Textbook of Advanced Dermatology: Pearls for Academia and Skin Clinics (Part 2) E-Book
Mohammad Reza Namazi
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Sprache: Englisch
Textbook of Advanced Dermatology: Pearls for Academia and Skin Clinics is an essential reference for practicing dermatologists in hospitals and clinics. The book aims to provide interesting tips which cannot be found in traditional dermatology handbooks. The contributors include top minds in dermatology and related fields such as Joe Niamtu, Samuel Lam, and Steven Feldman. Topics in the book include novel, original formulations for topical compounds, ways to improve patient adherence to prescriptions, business tips, novelties in skin surgery, and solutions for preventing patient complaints and legal suits. The book also highlights the author’s personal experiences gained over many years in improving everyday clinical dermatology practice. The book is divided into 5 sections each representing ‘pearls’ of advice: Teaching Pearls, Medical Pearls, Publication Pearls, Procedural Pearls, and Business Pearls, encompassing all of the broad realm of dermatology.
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Seitenzahl: 355
Veröffentlichungsjahr: 2024
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PREFACE
Bharathi Gourkanti"My intentions are to spread knowledge; I consider this the most important happiness."
Biruni, a Persian encyclopedic scientist (973 – after 1050)
The above sentences from Biruni describe the main reason for writing this textbook. It is a great pleasure to contribute to the advancement of science and the standards of care by sharing knowledge and unique experiences with colleagues.
In PART 1, we dealt with teaching, medical, and publication pearls. In the second part, we present procedural and business pearls. Some procedures mentioned in this textbook, such as the removal of glomus tumor, can hardly be found elsewhere. In fact, a strong point of this book is the presentation of novel tips that cannot be found or hardly can be found in other publications.
Fortunately, I have been successful and honored to receive the contributions of some world leaders in aesthetic procedures, such as Joe Niamtu and Samuel Lam, for the procedural part of this book.
A unique feature of this textbook is the inclusion of business pearls. Unluckily, business issues, while important, are not included in the dermatology curriculum. The result is that many expert dermatologists end up working in clinics belonging to businessmen.
Importantly, this book does not aim to provide detailed information on each topic, rather it is aims to provide interesting tips which cannot be found or can hardly be found elsewhere. Therefore, as an advanced dermatology textbook, many important essential information which can easily be obtained from other publications is not included in this book.
I would like to thank all my dear colleagues who have kindly referred surgical patients to me, especially Drs. Namiyan, Kalafi, Naseri, Koraee, Moradi, Abtahiyan, Khosravi, Abbaspour, Mehrabadi, Fereydounpour, Hamedpour, and other colleagues whom I may not remember.
I would also like to thank my assistants, Mr. Mohammad Khanchefalak and Ms. Bahar Bayat, for their help in taking photos.
This preface cannot be concluded without sincerely thanking Bentham’s publishing staff for their help in making the dream of this book a reality.
I hope the readers find this book interesting.
List of Contributors
DEDICATION
To Drs. Uranus Dasmeh, Aliakbar Mohammadi, Vahid Dastgerdi, plastic surgeons in Shiraz, Iran, and Dr. Mohsen Alirezai, dermatologist and plastic surgeon in Montpellier, France, for responding to my consultations and queries; and Dr. Behrooz Kasraee for his help
To all my dear colleagues who have kindly referred surgical patients to me
To my dear wife Masoumeh, who got headaches on weekends from the constant sound of typing this book from dawn to dusk, and our beloved flowers Sahand and Anahid
Video Contents and Transcripts
Mohammad Reza NamaziVideo 67.1: Filler Injection into the Nasolabial Fold (Namazi’s Technique)
Mohammad Reza Namazi
Infra-orbital nerve block and cleansing the site with alcohol are already performed. The cannula is inserted immediately under the skin with the hole on its tip facing the dermis. Aspiration may be done prior to the injection. The filler is injected while the syringe is rotated along its axis and simultaneously pulled back slowly. The area is massaged for having a uniform filler placement.
Video 68.1: Non-surgical Jawline Augmentation
Kay Durairaj
No transcript is provided for this video.
Video 80.1: How to Place a Buried Horizontal Mattress Suture?
