As the field of dermatology continues to evolve, cosmetic procedures have become a common part of how many patients care for their skin—and their self-esteem. These treatments are becoming more recognized for their role in supporting skin health, managing signs of aging and addressing concerns such as acne scars, hyperpigmentation and volume loss.
Cosmetic dermatology encompasses a wide range of noninvasive and minimally invasive procedures—such as neuromodulators, dermal fillers, chemical peels, microneedling and laser therapies—all designed with safety, precision and patient goals in mind. With advancements in technology and techniques, these treatments can offer natural-looking results with little downtime, making them more accessible.
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In this installment, William L. Waller III, MD, a dermatologist at Hattiesburg Clinic Dermatology–South, took time to discuss what patients need to know about cosmetic dermatology procedures.
Hattiesburg Clinic is part of the AMA Health System Member Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.
Be true to yourself
“Let the physician know what your focus is because everybody can have different ideas of what beauty looks like and what perhaps bothers them doesn't ring a bell with the physician or vice versa,” said Dr. Waller. “I always start the visit by asking the patient, ‘What is your concern?’
“The patient needs to be vocal on what they're expecting and what they're hoping to accomplish,” he added. “And then hopefully at that point the physician can give them options.”
Cosmetic dermatology can be used to address age spots and dark marks, cellulite and fat removal, hair removal, scars and stretch marks, wrinkles, tattoo removal and promote younger-looking skin. This can be accomplished with microneedling, laser therapy, injectable treatments such as Botox and fillers, chemical peels and microdermabrasion. Because every patient is different, it’s important to remember that results may vary from person to person.
It’s just one aspect of dermatology
As a specialized branch of dermatology, cosmetic dermatology focuses on improving the appearance of skin, hair and nails through various treatments and procedures. Cosmetic dermatology aims to address aesthetic concerns such as wrinkles, pigmentation and scars.
But dermatologists also identify and treat various medical conditions such as severe acne, eczema, psoriasis, rosacea and skin cancer.
Botox is a common procedure
“Most cosmetic treatments are for rejuvenation or anti-aging,” said Dr. Waller. “At my own practice, botulinum toxins—which most people know as Botox—is the most popular treatment.” That is “followed by soft-tissue augmentation, which people know as fillers.”
Botulinum toxins typically take a day or two to kick in, with full results visible within 10 to 14 days, and the effect can last for several months, “but patients are usually very happy with the result,” Dr. Waller said.
There are two classes of lasers
Laser therapy is a common cosmetic dermatology technique. Lasers are used to improve skin appearance and treat various conditions. For example, lasers can be used for skin resurfacing, treating acne scars, reducing pigmentation issues and even removing unwanted hair. For rejuvenating treatments, laser therapy stimulates collagen production and promotes the body’s natural healing process, resulting in smoother, younger-looking skin.
“There are ablative lasers, which actually cause a thermal damage to the top surface of the skin or the epidermis,” Dr. Waller explained.
“Then there are nonablative lasers that shoot through that layer and target more components of the dermis,” he added, noting “lasers are pretty specific, so you have a target and sometimes they can be stimulating collagen, destroying blood vessels or remodeling scars.”
“You have to determine what your goals are and then you collaborate to pick the laser that is specific for that goal,” Dr. Waller said.
Treatment time varies
“Typically, Botox or botulinum toxins last three to four months. Fillers you can get a year, sometimes even two years out of them, so those are very popular,” Dr. Waller said. “As far as lasers go, it depends on what you’re trying to accomplish. Some outcomes we can accomplish with just one treatment, such as reduction of redness or treatment of fine lines.”
“A lot of times we can get nice results with one treatment,” he said. “The more aggressive you go, the more results you see with lasers, so for people who are a little bit more conservative or worried about what they’ll look like, we can adjust the lasers to lighter settings.
“What that means, though, is you typically need more treatments to realize the result,” Dr. Waller added, noting “our most aggressive laser is an erbium. It’s a full surface resurfacing laser. We take that laser, and we take off sheets of skin down to the dermis, and that’s a one and done treatment, but it is the more aggressive treatment, so you’re looking at up to two weeks of down time of healing.”
Microneedling is safe for all skin types
Another cosmetic dermatology treatment is microneedling, which is used to improve skin conditions and appearance by stimulating collagen and elastin production through controlled microinjuries. It is commonly used for acne scars, stretch marks, wrinkles and enlarged pores.
“Microneedling involves the use of small needles to create controlled microinjuries into the skin. This process initiates a wound-healing cascade that includes inflammation, proliferation and remodeling phases,” said Dr. Waller. “What that ultimately leads to is increased collagen and elastin production, which will improve skin texture and tone.”
“The great thing about microneedling is it’s safe for all skin types,” he said, noting “there are six main skin types—what we call Fitzpatrick skin types one through six—and six is going to be darker skin, all the way up to type one, which is more fair skin.”
“The reason microneedling is so safe is there’s no thermal injury. With a laser, you always get heat and with heat, darker skin types can cause some pigment abnormalities, meaning that it can cause either darkening or lightning of the pigment,” Dr. Waller said. “Another great thing about microneedling is it has very low downtime. You’re looking at one to two days of mild redness and sometimes a little bit of swelling or an occasional bruise.”
“You shouldn’t get any crusting or major skin turnover because what we’re doing is creating the injury so micro that the healing happens very quickly,” he said. “There is also a newer treatment. It is microneedling with radio frequency.”
