A review of the literature and tips on which combinations will benefit your patients most.
Dermatologists and other cosmetic surgeons have the luxury of a number of wonderful products and devices available to them that can be used to enhance the appearance of and to rejuvenate the skin of our patients. Each of these modalities works very well on its own and clinical trials and personal experience from many will attest to the efficacy of these treatment options, but many adhere to the premise that combination therapy works even better when the proper device(s) is utilized along with the current group of dermal fillers and toxins available to us. It is the purpose of this article to review the clinical data with regard to combination therapy and then to show some clinical examples from a busy cosmetic dermatologic practice that demonstrate how combination therapy can work well with patients in your clinical practice. It is often noted that the cosmetic revolution we have all witnessed over the past decade can be attributed to the approval of botulinum toxin type A (Botox Cosmetic). Botox has resulted in more and more individuals seeking cosmetic surgery and making them aware of the myriad choices that we have in our armamentarium for the rejuvenation or improvement in the skin. According to the American Society of Plastic Surgeons (ASPS), our patients spent more than $12 billion in 2007 on cosmetic procedures, with “nonsurgical” procedures making up 83% of these procedures.1 Since 1997, the ASPS surveys have indicated that the total number of “nonsurgical” procedures has increased by 747%,1 an incredible number that translates into patients coming into your office asking about and wanting these nonsurgical choices — toxins, fillers and energy-based systems. Furthermore, statistics from the American Society for Dermatologic Surgery published in 2007, indicated that “skin lifting” procedures were up by 240% between 2005 and 2007. In addition, toxin injections and filler procedures were up by 130%, and non-ablative skin rejuvenation procedures increased by 110%.2 From these figures and the increase in new devices from our laser companies appearing on our radar screens with increasing frequency, there seems to be no end in sight for this trend. The Effectiveness of Botox-IPL Botox Cosmetic changed the face of cosmetic dermatologic surgery, and its safety and efficacy has been documented in numerous publications over these many years since its FDA approval in 2002.3-5 Botox Cosmetic is FDA approved for the temporary improvement in glabellar furrows, but it has been utilized “off-label” for many years by many skilled clinicians in relaxing muscles associated with the crow’s feet, horizontal forehead lines, periroal area and neck, to name just a few of its incredible uses. An example of the use of Botox Cosmetic is shown in Figure 1. In 2004, Carruthers et al6 published an important manuscript in which it was demonstrated that, when used in combination with the intense pulsed light (IPL) source, Botox enhanced the effects of the IPL alone by 15%, and the Botox-IPL combination showed an increase in efficacy in the reduction of pore size by 30%. It was felt that from this study that there was a previously unappreciated effect of Botox on the presynaptic network and other autonomic systems involved in facial aging, including the vascular system. Many have since utilized Botox Cosmetic in combination with the IPL as we have witnessed this effect in clinical practice time and time again. The Available Fillers Soft tissue augmentation is also on the increase in the United States. It has been suggested that only 1% to 2% of women in the United States have had a dermal filler and that more than 20% or more have indicated their interest in such a procedure.7 The number of dermal fillers currently available in the United States continues to rise. These include the hyaluronic acids Restylane and Perlane, Juvederm Ultra and Juvederm Ultra Plus, Elevess and Prevelle Silk. Elevess and Prevelle Silk are hyaluronic acids that also contain lidocaine, which may be beneficial to our patients in reducing the discomfort, which, at times, can be associated with these types of injections. Other hyaluronic acids with lidocaine are currently undergoing FDA evaluation and likely will be available to us shortly. Restylane and Juvederm injections — examples of which are shown in Figures 2 and 3 — have become the fillers of choice for most cosmetic surgeons utilizing dermal implants. Clinical trials showing their safety and efficacy have been published.8,9 Sculptra, or poly-L-lactic acid, is available for volume filling; and is currently FDA-approved for volumetric filling in those with HIV and associated lipoatrophy.10 An example of Sculptra injections is shown in Figure 4. Clinical trials for cosmetic use of Sculptra are underway, and it seems apparent that we will have this indication in the near future. Radiesse, or calcium hydroxyapetite, has found an increase in its use over the past several years. It has been shown to be safe, effective and long lasting (upwards to a year or more) in many individuals.11,12 An example of Radiesse is shown in Figure 5. Now we have Evolence, a collagen product that is porcine collagen associated with ribose sugar cross-linking to add to its longevity. Skin testing with this collagen is not required and clinical trials have shown its