Botulinum Toxin Therapies

Botulinum toxin was approved by FDA (Food and Drug Administration) in 1989 for treatment of neurologic diseases and it has been used for many diseases since then. It was approved for cosmetic use in 2002 and treatment of hyperhydrosis (abnormal sweating) in 2004.   Being commonly used in cosmetic dermatology since then, Botulinum toxin therapies was approved by FDA for treatment of wrinkles in forehead in 2017.
There are various toxins produced by Clostridium botulinum. Botox includes botulinum toxin type A. It acts by inhibiting the transfer of stimuli from nervous cells to the muscle. Therefore, excessive contraction of the muscle is prevented and the existing lines on skin are eliminated. The effect starts 3 to 4 days after the injection and reaches maximum level in 14 days.

The toxin remains in the muscle it is injected and it slowly fades away. It is acknowledged that the toxin does not migrate to other parts of body when applied to the correct body part at correct doses. Side effects are, therefore, quite rare. No systemic side effect, or in other words, any side effect secondary to Botox injection that affects others organs has been seen to date. Dermal side effects are rare and they disappear within several hours.

The potential side effects are headache, mild edema and bruising. Bruising may last for a few days. The effect of the procedure lasts for 4 to 6 months on average. Duration of the effect is subject to interpersonal variations.
The personnel who administer the botulinum toxin should have been well educated on muscle anatomy and skin structure. The most common intended use involves the lines between eyebrows, crow’s feet, wrinkles on forehead, lines above the lip, wrinkles on the neck and marionette lines.

It is also an effective therapy method for abnormal sweating (hyperhidrosis) in armpit, palm and feet. The hyperhidrosis area can be determined with iodine test before the injection and skin injections are performed at certain intervals -50 units for each armpit.

Toxin should be administered in cases of neuromuscular diseases, Botox allergy, pregnancy, breastfeeding and any dermatologic disease in the injection site.

The physician and the patient should discuss realistic expectations; targeted muscles and injection sites should be determined in advance. Necessary precautions should be taken for infection risk throughout the procedure. Treatment by an experienced dermatologist in a suitable environment is a must for an efficient therapy without any side effects. Outcomes can be more permanent with repeated applications.
 

Fillers

Fillers have been used to correct deep facial wrinkles and deformities and also for their anti-aging effects for almost 30 years. Moreover, the method is very effective for dorsal hand rejuvenation.

Following a dermatologic assessment, a personalized practice scheme is formed and the filling material is selected. There are many filling materials available on the market. It is preferred that the filling material to be used is approved by FDA (Food and Drug Administration). Filling materials can be autologous, synthetic or biological. The products that contain hyaluronic acid, hydroxyapatite, polymethylmethacrylate and silicone can be used. Hyaluronic acid is the most important glycosaminoglycan of the skin. When injected to the skin, it expands, softens and moistens the skin. In addition to these effects, it helps cellular growth. Restylane was approved by FDA as a source of hyaluronic acid in 2003. The material is long acting and has minimal risk of side-effect; it is easy to use, ready-to-use and does not require a skin test before the application. It can be administered with serial puncture, tunnel, fan and cross-sweeping techniques using a needle or cannula. Filling materials can be injected into the skin, beneath the skin or onto the bone. Pain is alleviated with anesthetic creams beforehand and redness and edema are prevented by applying cold pack after the procedure.

Selection of technique and product for a certain patient is dictated by anatomic features, ingredients of filling material, application site and experience of physician. Personal characteristics and structure of filling are the main factors that influence duration of the effect. Natural outcomes that should be the fundamental element of all cosmetic procedures should also be targeted for this therapy. Physician and patient should discuss the potential unwanted side effects. The therapy should aim the most optimal cosmetic result without sacrificing the natural appearance.
 