Mohammad Reza Namazi
The needle is entered into the subcutaneous fat beneath the dermis and then into the dermis from its undersurface and is directed towards the skin surface. Therefore, the path of the needle movement is vertical to the skin surface, not horizontal to it. When the needle tip is felt under the skin surface, the direction of the needle movement is changed and the needle is moved away from the skin surface to exit from the undersurface of the dermis and the subcutaneous fat. The same is repeated in the other side. Finally, the knot is tied. If the wound is under tension, you can avoid tying the knot after completing the stitch and repeat the same procedure at the same place to make a second stitch and then proceed with tying the knot.
Video 81.1: How to Tie a Sliding Knot?
Mohammad Reza Namazi
Sliding knot is used whenever there is tension in wound closure. The technique for tying a sliding knot is shown in this video for a buried horizontal mattress stitch, but it can be used with any other type of stitch. It is especially very useful for a purse-string stitch. The technique is very simple: Do not fasten the initial two throws; put them loosely. Then, place the thumb and the index finger of your non-dominant hand on the initial two throws and with your dominant hand pull the short end of the thread. Finally, put the third throw to complete the knot.
Video 81.2: How to Place a Subcuticular Continuous Suture?
Mohammad Reza Namazi and Mohammad Khanchefalak
The area shown in this video is the interscapular region. The wound is already closed with buried stitches. The needle is inserted at the intact skin slightly away from the wound apex to emerge from the wound apex. The bites are taken superficially just under the epidermis from each side alternatively. Big bites may bunch the skin. Care is taken to stay at the same level throughout the procedure and to take the opposite bites at the same lengths. We insert the needle just after its previous exit point to seal the wound better, otherwise the wound edema and exudate may separate the wound edges and lead to a less aesthetic scar. At the end, the needle is inserted at the wound apex to emerge from the intact skin. We cut the suture threads short and leave them on their own, but some surgeons tie them together.
Video 100.1: Submental and Submandibular Liposuction
Vahid Dastgerdi and Mohammad Reza Namazi
The area having excess fat is already marked out. We prepare the anesthetic solution with an epinephrine concentration of 1:200000 and inject it using a cannula entering a point at each mandibular angle and also a third point under the chin. The entry points were stabbed by the tip of a knife 11 to allow the entry of the cannula. It is important to inject 1-2 cm beyond the marking to prevent any pain in case the cannula tip crosses the marking. We have injected around 100 cc of the anesthetic fluid for this case. Liposuction is performed by inserting a harvest cannula, connected to a suction machine, through the entry points at the mandibular angles. If the fat is localized to the midline area under the chin, only one entry point, which is under the chin, is used for both anesthetic injection and liposuction. Pinching the skin over the cannula makes suctioning more efficient by moving the fat towards the cannula tip. The pinch test can help us know whether enough fat is removed or further suctioning is needed.
Video 102.1: Fox Eye Procedure
Nejat Can
(Voice and video-editing by Mohammad Reza Namazi)
The paths of the movements of the cannulas are already marked. Lidocaine-epinephrine mixture is injected. In each entry point, a hole is made using an 18-G needle; then, the cannula is inserted and directed toward the depth of the fat, and then it is moved upwards. The cannula is held and moved by the dominant hand, while the opposite hand holds the path of the cannula movement to help the cannula pass easier. After completion of the cannula movement, it is pulled back and removed from the skin. The skin is massaged and pushed upwards. The non-barbed portion of the free end of the thread is cut, and the barbed portion is placed inside an empty cannula and inserted into the skin for a stronger lift.
Video 103.1: Upper Lid Blepharoplasty
Mohammad Reza Namazi and Mohammad Khanchefalak
Incision is done on the marking. Removal of the excess skin is done while the assistant is pulling the eyelid using a gauze in the opposite direction. We try to resect only the skin and to leave the orbicularis muscle. Removal of the orbicularis muscle can increase the palpebral aperture and can be considered in those with eyelid ptosis.
Hemostasis is performed using bipolar electrosurgery. The rim of the orbicularis under the upper skin is excised. This resection makes the upper flap thinner and more delicate, so matching it with the thinner, more delicate lower flap. We then move to perform the surgery on the other eyelid. We perform septal tightening by heating the septum directly or indirectly via heating the overlying orbicularis. By this novel technique, opening the septum and resection of the fat pads is very rarely required. While heating the septum using bipolar, the assistant should drip normal saline to help with the conduction of the electricity. For prevention of the excessive warmth of the eyelids, which is unpleasant or painful to the patient, we perform this procedure in two rounds for each eye.
