The Power of Combination Treatments

Dermatologists’ favourite combos and a warning about potential unsuccessful combinations contribute to enhancing patient care and achieving desirable aesthetic outcomes in the field of aesthetic medicine.

L-R: Dr Geeta Patel, Dr Sonia Tekchandani, Dr Soma Sarkar, Dr Apratim Goel.

Dermatologists often employ combinations of treatments to address underlying conditions, resulting in higher efficacy in patient care. These synergistic treatment approaches are known to minimize adverse effects and reduce the development of drug resistance. Moreover, in certain cases, combination treatments lead to shorter downtime and faster recuperation after invasive procedures, providing a therapeutic advantage that is highly satisfying to witness.

Dr Apratim Goel, Medical Director, Cutis Skin Solution, aptly compares combination treatment to winning card combos in a game. These treatment combinations target the root cause from multiple angles, delivering the best possible results. Dermatologists utilize a diverse range of combos, including ultrasound technology HIFU, Radiofrequency technique (RF), Cryolipolysis, QS NdYAG Laser (commonly known as Q Switch), various chemical peels, skin polishing, toxin, fillers, biostimulators, and medi-facials to address various conditions.

Below are some of the dermatologists’ favorite combos that yield desired results:

Applauded combinations

Patients demand quick results, preferably minimally invasive, with minimal downtime. Combination treatments come in handy in such situations. Dr Geeta Patel, Dermatologist, Zahra Skin and Laser Clinic, says, «I like to use the Q-switch and booster in the same sitting. It gives vitality to the skin along with brightness. The results are a joy to behold.» Dr Patel also favors using HIFU and fillers spaced apart. Another combination she admires is the original Hydra facial and Q-switch laser. She confirms, “The patients are extremely happy with the result, and some even demand the combination upon seeing the results. There can be some dermal edema after the Q-switch, and vital skin boosters combined with the Q-switch help in breaking the melanin and controlling dermal edema.

Dr Soma Sarkar, Dermatologist and Aesthetic Physician, Dr Soma’s Aesthetic Clinic and Academy, likes to use a Q-switch followed by a glycolic acid or lactic acid peel. She calls it a time-tested combo and a regular treatment in her clinic. “HIFU and bio stimulator in the same session are another combination Dr Sarkar prefers. She also likes using Cosmelan peel followed by bio-stimulators with a gap between the treatments.

Dr Sonia Tekchandani, Consultant Dermatologist, Tender Skin International, prefers RF followed by a toxin in the same setting. She also likes working with pre-bridal treatment followed by a peel. She says that the results are gratifying. She uses salicylic peel for acne-prone skin and lactic acid peel for normal skin, and follows this with photo rejuvenation for the best results. Dr Tekchandani also does peel followed by Q-switch in carbon rejuvenation. She prefers to complete the non-invasive part of the treatment before the invasive part. She says this gives brightness and hydration and reduces uneven skin tones.

Combos to tackle facial hair

Facial hair removal effectiveness depends on the type and thickness of the hair. While any treatment can reduce hair growth and thickness to some extent, it may not work effectively for light hair growth. Dr Tekchandani recommends triple wavelength diodes for medium to thick hair growth, which can significantly reduce hair growth. Further, Dr Sarkar suggests that the Q-switch treatment works well for fine hair growth. After multiple Q-switch sessions, hair growth is considerably lessened.

Double chin reduction

The development of a double chin can have multiple causes, such as standalone submental fat, laxity from weight loss, or a redundant chin. Neck bands may also accompany a double chin. To address laxity, MNRF and HIFU are effective treatments. Threads can be used to lift the chin, providing one of the best solutions for dealing with laxity.

Standalone submental fat can be targeted with PPC injection lipolysis, sometimes in combination with deoxycholic acid (DCA). The combination yields good results. Injecting the solution below the mandible with a long needle is recommended, with 3 to 4 mg as the usual dosage for each sitting. Typically, three sittings are required to achieve the desired results.