effectiveness in longevity, with most patients receiving at least a 1-year response with these injections.13,14 A clinical example of Evolence is shown in Figure 6. And finally, ArteFill, a semi-permanent filler made up of PMMA beads and collagen. Clinical trials have shown its usefulness and safety, including data showing efficacy at 5 years.15,16 An example of ArteFill is shown in Figure 7. Each of these products has its own unique characteristics and has made its own contributions to the field of dermal fillers. It is beyond the scope of this discussion to thoroughly review all of the clinical trials that led to their FDA approvals; but suffice to say, each one has its own virtues in the dermal filler world, and each can be used or in combination with other modalities. Combining Botox and Fillers After the successful work of Carruthers et al7 in the treatment utilization of Botox Cosmetic and the IPL, they also looked at the use of Botox Cosmetic in combination with Restylane, one of the first of the hyaluronic acid products available in the United States. Thirty eight women with severe glabellar furrows were randomized to receive Restylane treatment alone or Restylane plus Botox Cosmetic. The study showed that those who received combination therapy had a better response at rest and at maximum frown compared to those receiving Restylane alone. The time frame to return to baseline in these patients was 18 weeks with Restylane alone and 32 weeks for those who received the combination of Restylane and Botox Cosmetic.17 Fillers and Skin Tightening Many patients are interested in dermal fillers and in skin tightening procedures. These skin tightening procedures usually consist of radiofrequency (RF) devices — monopolar, unipolar or bipolar in nature, all of which have shown efficacy in skin tightening. Non-ablative and ablative fractional resurfacing devices also have been used successfully for skin tightening. Skin tightening procedures have been on a large upswing, as has been previously indicated and as newer and safer devices continue to enter the market, there will continue to be an increase in these procedures. On occasion, patients will benefit from having both skin tightening procedures as well as dermal fillers, but questions remain about what would happen if the RF procedure were performed over the dermal filler. Several recent reviews have addressed this question, some in animal models and some in human subjects. The first, by England et al,18 looked at five different fillers on the market. The study compared treatment with the fillers alone to treatment with monopolar RF over the fillers in a pig model. In this clinical trial, there were no effects observed on the persistence of the dermal fillers over a period of 4 months, and fibroplasia and collagen deposition was seen surrounding the implants after the RF procedure, more than that seen with the implants alone. A second study, by Shumaker et al,19 examined the inflammatory response following the placement of dermal fillers and then monopolar RF treatment. They found a predictable inflammatory response, foreign body reaction and fibrotic response with the RF treatment, with no appreciable changes in the dermal implants. Alam et al20 looked at a similar approach in human subjects after they received either hyaluronic acid or calcium hydroxyapetite followed by treatment with monopolar RF skin tightening device 2 weeks later. Histological examination following the monopolar RF treatment showed no differences compared to controls in effect to the dermal filler as a result of the RF treatment. This was further confirmed by Goldman et al,21 in which 36 individuals were treated with hyaluronic acid in the nasolabial folds and then one of those folds was treated with one of the following energy-based systems: 1320-nm Nd:YAG laser, 1450-nm diode laser, monopolar RF or IPL. Wrinkle severity scales and global assessments showed no statistical differences and there were no differences noted under histologic examination. These studies have confirmed that dermal fillers and energy-based systems can be used together and that they may have a synergistic effect when the dermal fillers are utilized first, followed by the skin tightening or other laser/light source procedure. The Wave of the Future Based on the literature and experience in practice, dermatologists should feel comfortable utilizing toxins, dermal fillers and energy-based systems to improve the appearance of patients’ skin. Combination therapy has been promoted at numerous cosmetic meetings as being the wave of the future; with the current literature supporting this and our own clinical prowess, many of us truly believe in combination therapy, as demonstrated in Figures 8 and 9. Dr. Gold is Medical Director of Gold Skin Care Center and Tennessee Clinical Research Center. He is Clinical Assistant Professor, Department of Medicine, Department of Dermatology, Vanderbilt University School of Medicine, Vanderbilt University School of Nursing, Nashville, TN. Dr. Gold is also Visiting Professor of Dermatology at Huashan Hospital, Fudan University, Beijing, China. Disclosure: Dr. Gold is a consultant for Medicis and OrthoNeutrogena, speaks and performs research on their behalf and receives honoraria and research grants. Dr. Gold performs research on behalf of Artes Medical and Allergan. Dr. Gold is also consultant to Lumenis and Alma Lasers.
