Dermatologists have an important role in guiding their patients with regard to cosmetic and aesthetic issues and can offer a wide variety of treatment modalities for skin rejuvenation and restoration. Many patients with diseases of the skin are understandably concerned about the potential long-lasting adverse effects on their appearance. Understanding the range of options available and the potential treatment outcomes is an important component of helping these patients reach a desired outcome. Moreover, cosmetic treatments can improve a person’s self-image and, by extension, quality of life. When our patients feel comfortable with their bodies, they project self-confidence that others pick up on, which may lead to social and economic benefits.

Although many treatments are available, in this chapter we present favored treatment strategies. A comprehensive list of treatment options for specific conditions is summarized in Tables 40-1 and 40-2.

Evaluation of the Cosmetic Patient

The patient seeking advice and treatment for cosmetic concerns generally has a desired outcome in mind. The experienced clinician will help the patient identify these goals and accordingly choose an appropriate procedure. As part of this process, the astute physician will be realistic about the potential to achieve the patient’s primary cosmetic goals.

Every cosmetic surgeon will, at some point, be confronted with a patient who has unreasonable expectations. That is, the patient will have an outcome in mind that cannot realistically be achieved with any of the physician’s treatment modalities. While it is true that cosmetic surgery can often improve a person’s self-image and quality of life, patients with unrealistic expectations are unlikely to benefit in this manner, and they are more likely to be dissatisfied with their treatment and, by extension, their provider.^1,2

Patients with body dysmorphic disorder (BDD) represent a special subset of cosmetic patients with unreasonable expectations. BDD, a psychiatric condition that manifests as an unhealthy preoccupation with minor or imagined defects in one’s appearance, may be exacerbated by cosmetic surgery as the underlying issue is primarily psychiatric. While it may be difficult to diagnose mild cases of BDD based solely on an initial consultation, ultimately the cosmetic dermatologist is responsible for his patients’ health and should develop a sense of when a procedure is unlikely to satisfy the patients’ needs or lead to poor outcomes.

Fine and Deep Wrinkles

Fine wrinkles (rhytides), particularly around the eyes and mouth, are a common patient concern. They are related to natural aging and chronic sun exposure within the superficial dermis and epidermis. Chemical peels, lasers and light devices, and long-term use of topical retinoids as mono-therapy or in combination, can redress some of this structural damage and treat fine rhytides.³ Deep rhytides, both dynamic and static, are multifactorial and caused by years of underlying muscle movement, age-related soft-tissue volume loss, and deeper structural changes due to facial bone resorption. Botulinum toxin and dermal fillers can be used to treat periorbital, glabella, and perioral rhytides.⁴ Deeper rhytides, particularly in the nasolabial folds, and the prejowl sulcus, can be softened to become less prominent with fillers alone (Figure 40-1). A combination of botulinum toxin, dermal fillers, and rejuvenating lasers can be effective in treating patients with both fine and deep rhytides.^3,5,6