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Evaluation of the Cosmetic Patient
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The patient seeking advice and treatment for cosmetic concerns generally has a desired outcome in mind. The experienced clinician will help the patient identify these goals and accordingly choose an appropriate procedure. As part of this process, the astute physician will be realistic about the potential to achieve the patient's primary cosmetic goals.
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Every cosmetic surgeon will, at some point, be confronted with a patient who has unreasonable expectations. That is, the patient will have an outcome in mind that cannot realistically be achieved with any of the physician's treatment modalities. While it is true that cosmetic surgery can often improve a person's self-image and quality of life, patients with unrealistic expectations are unlikely to benefit in this manner, and they are more likely to be dissatisfied with their treatment and, by extension, their provider.1,2
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Patients with body dysmorphic disorder (BDD) represent a special subset of cosmetic patients with unreasonable expectations. BDD, a psychiatric condition that manifests as an unhealthy preoccupation with minor or imagined defects in one's appearance, may be exacerbated by cosmetic surgery as the underlying issue is primarily psychiatric. While it may be difficult to diagnose mild cases of BDD based solely on an initial consultation, ultimately the cosmetic dermatologist is responsible for his patients' health and should develop a sense of when a procedure is unlikely to satisfy the patients' needs or lead to poor outcomes.
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Fine and Deep Wrinkles
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Fine wrinkles (rhytides), particularly around the eyes and mouth, are a common patient concern. They are related to natural aging and chronic sun exposure within the superficial dermis and epidermis. Chemical peels, lasers and light devices, and long-term use of topical retinoids as mono-therapy or in combination, can redress some of this structural damage and treat fine rhytides.3 Deep rhytides, both dynamic and static, are multifactorial and caused by years of underlying muscle movement, age-related soft-tissue volume loss, and deeper structural changes due to facial bone resorption. Botulinum toxin and dermal fillers can be used to treat periorbital, glabella, and perioral rhytides.4 Deeper rhytides, particularly in the nasolabial folds, and the prejowl sulcus, can be softened to become less prominent with fillers alone (Figure 40-1). A combination of botulinum toxin, dermal fillers, and rejuvenating lasers can be effective in treating patients with both fine and deep rhytides.3,5,6
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The appearance of lax skin is a manifestation of aging, particularly on the face and neck due to age-related loss of elastic tissues, fat, muscle, and bone. Treatment options include filling the underlying tissue, tightening the lax skin, or surgical excision.3–8 Topical agents can serve as adjuncts, but the combination of dermal fillers and devices that induce neocollagenesis and new elastin (resurfacing and/or fractionated lasers) can provide excellent cosmetic rejuvenation.3–6,9,10
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Liposuction has traditionally been the procedure of choice for the treatment of excess body fat.11 Recently, noninvasive devices have been developed that target fat and induce lipolysis. These modalities include cryolipolysis (Figure 40-2), radiofrequency, and high-intensity focused ultrasound.12 Mesotherapy is an injectable approach to treating medical and aesthetic problems, but has a checkered history. Current mesotherapy agents are imprecise and fraught with complications, but newer agents such as Kythera's ATX-101 are being developed which are safe, predictable, and efficacious in reducing submental fat.13
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Facial Erythema and Facial Telangiectasia
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There are numerous causes for facial erythema, from inflammatory to neoplastic and actinic. Because this chapter is focused mainly on cosmetic concerns, we will address the cosmetic treatment of port-wine stains, rosacea, and photodamage with associated telangiectases. Sunscreen use can mitigate the erythema associated with photoaging and rosacea, and is also an adjunct to the vascular lasers. A variety of vascular lasers can be used, although the 595 nm pulsed-dye laser (PDL) and the 532 nm KTP laser are very effective and commonly used.14,15 Intense-pulsed light (IPL) is also very effective when treating large areas of pigmentation, atrophy, and telangiectases on the face, neck, and chest, generally referred to as poikiloderma.14
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Commonly found on the legs, these superficial dilated veins are best removed by direct injection of a sclerosing agent (sclerotherapy) or very occasionally by destruction with a deeply penetrating vascular laser such as the 755 nm Alexandrite or the 1064 nm Nd:YAG.16–18 Compression stockings are an adjunct treatment and may be used for secondary prevention.