A review of the literature and tips on which combinations will benefit your patients most.
Dermatologists and other cosmetic surgeons have the luxury of a number of wonderful products and devices available to them that can be used to enhance the appearance of and to rejuvenate the skin of our patients. Each of these modalities works very well on its own and clinical trials and personal experience from many will attest to the efficacy of these treatment options, but many adhere to the premise that combination therapy works even better when the proper device(s) is utilized along with the current group of dermal fillers and toxins available to us. It is the purpose of this article to review the clinical data with regard to combination therapy and then to show some clinical examples from a busy cosmetic dermatologic practice that demonstrate how combination therapy can work well with patients in your clinical practice. It is often noted that the cosmetic revolution we have all witnessed over the past decade can be attributed to the approval of botulinum toxin type A (Botox Cosmetic). Botox has resulted in more and more individuals seeking cosmetic surgery and making them aware of the myriad choices that we have in our armamentarium for the rejuvenation or improvement in the skin. According to the American Society of Plastic Surgeons (ASPS), our patients spent more than $12 billion in 2007 on cosmetic procedures, with “nonsurgical” procedures making up 83% of these procedures.1 Since 1997, the ASPS surveys have indicated that the total number of “nonsurgical” procedures has increased by 747%,1 an incredible number that translates into patients coming into your office asking about and wanting these nonsurgical choices — toxins, fillers and energy-based systems. Furthermore, statistics from the American Society for Dermatologic Surgery published in 2007, indicated that “skin lifting” procedures were up by 240% between 2005 and 2007. In addition, toxin injections and filler procedures were up by 130%, and non-ablative skin rejuvenation procedures increased by 110%.2 From these figures and the increase in new devices from our laser companies appearing on our radar screens with increasing frequency, there seems to be no end in sight for this trend. The Effectiveness of Botox-IPL Botox Cosmetic changed the face of cosmetic dermatologic surgery, and its safety and efficacy has been documented in numerous publications over these many years since its FDA approval in 2002.3-5 Botox Cosmetic is FDA approved for the temporary improvement in glabellar furrows, but it has been utilized “off-label” for many years by many skilled clinicians in relaxing muscles associated with the crow’s feet, horizontal forehead lines, periroal area and neck, to name just a few of its incredible uses. An example of the use of Botox Cosmetic is shown in Figure 1. In 2004, Carruthers et al6 published an important manuscript in which it was demonstrated that, when used in combination with the intense pulsed light (IPL) source, Botox enhanced the effects of the IPL alone by 15%, and the Botox-IPL combination showed an increase in efficacy in the reduction of pore size by 30%. It was felt that from this study that there was a previously unappreciated effect of Botox on the presynaptic network and other autonomic systems involved in facial aging, including the vascular system. Many have since utilized Botox Cosmetic in combination with the IPL as we have witnessed this effect in clinical practice time and time again. The Available Fillers Soft tissue augmentation is also on the increase in the United States. It has been suggested that only 1% to 2% of women in the United States have had a dermal filler and that more than 20% or more have indicated their interest in such a procedure.7 The number of dermal fillers currently available in the United States continues to rise. These include the hyaluronic acids Restylane and Perlane, Juvederm Ultra and Juvederm Ultra Plus, Elevess and Prevelle Silk. Elevess and Prevelle Silk are hyaluronic acids that also contain lidocaine, which may be beneficial to our patients in reducing the discomfort, which, at times, can be associated with these types of injections. Other hyaluronic acids with lidocaine are currently undergoing FDA evaluation and likely will be available to us shortly. Restylane and Juvederm injections — examples of which are shown in Figures 2 and 3 — have become the fillers of choice for most cosmetic surgeons utilizing dermal implants. Clinical trials showing their safety and efficacy have been published.8,9 Sculptra, or poly-L-lactic acid, is available for volume filling; and is currently FDA-approved for volumetric filling in those with HIV and associated lipoatrophy.10 An example of Sculptra injections is shown in Figure 4. Clinical trials for cosmetic use of Sculptra are underway, and it seems apparent that we will have this indication in the near future. Radiesse, or calcium hydroxyapetite, has found an increase in its use over the past several years. It has been shown to be safe, effective and long lasting (upwards to a year or more) in many individuals.11,12 An example of Radiesse is shown in Figure 5. Now we have Evolence, a collagen product that is porcine collagen associated with ribose sugar cross-linking to add to its longevity. Skin testing with this collagen is not required and clinical trials have shown its