Board Forum: Minimally Invasive Trends and Opportunities

What are your most common uses for chemical peels in practice? Has this been an area of growth?

Michael Somenek, MD: I provide chemical peels, most commonly Jessner’s or TCA peels. Most common uses are to treat pigmentation and general improvement of skin texture. I don’t think it has particularly grown over the past few years, but there is certainly still an interest in select patients.

Cheryl Burgess, MD: I most commonly use peels for dyschromia and acne with post-inflammatory hyperpigmentation (PIH). I learned the chemical peeling procedures in dermatology residency as a therapeutic regimen for acne and PIH.

Todd Schlesinger, MD: Our practice continues to use superficial and medium-depth chemical peels. Our most common uses are as a refresher treatment, dyspigmentation, and the improvement of skin quality. We have seen some growth, but it has not been as significant as that of energy-based devices. I think that patients could benefit with additional clinician education on the benefits of peels.

Flora Levin, MD: We do PCA peels—mostly lighter ones—with minimal downtime. We do offer them as an “in-between” treatment and maintenance after lasers or microneedling (i.e., a series of microneedling or non-ablative laser Q1 month for three to four sessions, then peel every one to two months until the following year). There has not been much growth; I would say the same or decreased.

Tina Ho, MD: I have a new practice with two senior aestheticians. They do chemical peels like TCA peels and Melanage peels for antiaging and hyperpigmention. Demand seems status quo.

Joe Niamtu, DMD: I have done peels for decades, and they are a very economical means of treating dyschromias, fine lines, and wrinkles, and promoting skin turnover. I usually perform medium-depth 30% TCA peels or 20% on darker skin types. I think it is safe, predictable, and patients are back in makeup in a week.

Steven Pearlman, MD: I’ve asked my nurse, Christine Ross, who does all skincare and minimally invasive laser treatments to weigh in on these topics, since my focus is on surgery:

Christine Ross, RN: We use the Canfield VISIA Skin Analysis system to customize treatments plans and skincare regimens for each patient. The most popular peels address superficial pigmentation, texture, and pore reduction using a combination of active ingredients such as salicylic, TCA, and lactic acids.

We have seen a slight increase in patients requesting chemical peels. Trends for “filtered” skin without the filter have brought more awareness to skin tone and texture.

Brian Kinney, MD: Most commonly, we offer peels for dyspigmentation and early wrinkling. This is status quo for my practice in terms of demand. As a plastic surgeon who does not promote spa services, it is not a big part of my practice.

What proportion of patients have lingering concerns about skin quality after injectable treatments or surgical lifting procedures?

Dr. Schlesinger: I think in many cases, if patients present for neuromodulators and fillers but they have poor skin quality, I would suggest that it be addressed first, especially before certain fillers. Fillers work best when there is good to excellent skin quality at baseline. Our philosophy would be to suggest the use of skin care products, chemical peels, non-ablative and ablative laser resurfacing, and/or photorejuvenation to improve skin quality before proceeding with certain fillers.

Dr. Ho: I see this concern in about five to 10 percent of patients post-surgery. I offer CO₂ laser resurfacing or aesthetician consult.

Dr. Levin: The most common concern after procedures is persistent erythema after CO₂ laser; PIH is second; bruising is third. Managing expectations, patient selection, and post-operative care are essential.

We modify timing to avoid procedures with possible risk of PIH in the summer months and pre-treat with hydroquinone if necessary.

Dr. Burgess: Patients notice there is uneven or chronic photodamage of the skin once volume is restored and filling in of the fine lines and wrinkles. Occasionally, patients will ignore the physician’s skincare recommendations, because they are anxious to get their fillers and neuromodulators!

Skin clarity is the first step in an antiaging process. I stress the continuous use of sun protection including protection against UV, blue, and indoor light; reversing visible photodamage; epidermal exfoliation, and dermal stimulation. Occasionally, blending of the complexion involves lightening agents introduced to the skincare regimen.

Ms. Ross: The take-away here is to educate the patient about the benefits and limitations of injectable treatments. By setting the correct expectations and laying out a multimodality treatment plan to address the patient’s full concerns, lingering concerns should be minimized.

We address the patient’s full concerns and often recommend a multimodality approach for optimal results. This could include injectables, lasers and EBD, and medical grade skincare. Our practice currently offers the following non-invasive treatments for skin: Chemical Peels, Broad Band Light, Fractionated ablative and non-ablative Lasers, Microneedling, RF microneedling, Ultherapy, and Hydrafacial.

Dr. Kinney: Only one-quarter would have “concerns,” but three-quarters are open to discussion about improvements. We address them via discussion of intradermal toxin injections and peels.

