This week in aesthetics, we highlight skincare products for the aesthetics practice, LED therapy for capsular contracture and how to safely treat patients with darker skin types. We compare fat versus filler for facial rejuvenation and Dr. Suneel Chilukuri offers opportunities for patient self-care during the pandemic.

Featured Skincare for The Aesthetic Practice

From new summer launches to consumer favorites, our featured skincare includes sun care products, CBD drops and more.

LED therapy for capsular contracture requires patient commitment, but outcomes are promising.

Use of LED device and milk thistle after surgery may significantly reduce the risk of re-encapsulation.

How to Safely Treat Patients with Darker Skin Types

Dr. Suzan Obagi says she’s not afraid of causing PIH in darker skin types. She offers her expertise and approach to understanding and treating pigmentation issues.

Dr. Obagi’s Skincare Routine for Dyschromia

Ephelides, lentigines, PIH, melasma? This is Dr. Suzan Obagi’s go-to skincare routine for patients with dyschromia.

An expert panel shares how they choose between filler and fat for facial rejuvenation.

Fillers and fat aren’t necessarily mutually exclusive, say experts. Fat is great for global volume, while fat offers finesse.

Dr. Suneel Chilukuri offers observations and opportunities for patient self-care and maintenance during the pandemic.

Articles

In case you missed it, this week we talked about LED therapy for capsular contracture, how to safely treat patients with darker skin types and more. 

This Week in Aesthetics: July 6-10

Part 1: LED Therapy for Capsular Contracture

Two years ago, Dr. Haiavy and his surgical fellow launched a study of about 50 patients. The study has two treatment arms: one of patients that had developed capsular contracture and wanted conservative treatment; the other of patients who failed conservative treatment or were so contracted and uncomfortable that they didn’t want conservative treatment.

“For them, we did the surgery, a capsulectomy, and exchanged the implant. Then we put them on this therapy,” Dr. Haiavy says.

All patients in the study also took milk thistle for its anti-inflammatory and antioxidant properties.

LED therapy for capsular contracture requires patient commitment. The protocol Dr. Haiavy uses is for six weeks of 30-minute daily treatments. If patients can’t do that, Dr. Haiavy recommends no less than three treatments a week for six to twelve weeks. Some patients buy the device and use it at home to avoid having to come to the office, he says.

The results have not yet been published, but Dr. Haiavy says outcomes from the treatment are impressive.

“On the conservative side, without surgery and using this modality, we can basically treat the patients to where they are happy, softer and to a point where they do not want surgery or need surgery 75% of the time,” he says. “On the surgical side 96% of patients on the LED protocol were softer, satisfied and did not need additional surgery or additional treatment.”

The risk of developing capsular contracture is higher among patients who have had their capsules removed previously. Their risk jumps higher with every surgery. At second surgery it rises 15% to 20% and with additional surgery it may go up to 50%, according to Dr. Haiavy.

“With the use of the LED device and milk thistle after surgery, we can reduce the risk of re-encapsulation to less than 5%. That is a significant change,” he says.

Dr. Haiavy says his goal is to convince BioPhotas to sponsor a multicenter, prospective study looking at using Celluma Light Therapy to treat and possibly prevent capsular contracture.

“I’ve read hundreds of capsular contracture studies. It’s so hard to standardize and control the variables. I think that’s why practitioners have a tough time, because it’s not exact science. But I think if we do multicenter prospective study that limits most of the variables and has a protocol, we will have better answers,” he says.

Dr. Haiavy reports no relevant disclosures.

Headon H, Kasem A, Mokbel K. Capsular Contracture after Breast Augmentation: An Update for Clinical Practice. 

https://www.e-aps.org/journal/view.php?doi=10.5999/aps.2015.42.5.532

LED Capsular Contracture Protocol

Capsular contracture remains a concern among breast augmentation and breast reconstruction patients. There’s no gold standard for treating or preventing severe cases.

But cosmetic surgeon Jacob Haiavy, M.D., says he might have stumbled onto a safe and effective way to treat even severe capsular contracture by using noninvasive light therapy. He presented on the topic at the American Academy of Cosmetic Surgery meeting in February 2020. Dr. Haiavy, who practices in Rancho Cucamonga, Calif., recently completed a study using a light-emitting diode (LED) device with infrared, red and blue light (Celluma Light Therapy, BioPhotas). He found the therapy significantly reduced the need for surgery to treat capsular contracture among women who had started to develop capsular contracture after their first breast augmentations, as well as among women who had surgical intervention to treat capsular contracture and started to develop it again.