This is the second round of the septal tightening for the first eye.
This is the second round of the septal tightening for the second eye.
Next, we move to the suturing stage. We place a buried vertical stitch with an absorbable thread at the base of the lateral wound triangle to close it. This improves the lateral scar. This is followed by putting the simple cutaneous stitches using the rule of halves. The stitches are placed very close to the lid margin to avoid any visible cross-hatching.
We are showing the placement of the buried vertical stitch for the second lid.
Eversion of the lid margin at the end of the operation is due to the swelling of the lid secondary to the injection of the anesthetic and is not worrisome at all.
Video 103.2: Repositioning of the Prolapsed Lacrimal Gland
Mohammad Reza Namazi
The prolapsed lacrimal gland is already exposed through an incision on the overlying orbital septum. The tip of the gland is engaged with 5-0 nylon suture. The assistant pushes the gland into the lacrimal gland fossa using forceps. Then, the posterior portion of the periosteum of the superior orbital rim is engaged with the suture. The suture is tied while the assistant is pushing the gland into the fossa.
Video 105.1: Strip Harvesting for Follicular Unit Transplant (FUT) Technique of Hair Transplantation
Mohammad Reza Namazi and Mohammad Khanchefalak
Marking of the strip based on the estimation of scalp laxity is already done. Local anesthesia, as ring block and tumescence, is also already performed. Using knife No.10, incision is done parallel to the direction of the hair growth so that the hair is not cut. The strip is excised as superficial as possible, i.e. to the base of the hair bulbs and not deeper. Hemostasis is done. Trichophytic cut is performed at the lower wound edge. If there is tension on wound closure, undermining is performed under the deep fat. Closure is done by taking shallow bites near the wound margin (to avoid damaging hair bulbs) as running cuticular stitches.
Video 108.1: Treatment of Telangiectasias with Sclerotherapy
Payman Kosari
This video has no voice.
Video 108.2: Treatment of Reticular Veins with Sclerotherapy
Payman Kosari
This video has no voice.
Video 109.1: Pilar Cyst Removal
Mohammad Reza Namazi and Mohammad Khanchefalak
Marking of the margins of the cyst and ring block are already performed. A very shallow elliptical incision is done over the middle of the cyst, being very careful not to cut the cyst wall. The ellipse is carefully excised, exposing the cyst. The lateral skin overlying the cyst is carefully undermined up to the marked up area. A clamp is used to further release the adhesions between the cyst wall and the surrounding tissues, esp. the deeper tissues, and finally to scoop off the cyst.
Video 109.2: How to Prepare a Piece of Cellophane for Placing in a Surgical Pack for Autoclaving?
Dr.Namazi Skin & Hair Clinic
This video has no voice.
Video 109.3: Mechanical Matricectomy(Dr. Namazi's Matricectomy Technique)
Mohammad Reza Namazi
Digital nerve block is already performed. Partial nail avulsion is done using a hemostat and scissors (it can also be done using a nail splitter). Then, a serrated jaw of a sterile hemostat is pushed under the lateral part of the proximal nail fold and is rubbed against the lateral matrix to destroy it. At the end, the lateral nail fold is sutured to the nail plate to close the gap. The suture is removed after 2 weeks. To our knowledge, this is the first report of this novel technique.