Chemical Peeling

Peeling is the procedure of applying various chemicals on the skin to peel off the superficial layers. The procedure is used for spots, superficial and deep acne scars, symptoms of aging due to exposure to sun, fine wrinkles and large pores. Regular and repeated applications are necessary for positive outcomes.

Various solutions such as alpha hydroxy acid, glycolic acid, lactic acid, bicarboxylic acid, malic acid, citric acid, beta hydroxy acid (salicylic acid), trichloracetic acid, alpha-keto acids (pyruvic acid), retinoic acid and resorcinol can be used for peeling. In addition, mixtures of salicylic acid, lactic acid, ethanol and resorcinol, called Jessner Solution, are also available. Phenol is a compound used for deep peeling. Peeling solution is selected by the physician according to skin features of the patient and targeted depth.

Face is cleaned before the therapy. Peeling is performed and the target site is wiped with neutralizing solution after a certain period of time. Cold compresses can be applied at the end of the procedure, if necessary. Therapy is completed with light moisturizers and sunscreens. Heavy drying and rubbing are not recommended after the procedure. Very mild swelling, redness and flaking can be seen in subsequent days. This condition may last for 1 to 3 days in some patients. Sun protection is especially important in this period.
 

Enzymatic Peeling

Enzymatic peeling implies the application of a product containing combinations of many active agents on the skin to eliminate spots. The aim is to peel off the upper layer of skin and reduce the spots. In addition to reducing the visibility of spots, it helps regeneration of skin, elimination of fine lines and narrowing the pores.
The procedure is performed by a physician and the materials remain on the relevant body part (face, neck, décolleté, hand etc.) for the recommended time. The therapy is not expected to cause burn or irritation. Redness, peeling, crusting and sometimes blisters may develop in the subsequent days after the product is wiped off. Patients should follow advices of the physician and avoid sun exposure during this period. Recovery takes 1 to 2 weeks, but it may last longer in some patients.

The procedure is performed in a single session. Physician may recommend extra sessions depending on severity of complaints. Using the products recommended by the physician before and after the session affects the success. Patients should avoid sun exposure and use sunscreens with high protection factors throughout the therapy. Applications such as laser, waxing and rubbing should be strictly avoided during the week before the therapy and for at least one month after the therapy. Too hot shower, solarium, sauna and Turkish bath should be avoided.
 

Mesotherapy

Mesotherapy is a method where various medications, amino acids and vitamins are administered to the middle layer of the skin using thin needles. It was first introduced by a French doctor, Micheal Pistor, in 1952. Mesotherapy has been commonly used worldwide for many years.

Fibroblasts are the primary cells of the connective tissue in skin.  Collagen, elastin and fibronectin synthesized by fibroblasts are the elements that tighten the skin, prevent sagging and thus fight against aging. If used for anti-aging, mesotherapy principally targets this area.  The skin appears more vivid and bright. Repeated applications reduce depth of wrinkles and revitalize and tighten the skin. The procedure can be applied to the face, neck, décolleté and dorsum of the hand. Deeper applications can target fat cells in order to burn fat and reduce and shrink fat cells. It increases blood supply to the scalp and nourishes hair follicles.

Mesotherapy can be adjuvant to treatment of different types of hair loss, facial rejuvenation and treatment of regional fat deposition in the trunk, cellulite, striae, spot and scar. Mixtures that contain multiple active substances are used to ensure an effective therapy. Typically, mesotherapy solutions contain various vitamins, minerals, amino acids and antioxidants. Hyaluronic acid mixtures provide the skin with volume, moisture and elasticity. Mixtures prepared by the doctor can also be used in addition to commercially available mesotherapy solutions. Repeated sessions are required to achieve the intended outcome.

In facial applications, solutions are injected to subcutaneous tissue using a specially designed mesotherapy gun or fine needles at certain intervals. For deep wrinkles, the line injection technique is used. Mesotherapy guns are preferred for scalp applications.  It is usually tolerated well. As the needles are very thin, side effects, such as bruising, are rare. This therapy does not cause pain, but sensitivity may be felt. No major side effect is reported to date. After the therapy is completed, the patient can resume daily life activities. Make-up is allowed one day after the therapy.
 

