Special Feature: Utilising a Combination Approach

By Holly Carver / 05 Jul 2023

Three practitioners discuss the benefits of combination treatment plans for facial rejuvenation and provide considerations for best approaches

Aesthetic medicine is an ever-evolving industry with more and more treatments and products becoming available on the market. As a result, practitioners are increasingly creating treatment plans using more than one modality.

Over the last few years, there have been a plethora of studies highlighting the importance of using a combination approach for optimal treatment results. Earlier this year, the combined use of exosomes and calcium hydroxyapatite (CaHA) was shown to have a positive impact on skin quality1, while another study of 20 women highlighted the importance of utilising skincare following hyaluronic acid injections.2 Research has also indicated positive outcomes using combinations such as threads and dermal filler, radiofrequency with dermal fillers and subcision, chemical peeling and microneedling, as well as many more.3,4,5

Aesthetic practitioner Dr Ryan Hamdy believes the increasing interest in utilising more than one treatment modality is partly because the industry is starting to recognise there are limitations to botulinum toxin and dermal fillers, the bread and butter of the aesthetics specialty. “While they remain a staple of aesthetic practice, there is only so much they can do when used in isolation,” he says.

He adds, “We are at a point now where there are so many treatments and modalities available for practitioners, and we are looking at patients’ faces as a whole, rather than just single areas like the lips or forehead. Thinking about patients in their entirety is vital in aesthetic medicine, and to me this means using the combination treatment approach.”

Aesthetic nurse prescriber Anna Baker explains that her clinic utilises a team approach of practitioners with different specialties to treat different age related changes on the face, neck and body. She notes, “There are so many treatment options for practitioners now in medical aesthetics. It’s all about a comprehensive approach and explaining to patients how treating the full profile will help improve their initial individual area of concern. In our clinic, we offer injectables, energy-based treatments, a variety of skin treatments and topical options, as well as consultations for surgical/invasive treatments. This is so we can provide the patient with a full range of procedures.”

According to aesthetic practitioner Dr Philippe Hamida-Pisal, implementing combination treatment plans has helped his overall patient satisfaction. He explains, “In my experience, a combination approach helps many treatments last longer. For example, if you have existing sun damage it can affect the longevity of your injectable product,6 so correcting this first with skincare is beneficial. I also find that using more than one treatment can help reduce and repair side effects such as inflammation. Both have helped boost my patient outcomes and therefore satisfaction.” 

So what works best for a combination approach? And what are the key elements to success?

Patient suitability

According to Dr Hamdy, every patient can benefit from a combination treatment in some way. “It’s like going to a restaurant – you get starter, main and dessert for the full experience. Typically, the starter for me would be skincare, followed by platelet-rich plasma (PRP), and then filler or toxin. Of course, the younger patient can get away with only having a single treatment as they have less signs of obvious ageing to address. It’s my patients who are 40+ who can really see a visible benefit from getting the full approach,” he explains.

Baker agrees, adding that all patients can receive combination treatments depending on what is discussed and agreed during the consultation. “I always have an open discussion with them about what we offer and the benefits this can bring them – I’m not necessarily encouraging them to have combination treatments but educating them on how it can really optimise their results,” she says. Baker adds that a single concern can often have a number of underlying causes, which is frequently why a combination approach is recommended to treat effectively.

Dr Hamida-Pisal will recommend combination treatments depending on the patient’s age. He explains, “If a 23-year-old wants lip filler, there isn’t a need to combine this with another treatment as it won’t change the outcome, although I do tell my patients that certain treatments like mesotherapy and fillers can make the effect last longer. A 45-year-old who wants lip filler, however, will need to have filler alongside treatments for correcting the surrounding area, like smoker’s lines and wrinkles, for optimal results.” 

He adds that this is completely dependent on the concern, noting, “Of course, if a younger patient comes to me with acne, I will still recommend a combination treatment, as I would for the older generation. It’s dependent on what the patient will get out of it.”

Creating an optimal treatment plan

Baker explains that all treatment plans should be bespoke to the individual. She always starts by focusing on skin quality, before moving on to injectable or device-based treatments depending on what the patient needs. “Everything starts from the skin,” she says. “When a patient comes to our clinic, the consultation involves skin analysis and a discussion of their main concerns and what our assessment has found. I usually place them on a skincare regimen to support and bring out the best of any further aesthetic treatments,” she adds. 

Baker notes that these regimes typically involve SPF, antioxidants and an appropriate cleanser. “This is particularly important if I am planning to perform an energy-based or injectable treatment, as it helps to prepare the skin barrier accordingly," she adds. Baker explains that she finds the skinbetter science range works well, and she has recently introduced her patients to Hydropeptide as well, "These are both brands with effective and multi-tasking ingredients,” she adds.

Baker explains that for her patients who more corrective concerns such as photodamage, she will often combine the skincare regime with Profhilo for bioremodelling, as well as energy-based devices. “I find that Profhilo brings out the best in all aesthetic treatments as it delivers unrivalled benefits in terms of skin quality, and tightening, and works well with fractional radiofrequency, LED and even intense pulsed light devices. In our clinic we use Froma RF, Morpheus8, Lumecca IPL, Motus AY Nd:YAG for skin rejuvenation, and Dermalux LEDs," she adds.