https://drive.google.com/file/d/11WxnLK5ad-SNIXCTq_fchmGyH7AKkSkp/view? usp=sharing
https://drive.google.com/file/d/14TKdVL4bR82U-gRaHoZeLHRBGKEP9_0M/view? usp=sharing
https://drive.google.com/file/d/16XHnLg1cHKpZr_rGU_q2DUnHJaoSoSzI/view?usp=sharing
https://drive.google.com/file/d/1JeOXrPVGvDbe71SDgBjwVHKFnIAueflY/view?usp=sharing
https://drive.google.com/file/d/1JrqJ89LW5GkX8ICdgv-uly8iuxR21nDI/view?usp=sharing
https://drive.google.com/file/d/1MfB63929SslLsmSP4bldAN3e0OWqHVJe/view?usp=sharing
https://drive.google.com/file/d/1N0THaOB8L15biQ_mZ-OCsepJZdNNjzA7/view? usp=sharing
https://drive.google.com/file/d/1NCltYqNLFA-nALhFbbWyhLH4Ko6szNIQ/view? usp=sharing
https://drive.google.com/file/d/1QAJXlHxYj0NFGkY7BgSAdFMgDPgITLvK/view?usp=sharing
https://drive.google.com/file/d/1g8fx9EOQ3kbyNVcuAQKU-QKr2_I3T_Jg/view? usp=sharing
https://drive.google.com/file/d/1hheOmk_RCWiS7eTkfmjVr4t7lkEDo4Gp/view?usp=sharing
https://drive.google.com/file/d/1in2I29oyXeLWYx9uODTVleqsS4c7b15T/view?usp=sharing
https://drive.google.com/file/d/1mzODufyWpiQPwdM7HcFFp41keAtUN5nZ/view?usp=sharing
https://drive.google.com/file/d/1wA6yUPkqt55LV3pOpwP-jSyovBAFnfFv/view? usp=sharing
https://drive.google.com/file/d/1wYCBEDiDGJMSpnMIx19tXo3g1NJfd8k1/view?usp=sharing
Procedural pearls
How to Prevent Lawsuits and Complaints?
Mohammad Reza Namazi1,*More than 95% of physicians react to lawsuits by experiencing periods of emotional distress. An internist mentioned awakening with his first episode of atrial fibrillation after being served with his first malpractice suit the previous afternoon [1].
-There is a nice aphorism from Avicenna, the Prince and Chief of Physicians, which says: “The physician should have the heart of a lion and the cautiousness of a snake”. Keep in mind that the symbol of medicine is a snake wrapped around a stick. Snake is the symbol of cautiousness in some ancient stories, as its eyes are always open (it does not have any eyelids), seeming to be hypervigilant (Fig. 1).
Richard Smith, the editor of The British Medical Journal until 2004 says: “Good surgeons know how to operate, better surgeons when to operate, and the best surgeons when not to operate. This applies, I think, across all of medicine.”
-While bravery is a virtue for a surgeon, foolhardiness and incautiousness are definitely vices. Being unwatchful to the patients with personality problems and proceeding with cosmetic interventions for them will damage your credit and fame and ruin your life. Life is too short to be spent for satisfying a moaning irrational patient or going to the court for answering his/her litigation. Saadi Shirazi, one of the eminent Persian poets, whose poem adorns the UN building in New York, wisely advises others metaphorically to be careful while dealing with people:
“Think not that every grove is empty. A tiger may be lying there…”
-Many young physicians think that dealing with people with different personalities shows the capability and competence of a physician. However, as they age, they reach the conclusion that detection of people with abnormal personalities and avoidance of offering cosmetic treatments to them is a sign of physician’s capability and maturity. You may say that exclusion of so many cases may cause you not to have many cases for surgery. Keep my advice: It would be better to go to the park than to the court! Moreover, keep in mind that unhappy patients will denigrate you and ruin your reputation, causing you losing many future cases.
You can find the advice regarding prevention of patients' complaints in papers and surgery books, e.g. mentioning all the possible complications to the patients prior to the surgery and avoiding surgery for individuals with unrealistic expectations, etc. Here, I add some extra points from my own experience:
Fig. (1)) A) The reverse of the silver medal awarded to the Alfred Nobel Nominating Committee for Medicine, showing the rod of Aesculapius, god of healing, with a snake wrapped around it. Snake is a symbol of healing, as well as cautiousness. B) A pendulum awarded by the Iranian Society of Ophthalmology (1948), showing a snake with the colors of the Iran’s flag, wrapping around an ophthalmoscope.-Patients you feel have “hard” personalities, i.e. being tough and inflexible, are not good choices for cosmetic surgery and respond toughly to the possible complications, or even to the results which are good in your view, but not good in their views. These patients are usually men.
-Patients who ask more questions than usual patients or during the preoperative consultation mention that they are “sensitive” individuals are not good candidates for cosmetic surgery. These patients are usually female.
