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In modern aesthetics practice, patients are arriving in our offices wanting to look and feel more youthful. Fortunately, the ever-growing cosmetic armamentarium of injectables, devices, and cosmeceuticals allows us to address color, texture and static lines, volume, laxity, dynamic lines, and facial and body contouring.

It’s important to recognize, however, that despite the number of non-invasive tools available to us, each tool on its own may not give patients the “wow” results they are looking for. Therefore, optimal treatment may require a comprehensive package that combines the various modalities available to us. In particular, non-invasive laser procedures can be combined to great effect with other procedures to optimize results with little down time. Since each device is unique, the exact manner in which we combine these procedures can have a measured effect on outcomes.

Ahead, I will offer tips on layering various modalities to maximize safety and efficacy.

Why Mega-Combinations?

What I’ve found in practice is that patients have less and less time to take off from work and less patience for downtime in general. Many patients want quick results with minimal healing time. Therefore, a layered multimodality approach to rejuvenation can help them to maximize results in a minimum number of visits. Nevertheless, while the number of savvy patients who want to do everything at once appears to be growing, there are also still patients who approach these procedures with caution. During the consultation, we should be attentive not only to what are patients are saying but also their body language and general comfort with cosmetic procedures. This should play a significant role in whether we suggest a comprehensive combination regimen.

Fortunately, the substantial growth of non-invasive cosmetic treatments has created an environment that allows physicians to be creative with using multiple non-invasive therapies. In addition to limiting the number of visits to the office, mega-combinations can also yield improved outcomes. For instance, when we treat two different cosmetic concerns with two different procedures, each procedure when done together can enhance the effect of the other.


• Separate Neuromodulators at LC and Fractionated Laser to reduce risk of diffusion to Zygomaticus Muscles.
• Laser color first then target texture so that the color is not obscured. Pigment specific laser/PDL/ED, then Fractionated Resurfacing overtop.
• Place filler before fractionated resurfacing to reduce swelling.
• Use Ultherapy before Filler because of the benefits of Demerol.
• Other laser treatments can be performed while also on Coolsculpting, but not RF or ED.

Designing the Regimen: A Layered Effect

In general, it is best to address color before texture. Addressing texture first can obscure the color you are trying to treat.

Before addressing color, consider addressing the deepest layers of the skin with skin tightening devices. These technologies include radiofrequency or ultrasound technology, such as Thermage or Ultherapy respectively. These treatments heat the skin very deeply to cause tissue tightening and can “set the stage” for other treatments that day. Additionally, some patients elect to take anxiolytics or pain medication for this treatment that helps ease the discomfort of the treatments that follow.

After skin tightening, it is best to do filler if that is part of the plan. Some of the initial lift from the skin tightening is present which may allow you to use a bit less filler in the midface. Be sure to inform the patient that the initial lift from skin tightening will go away and then return when collagen remolding occurs about 3-6 months post treatment. It is best to do fillers before resurfacing as resurfacing may cause swelling and distort the treatment area.

The next step is to address redness or pigmentation. You should also do any electrocaudery to keratoses or sebaceous hyperplasia at this point.

Now it’s time for ablative or non-ablative resurfacing, such as the Fraxel repair or Fraxel Dual respectively.

Lastly are the neuromodulators. When treating crow’s feet on a resurfacing patient, it may be prudent to allow at least one week between facial resurfacing and neuromodulator treatment to the lateral canthi to avoid the risk of diffusion to the zygomaticus muscles.

Also, as a rule of thumb, although it is generally safe to use these modalities in succession, it can also build a lot of heat in the skin. Thus, if you are layering several laser treatments, keep in mind that you may need to adjust your energies with the later procedures as the skin temperature may be elevated.

Cost, Flexibility, and Education

Using various modalities can be costly for both the physician/practice and the patient. Indeed, patients seeking these procedures often pay a premium for such an advanced level of care. However, given the extent to which the growing non-invasive market has transformed the practice aesthetics, we should all be considering ways of incorporating available modalities in creative, innovative ways. This is critical toward meeting patient expectations as well as expanding our own knowledge and experience in the changing aesthetic spectrum.

Not every practice can offer every procedure, but the mindset of mega-combinations is arguably more important than the resources. If you can treat color with an IPL laser for red and brown spots and can also offer contouring along with fillers and toxins, you can accomplish quite a bit. Additionally, the scope of treatment with combination regimens is wide open. As dermatologists, we have become accustomed to treating scars, birthmarks, and other undesired skin “blemishes.” But patients are not always aware that dermatologists can address these areas so comprehensively in the same way we can address wrinkles and sagging skin. That’s why I educate patients about the various ways we can address more underlying medical issues with what can otherwise be considered cosmetic means. Still, some patients may need surgery to address their concerns and in some cases, the cosmetic surgery can be done the same day as a laser procedure to the same area.

Surgical Results, Non-Invasively

Although there are several factors to consider when combining many modalities and treatments in such a way to achieve the most benefit, in the end it breaks down to understanding what each tool addresses and identifying how we can maximize each tool based on what it can accomplish. Each element of a regimen should be designed to treat a specific component, and we must be scientifically rigorous in how we discern the best time and place for each piece of that regimen. This will be essential particularly as new modalities are introduced to the market.

Patients often tell me, “I don’t need surgical results, like a washboard stomach, I just want to feel better in my clothes.” Thanks to advancements in non-invasive aesthetics over the last decade, we can now offer services that help patients feel better without surgical intervention. As demand grows and the non-invasive market continues to evolve, multi-modality approaches will not only be beneficial but likely essential to delivering the best results and carrying the practice of aesthetics forward. n

Rebecca Kazin, MD is a board certified dermatologist practicing at the Washington Institute of Dermatologic Laser Surgery. She is also on faculty at the Johns Hopkins School of Medicine.

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