to Dr. Narurkar, one of the biggest mistakes with combination therapies is pairing procedures together that shouldn’t be performed on the same day. Doing so can prompt adverse effects for the patient. For example, dermal fillers that are placed deep shouldn’t be completed on the same day you provide any resurfacing procedures, such as micro-needling or laser resurfacing. If you do, infection, biofilm, and granulomas can occur.
In addition, fillers and laser interventions can sometimes cause discomfort, and improperly managing a patient’s pain can be problematic, said Dr. Ross, who discussed upper and mid-face combination jewels.
“You have to move quickly when you’re using numbing cream and removing it. If you’re performing multiple procedures, everything will take longer,” he said. “You can’t dilly-dally because the effects of the numbing cream wear off quickly.”
Be sure you don’t use too much numbing cream, though. Limit the amount you use to between 50 grams-to-60 grams, he said. Any more than that can reach toxic levels.
It’s also important, when you’re performing laser procedures, to keep the skin cool and avoid overheating. If you’re completing multiple laser treatments, reduce the settings to ensure patient safety. Use an air cooler or contact chiller to decrease the effects of the heat you’re introducing to the patient’s body, he said.
Proper sterilization with open-skin wounds can sometimes be a sticking point, as well, Dr. Ross said. In any case where bleeding is possible or if the skin is broken, be sure to use devices that allow for single-use tips.
Ultimately, he said, combining energy-based devices with injectables opens doors for treating patients more effectively and swiftly. But, there’s no cookie-cutter, mandated approach. Instead, dermatologists should use their best judgment when combining therapies with individual patients.
“If you base your treatment decisions on what the patient presents with and how you can try to fix it or reverse it, your treatment plan will make sense,” he said. “And, if you’re careful, you can do a lot of things at the same time to help your patients.”