effectiveness in longevity, with most patients receiving at least a 1-year response with these injections.13,14 A clinical example of Evolence is shown in Figure 6. And finally, ArteFill, a semi-permanent filler made up of PMMA beads and collagen. Clinical trials have shown its usefulness and safety, including data showing efficacy at 5 years.15,16 An example of ArteFill is shown in Figure 7. Each of these products has its own unique characteristics and has made its own contributions to the field of dermal fillers. It is beyond the scope of this discussion to thoroughly review all of the clinical trials that led to their FDA approvals; but suffice to say, each one has its own virtues in the dermal filler world, and each can be used or in combination with other modalities. Combining Botox and Fillers After the successful work of Carruthers et al7 in the treatment utilization of Botox Cosmetic and the IPL, they also looked at the use of Botox Cosmetic in combination with Restylane, one of the first of the hyaluronic acid products available in the United States. Thirty eight women with severe glabellar furrows were randomized to receive Restylane treatment alone or Restylane plus Botox Cosmetic. The study showed that those who received combination therapy had a better response at rest and at maximum frown compared to those receiving Restylane alone. The time frame to return to baseline in these patients was 18 weeks with Restylane alone and 32 weeks for those who received the combination of Restylane and Botox Cosmetic.17 Fillers and Skin Tightening Many patients are interested in dermal fillers and in skin tightening procedures. These skin tightening procedures usually consist of radiofrequency (RF) devices — monopolar, unipolar or bipolar in nature, all of which have shown efficacy in skin tightening. Non-ablative and ablative fractional resurfacing devices also have been used successfully for skin tightening. Skin tightening procedures have been on a large upswing, as has been previously indicated and as newer and safer devices continue to enter the market, there will continue to be an increase in these procedures. On occasion, patients will benefit from having both skin tightening procedures as well as dermal fillers, but questions remain about what would happen if the RF procedure were performed over the dermal filler. Several recent reviews have addressed this question, some in animal models and some in human subjects. The first, by England et al,18 looked at five different fillers on the market. The study compared treatment with the fillers alone to treatment with monopolar RF over the fillers in a pig model. In this clinical trial, there were no effects observed on the persistence of the dermal fillers over a period of 4 months, and fibroplasia and collagen deposition was seen surrounding the implants after the RF procedure, more than that seen with the implants alone. A second study, by Shumaker et al,19 examined the inflammatory response following the placement of dermal fillers and then monopolar RF treatment. They found a predictable inflammatory response, foreign body reaction and fibrotic response with the RF treatment, with no appreciable changes in the dermal implants. Alam et al20 looked at a similar approach in human subjects after they received either hyaluronic acid or calcium hydroxyapetite followed by treatment with monopolar RF skin tightening device 2 weeks later. Histological examination following the monopolar RF treatment showed no differences compared to controls in effect to the dermal filler as a result of the RF treatment. This was further confirmed by Goldman et al,21 in which 36 individuals were treated with hyaluronic acid in the nasolabial folds and then one of those folds was treated with one of the following energy-based systems: 1320-nm Nd:YAG laser, 1450-nm diode laser, monopolar RF or IPL. Wrinkle severity scales and global assessments showed no statistical differences and there were no differences noted under histologic examination. These studies have confirmed that dermal fillers and energy-based systems can be used together and that they may have a synergistic effect when the dermal fillers are utilized first, followed by the skin tightening or other laser/light source procedure. The Wave of the Future Based on the literature and experience in practice, dermatologists should feel comfortable utilizing toxins, dermal fillers and energy-based systems to improve the appearance of patients’ skin. Combination therapy has been promoted at numerous cosmetic meetings as being the wave of the future; with the current literature supporting this and our own clinical prowess, many of us truly believe in combination therapy, as demonstrated in Figures 8 and 9. Dr. Gold is Medical Director of Gold Skin Care Center and Tennessee Clinical Research Center. He is Clinical Assistant Professor, Department of Medicine, Department of Dermatology, Vanderbilt University School of Medicine, Vanderbilt University School of Nursing, Nashville, TN. Dr. Gold is also Visiting Professor of Dermatology at Huashan Hospital, Fudan University, Beijing, China. Disclosure: Dr. Gold is a consultant for Medicis and OrthoNeutrogena, speaks and performs research on their behalf and receives honoraria and research grants. Dr. Gold performs research on behalf of Artes Medical and Allergan. Dr. Gold is also consultant to Lumenis and Alma Lasers.