Dr. Niamtu: I have a surgical practice and perform over 100 facelifts a year. I would say that 100 percent of these patients need skincare, and this is something that we stress in the evaluation and postoperative stages. I don’t have an aesthetic wing to my practice or an aesthetician, so it is a little bit harder to address these concerns.

Dr. Somenek: I try to establish expectations with patients during their initial consultation to give a more comprehensive overview of what I think they’ll need. For lifting procedures specifically, I will recommend laser resurfacing if they are appropriate candidates, because this is able to address texture that a lift cannot address. This approach typically avoids patients being surprised that one thing or another did not address all of their concerns.

What is your philosophy on protection from UV, IR, and blue light exposure? Do you modify recommendations seasonally?

Dr. Somenek: I prefer a 365-days approach, as this is most preventative long term on the cumulative nature of sun damage. My patients are encouraged to routinely incorporate sunscreen into their daily skincare regimen, which I always tell them protects their investment!

Dr. Kinney: Generally, we offer a 365 approach and just have patients limit exposure during sunnier months (which in LA can be most of the time).

Dr. Burgess: 365/24/7!

As noted, patients require protection against UV, blue, and indoor light.

Dr. Schlesinger: I think that the role of visible light and fringe ultraviolet exposure is becoming understood more and more. It is therefore my standard practice to entertain a discussion about these topics with the patient and suggest sunscreen products that have better visible-light-blocking qualities. Ultraviolet and visible light exposure can be a year-round problem in many climates, and there is also the exposure to certain indoor lights to consider, so I do think it is a year-round discussion.

Ms. Ross: Protect, protect, protect! Comprehensive sunscreen use is an everyday essential.

We always recommend wearing sunscreen year-round (even when inside working on a computer) and also doing treatments year-round to maintain healthy skin. We defer on stronger, energy based, ablative treatments until a patient can stay out of the sun for a significant period of time after treatment.

Dr. Ho: I take the 365 approach but am not widely recommending iron oxide yet.

Historically, many practices have reported an uptick in resurfacing procedures in the fall and winter. Are you seeing or predicting any changes to these trends as the post-shutdown boom continues?

Dr. Niamtu: Resurfacing procedures have always been a big part of my practice, and historically people don’t do them in the summer so there is always an uptick in the fall. There’s also been an uptick, since many people are working from home during COVID. One problem, however, is wearing a face mask on resurfaced skin and for that reason I have been discouraging significant resurfacing procedures unless a patient can go two weeks without wearing a mask. I have had several cases of irritation and delayed healing because of mask abrasion over resurfaced skin. (Editor’s Note: Read Dr. Niamtu’s article on face masks and post-procedure healing in the July/August edition at ModernAesthetics.com.)

I only use CO₂ laser and TCA peels to address photodamage and pigmentary changes. I don’t treat isolated melasma and refer that to the skin pros.

Dr. Burgess: There is an uptick in all cosmetic procedures since the beginning of the COVID pandemic. Normally, no one spends hours looking at themselves in front of a mirror; however, patients are spending a lot of time in front of the “Zoom mirror.” Critiquing themselves and others is a standard pastime to a boring meeting!

We are just very busy everyday!

Dr. Ho: It seems like IPL/BBL uptick in the fall/winter, as do all lasers. I’m anticipating the same trend. I’m actually planning on a launch party open house for my new practice in a few weeks.

Dr. Pearlman: We found an increase in patients asking for stronger treatments, not minding the downtime like they did prior to COVID.

Tracking is key to knowing your audience and successful marketing. The front office staff tracks all lead referrals, procedure inquiries and conversion rates. Given the post-COVID trends in plastic surgery and the acceptance of downtown, we will build campaigns around surgeries, preventative and ongoing maintenance through non-invasive treatments and medical grade skincare.

Dr. Somenek: I think the fall and winter will still continue to be busier months for resurfacing. I am seeing many more of my patients heading back to the office, at least once a week, which is minimizing their flexibility for the downtime luxury that we have gotten used to over the past year and a half. I haven’t adjusted any marketing campaigns specifically for this, as it usually will happen in a very organic manner for our patients.

Dr. Schlesinger: There has been a predictable uptick in more invasive laser procedures during the off-summer-season months, but the COVID-19 pandemic changed this to some degree with the #WFH movement. We have adjusted some of our marketing to target potential patients that are home a lot more, even using direct mail. This might be counterintuitive, but with the decrease in physical mail and people being at home more, our mailings have had more impact than we thought they would.

Dr. Kinney: Even in So Cal, we see an increase in the fall and winter for resurfacing, but just a bit. I would anticipate a slight uptick, but am not currently looking to a marketing campaign.

Dr. Levin: We expect an increase and my RN, who does most of the laser procedures, is booked out a few weeks (which was not the case in the summer). Social media is the primary marketing strategy with advertising fall as the “laser season.” I think the boom will continue, as there has been no change in the past few quarters.