Expert Offers 10 'Tips and Tricks' for Everyday Cosmetic Practice

Doug Brunk

June 22, 2021

During the annual conference of the American Society for Laser Medicine and Surgery, H. Ray Jalian, MD, shared his "top 10" tips and tricks for everyday cosmetic practice, based on nearly 10 years of experience treating patients on both coasts of the United States.

They are as follows:

1. Know your clinical endpoints. "One of the things that was drilled into me during my fellowship in lasers and cosmetics at Mass General was to know your clinical endpoints and to avoid a cookbook approach," said Jalian, who practices dermatology in Los Angeles. "You should treat based on the pathology that you're seeing on the skin and let the endpoints be your guide. The skin will tell you what you're doing right, and the skin will tell you what you're doing wrong. Picking up on these cues will allow you to deliver a safe and effective treatment to your patients."

The selection of proper treatment parameters is driven by selective photothermolysis, a microsurgery technique that uses customized wavelengths, pulse durations, and fluences to target a chromophore. "Knowing the size and shape of your target allows you to pick the right pulse duration," he said. "This is dictated by thermal relaxation time, which is proportional to the size and shape of the target. Smaller targets require a shorter pulse width, while larger targets require a longer pulse width."

2. Do not perform a procedure for which you cannot recognize and treat the side effects. "I can't tell you how many times I've gotten referrals from outside providers with a side effect that, if it had been recognized and treated, would have been inconsequential long-term for the patient," Jalian said. "You can only avoid complications by not firing the laser. The more you practice, the more complications you're going to have. This is inevitable, but good practice and common sense can reduce complications significantly."

Even the most skilled clinicians encounter side effects from time to time. "The most important thing is to form a network of physicians you trust that you can call or text when you need help in managing a particular complication," he continued. "This happens to all of us," he said. Don't be afraid to phone a colleague, he advised, "and get a fresh set of eyes because oftentimes they can provide insights, especially when you're having tunnel vision during a complication, that can ultimately result in better patient care."

3. Don't forget your clinical training. "Trust your clinical judgment," Jalian said. "If something doesn't seem right, even if it was a case referred to you by experienced practitioners, you are a clinician first and foremost, and you are allowed to make a clinical judgment on lesions." He referred to a 2011 report in which the authors described a series of four cases where patients presented for cosmetic evaluation of vascular lesions that turned out to be more significant pathologic disease. "Trust your clinical insight because this will serve you in the long term," he said.

4. Set realistic expectations. Patients with unrealistically high expectations are likely to express dissatisfaction with their treatment results, "no matter how good of a job you do," Jalian said. "In addition to safely treating the patient, we strive for patient satisfaction, because with these elective procedures we're trying to give a patient a result they're looking for. But our No. 1 job is also to be realistic about the results we can obtain. If someone comes in wanting treatment with a skin-tightening device but clearly needs a face-lift because they have too much laxity, your job is to tell them that this is not the appropriate device for them. Learn the art of saying no. If handled correctly, the patient will often thank you before she heads out the door. Ultimately, honesty is the best policy. I may say something like, 'I'm not telling you the answer you want to hear, I'm telling you the truth.' That often goes over well."

5. Use proper anesthesia. Patients come to you for results, but they're also likely to remember how well you controlled their pain during procedures. Strategies favored by Jalian include applying extra topical anesthetic to "hot spots" and splitting up treatment sessions when tackling a large area. "Consider using adjunctive analgesics such as oral medications and nitrous oxide," he added. Other options, he said, are cooling techniques and distraction techniques, such as the use of a stress ball, consideration of the gate control theory of pain, and "talkesthesia"(using conversation to distract the patient).

6. Obtain proper informed consent. A lack of informed consent ranks as a common reason why doctors get sued. "This happens when a physician fails to inform the patient of all medically reasonable alternatives and their risks, even for noninvasive procedures prior to administering treatment," Jalian said. "All patients have the right to an informed consent prior to any treatment. It doesn't necessarily have to be in a written form, but it's important to at least have a discussion and document it for all procedures, including medical and cosmetic procedures and oral and topical treatments. Keep it simple. A written consent is ineffective if the patient does not understand material about the procedure." Avoid the use of excessive medical terms. For example, use bruising instead of purpura, redness instead of erythema, and drooping instead of ptosis.

7. Lower the laser treatment density for darker skin types. According to Jalian, several clinical studies have demonstrated that lower densities are associated with less postinflammatory hyperpigmentation in Asian and Black patients, without sacrificing clinical outcomes. "Density determines how 'aggressive' a treatment is," he said. "The greater the density, the more downtime is required."

8. Have a vascular occlusion emergency kit on hand. At a minimum, the kit should contain at least 1,500 units of hyaluronidase, aspirin, timolol/acetazolamide, a Snellen chart, steroids, and an EpiPen.

9. Use standardized photography. Even the slightest change in lighting can manipulate your results. According to Jalian, standardized photos enable you to monitor patient progress, minimize liability, and can serve as a marketing tool "so that you can capitalize on your talent."

10. Consider combination treatments. He combines lasers based on target and depth. For example, prior to resurfacing he often performs a pass or two with a color laser such as intense pulsed light. "Depending on what's being done, we'll do soft-tissue augmentation before or after treatment with certain lasers," Jalian added. "If you're performing a toxin treatment on the same day as a laser procedure, do not treat the lower face or neck. Do the laser procedure first and limit that to the upper third of the face."

He reported having no relevant financial disclosures.

This article originally appeared on, part of the Medscape Professional Network.


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