-Other examples of bad candidates for procedural interventions include indecisive and hesitant patients, overflattering patients, price-hagglers, patients involved in litigation, and VIPs.
Patients who haggle over the costs of the procedure are usually more sensitive to the results of the procedures.
Be careful when you plan to conduct surgery on judges and health personnel. Be also careful not to get trapped by the exploitative nature of some real estate agents.
Do not forget that the personality of a patient’s partner is also very important. A lady whose partner dislikes cosmetic surgery is not a good case because her partner may try to find fault with your surgery to prove his viewpoint. I had a female patient who was an appropriate case for blepharoplasty but I refused to perform surgery for her as she mentioned that her husband was a very picky person and asked her several times “what if the result of surgery is not good?”.
-Inexperienced doctors may like patients who denigrate other doctors; however, experienced doctors know that a person who is expressing strong, especially inappropriate, dissatisfaction with another colleague today may do the same to them tomorrow.
-Noteworthy, the patients you or your staff dislike also constitute other inappropriate choices to cosmetic surgery. Ask your staff to report to you any patient showing abnormal behavior. If you feel you dislike a patient or you have become nervous while giving preoperative consultations, you are very probably facing a patient with an abnormal personality who will not give you a good, energizing feedback postoperatively.
Have you ever heard of “precox feeling”? It is a characteristic feeling of bizarreness or unease that a psychiatrist experiences when encountering an individual with schizophrenia. Try to develop a similar feeling in yourself towards patients with abnormal personalities while offering preoperative consultation; reviewing the behavior of patients who have troubled you can be helpful. This feeling can help you avoid cosmetic surgery for troublesome patients.
-Rude and impolite patients are not good choices for even minor procedures like botulinum toxin injections. Even if you perform a non-invasive procedure very skilfully, a rude patient can find an irrational pretext to disrespect you.
-Sometimes the bad procedural candidates insist on undertaking a procedure more than the good candidates or even force you to proceed with a cosmetic procedure you think will not have a satisfactory result. Do not get fooled by their insistence and remain determined to avoid the procedure. You are the person who should make the final decision, not the client.
-If you guess a person might not be an appropriate case for procedural works and he/she requires several procedures, e.g. removal of several nevi, do not rush to perform all the procedures in one session. First do one of them and if his/her reaction is acceptable postoperatively, proceed with the other procedures.
-While dealing with a complication, be polite and kind (even be more polite to a complicated case than to the other clients), but decisive. Even if you are fearful or worried about the possible lawsuit, the patient should not recognize it at all. Your decisive voice during consultation is a good coverage for your internal worry. Try to open a non-medical communication channel with the patient. For example, ask the patient about his/her residence/birth place and start a communication about it. People like others to speak about and admire their living/birth place.
-If you want to refer a complicated case to another colleague for revision, do not just write him a referral letter but try to contact him by phone, whatsapp, etc. or even attend his office to mention the problem. This makes him pay especial attention to calming your patient down and resolving his/her problem. If the patient needs a revision surgery, ask your colleague to kindly perform the surgery as soon as possible to prevent the patient’s anger due to long waiting time or referral to other doctors who may find fault with your management, leading to the patient’s litigation.
-If you would like to prescribe a medication to manage a complication, do not prescribe an expensive medication, as this leads to the patient’s further anger. For example, do not prescribe an expensive lightening cream for an angry patient with laser-induced post-inflammatory hyperpigmentation. If you have a sample of a skin-lightening cream, give that to the patient as a “gift”. This calms her down.
- Do you know how to calm down an irrationally unhappy patient for whom you have done a skin tumor surgery with complete removal of the tumor? Say: “The pathology result shows that the surgery has been successful and the tumor is resected fully. You do not need any radio- or chemo-therapy”. This “true” statement makes the patient happy and in the case of a suboptimal result or complication deviates his attention to the positive, compliment-deserving aspect of your surgery.
-If you are planning to proceed with a revision/corrective procedure, such as laser for managing a bad scar occurring after a surgery you have done, doing it free of charge makes the impression that you are guilty and responsible for the poor result. Even after doing it free of charge, a picky patient may be unhappy and sue you. Charge the patient even a small amount of money for revision/correction! But do not overcharge at all! If an unhappy patient asks for returning his money, do not return all his money as this also makes the impression of guiltiness/fearfulness. When returning a part of the charge, try to make the impression that you are doing it as a kind measure, not for prevention of a litigation/complaint. For example, if the patient tells you that he/she has earned the money for undertaking the surgery with difficulty, tell him/her that you are returning a part of the charge as he/she is facing economic constraints (not because he is unhappy with your procedure).
