Episode 20: Case Studies

 Welcome Back! In this episode, Dr. Saluja and Kane will be analyzing fictitious case studies of patients who are seeking to enhance their appearance through various cosmetic procedures. 

From tackling fine lines and wrinkles to addressing skin discoloration and texture irregularities, we'll explore the nuanced decisions that go into recommending treatments such as neuromodulators, fillers and energy-based devices as well as how to protect and improve you skin at home!  

Thank you for your listenership!

Transcript

Dr. Minni Saluja 0:01

Hi, everyone. I hope you're well. Kane, it's been a long time since we've done one of these. We're kind of dusting off the dust up here.

Kane Rogers 0:10

literally dusting off the dust of the microphone. But it's such a nice day, we have the window open, so if you listen real carefully,

Dr. Minni Saluja 0:17

I can hear some birds. I love that. I love that. Well, I wanted to do a podcast. I was actually in the office and I had a patient I was talking to and she was telling us how much she enjoyed the podcast. And she said, when are you going to do another one? And I said, you know what, we're going to have to do one. And I asked her, is there anything that she'd recommend for a podcast? And she said, you know, you've talked about all the different Podcast. But what I'd like to know is what lasers for what purposes, what procedures can you kind of go through it a little bit more in combination? So I thought what I would do is present patients or I'll have you present patients that come in kind of like a fictitious patient that comes in for a consultation and basically what we go over with them. And so that's what we're going to do today.

Kane Rogers 1:05

it's a pretty broad topic. So yeah, I'll present a case study and you just kind of go through kind of a pretend consult, I guess. Right.

Dr. Minni Saluja 1:14

like a plan.

Kane Rogers 1:15

All right.

Dr. Minni Saluja 1:15

So what you got?

Kane Rogers 1:16

All right. So the first case study is a 43 year old patient with fine lines also has wrinkles, especially around the eyes and crepiness to the skin, along with some pigmented sunspots. So fine lines, wrinkles, crepiness. sunspots.

Dr. Minni Saluja 1:33

Okay, and has she ever had Botox before? Any neuromodulators before?

Kane Rogers 1:36

I don't really know who this person is. So,

Dr. Minni Saluja 1:39

you be the person that answers yes or no.

Kane Rogers 1:41

yes, she, she has had

Dr. Minni Saluja 1:43

has. Okay, so I would start there. I would start with the fine lines and wrinkles and especially the The crows feet around the eyes with a little bit of neuromodulator. In our practice, we primarily use Botox and Dysport, but know that there's five different ones out there, Botox, Dysport, Javu Daxify, and Xeomin.

Kane Rogers 2:02

So that's just kind of a basic go to for the fine lines.

Dr. Minni Saluja 2:06

more of the dynamic lines, the wrinkles around the eyes, the crows feet, et cetera. Yes, that's, you always want to start there because if you can minimize the dynamic lines when. And what I mean by dynamic lines are the lines that are created with movement. If you can minimize that, then you're going to lessen the chance of having deeper static lines. So that's where we typically always start, is with a little neuromodulator. And for

Kane Rogers 2:29

people that maybe haven't had a toxin before this, this would, you'd expect it to last around three to four

Dr. Minni Saluja 2:36

Correct. It's FDA for 3 months. Now there is, Daxify was FDA cleared for 6 months. It's a newer one. And I'll have to say, we brought it into the practice last year. We weren't quite getting six months in seven out of ten of the patients that we treated. I think it is a good option, maybe for four months or so, but because it was more expensive, I think more people deviated back to, to Botox and Dysport. So nothing against Daxify, but it just didn't seem to last as long as six months. But yes, typically three to four months, patients will come in for that. So that's a good place to start. Okay. With the dynamic lines now in regard to the creepiness around the eyes You know, there's multiple different lasers and devices energy based devices

Kane Rogers 3:22

Can I stop you first, like, can you give us a visual of what creepiness looks like?

Dr. Minni Saluja 3:26

So creepiness is kind of it's kind of Almost like little fine lines that you that you see on the skin. It's you can really see it under the eyes It's not like deep lines, but it's just kind of a creepy appearance like thin skin to the area And so I really like plasma for that. I think, I think plasma energy works well with the elastin production, which is kind of what creepiness entails collagen and elastin, but the elastin production. So one of my favorite treatment modalities for that is the age jet. Around the eyes. And there is a

Kane Rogers 4:00

episode on H jet for those of you that maybe want to go listen to that.

Dr. Minni Saluja 4:03

that. There is. And what we mean by plasma is not blood plasma and it's not plasma pen, but it's rather nitrogen plasma for the area. And it, and it works really well. There's kind of two different settings that we use, a lower level setting that typically does not have much of a downtime or a higher level setting that does have a different different downtime. And there's different cost perspectives for these two as well.