Fibroblast Culture Therapy

Fibroblast culture, colloquially known as stem cell therapy, involves injecting patient’s own fibroblasts collected at special laboratories.

Aging reduces collagen and elastin fibers in the dermis (the lower layer of the skin), resulting in skin folds and wrinkles. The fibers, such as collagen, synthesized by fibroblasts aim to eliminate those effects and rejuvenate skin of the patient. There is no risk of side effect as the patient’s native cells are used. It is a good option for those who refuse the injection of foreign substances such as dermal filling and mesotherapy.

Blood of the patient is drawn (50 cc) and a small tissue piece is obtained from the skin behind the ear; next, fibroblasts are produced under special conditions. The biopsied area generally heals within a week and the wound site is not visible in many patients.

The produced fibroblasts are administered using fine needles. After a local anesthetic cream is applied, approximately 20 million cells are injected into the skin. Injection should be done twice at two-week intervals.  Efficacy of the procedure has been demonstrated by various studies.

PRP

In PRP (Platelet rich plasma), patient’s own plasma is specially processed and administered back to the patient. Various growth factors and cytokines released by platelets stimulate cell growth and healing. The procedure both slows down skin aging and alleviates hair loss.

It is demonstrated that the procedure helps wound healing and some orthopedic conditions, such as joint damage, in addition to hair loss, anti-aging and sun damage.

During the procedure, venous blood of the patient is drawn, centrifuged and injected to multiple areas of skin. The procedure should be performed by an experienced dermatologist under sterile conditions. Local anesthetic agent is administered before the procedure.
 

Microneedling

Microneedling refers to formation of microscopic channels on the skin surface using very fine steel needles attached to the tip of devices such as dermastamp, dermaroller or dermapen. The skin is revitalized with various growth factors and cytokines released during the repair of artificially formed wounds.  The procedure can be effective alone or combined with other methods, such as growth serums, hyaluronic acid, mesotherapy and PRP. In this way, the products to be applied immediately before or after the channels are created can penetrate more quickly and deeper. The procedure can be used for anti-aging, removal of wound and acne scars, treatment of fine wrinkles and cracked skin, reduction of pore size and hair loss. Therapy is applied in sessions. Session intervals may vary from 2 weeks to 6 weeks depending on the intended outcome.

This therapy may cause minimal pain. Anesthetic cream to be applied before the procedure can alleviate the pain. Small bleeding foci are normal during the procedure. The redness that develops after the procedure usually regresses within several hours. Mild redness and mild edema may persist for one to two days in some patients. The recommended creams should be applied after the procedure. It is required to avoid sun exposure after sessions.
 

Golden Needle Radiofrequency

Recently, needle radiofrequency is ever increasingly used for scar treatment, tightening and rejuvenation. In this procedure, radiofrequency energy is delivered to the lower layers of the skin through needles.
When the headpiece of the device contacts the skin, radiofrequency energy is delivered that can reach the intended depth. Steel needles are covered with gold. Thus, the procedure is also called golden needle therapy. Healing of micro-holes created by needles and radiofrequency energy trigger production of collagen and elastin in the skin. As a result, scars and lines regress, skin tightens and looks younger.

The outermost layer of the skin is conserved since radiofrequency is delivered after the needle is inserted into the skin. Protecting the outermost layer of the skin shortens recovery period and thus, the patient can resume social activities in a short time.