-There are some patients who try to get their money back by threatening you to make a lawsuit against you for an acceptable result, e.g. an unavoidable, normal scar. An approach towards such patients is to advise them that in the case of choosing to go to the court, because the experts will not find their pretext logical and will not issue a verdict against you, they will be just wasting their time and money, warning them, in addition, that you will sue them for harassment following the court's verdict on your innocence. This may be a harsh approach, but usually works well for the threatening patients.
-If an angry patient sends insulting or threatening messages (e.g. to your secretary’s whatsapp), save them and text him/her that his/her messages are saved and legal actions will be put in place in case he/she continues his/her behavior. This can even help to prevent him/her from suing you, as he/she will be afraid of a retaliating legal action by you.
-In some situations, it may be good to ask a colleague who likes you (not pretends to like you!) to see and speak with an unhappy patient who is not satisfied with your post-operative consultations.
-In some countries and cultures, it is considered a negative point if you reply to a complaint/lawsuit at the end of the timeframe given to you for providing your answer. If this is not the case in your country/culture, responding at the end of the given timeframe is usually better as most complainers/plaintiffs become calmer with time.
- It is important to ask your staff to refrain from teasing patients as a sign of friendliness, as some patients dislike this and displace their anger to you.
I hope the above comments can help you have a less tense and happier life and serve your society with high spirits. I know that some approaches mentioned above may not be completely practicable in all cultures. In a nutshell, train yourself to detect and avoid people with abnormal personalities, even those who are flattering you excessively!
-How to cope with a medical malpractice? The malpractice charge suggests that we are “bad doctors.” We need to alter this perception and develop good feelings about ourselves. It helps to understand that litigation is about compensation, not competence, and that those who are sued are often the best in their fields in working with high-risk patients, and that most physicians are eventually vindicated [1]. Keep in mind that medicine, by its very nature, is a field associated with lawsuits and complaints, being in striking contrast to some fields like mathematics, chemistry, etc., and that almost all physicians face these problems in their career lives. Also, think of the lawsuit/complaint as a learning experience helping you evolve to a more experineced, cautious physician. Do not hesitate to counsel a psychologist if you feel you need psychologic support.
Reference
[1]Charles SC. Coping with a medical malpractice suit. West J Med 2001; 174(1): 55-8.[http://dx.doi.org/10.1136/ewjm.174.1.55] [PMID: 11154674]Laser Hair Removal: Pearls
Mohammad Reza Namazi1,*In laser hair removal, a light is emitted which is absorbed by hair melanin. The light energy is transformed to heat, which injures the hair follicles, inhibiting or delaying ongoing hair growth.
- Vellus hair is resistant to laser hair removal because of the lack of melanin. Overall, facial hair is lighter and finer in comparison to the body hair, so being more difficult to treat.
- There is no specific lower age limit for laser hair removal. However, it is imperative to refrain from lasering the vellus hair to avoid the paradoxical growth of hair on the face.
- The desired endpoint of lasering is perifollicular edema and redness, which develop within a few minutes.
- It is necessary to emphasize that lasering causes permanent hair reduction, not removal. Maintenance treatments are needed, which vary from case to case from 3 to 4 times yearly.
- Patients with polycystic ovary syndrome need more frequent treatments (around 10 to 15 sessions).
- A fortnight wait prior to lasering is required for burnt or sun tanned patients.
- When lasering the face, application of ice on the nearby areas limits heat dissipation, which can cause paradoxical hair growth.
- The damaged hair shafts on the face are normally fallen in the first week of treatment. Assurance should be given that this is not a new hair growth [1].
- The interval between sessions has to do with the hair growth cycle of the area. For hair removal on the face the interval should be 4-6 weeks, for body 6-8 weeks and for legs 8-10 weeks. If doing all in one sitting, perform the laser every 8 weeks.
