Cosmetic procedures: What comes first?

Consider timing and order in multimodal cosmetic procedures.

Professional headshot of dermatologist Shawna A. Flanagan, MD, FAAD.
Shawna A. Flanagan, MD, FAAD

Timing and order are key considerations when delivering multimodal, same-day aesthetic treatments. It also requires a thorough and proper patient evaluation.

That guidance was front and center during the March 8 session, U019 – Multimodal Cosmetic Treatments: What to Combine When and How at the 2024 AAD Annual Meeting in San Diego. Shawna A. Flanagan, MD, FAAD, a dermatologist in Jupiter, Florida, led a panel discussion on various multimodal treatments and the suggested timing for the different combinations. Similarly, the panel discussed laser and light source treatments, particularly skin of color multimodal treatments.

“Combining certain treatments like neurotoxins and lasers the same day helps patients have less down time, possibly less pain because they aren’t getting separate procedures, and helps them save time in their busy schedules,” Dr. Flanagan said.

Lining up the treatments

According to Dr. Flanagan, the order appears to be safe when combining a filler and neurotoxin with either a non-ablative laser, such as IPL, a pulsed dye laser, or a 1927 non-ablative fractional laser. 

“I prefer to do the filler and neurotoxin first as the non-ablative lasers at all these wavelengths have been shown to help with post-injection bruising,” she said. “Also, I would rather do the filler on the epidermis that has not been interrupted by the laser first.”

When doing ablative laser resurfacing, RF microneedling, or any procedure that causes edema and swelling, Dr. Flanagan said she prefers to do the filler and toxin at least two weeks prior to the procedure.   

First things first

As part of a proper evaluation and creating the appropriate multimodal treatment plan, Dr. Flanagan said every patient has unique issues, whether it involves volume loss, etched-in rhytids, pigmentary changes, or rosacea. As such, creating a multimodal treatment plan for a patient must include consideration of these issues, including medical dermatology conditions. Dr. Flanagan said board-certified dermatologists and their patients should work together to create a multimodal plan that incorporates treating their main areas of concern.

“This may sometimes be a six-month plan or longer with ongoing treatments to meet each patient’s needs,” she said.

Additionally, Dr. Flanagan said microbotox can be injected into erythematous rosacea patients the same day they have a vascular laser or an IPL. The patients will get a synergistic effect, which leads to better overall results and control of their rosacea. 

Guide your patients 

Other timing essentials to consider when properly treating patients with various fillers, toxins, lasers, and threads includes acknowledging that timing is a personal preference both by the patient and the physician, Dr. Flanagan said. 

“For example, when I am treating the neck with a neurotoxin and treating the platysmal bands, I prefer to do the neurotoxin first. This is because the hyper-diluted calcium hydroxyapatite used as a biostimulator can anesthetize the patient and they won’t be able to create the movement to show their platysmal bands,” she said. “I also like to do the neurotoxin in the neck prior to injecting the horizontal neck rhytids with hyaluronic acid fillers. Again, I prefer to do the non-ablative laser treatments after the neurotoxin and fillers.”     

There may be division of treatment plans based on anatomical areas as well, Dr. Flanagan said.

Additionally, she reminds dermatologists to assess all aspects of the patient, including the neck, décolletage, and hands. For example, something like filling the chin and jaw line will correct a patient’s cervicomental angle and make their neck look 10 years younger. 

“Many patients have no idea we can do rejuvenating treatments on these body parts and don’t think to ask. As a cosmetic dermatologist and skin expert, it is our role to let patients know what we can do for them,” Dr. Flanagan said. “Discussing what can be done to make our patients’ skin healthier usually leads to patients taking better sun-protective measures, which I think in the long term leads to fewer skin cancers.”