Intended Use of Golden Needle Radiofrequency

  • Acne scars
  • Incision and wound scars
  • Pore tightening
  • Treatment of wrinkles
  • Skin tightening
  • Neck-jowl and décolleté lift
  • Treatment of lines
  • Reduction of sagging skin in arms and legs
  • Treatment of excessive sweating
  • Golden Needle Radiofrequency

The procedure is tolerated well, as local anesthetic creams are applied in advance. The doctor determines depth of the needles and the amount of energy to be delivered according to the intended body part, features of the skin and the indication. The practitioner should be familiar with the structure and anatomy of the skin. In this application where fine needles, albeit small, are penetrated into the skin, the practitioner should also follow the rules of medical hygiene. Redness regresses within a few hours after the procedure. A slight pink discoloration of the skin and minimal edema may persist for a few days in some patients. This condition does not usually hinder social activities. The patient can make up the next day.
 

BBL

BBL (Broad Brand Light) is a source of intense pulsed light. Regular applications slow down aging and revitalize the skin by stimulating the skin. Studies conducted by Stanford University indicate that regular BBL therapy affects gene structures in the skin and reduces age of the skin.

An anesthetic cream is not, usually, required before the therapy. The frequency of sessions varies depending on the patient’s age and condition of the skin.

During the procedure, patient’s eyes are protected with a special eyewear. Ultrasound gel is poured onto the skin to help the light penetrate into the skin more efficiently. Filters are selected according to the skin type and target lesion and attached to the head of the device. The procedure is usually tolerated well. No pain is expected. Additional coolants can be applied to prevent sensitivity for patients with sensitive skin.

The patient can usually resume daily life activities after the procedure. Redness and mild edema (swelling) may persist for a short time in patients with sensitive skin. Cosmetics and concealers can be applied after the procedure. It is recommended to apply sunscreens regularly after the procedure.


Intended Use of BBL

  • Sun damage
  • Skin discoloration
  • Skin tone equalization
  • Various spots, red spots
  • Fine wrinkles
  • Rosacea
  • Red face
  • Treatment of fine blood vessels
  • Poikiloderma of Civatte (red spots and redness spreading to the neck and décolleté)
  • Loss of skin elasticity and rejuvenation.
  • Targeted Body Parts
  • Face
  • Décolleté
  • Neck-shoulder
  • Hand-forearm
  • Leg
 

IPL

IPL (Intense pulse light) is an intense light source that scatters to the peripheral tissue, contrary to the laser that follows a linear route. All chromophores (superficial melanin, hair follicle, melanin and hemoglobin) are targeted simultaneously during the treatment. Therefore, side effects of the IPL, which is a very effective treatment, are also severe and this method should only be used by experienced physicians.

During the procedure, patient’s eyes are protected with a special eyewear. Ultrasound gel is poured onto the skin to help the light penetrate into the skin more efficiently. Filters are selected according to the skin type and target lesion and attached to the head of the device. The procedure is usually tolerated well. While duration of the sessions depends on the size of intended body part, it generally lasts for 10-30 minutes. Session intervals are 3 to 4 weeks. Number of sessions is dictated by various factors such as type of skin, type and thickness of spot, the time elapsed since onset of the spot and depth of the blood vessel. Patients may engage in activities of daily life after the therapy. Moisturizing creams and sun screens are recommended.


Intended Use of IPL

  • Skin rejuvenation
  • Alleviation of sun damage
  • Reduction of wrinkles
  • Treatment of aging spots
  • Treatment of capillaries and redness
  • Hair Removal


Pulse Dye Laser (PDL)

Pulse dye laser beams with wavelength of 595 nm are delivered and focused on the blood vessels lying beneath the skin. This method is particularly effective on congenital or acquired vascular lesions. This treatment method is regarded as standardized golden standard with proven effect and safety for treatment of birthmarks in children and adults.

A brown discoloration occurs on the surface of the skin during the procedure. This discoloration is not irreversible. It pales gradually within 1-2 weeks and normal skin color is restored at the end of the second week. Skin lesions become paler than before with every session of therapy. A dark discoloration (bruising) occurs on the skin area which is scanned with laser treatment. This gradually disappears within 1-2 weeks. Normal skin color is restored at the end of this period. Swelling may occur in the targeted area, but it persists for 72 hours at most and it is completely transient.