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Lentigines are epidermal cutaneous lesions indicative of photodamage. They can be treated with a variety of agents. Common topical regimens include a tyrosinase inhibitor (eg, hydroquinone), with or without a topical retinoid, and sunscreen to mitigate recurrence and repigmentation.19 Superficial and medium-depth peels are sufficient to treat these superficial lesions, although repeat treatments may be needed.20,21 Q-switched lasers (eg, QS 532 nm KTP, QS 694 nm Ruby, and the QS 755 nm Alexandrite), the normal-mode 532 nm KTP, the IPL, and the 1927-nm Thulium fractionated laser are devices that can effectively be used for the treatment of lentigines.22
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Treatment of melasma can be very difficult, particularly due to the frustrating ease with which repigmentation occurs. Epidermal melasma can be treated in a similar manner as lentigines, with topical sunscreens, tyrosinase inhibitors, retinoids, and lasers or chemical peels.22,23 Dermal melasma is much more difficult to treat, although fractionated lasers may enhance the efficacy of topically applied tyrosinase inhibitors.22,23 Avoidance of all pigmentary triggers should be stressed, including regular sunscreen use and sun avoidance.23
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Multiple modalities exist for treatment of depressed scars. Topical retinoids may improve the superficial texture of scars. Treatments that induce new collagen and improve the texture and tone of scars include chemical peels, resurfacing and/or fractionated lasers, and subcision.3,5,9,21,24 Individual scars can be improved with dermal fillers, treated with a pinpoint trichloroacetic acid (TCA) application (CROSS technique), or excised with small punch excisions.24 Fractional resurfacing can achieve excellent results in a safe and predictable manner (Figure 40-3).3,5,9,25
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Intralesional triamcinolone is the mainstay of treatment for elevated scars. Combination treatments that include intralesional 5-fluorouracil, the PDL, and resurfacing and/or fractionated lasers can also be effective for larger or recalcitrant lesions.5,24 Silicone gel sheets are also favored by many dermatologists as a painless adjunct but have limited benefits.
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Permanent hair removal can be achieved with various lasers and is most efficacious in fair-skinned patients with dark coarse hairs. The 810 nm diode and 755 nm Alexandrite lasers are most commonly used, although the 1064 nm Nd:YAG laser may be safer to use in patients with darker skin tones.26 Multiple treatments are commonly needed. Eflornithine (Vaniqa) cream may be a useful adjunct but is not a permanent solution as it simply slows hair growth.
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Treatment of hair loss depends on a number of factors, most of which address the specific cause of hair loss. For inflammatory alopecias, control of the inciting inflammation is paramount to treating the alopecia. If there is any residual scarring, hair transplants may repopulate the cicatricial patches if the underlying inflammation is quiescent. Inhibitors of 5-α reductase such as finasteride can be used in androgenic alopecia. Hair transplantation may yield the best natural-appearing outcome, although not all patients may be eligible candidates.27
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The mainstay of tattoo removal is laser therapy, and a variety of lasers can be used for this purpose.28 Multicolored tattoos may require treatment with more than 1 laser. Successful treatment, in general, requires multiple treatments. Extreme caution should be taken, however, in the treatment of white, red, orange, yellow, turquoise, lavender, pink, tan, and brown tattoos as they may contain either titanium dioxide or ferric oxide.28 Laser treatment of these 2 metal oxides can result in immediate pigment darkening. Fractionated ablative lasers are nonselective but may allow transepidermal elimination of pigment, particularly after treatment with a Q-switched laser.29 A new technique is the Dora Q4 protocol, which calls for 4 sequential laser passes at 20-minute intervals, resulting in more rapid and effective clearing of tattoos compared to traditional therapies.30 Finally, traditional laser ablation (with the CO2 or Er:YAG lasers) or surgical excision may be used to physically remove the tattoo. These latter two treatments are the mainstay of tattoo removal when concerned about hypersensitivity to tattoo particles, as treatment with the q-switched lasers can result in anaphylaxis in a sensitized individual.28,29 Chrysiasis (cutaneous gold deposition) can be difficult to treat, and paradoxical darkening does occur with some lasers.31 However, laser treatment of argyria (cutaneous silver deposition) has recently been reported to be safe and efficacious, though quite painful.32
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The on-line learning center at www.LangeClinical-Dermatology.com has a self assessment quiz for this chapter.