Breast augmentation is number one among the top five cosmetic surgeries in the U.S., according to the latest statics by The Aesthetic Society. However, in May 2020, The Aesthetic Society reported a nearly 15% decrease in breast augmentations since 2017. That’s while implant explantations rose by 34.4%, according to a Society 

“Overall, patients are very satisfied. I think satisfaction rates run from 95% to 98% in every study that comes out, but it doesn’t mean there are no issues with breast augmentation. I think one of the main problems with breast augmentation ever since the procedure existed is capsular contracture,” Dr. Haiavy says.

Every breast implant patient develops a layer of scar tissue around the implants as a normal part of the body’s defenses and the healing process, according to Dr. Haiavy.

“Usually the scar tissue is very thin and very soft and the implant moves around just like a normal breast and you’re fine. That’s what happens 95% of the time. But 5% of people can form a thick scar that can contract and shrink over the implant over time. It can make the breast feel hard. It can cause pain or discomfort. It can distort the breast,” he says.

It’s not entirely clear why it happens or who is at highest risk. Factors that can trigger capsular contracture include bleeding inside the pocket, an infection or bacteria on the implant surface. Sometimes, trauma years after breast implant surgery.

The FDA has not cleared or approved any devices to treat or reduce the incidence of capsular contracture. And while there is no magic bullet, research suggests some things might help prevent capsular contracture, including how the surgeon does the dissection, use of IV antibiotics prior to surgery, surgical technique, the degree of cauterization, how the surgeon places the implant and more.

“All those things can reduce the bacterial load on the implant and the patient,” Dr. Haiavy says. “I’ve been in practice for almost 20 years now. Breast augmentation is more than 50% of the practice. Our capsular contracture rate is lower than the national average, at about 3.6%. But it’s still a problem when a patient gets it, so we’ve been thinking for years how we can lower the percentage.”

Worldwide rates of capsular contracture vary by study, with reported incidence between 2.8% to 20.4%. The overall incidence is 10.6%, according to a paper published in 2015 in the 

Dr. Haiavy says he heard a physician speak at a meeting about using an LED device to treat lymphedema in breast cancer patients. The physician presented a series of patients, all of whom had capsular contracture.

“He found that when he was using the device close to the breast, in the axilla and the area of the chest, the capsular contracture actually improved. That’s when the lightbulb went off in my head that this might be a possibility,” Dr. Haiavy says.

The infrared wavelength penetrates the muscle and breast tissue. Providers from physical therapists to dermatologists have safely used LED light therapy for many years.

“The blue light is approved for acne. Interestingly there are studies that show that the way the blue light works for acne is by reducing the bacterial load,” he says. “I wondered if blue light also has an effect on the bacterial load on the implant surface and the reduction of growth. The infrared light in combination with that reduces oxidative damage to the muscle and the breast tissue. It helps the cells, specifically the DNA and RNA portion of the cells, to repair themselves faster.”

Dr. Haiavy’s aesthetician already used Celluma Light Therapy for antiaging and other indications. Applying it to the breast would be simple because the device is flexible and conforms to different body surfaces.

“It’s large and has a preset mode at 385 diodes that emit this light for half an hour on its own,” he says. “The practitioner or staff do not have to be in the room.”

He started using the LED device about five years ago on patients at the first indication of implant hardness or stiffness.

“I noticed that over the course of using it that my reoperation rate on capsular contracture had gone down tremendously. The only change that I made in my treatment was adding the light,” he says.

LED therapy for capsular contracture requires patient commitment, but outcomes are promising. 

LED Therapy for Capsular Contracture

No matter which condition the patient has, it is imperative that the skin is prepped properly before any procedure and that the skincare is resumed immediately once the skin has healed from any procedure. My go-to skincare routine for any patient with dyschromia, regardless of skin type is:

An easy way to make sure patients are measuring the products they apply to their skin properly is by instructing them on measuring 1 g, as one finger-tip unit.

The key with the skincare routine is to target the keratinocytes (normalize atypia, increase turnover, make the stratum corneum more hydrated and compact) and the melanocytes (decrease pigment production, normalize melanin distribution to keratinocytes, normalize skin distribution of melanocytes). Thus, each product suggested has a key function to play in improving the condition of the skin.

I hope that this article helps to demystify the pigmentation issues our patients present with and helps physicians feel more comfortable treating patients with darker skin. Treating pigmentation issues in patients with darker skin can be very rewarding for both the physician and the patient. Tread carefully and build your confidence by seeing these patients closely in follow up until you are able to predict the outcomes of your treatments and the patient’s skin response to them.

Dr. Suzan Obagi is recognized as one of the world's most respected cosmetic surgeons and dermatologists. Dr. Obagi is an associate professor of dermatology and associate professor of plastic surgery at the University of Pittsburgh Medical Center and serves as the director of the state-of-the-art UPMC Cosmetic Surgery & Skin Health Centers.

It is not unusual for me to see a patient in consultation for skin concerns only to find out that they were referred by their dermatologist or cosmetic surgeon because of fear of treating their darker skin complexion without risking more pigmentation issues. While I am thankful that the physician referred the patient if they were concerned about treating their skin safely, it makes me wonder how many patients out there are being turned away from treatments based solely upon their skin color.

