A set of beneficial pearls

For many dermatologists, a “pearl” carries more weight than opinions or words of wisdom. Such pearls are priceless, providing physicians with key insights and positive patient outcomes grounded in real-world clinical experience.

DermWorld Skin Care News recently tapped the expertise of four cosmetic dermatologists who offered their own pearls on hot topics, such as cosmetic assessments, fillers, neurotoxins, and treatment of patients with skin of color.

As far as the eye can see: Pearls for accurate and effective cosmetic assessments

One key to an effective consultation is recognizing and distinguishing fundamental factors that optimize patient outcomes, said Carolyn I. Jacob, MD, FAAD. Her top-three assessment pearls both validate the tried and true and serve as good reminders for often overlooked considerations — and it all begins with a handshake.

1. Palm crease pigmentation: Look at the patient’s hands, Dr. Jacob said. Traditionally, this assessment technique is used to predict post-laser hyperpigmentation risk, but it’s not reliable across all ethnicities.
2. Ricketts E-Line: This facial measurement tool for chin projection remains the gold standard, she said, but it can also be inaccurate for patients with skin of color due to anatomical differences.
3. Submental fat evaluation: This technique requires physical examination to distinguish between fat, skin, and muscle laxity. Dermatologists cannot rely solely on photographs.

Carolyn I. Jacob, MD, FAAD“Pearls must be re-evaluated for different ethnicities. One pearl doesn’t fit all,” said Dr. Jacob, who is founder and director of Chicago Cosmetic Surgery and Dermatology and clinical assistant professor of dermatology at Northwestern Feinberg School of Medicine. “You must also take into consideration different shapes of faces and colors of skin, because those pearls may have been derived from a Caucasian population that has one set of features.”

For example, Dr. Jacob said that if the creases in the palms of a patient’s hands look darker and brown, then that person might be at higher risk for post-inflammatory hyperpigmentation following laser treatments.

“This tells me I should definitely be cautious with this patient when considering lasers or anything with heat, because it could cause some serious issues,” she said. “However, some patients with skin of color lack the palmar crease hyperpigmentation, so it is not a foolproof way to look for safety with laser treatments.”

Beyond the lines: Pearls for neurotoxin treatments

Shraddha Desai, MD, FAADShraddha Desai, MD, FAAD, sees a wide range of patients seeking neurotoxin treatments for aesthetic and therapeutic purposes. Whether the patient wants to soften frown lines or is attempting to prevent signs of aging, neurotoxins play an important role in cosmetic dermatology and even in the treatment of migraine headaches.

“Many patients come in because they’re tired of being told they look angry. Others simply want to look refreshed,” said Dr. Desai, who is a dermatologist at Duly Health and Care in Naperville, Illinois. “For people with ocular or imploding migraines, using neurotoxins to treat the glabella — the area between the brows — can offer real relief.”

Neurotoxins differ by onset time, duration, and protein composition. However, when using these products, Dr. Desai said she relies on these 10 step-by-step pearls to guide her daily practice:

1. Minimize patient discomfort: To achieve this, Dr. Desai uses bacteriostatic saline and ultra-fine 32-gauge needles to reduce stinging.
2. Pinch the muscle: This stabilizes the injection site and distracts the patient.
3. Inject perpendicularly: This helps limit transection of multiple nerve bundles and reduces pain.
4. Mark first: “Even after years of practice, I still mark patients before injecting,” Dr. Desai said.
5. Observe patient expressions: Pay close attention to facial movement to avoid unwanted outcomes, like droopy eyelids in patients who rely on forehead muscles to lift heavy lids.
6. Map the face: Document units and injection sites to ensure consistency and allow for precise adjustments.
7. Treat by area, not by unit: This allows for customized dosing without penalizing patients for requiring more units.
8. Offer follow-up: Dr. Desai invites patients back after two weeks for free touch-ups.
9. Know when to say no: “Education is key,” she said. “If neurotoxins aren’t the right solution, I explain why and offer alternatives.”
10. Measure success by patient loyalty: “Patients who leave for competitive pricing at med spas often come back. That’s how I know I’m doing something right,” Dr. Desai said.