Instead of bruising, short-term redness is observed after this therapy is used for red face and Rosacea.
Moisturizing creams and sunscreens will soothe the skin after the procedure is completed. Cold pack can be performed to prevent swelling, especially the one that occurs around the eyes. Patients generally do not feel pain after the procedure. Concealer can be used 72 hours after the procedure to mask the brown discoloration. The patient can immediately return to normal daily life after the therapy.

The procedure is performed in sessions. The intended outcome can be obtained in 2 to 6 sessions on average. The recommended session interval is 4 to 6 weeks. Number of sessions required for treatment of a vascular lesion depends on the size, depth, color and type of the lesion and whether the lesion is congenital or acquired.
 

Intended Use of PDL Laser

  • Wine stains, Portwine stains, Rosacea
  • Hemangioma (benign vascular tumors)
  • Dilated capillaries (Telengiectasia)
  • Spider angioma
  • Flushing
  • Rosacea
  • Hypertrophic scars and keloids
  • Warts

Other than above mentioned common fields of use, PDL can also be for in treatment of various skin diseases with vascular etiologies.
 

Nd:YAG Laser

Neodymium Yag (Nd:YAG) laser has a wavelength of 1064 nm and it is capable to reach deeper tissues in comparison to other lasers. This laser system that targets water, melanin and hemoglobin is used for numerous indications in dermatology practice. It is commonly used for treatment of vascular lesions, skin rejuvenation, acne, rosacea, warts and nail fungus.

Local anesthetic creams can be used before the application depending on the targeted site. Cooling agents are used during the procedure to preserve the skin surface. Conditioning creams and sunscreens are recommended to be used after the procedure.

Intended Use of Nd:YAG Laser

  • Non-ablative skin rejuvenation
  • Blue blood vessels (those measuring up to 4 mm in thickness)
  • Telengiectasia (capillary vessels / thin and superficial vessels)
  • Spider veins
  • Cherry hemangioma
  • Acne
  • Treatment of scars and spots
  • Treatment of nail fungus
  • Treatment of warts
  • Hair Removal
 

Q-switched (Q-switch; QS) Nd:YAG Laser

Powerful outcomes are achieved in a very short time with Q-switched laser system due to storage of laser beams. Two different wavelengths are used in Q-switched Nd:YAG therapies in our Clinic; 1064nm Nd:YAG and 532 nm KTP. It affects superficial and deep pigments with high-energy and high-length shots. It is most commonly used in treatment of melasma, sun spots, age spots, birthmarks and removal of tattoos. Different doses are used depending on color of the pigment and skin tone of the patient. While no crust formation occurs in treatment of melasma – also referred to as the mask of pregnancy-, discoloration and mild crust formations are likely after the therapy is applied for aging-related spots, speckles and some sun spots. The crust formation falls off after a short time. Moisturizing creams with skin rejuvenating effects and sunscreens are prescribed for the patient during this period of time.

Hair lightening applications can be performed on thin hairs that cannot be seen by other laser systems. Hairs lighten and become invisible; a part of thin hair falls off subsequently. This effect lasts for 2 to 3 months. This therapy can be used for all skin types in all seasons. It can be combined, especially with treatment of various facial spots.

The procedure is usually tolerated well. The procedure is performed in sessions. The intended outcome can be obtained in 2 to 6 sessions on average. The recommended session interval is 4 to 6 weeks. Sunscreens should be regularly used after the procedure.


Intended Use of Q Switched Nd:YAG Laser

  • Melasma
  • Skin spots in pregnancy
  • Aging-related spots and Sun Spots (Solar and Senile Lentigo)
  • Speckles
  • Café au lait spots
  • Tattoo removal
  • Hair lightening
 

Erbium Yag Laser (Er:YAG Laser)

Er:YAG laser, which has a wavelength of 2940 nm, is a laser system that is quickly sensed by the skin, although it is invisible to the eye. It takes action through absorption of laser beams by water molecules without any thermal damage; it creates safer and controllable tissue ablation in comparison to similar systems that cause skin damage.