I think we have been taught, rightfully so, to be concerned about post-inflammatory hyperpigmentation (PIH) when treating darker-skinned patients, but there are steps we can take to prepare the patient’s skin well so that we can safely treat them.

First, let’s look at the difference between ephelides (freckles), lentigines (sunspots), PIH, and melasma. Patients may have a genetic predisposition to forming ephelides, but that gene varies racially. Biopsies show increased pigmentation but not increased melanocytes; however, ephelides have a predilection for sun-exposed skin. This suggests that there is an overproduction of melanin by melanocytes. Solar lentigines, on the other hand, arise in areas where repeated sun exposure induces mutations, resulting in increased melanin production and abnormal pigment retention by the keratinocytes. In these lesions, there is a mild increased number of melanocytes as well as evidence of photodamage in the dermis.

PIH is a temporary overproduction of pigment in response to an epidermal injury or trauma. Usually, this injury is thermal but PIH can be seen in patients that excoriate their skin or that have had inflammatory lesions in the skin. Rarely, severe inflammation can cause melanin to drop into the dermis and to be engulfed by melanophages. PIH is worsened by sun exposure.

Melasma, on the other hand, is a much more complex disorder that may have a genetic predisposition. Melasma arises mostly in women of child-bearing age but it can be seen in men and older women. In melasma, some unknown trigger has induced melanocytes to overproduce and distribute melanin to the keratinocytes. Sometimes, this pigment can drop into the dermis and be taken up by melanophages resulting in dermal melasma. While the trigger may be elusive, there is certainly a link to things that worsen melasma. These include ultraviolet light and certain visible light wavelengths, hormones (pregnancy, oral contraceptives, hormone IUD), and certain topical agents (chemical sunscreens, fragrances and certain botanical agents), heat (spas, saunas, hot yoga, cooking). Once these melanocytes are sensitized and over-produce pigmentation, it is challenging to quiet them down or to clear the melasma fully.

When I see patients with dyschromias, it is important to assess the following:

Diagnosis of condition: ephelides, lentigines, PIH, melasma

Is this strictly epidermal or is there a dermal component?

What has been tried, what has worked and what has failed or worsened the condition?

For melasma, is the patient exposed to exogenous hormones such as oral contraceptives, excessive soy intake or the presence of a hormone IUD?

How motivated the patient is to follow an aggressive skincare regimen?

Patients with ephelides and lentigines can be safely treated with light peels and non-ablative fractionated lasers, Q-switched lasers, and broadband light (BBL). However, the darker the patient’s complexion, the longer I pretreat with a comprehensive skincare regimen before performing any of these treatments. The risk of not doing so is that you will induce PIH during the healing process.

Patients with PIH — the dreaded complication — are actually easy to treat. It may resolve with proper management in one month, three months or six months, but in the end, it all resolves. Patients that develop hyperpigmentation in response to acne or oven burns are at risk for PIH from any face procedure. PIH is not permanent thus it does not scare me if it arises, but I try my utmost best to minimize the risk of PIH and to treat it preemptively. Any patient at risk for PIH should be pretreated with a comprehensive skincare regimen, and once they have healed after a procedure, the patient should quickly resume the topical regimen. If, despite this, PIH develops, the patient must be diagnosed quickly and started on a series of 30% salicylic acid peels at two- to four-week intervals until the PIH resolves. Being more aggressive with peels, or by performing a laser (heat trauma), will only aggravate the condition. Lasers have no role to play in treating PIH.

Melasma is the one condition for which I do not over-promise the results. If the patient has eliminated all their contributing factors (hormones, heat, certain topical agents) and they have used their comprehensive skincare regimen faithfully, epidermal melasma should show considerable improvement by six weeks (one skin cell turnover cycle). If at six weeks the patient is doing well, I then see them back at three months. However, if at six weeks, they are not improved despite using their products correctly, I add light peels to their regimen with 30% salicylic acid every four weeks. At three months, I reassess their skin. If it is considerably improved, I continue the skincare regimen unchanged for one year. The light peels can continue. If the patient is only moderately improved, I might add a non-ablative fractionated laser combined with a salicylic acid peel or Jessner’s solution peel. However, if there is little change at the three-month evaluation, it may indicate that the pigmentation is dermal. If so, I may proceed with a medium-depth trichloroacetic acid (TCA) peel to try to eliminate some of the dermal melanophages. I do not use more than a 24% or 25% concentration TCA peel, as higher concentrations can cause an inflammatory reaction in the skin. Of course, once the patient has healed, they resume their topical skincare regimen immediately. It is important not to let the melasma rebound.

NEXT: Dr. Obagi’s Skincare Routine for Dyschromia