Reference
[1]Goel A, Rai K. Methods to overcome poor response and challenges of facial laser hair reduction. J Clin Aesthet Dermatol 2022; 15(6): 38-41. [PMID: 35783561]Laser Vaginal Tightening
Mohammad Reza Namazi1,*Dermatologists are frequently pained by other physicians trespassing their territory, esp. in cosmetic dermatology. Unfortunately, their endeavor to prevent this problem has been largely futile. Dermatology should expand its field by including some simple procedures such as laser vaginal tightening and G-spot enhancement which will be discussed later.
The loss of vaginal tone after pregnancies causes the decrease in the friction on the anterior vaginal wall during sex, decreasing female sexual pleasure. This is the reason for seeking vaginal tightening.
- Refer the patient to a gynecologist if you see any anterior or posterior vaginal prolapse while the patient is pushing in lithotomy position. Also, note that vaginal tightening can improve stress in continence but cannot treat it.
-Co2, erbium, and diode lasers can be used for vaginal tightening (special vaginal handpieces are used) (Fig. 1).
-There are too few studies to support the approval of laser vaginal tightening by FDA, which has issued a warning on it.
- Lasers can improve mucosal quality and increase vascularization and collagen deposition which thickens vaginal walls.
-Anesthesia is not needed. In lithotomy position, dry the vaginal wall with gauze. Introduce the handpiece. Rotate it while moving out slowly, without leaving the handpiece still at any time. One to three passes can be done in each session. For better results, three or more sessions spaced 4-8 weeks apart are needed. No ointments or medications are applied after treatment. The patient can resume sex three days after the procedure [1].
Fig. (1)) Laser vaginal tightening (https://www.jenesislipoplasty.com/non-surgical-lift-procedures-san-jose/vaginal-tightening-rejuvenation/)Reference
[1]Triana L. Vaginal Rejuvenation and Perineoplasty, Surgical Alteration and Minimally Invasive Procedures. Nahai F, Nahai S the Art of Aesthetic Surgery (3rd ed.) 3rd ed.20201574.Miscellaneous Laser and Light Pearls
Mohammad Reza Namazi1,*-Whitening of the lashes due to Q-switch removal of the lid tattoos is very rare.
-In using Q-switch Nd:Yag for tattoo removal, the desired response is the bright tissue whitening caused by water vapor. Some pinpoint bleeding is acceptable, but epidermal disruption and bleeding require decreasing the fluence. As the pigment lightens, higher fluences can be used [1]. Importantly, the fluences recommended by some manufacturers may not be applicable to all cases and skin types.
Multiple passes done after resolution of the whitening of the previous pass can increase the response without increasing the side effects [1].
-The tattoos made using fountain pen ink respond favorably to Q-switch laser (Fig. 1)
-Co2 laser on the eyelids of dark-skinned people frequently causes post-inflammatory hyperpigmentation which is difficult to treat.
-In fractional Co2 lasering, by using dots in their maximum concentration, you can make a superficial peeling of the skin. Do not use a high energy for this purpose as it can burn the skin due to the proximity of the dots.
-For treating depressed scars by Co2 laser, if the scar has a steep vertical edge, try to bevel the circumference of the lesion by the “ultra” mode to make a smooth sloping edge. This technique enhances the cosmetic appearance of the scar.
-IPL can cause severe burns and is much less safe than lasers for hair removal.
Fig. (1)) A tattoo made using fountain pen ink, which responds to Q-switch laser.-In the author’s experience, IPL can be used for treatment of fine, very superficial port-wine stains.
Reference
[1]Pritzkar RN, Iyenar V, Rohrer TE, Arnds KA. Laser treatment of tattoos and pigmented lesions. In: Robinson JK, Hanke CW, Siegel DM, Fratila A, eds. Surgery of the Skin (3rd ed.) 3rd ed.Robinson JK, Hanke CW, Siegel DM, Fratila A. 2015532.Microneedling, Co2 Laser and Topical Vitamin D to Improve Scars Rapidly
Mohammad Reza Namazi1,*Co2 laser and microneedling are very frequently used for the treatment of various scars.
- Combining microneedling and Co2 laser can lead to more improvement of scars than either agent alone. You can inject xylocaine-epinephrine combination to both anesthetize the scar and to decrease the bleeding due to microneedling. Then, start with microneedling and proceed with the Co2 laser afterwards. Starting with Co2