Dr Goel suggests an alternative method of injecting the solution using a 100 mm cannula below the bone, holding the skin in a stretched head position. While this process can be painful, the carnitine in the chin helps with PPC and delivers good results.

For a redundant chin, fillers work well. To address neck bands, toxins can be used to lift the skin with the help of threads, resulting in an appealing outcome.

Loose skin on face and body

This is a common concern for clients, often resulting from significant weight loss or aging. A proven and time-tested method to address this issue is a combination of different threads to lift the skin. However, for those on a budget, RF can provide sufficient results.

For body skin, the combination of cryo lipolysis with cigs and monofilament threads is highly effective. Alternatively, HIFU at a depth of no more than 7 mm, combined with 10 to 12 threads in the outer quadrant of the body and mono fillers in the center, can yield excellent results. Hip dips can be easily resolved using fillers, while PMLA and floating threads have gained popularity among practitioners.

Under eye treatment

Patients often seek treatments for hollowed under eyes, eye bags, and dark circles. Pigmentation issues can be addressed with a Q-switch laser along with lactic acid, arginine, or retinol peel. To combat volume loss, fillers and toxins combined with HIFU for tightening can be employed.

Treating eye bags can be approached in various ways. Dr Sarkar suggests that surgery is an option, but if not, HIFU combined with fillers in two to three sessions spaced 15 days apart can achieve the desired results. Dr Patel praises the use of plasma pen, with two sessions set three months apart providing delightful results with no downtime. She administers topical anesthesia, and fillers are added after the procedure for excellent results.

Dr Tekchandani prefers supporting under-eye area with supraperiosteal, as the eye is a delicate area where she avoids direct contact. She utilises the cheek muscle to complete the procedure.

Dr Goel emphasises the remarkable results achieved for undereye bags and double chin using injectables administered through a cannula.

Hair loss treatment

Hair loss can be attributed to various factors such as long illness, lowered immunity, and inflammatory conditions. PRP is effective in curbing hair loss, but it may cause some initial inflammation. Dr Sarkar emphasises the importance of stabilising patients and understanding their condition before initiating hair-vitalising solutions. A course of multivitamins proves helpful, followed by minoxidil medication after two months and PRO after three to four months. Although a longer process, it yields fruitful results. Mesotherapy and QR678 is also effective in arresting hair loss.

Amyloidosis and Keratosis Pilaris treatment

Amyloidosis and Keratosis Pilaris present challenges for aesthetic medicine practitioners, as promising aesthetic outcomes can be difficult to achieve. Counseling plays a crucial role in managing patients with these conditions.

For Keratosis Pilaris patients, the application of moisturiser with lactic acid and urea can gradually smoothen and hydrate the skin. In some cases, Q switches and hair removal lasers may be helpful. Dr Tekchandani occasionally uses a hair removal laser with retinol peel and low-dose oral medication. Dr Sarkar believes that TCA and lightening agents also contribute to improving appearance.

Beware of these combos!

While combination treatments can be effective, some combinations may yield no results or even scary outcomes. Medicine involves a healthy amount of knowledge and experimentation to advance, and not all combinations work as expected.

Dr Patel cautions against following HIFU immediately with filler, as the filler might evaporate. A gap of 10 to 12 weeks between the procedures is necessary for fruitful results.

Dr Sarkar noticed that fractional CO2 lasers followed immediately by PRP injections cause significant swelling, inflammation, and soreness. The recovery period can be long and daunting for the patient. Dr Goel adds that using Fractional CO2 after an intense treatment, with a lot of heat (10,600 nm) and blood coagulation, is not advised.

Even proven combinations can sometimes yield unsatisfactory results in unique cases. The human body is complex, and no procedure can be foolproof.

Hence, multiple modalities in combination treatments work wonders in aesthetic medicine. A happy customer is everything in this field, and these combination treatments lead to that happy, glowing smile!

(The above insights were gathered from a panel discussion at the recently concluded Aesthetic Medicine Conference in Mumbai.)