Kane Rogers 4:26

Okay, and then the last thing that was presenting on this patient was some pigmented sunspots. So,

Dr. Minni Saluja 4:31

sunspots. So always, always want to wear our sun protection, at least SPF of 30 for sure. And opt for a zinc and titanium based one if possible. So that's important. And also a little bit of a retinol at nighttime is important as well. Just some good skincare, retinoic acid, might be a good thing to utilize as well. But I, for sunspots, If it's not in the summertime, then I love IPLI think IPL can really target the superficial pigmented spots, and that's of course assuming that the skin has been checked, that there's no issues of any type of, of cancerous area skin cancers and whatnot. But just for the classic sunspot, I love IPL for that.

Kane Rogers 5:14

Okay. So for this patient, you can look at a plan of some neurotoxin, like Botox or Dysport, maybe hit around the eyes for some of that creepiness with plasma or age jet, which, which we have. And then also the sunspots, there's some products that you'd want to be able to use, but ultimately you're going to look at doing an IPL for the

Dr. Minni Saluja 5:33

Correct, and the way I'd stage it is I'd do my Botox first and IPL second, and then I would chase it with a plasma afterwards. Again, assuming that we're not doing this in the summertime, otherwise IPLs I typically shift off until October.

Kane Rogers 5:49

Okay.

Dr. Minni Saluja 5:49

then it's also one more thing that's important. If you are on a retinol or retinoic acid, remember to stop it one week prior to any energy based devices. So we would make sure the patient stops that. You just don't want to have any type of redness or some peeling. You just want to make sure that that is not a part of it so that when they do, and also patients, We use topical numbing and sometimes that can even sting a little bit more when the skin has been dried out and has been peeling.

Kane Rogers 6:18

Okay, all right, so let's move on to our next case study. We have a 62 year old smoker wanting a laser for the deep lines Around the mouth deep lines around the mouth the nasolabial fold and there's also hollowing of the midface. What would you recommend?

Dr. Minni Saluja 6:33

recommend? So one thing that's important that you pointed out is a smoker. And unfortunately, a lot of collagen stimulation is thwarted with smoking because it minimizes the vitamin C, the systemic vitamin C, and you need vitamin C as a co factor to build collagen. So, I always tell patients that with lasers, you're really not going to get as much of of a, of a benefit with that. So I would probably, it sounds like, even though she's thinking of a laser, it sounds like these deeper nasolabial fold areas and mid face hollowing would be more of a filler. And patients who are smokers can certainly do well with fillers. I probably would not do Sculptra, which Sculptra is a biostimulatory, again, that stimulates collagen because of the fact that she might have a lessened response to stimulating collagen.

Kane Rogers 7:22

So, because of, of smoking, there are limitations and it's important for people to know.

Dr. Minni Saluja 7:27

There are. I mean you have to really modulate expectations and I always say don't waste your money. I mean, I do like IPLs. I like anything where I don't need to stimulate their collagen. And I think so fillers, neuromodulators, IPLs, threads, PDO threads, those are things that can be done.

Kane Rogers 7:43

And things, other things can be done, you're just not going to probably see the results. Nothing bad's going to

Dr. Minni Saluja 7:48

correct, you just might see a portion, a very small fraction of the results.

Kane Rogers 7:52

So when I'm looking at these two first two case studies that we have the first one of the fine lines and wrinkles and the second one is talking about deep lines. What's the difference?

Dr. Minni Saluja 8:02

now if there's true deep lines, what she was describing, sometimes patients will say, I have these deep lines around my mouth when it's really volume loss. So you have to differentiate between volume loss and true deep lines. Deep lines are, you've seen some of the patients who might have been, you know, Tennis players or runners and they've been out in the sun and they get really deep, deep grooves within their skin. Those are deeper lines that you have to do something more aggressive, such as a high level plasma or a CO2 laser to try to get to those steps. But this sounds more like volume loss.

Kane Rogers 8:32

Okay, all right, let's move on to our next Patient we have a 51 year old male with deep glabellar line. So that's the 11s, right? Static and dynamic with a full face. So kind of a round face Wants to address these and also discuss options to help tighten just tighten his face

Dr. Minni Saluja 8:53

So you mentioned both dynamic and static lines. Now that's really important because if I just did Botox, which I still would do because you want to minimize the dynamic lines that's causing the deeper static lines, but I would really have to let them know that, okay, see these lines at rest. They're not going to go away with Botox. Botox is going to help minimize that movement, but those lines will still be present there. So we have to do something different. Now remember, there are some important arteries that travel right through that area. So I am not a big filler

Kane Rogers 9:27

When you say that

Dr. Minni Saluja 9:28

Right in these 11 areas here. So,

Kane Rogers 9:31

that, kind of that angry

Dr. Minni Saluja 9:33

correct. The supratocular artery we want to stay away from. So we would want to be able to I do like smooth threads. that I, that I pass through there and that way smooth threads can augment that static line there without the worry of causing a arterial occlusion with with a filler. So that is one area I stay away from that area with filler and I stay away from the nose with filler as well, just as a side note. And I stay away from the infraorbital area too,

Kane Rogers 10:00

is, is the nose for the same reason or

Dr. Minni Saluja 10:02

but the nose has got an angular artery and it typically runs on the side and not the front. up the middle of the nose, but if someone's had a rhinoplasty done a note, you know, if they've had a nose procedure done, then the anatomy can be distorted. So I, I stay away from that as well as far as fillers concern. Do

Kane Rogers 10:18

Are, do people inject fillers in those areas? Is that a, is that a thing?