A review of the literature and tips on which combinations will benefit your patients most.
Dermatologists and other cosmetic surgeons have the luxury of a number of wonderful products and devices available to them that can be used to enhance the appearance of and to rejuvenate the skin of our patients. Each of these modalities works very well on its own and clinical trials and personal experience from many will attest to the efficacy of these treatment options, but many adhere to the premise that combination therapy works even better when the proper device(s) is utilized along with the current group of dermal fillers and toxins available to us. It is the purpose of this article to review the clinical data with regard to combination therapy and then to show some clinical examples from a busy cosmetic dermatologic practice that demonstrate how combination therapy can work well with patients in your clinical practice. It is often noted that the cosmetic revolution we have all witnessed over the past decade can be attributed to the approval of botulinum toxin type A (Botox Cosmetic). Botox has resulted in more and more individuals seeking cosmetic surgery and making them aware of the myriad choices that we have in our armamentarium for the rejuvenation or improvement in the skin. According to the American Society of Plastic Surgeons (ASPS), our patients spent more than $12 billion in 2007 on cosmetic procedures, with “nonsurgical” procedures making up 83% of these procedures.1 Since 1997, the ASPS surveys have indicated that the total number of “nonsurgical” procedures has increased by 747%,1 an incredible number that translates into patients coming into your office asking about and wanting these nonsurgical choices — toxins, fillers and energy-based systems. Furthermore, statistics from the American Society for Dermatologic Surgery published in 2007, indicated that “skin lifting” procedures were up by 240% between 2005 and 2007. In addition, toxin injections and filler procedures were up by 130%, and non-ablative skin rejuvenation procedures increased by 110%.2 From these figures and the increase in new devices from our laser companies appearing on our radar screens with increasing frequency, there seems to be no end in sight for this trend. The Effectiveness of Botox-IPL Botox Cosmetic changed the face of cosmetic dermatologic surgery, and its safety and efficacy has been documented in numerous publications over these many years since its FDA approval in 2002.3-5 Botox Cosmetic is FDA approved for the temporary improvement in glabellar furrows, but it has been utilized “off-label” for many years by many skilled clinicians in relaxing muscles associated with the crow’s feet, horizontal forehead lines, periroal area and neck, to name just a few of its incredible uses. An example of the use of Botox Cosmetic is shown in Figure 1. In 2004, Carruthers et al6 published an important manuscript in which it was demonstrated that, when used in combination with the intense pulsed light (IPL) source, Botox enhanced the effects of the IPL alone by 15%, and the Botox-IPL combination showed an increase in efficacy in the reduction of pore size by 30%. It was felt that from this study that there was a previously unappreciated effect of Botox on the presynaptic network and other autonomic systems involved in facial aging, including the vascular system. Many have since utilized Botox Cosmetic in combination with the IPL as we have witnessed this effect in clinical practice time and time again. The Available Fillers Soft tissue augmentation is also on the increase in the United States. It has been suggested that only 1% to 2% of women in the United States have had a dermal filler and that more than 20% or more have indicated their interest in such a procedure.7 The number of dermal fillers currently available in the United States continues to rise. These include the hyaluronic acids Restylane and Perlane, Juvederm Ultra and Juvederm Ultra Plus, Elevess and Prevelle Silk. Elevess and Prevelle Silk are hyaluronic acids that also contain lidocaine, which may be beneficial to our patients in reducing the discomfort, which, at times, can be associated with these types of injections. Other hyaluronic acids with lidocaine are currently undergoing FDA evaluation and likely will be available to us shortly. Restylane and Juvederm injections — examples of which are shown in Figures 2 and 3 — have become the fillers of choice for most cosmetic surgeons utilizing dermal implants. Clinical trials showing their safety and efficacy have been published.8,9 Sculptra, or poly-L-lactic acid, is available for volume filling; and is currently FDA-approved for volumetric filling in those with HIV and associated lipoatrophy.10 An example of Sculptra injections is shown in Figure 4. Clinical trials for cosmetic use of Sculptra are underway, and it seems apparent that we will have this indication in the near future. Radiesse, or calcium hydroxyapetite, has found an increase in its use over the past several years. It has been shown to be safe, effective and long lasting (upwards to a year or more) in many individuals.11,12 An example of Radiesse is shown in Figure 5. Now we have Evolence, a collagen product that is porcine collagen associated with ribose sugar cross-linking to add to its longevity. Skin testing with this collagen is not required and clinical trials have shown its