Both ablative (controlled skin damage) and non-ablative (a micro-damage is created while superficial layer of the skin is preserved) applications of Erbium Yag laser are performed in our clinic. Er:YAG laser, which is able to affect both upper (epidermis) and lower (dermis) layers of the skin with different headpieces that can be attached to the device, ensures that the damaged skin surface is replaced by new and fresher skin.  Fractional headpieces cause ablation –induce damage - without peeling off the superficial tissue (Fractional laser). As the tissues at the periphery of micro-canals opened by the laser are preserved, recovery is quicker. This way, it helps treatment of thin and thick lines, alleviation of sun damage and treatment of acne scars and various wound and burn scars. Moreover, ablative headpieces makes this therapy useful for treatment of various dermatologic diseases such as erupted or skin-level moles (not all moles are cauterized; please refer to your physician), seborrheic keratosis, warts and xhantalesma.

Redness, tenderness and crust formation in skin may be observed after the application; use of conditioning creams and sunscreen are recommended following the procedure. Redness and crust formations depend on the thickness of lesion, depth of application and dosage. Three to nine sessions may be required at three- to four-week intervals depending on the existing problem.
 

Intended Use of Er:YAG laser

  • Superficial and deep peeling
  • Treatment of wrinkles
  • Treatment of acne and acne scars
  • Treatment of striae
  • Treatment of wound scar
  • Hypertrophic (erupted) marks
  • Elimination of various lesions (some moles, warts, seborrheic keratosis etc.)
  • Treatment of acne and acne scars
  • Non ablative (without causing damage on the skin surface) skin rejuvenation
  • Skin rejuvenation and tightening
 
 

4D skin rejuvenation

Four-dimensional skin rejuvenation is a non-invasive rejuvenation program where laser modality is used. Both Er:YAG laser and Nd:YAG laser are used. The fact that it does not involve any skin injection is the major advantage of the method. The aim is to stimulate new collagen synthesis, reduce wrinkles and spots, tighten the skin and improve firmness.

The first stage is ‘Smooth lifting’. The procedure is performed with a special headpiece of Er:YAG laser and applied on inner surfaces of cheek and lip. Controlled heat accumulation is ensured in this region and collagen is synthesized and shaped.

The second stage is ‘Frac 3’ mode. Frac 3 modality involves quick delivery of Nd YAG laser beams to both superficial and deep layers and formation of a three-dimensional fractional pattern. It triggers collagen production with high temperature. The procedure is applied on the skin of the face. It also ensures an even skin tone and firm skin.

The third stage is ‘Piano’ mode. The procedure is applied on the skin of the face. Thanks to the special piano Nd:YAG mode that creates a deep heat effect, deep heating is achieved without damaging the superficial layers. Temperature on the surface of skin is monitored with a special thermometer. This deep heating reconstructs and shapes collagen fibers and improves the elasticity and firmness of skin especially in cheek, chin and jowl.

The fourth stage is called ‘Ultralight peel’. The procedure is a cold ablation therapy performed using Er:YAG with a special headpiece. It reduces superficial scars, wrinkles and spots. This mode improves the smooth appearance of skin.
 
4D procedure is usually tolerated well. The procedure lasts for approximately 45 to 50 minutes. It does not require use of local anesthetic cream beforehand. However, anesthetic creams can be used if the procedure is more intensely performed for sensitive areas, such as around eyes or lips. Patients continue their daily lives after the procedure. Skin moisturizers and sunscreen are prescribed. 4D skin rejuvenation can also be performed in summer. Although frequency of sessions varies for each patient, 3 to 5 sessions, on average, are performed at 1-month intervals. Subsequent protective sessions help maintenance of the well-being.