Dr Hamida-Pisal also begins with treating the skin, noting that he goes through a patient’s current skincare list during the consultation. He says, “I need to be happy with their skincare regimen before I go onto any other treatments. I always say to them why pay £300 for botulinum toxin if you have a bad skincare routine – in my experience the results won’t be optimal, and they won’t last as long. So, during the initial consultation I find out what they are currently using and let them know what (if anything) needs adapting. I will get them to put this regimen into practice for six weeks, receiving regular picture updates of their progress. Once I feel their skin is in a good state, we will discuss their next procedure.”

Dr Hamida-Pisal typically uses the SVR or Skin Perfusion skincare range. He explains that when skincare has been perfected, he chooses to combine his more invasive aesthetic treatments with mechanical massage device LPG endermologie. He says, “This is because it activates the fibroblasts, meaning the body responds better to trauma and the repair is going to be quicker. So, before any kind of injectable I always perform this treatment. I also do it before thread procedures as I find it helps the cogs to integrate better into the skin.”

He adds that other combination choices include pairing chemical peeling and mesotherapy. He explains, “I find that it helps create better integration of the mesotherapy cocktails and helps to maintain satisfaction in between each session of mesotherapy. We can also add LED to this treatment using the Celluma LED device or Fotoage device, as it helps to lessen the appearance of marks and redness.” He adds that combination treatments aren't exclusive to the face and he uses the above approaches on other areas of the body such as the hands.

Dr Hamdy notes that he likes to combine skincare and injectable treatments with regenerative medicine, particularly PRP. He says, “Knowledge and research in regenerative medicine is really growing and I think it’s going to revolutionise our practice going forward. In my experience, using these approaches really improves the outcomes of the overall treatment. Personally, I use RegenLab’s PRP kits. While there will always be a place for toxin and fillers, in the future I think it’s more likely they will be used in conjunction with more natural treatments to prepare the skin and make it more receptive to other interventions.” 

Dr Hamdy adds that he likes to use light therapy for 15 minutes at the end of any treatment because it’s easy to use, low cost to the practitioners and has evidence-based synergistic effects with other modalities.

Considerations for combining procedures

Dr Hamdy notes that price is a factor for many of his patients when considering combination treatments. “It really depends on what they can afford, as well as how much time they are willing to invest,” he says, explaining, “I find that my younger patients have more of a desire for instant gratification, so want treatments done then and there. My older patients however are more inclined to go through a process to reach their end result, which can sometimes take months. This means that they typically invest in more expensive modalities like PRP in conjunction with other procedures, instead of a singular filler treatment.” 

He adds that you should also ensure you educate your patients that the combined approach is not a quick fix and will take a bit longer to lead to the desired result.

Dr Hamdy explains that side effects and downtime are also a factor in whether he will combine more than one treatment per session. He says, “PRP products are very safe, and so lend themselves to being combined with multiple treatments in the same session. However, I personally wouldn’t use botulinum toxin and fillers at the same time and would spread them over multiple sessions. This is because the more injections you do to the face the more likely the side effects of swelling and bruising will be. I find it’s better to let things settle before you do more.”

Of course, he notes that some procedures can actually help speed up the downtime of the patient after injectable procedures. “For example, I’ve found that post-laser resurfacing can accelerate healing from seven to 10 days to three to four days. Whether you wait in between treatments really depends on what you’re combining, so you need to do your research,” he says.

Baker explains she is cautious about how quickly Profhilo, skinboosters and hyaluronic acid dermal fillers are combined with energy-based treatments. She explains, “These products may cause bruising, so I would recommend two to four weeks between these treatments and a device procedure, giving the initial injectable time to settle.”

She adds that when combining Profhilo with energy-based devices, it is important to allow time for the skin to cool and the barrier to recover, as the skin is typically inflamed and barrier is disrupted. Baker advises to leave time in between each combination treatment, so that you can monitor and review the results of the initial treatment. “Leaving enough time between each combined treatment means you don’t run the risk of overtreating the patient and can often see the full and final result of one modality before you start bringing something else in,” she says.

Combining aesthetics with functional medicine approaches

Alongside combination treatment plans using a variety of aesthetic procedures, Dr Hamida-Pisal also incorporates various wellbeing approaches. He explains that depending on their concerns, he will implement weight management and nutritional services, exercise regimes and also reiki. These approaches can benefit the entire body, as well as facial aesthetics.

“I didn’t really believe in the functional medicine approach before,” he says, “However, I found that a lot of the time it can be necessary for providing optimal results. Having good skin is easy, but maintaining it is not – that’s why lifestyle changes are important here. There are certain foods, stress or a lack of sleep that can trigger a breakout for example. So even if you are following your skincare regime religiously, it doesn’t mean your issues won’t return. If you can improve your skin quality, then all other procedures will also look better too!”

Embracing combination treatments

Dr Hamdy notes that all practitioners will need to start looking into combination approaches to stay abreast of industry developments. He says, “Combination treatments are here to stay. As the specialty evolves, patients also become more aware of what is available to them and what results can be achieved. With a negative perception of fillers still around and a lot of celebrities getting theirs dissolved, practitioners are going to need more in their toolbox in order to meet patients’ needs and demands.”

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