“There are devices that have the small needles that are inserted into the skin, but at the tips of these needles there are radio-frequency transmitters that end up heating up with the device,” Dr. Waller said. “You add a little bit of heat or thermal injury, which can accelerate the results and it can give you a little bit more of an immediate result with tightening and collagen stimulation.”
“If you add the radio frequency to microneedling, you often need fewer sessions. We generally recommend about three sessions with the radio frequency and about five to six sessions without,” he said.
Platelet-rich plasma is add-on to microneedling
“Platelet-rich plasma, or PRP, is an add-on to microneedling. After we do the microneedling and create those pores in the skin, you can apply this PRP and that enhances the results,” Dr. Waller said. “PRP uses the patient’s own blood, and we spin it down to remove the red blood cells, keeping the plasma and platelets.”
“The reason for that is platelets have a high concentration of growth factors, cytokines and chemokines, which promote healing and tissue repair and help to modulate inflammation,” he said. “We use all that to help with skin rejuvenation, and it’s a good pairing with microneedling because you get the microinjuries with the needling, and then you get the growth factors with the PRP.”
There can be side effects
That is especially the case “with lasers, if you’re too aggressive or perhaps you have some kind of underlying autoimmune condition or some kind of condition that increases your chances of scarring,” Dr. Waller said. “We do see scarring from time to time, but if you’re prone to keloids,” which are raised, overgrowths of scar tissue that occur after a skin injury, such as a burn, cut or piercing, “you don’t want to do anything too aggressive or ablative because that could cause a scar or keloid to form.”
“If you have any open sores or infections, you don’t want to have a treatment at that point. You want the skin to be intact and healthy when you do these types of treatments,” he said. “One thing that comes up occasionally, especially with lasers around the mouth, is it can reactivate a fever blister or herpes simplex.
“So, if you have a history of fever blisters, it’s probably good to take something preventatively so you avoid that trigger,” Dr. Waller added.
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Touch-up timing will vary
When it comes to touch-ups or doing additional sessions, “everybody’s different. Some people do remarkable after one or two sessions. Some people need more,” Dr. Waller said. “Some of it’s genetic, some of it is lifestyle.”
For example, “smokers, we have a harder time treating because their healing is not as good as people who are nonsmokers,” he said. It’s the same for people with “lots of medical issues where their immune system might be compromised—their skin may heal slower.”
“Especially lasers and microneedling. You’re creating injuries to the skin. You’re doing it in a fashion to improve appearance, but there is some healing that has to be done,” Dr. Waller said. “So, the healthier you are overall, the better results you tend to get.”
Results build up with repetition
“With microneedling, I would recommend about five sessions for most people. For lasers, it depends on what you’re coming in with and what you’re trying to accomplish, but I would say multiple treatments,” Dr. Waller said. “Sometimes it’s one or two. Sometimes it’s more than that. But with lasers, the results build over time with repetition.”
“Once you do the series of three or five treatments, often you get a result for several years with microneedling,” he said. “It’s a longer lasting result. Again, not forever, not permanent, but you do get a longer lasting result once you complete the series.”
“The nice thing about Botox, though, is you come in and you have it done, then you’re good for a shorter period of time, but you don’t have the frequency of treatments necessary to see a result,” Dr. Waller said.
Most is paid for out of pocket
“These are generally considered cosmetic treatments, so this would be out of pocket in most situations,” said Dr. Waller. “Now, occasionally things such as vascular birthmarks and hemangiomas can be covered by insurance as far as a laser treatment, especially if they're symptomatic, bleeding, tender or ulcerated.
“Services like these can get covered by insurance,” he added. “Sometimes, some scar treatments can be covered by insurance, but most of these procedures are out-of-pocket cosmetic expenses.”
Avoid the sun before and after
“Especially with lasers, you really want to avoid sun exposure,” said Dr. Waller. “If you are tan when you come in for treatment, your risk increases for discoloration and results are not as good because you have a darker layer of pigment that the lasers have to compete with.”
“I do advise my patients, especially with lasers, to really avoid sun strictly two weeks before, two weeks after treatments and preferably to come in not tan,” he said. “A lot of lasers we end up doing in the fall and winter when the days are shorter, and people are just not out as much.”
“Now, back to microneedling, which is another reason why it's so popular is it's not as crucial as far as the sun exposure because there's no thermal injury with that treatment,” Dr. Waller said. “But I still do advise that people try to avoid the sun before and after treatments.”
Maintain good skin-care routine
“As far as each cosmetic procedure, you certainly don't want to come in with any kind of active skin infection. You also don't want your skin to be irritated,” said Dr. Waller. “So, if you are doing a retinol at home or some kind of chemical peel, you don't want to couple that with an in-office procedure because you might end up with an adverse effect because of the combination.”
“I recommend just a gentle skin-care routine,” he said, and to avoid any at-home skin care activities that would leave “your skin irritated or red.”
You need to allow the skin to heal
“Once we're done, especially with lasers and microneedling, your skin has to heal,” said Dr. Waller. “We often recommend products that assist in healing and reduce any chances of infection.”
The skin care routine and products used “depends on the treatment as far as specific recommendations, but you need the skin to heal, so you want to try to promote that with using products that will help with skin healing,” he emphasized.
Gradual results over time
“Most of these procedures we've talked about have very natural results,” said Dr. Waller. “A lot of times, especially with microneedling and lasers, you get a gradual result over time.
“So, I tell people not to worry about looking fake or overdone, especially with a single session. You should expect a very natural result with most of these treatments,” he added.