effectiveness in longevity, with most patients receiving at least a 1-year response with these injections.13,14 A clinical example of Evolence is shown in Figure 6. And finally, ArteFill, a semi-permanent filler made up of PMMA beads and collagen. Clinical trials have shown its usefulness and safety, including data showing efficacy at 5 years.15,16 An example of ArteFill is shown in Figure 7. Each of these products has its own unique characteristics and has made its own contributions to the field of dermal fillers. It is beyond the scope of this discussion to thoroughly review all of the clinical trials that led to their FDA approvals; but suffice to say, each one has its own virtues in the dermal filler world, and each can be used or in combination with other modalities. Combining Botox and Fillers After the successful work of Carruthers et al7 in the treatment utilization of Botox Cosmetic and the IPL, they also looked at the use of Botox Cosmetic in combination with Restylane, one of the first of the hyaluronic acid products available in the United States. Thirty eight women with severe glabellar furrows were randomized to receive Restylane treatment alone or Restylane plus Botox Cosmetic. The study showed that those who received combination therapy had a better response at rest and at maximum frown compared to those receiving Restylane alone. The time frame to return to baseline in these patients was 18 weeks with Restylane alone and 32 weeks for those who received the combination of Restylane and Botox Cosmetic.17 Fillers and Skin Tightening Many patients are interested in dermal fillers and in skin tightening procedures. These skin tightening procedures usually consist of radiofrequency (RF) devices — monopolar, unipolar or bipolar in nature, all of which have shown efficacy in skin tightening. Non-ablative and ablative fractional resurfacing devices also have been used successfully for skin tightening. Skin tightening procedures have been on a large upswing, as has been previously indicated and as newer and safer devices continue to enter the market, there will continue to be an increase in these procedures. On occasion, patients will benefit from having both skin tightening procedures as well as dermal fillers, but questions remain about what would happen if the RF procedure were performed over the dermal filler. Several recent reviews have addressed this question, some in animal models and some in human subjects. The first, by England et al,18 looked at five different fillers on the market. The study compared treatment with the fillers alone to treatment with monopolar RF over the fillers in a pig model. In this clinical trial, there were no effects observed on the persistence of the dermal fillers over a period of 4 months, and fibroplasia and collagen deposition was seen surrounding the implants after the RF procedure, more than that seen with the implants alone. A second study, by Shumaker et al,19 examined the inflammatory response following the placement of dermal fillers and then monopolar RF treatment. They found a predictable inflammatory response, foreign body reaction and fibrotic response with the RF treatment, with no appreciable changes in the dermal implants. Alam et al20 looked at a similar approach in human subjects after they received either hyaluronic acid or calcium hydroxyapetite followed by treatment with monopolar RF skin tightening device 2 weeks later. Histological examination following the monopolar RF treatment showed no differences compared to controls in effect to the dermal filler as a result of the RF treatment. This was further confirmed by Goldman et al,21 in which 36 individuals were treated with hyaluronic acid in the nasolabial folds and then one of those folds was treated with one of the following energy-based systems: 1320-nm Nd:YAG laser, 1450-nm diode laser, monopolar RF or IPL. Wrinkle severity scales and global assessments showed no statistical differences and there were no differences noted under histologic examination. These studies have confirmed that dermal fillers and energy-based systems can be used together and that they may have a synergistic effect when the dermal fillers are utilized first, followed by the skin tightening or other laser/light source procedure. The Wave of the Future Based on the literature and experience in practice, dermatologists should feel comfortable utilizing toxins, dermal fillers and energy-based systems to improve the appearance of patients’ skin. Combination therapy has been promoted at numerous cosmetic meetings as being the wave of the future; with the current literature supporting this and our own clinical prowess, many of us truly believe in combination therapy, as demonstrated in Figures 8 and 9. Dr. Gold is Medical Director of Gold Skin Care Center and Tennessee Clinical Research Center. He is Clinical Assistant Professor, Department of Medicine, Department of Dermatology, Vanderbilt University School of Medicine, Vanderbilt University School of Nursing, Nashville, TN. Dr. Gold is also Visiting Professor of Dermatology at Huashan Hospital, Fudan University, Beijing, China. Disclosure: Dr. Gold is a consultant for Medicis and OrthoNeutrogena, speaks and performs research on their behalf and receives honoraria and research grants. Dr. Gold performs research on behalf of Artes Medical and Allergan. Dr. Gold is also consultant to Lumenis and Alma Lasers.