A diverse approach: Pearls for treating patients with skin of color

Rohit Kakar, MD, FAADRohit Kakar, MD, FAAD, is a Michigan- and Indiana-based dermatologist specializing in cosmetic dermatology, hair loss, and medical dermatology, whose passion is getting it right in patients with skin of color.

“By 2044, the United States Census Bureau projects more than 50% of the U.S. population will be of non-white descent,” Dr. Kakar said. “We have seen a steady increase in racial and ethnic diversity of patients seeking minimally invasive cosmetic dermatology procedures​.”

These statistics and Dr. Kakar’s dedication should not be ignored. He was happy to share several cosmetic dermatology pearls that serve as the foundation of his practice.

1. Identify differences in facial morphology compared to European counterparts: There is a wide spectrum of features within race, ethnic, skin type, and gender groups, Dr. Kakar said. It’s important to recognize differences in facial morphology as well as the variations in cultural beauty standards when approaching a patient’s desired result. Patients of color typically have less intrinsic facial aging and less susceptibility to some extrinsic factors. Still, Dr. Kakar emphasized, “Despite these factors, always treat the individual first.”
2. Recognize aging in different populations: In Black patients, aging often appears first in the upper face and jowling is generally less pronounced except for the submental area. In Hispanic patients, common features of aging include increased forehead-glabella supraorbital prominence, superior concavity, and shadowing of the forehead as well as orbital bone resorption and thicker skin, leading to descent of brows and hooding of the eyelids. In Asian patients, consider pigmentation, weaker skeletal facial framework, and heavier malar fat pads, leading to midfacial ptosis and skin redundancy in the lower face.
3. Treat the individual patient: As discussed, facial anatomy, anatomical aging, cultural preferences, and beauty ideals can vary widely between patients with skin of color and differ from westernized standards. Personal preference must help guide selection and administration of soft tissue fillers to aim for ultimate satisfaction from patients of color.
4. Optimize outcomes: Dr. Kakar recommends ways to reduce damage, such as considering use of a cannula, treating multiple areas with one entry point, using smaller-gauge needles or retrograde linear threading/fanning, and being transparent about risk.

“Younger patients with skin of color are increasingly seeking cosmetic procedures,” he said. “It’s essential to recognize how they age and what their aesthetic goals are. Learn from colleagues, attend lectures, and always listen to your patient. That’s how you deliver results that matter.”

Precision over volume: Pearls for filler use and patient safety

Ardalan Minokadeh, MD, PhD, FAADArdalan Minokadeh, MD, PhD, FAAD, a California dermatologist with Skin Care and Laser Physicians of Beverly Hills, said fillers are primarily used to address volume loss due to aging whether from bone resorption or fat depletion.

“We’re strategically volumizing to make the face look less hollow, more lifted, and more youthful,” Dr. Minokadeh said. “Now, we’re also treating a new trend — volume loss due to the use of GLP-1 weight loss medications.”

When done well, fillers should make a person look refreshed, not remodeled, Dr. Minokadeh said. As such, he offered a series of insightful pearls for dermal fillers as well as how physicians can best address growing concerns in the cosmetic dermatology space.

1. Know your products: Understand FDA-approved fillers and their indications and be aware of on-label versus off-label use.
2. Think vector, not volume: Focus on directionality and lift rather than quantity to avoid overfilling.
3. Don’t overlook the temples: Temple hollowing is often undertreated but can dramatically improve facial contour.
4. Rely on best judgment with hyaluronic acid: Consider biostimulatory fillers like calcium-based or poly-L-lactic acid for collagen stimulation and skin texture improvement.
5. Have an undereye strategy: Volumize the lateral cheek and medial cheek before treating the undereye area to achieve better results.
6. Manage complications: Clinicians must be trained to recognize and respond to adverse events, such as vascular occlusion or, in rare cases, vision loss. 

Finally, Dr. Minokadeh reminded colleagues, especially those newer to aesthetic procedures, that fillers are medical treatments requiring anatomical expertise and ongoing education — and he proposed these final safety pearls: 

“Understand danger zones and have a plan for complications,” he said. “Also, stay current with literature and attend professional meetings for maintaining a safe practice.”