Dr. Minni Saluja 10:23

less and less because those are the risk areas for blindness less and less, but those are, you know, there are some nose injections that if you go stay in the midline, no one's ever had a rhinoplasty that you can get down to the bone and stay a little safer, But those are higher risk areas. But I, I stay away from them.

Kane Rogers 10:41

And then also he wanted to discuss options to help tighten his face, his full skin, his full face.

Dr. Minni Saluja 10:49

Sure. Okay. So another good point you bring up, when a patient has a fuller face, then one of the procedures I really like for those type of patients is something called DENSA. And you've heard us talk about DENSA on a podcast too. DENSA combines both monoplasticity. Polar and bipolar radiofrequency really does not hurt. We, we do numb for this, but there are some cryogen cooling. That's part of the procedure so that patients feel a little coolness as the procedure is being done. There's really not much of a downtime. Sometimes it can be like a little area of redness that might be prolonged for about a couple of days, but typically I would say 90 percent of patients hardly experience any redness. post densa. I like a fuller face for that because that's where you can see the, the the results of that more. So you kind of see a lifting of the tissue. I found that very thin face faces with laxity don't Do as well. So I like the fuller face, the hydrated face for Denza. If they're more skinnier and more lax, then there might be other options. There's a, there's a device called a Tiva RF that's going to be coming out. That might be an option for something like that as well. But that is a patient that I think Denza would be really nice for. And, and again, we have before and after photos on our Instagram page, which is under Saluja Laser MD.

Kane Rogers 12:11

Okay. Okay. And let's move on to the last case study.

Dr. Minni Saluja 12:15

Okay, we're moving right along. We

Kane Rogers 12:16

we have a 46 year old female who just got engaged, yay for her and wanted her hands to look better.

Dr. Minni Saluja 12:22

Okay, so this is

Kane Rogers 12:23

got to, you got to have that nice diamond ring shining on

Dr. Minni Saluja 12:26

the next hand. That's right. That's right. And so typically in our 40s, we start to see more of, again, we see volume loss and we can see pigmentation. And I always tell patients go on Amazon or go to Cooley Bar or you get your UPF clothing. And get yourself some UPF gloves. And Cain, you've seen me wear them. I've

Kane Rogers 12:45

You wear them.

Dr. Minni Saluja 12:46

all at the

Kane Rogers 12:47

You think you're a race car driver.

Dr. Minni Saluja 12:48

The minute I, the minute I step into my into my car, I put those. We're having some microphone issues here. Are you also, I hope this is recording, but the minute I get into my car, I immediately put those gloves on and they're very inexpensive and they're just something that you can just protect your hands with. But again, assuming that it's not the summertime. A nice IPL is really nice to clean up the pigmentation and then I do inject filler into the hands because we get Such a tenderness look to the hands and just a little bit of filler can can really be lovely there

Kane Rogers 13:26

Okay, so when I kind of think about these four different case studies, there's, there's some consistencies. Number one, you want, you, there are some injectables that can address a lot of issues

Dr. Minni Saluja 13:36

Well, actually even number one is what you can do at home, what you can do to with sunscreen at home, what you can do with moisturizers and also retinoic acids. These are important and vitamin C serum of a big antioxidant person in the morning time as well. So those are things that you could do at home. And then in the office, yes, if there's dynamic lines or wrinkles, neuromodulator, that's, it's almost like. I know you think this is a silly analogy, but it's almost like you think about a symphony and total rejuvenation is like a symphony, meaning that if you want one part addressed and you're just a drummer, well, you'll still hear music, but you might just hear a drum beat. But if you want. every aspect of the face to be as rejuvenated without surgery, then sure you have to look at dynamic lines and wrinkles. You have to look at volume loss and you have to address the quality of the skin and, and with lasers and energy based devices, because you could even have a surgical procedure, a facelift, but you would still have old skin if you're not addressing the quality of the youthful skin. So

Kane Rogers 14:41

Yeah, I think that, I think that's one of the things a lot of people overlook, right? I mean, it's, it's the Botox and Dysport and the neuromodulators are so well known that people want that done, but they overlook addressing just the overall health and quality of the skin.

Dr. Minni Saluja 14:55

I mean, you really want to look at the dermal health and it can really make such a difference cleaning up the pigment or just addressing some of these textural issues in, in how we look.

Kane Rogers 15:05

Okay, so these are just four typical patients that would come in and if you want more details on some of the things that we Discussed there's probably a podcast for it. So just just look at the other episodes. You can get a little more information

Dr. Minni Saluja 15:16

information. That's right. And we'll try to do more. And certainly if you all have any suggestions and next time you're in, just let me know and I'll try to address it probably the next couple of months, but thanks again for listening and we appreciate it.

Kane Rogers 15:29

All right. Thank you

Dr. Minni Saluja 15:29

Bye bye.