Procedural & Laser Surgery

Botulinium toxin is a produced by the Clostridium botulinum bacteria. The toxin causes paralysis in the muscles.  In botulinium toxin treatment, the toxin is injected to specific areas to paralyse the muscles. Dynamic wrinkles, or wrinkles caused by the contraction of muscles, will disappear after the botulinium toxin treatment. The toxin from the bacterial has been extracted and purified from the bacterium for clinical use.

Botulinium toxin can be used to the following areas.:

1. Crow’s feet (wrinkles on the sides of the eyes)

2. Frown line (wrinkles between the eyebrow)

3. Horizontal wrinkles on the forehead

4. Chin puckering

5. Bunny lines

6. Face slimming (for square jaws)

The botulinium toxin is administered by injecting small amounts into the muscles that cause the wrinkling, using a very fine needle.  The injection is given to the sides of the eye, between the eyebrows and on the forehead when treating the crows’ feet, frown line and horizontal forehead wrinkles respectively. A few injection points are given at each side.

There is mild pain from the needle injection. The whole treatment will last only for a few minutes.

Following the treatment, you should try to exercise the injected muscles to maximise the effect of the treatment.

The effect of the botulinium toxin will be seen by 2 weeks. You may be reviewed at 2 weeks to determine if a top-up injection is needed to improve the result.

The botulinium toxin treatment will last for 3 to 6 months. This is not a permanent treatment and repeated treatment sessions will be needed to maintain the effect.

Botulinium toxin is a safe procedure.  There are no permanent side effects as the effect of the toxin will wear off after a few months.

Side effects include:

1. Bruising. This can occur at the injection site and will settled in a few days

2. Transient headaches.

3. Drooping of the eyes and eyebrows. This is uncommon and the effect is transient

4. Facial asymmetry. This may be corrected with touch up injections.

Chemical peel is a treatment that employs a chemical solution to regenerate the skin and it is often used as an anti-aging treatment.  Different types of solutions like fruit acids, salicylic acid and lactic acid can be used.

The solution causes the surface cells of the skin to peel off or exfoliate and this results in a more radiant complexion. Your dermatologist will assess you and determine your suitability for chemical peel.

1. Skin pigmentation. Chemical peels can treat pigmentation such as freckles, sun spots (solar lentigines) and melasma.

2. Acne and acne scars. Chemical peels can be used to treat acne and help to clear the black and white heads. It can also be used to treat superficial scars on the face.

3. Wrinke and anti-aging treatment. Chemical peels can improve fine wrinkles, such as the fine wrinkling around the eyes. However, it is not used to treat severe wrinkles.

There are 3 main types of chemicals used:

1. Glycolic acid eg AHA or alpha-hydroxy acids

2. Trichloracetic acid (more potent)

3. Jessners solution (comprising lactic acid and salicylic acid)

Firstly, you will be assessed by your dermatologist to see if you are suitable for the chemical peel and what type of chemical peel is best for your skin and condition. You may need to stop the use of strong vitamin A creams prior to the procedure.

In general, you may need 3 to 4 treatments for conditions like superficial pigmentation and black head and whiteheads but more treatment is required for deeper pigmentation and acne scars.

When the acid is applied to the face, you will feel a hot, stinging sensation. This is usually applied for several minutes. Deeper peels may cause greater discomfort.

Following the treatment, there may be a transient redness.  This will usually fade after a few hours to days. For deeper peels, crusting and swelling can develop which may take 1 to 2 weeks to resolve.

1. There is a risk of developing pigmentation after the peel. This is termed post-inflammatory hyperpigmentation and occurs when the skin has been excessively irritated by the peel. This will usually settle after 2 to 4 months.

2. The is a very small risk of scars forming after a chemical peel. This is particularly so if the scabs become infected. There is also a risk of herpes virus reactivation in those who have a history of cold sores. Chemical peels should be avoided if there is an active cold sore infection.

3. There is also a small risk that you can be sensitive to the solution applied and this can lead to eczema and blister formation.

Cryotherapy is a treatment that causes the surface lesions of the skin to freeze. This is done by applying a freezing liquid to the skin. The most commonly used liquid is liquid nitrogen, which is at a temperature of -196C.

Many skin conditions can be treated with liquid nitrogen.

These include:

1. Viral warts

2. Seborrhoeic warts

3. Molluscum contagiosum

4. Actinic keratosis

5. Certain superficial skin cancers (this must be discussed with your dermatologist)

Your dermatologist or nurse will spray the liquid nitrogen directly on the affected area.  The extreme cold on the skin can cause some pain and discomfort. This is usually applied to the skin for a few seconds only.  In children, a cream to numb the pain can be applied prior to the procedure to reduce the pain.

Depending on the condition, only a single treatment may be needed, or repeated treatments spaced weekly, fortnightly or monthly may be needed.

Following the treatment, the skin may become red and a blister may develop depending on the degree of freezing. If the pain is still persistent, you can consider taking simple pain killers like panadol to relieve the pain.  A scab may form over the blister and this may take about 1 to 2 weeks to heal. Do not actively peel off the scab. It will drop off when the underlying skin has healed. During the blister phase, you can consider pricking it with a sterile needle if the blister is causing you discomfort.

Cryotherapy is generally a safe treatment.   The main side effect is the pain during and after the treatment.  In some cases, the skin may heal with an area of darker pigmentation (post inflammatory hyperpigmentation). This will take several weeks or months to fade off. The skin may also leave areas of white spots at the treatment site. This may also take weeks or months to resolve but in some cases, this may be permanent.

Electrosurgery is a quick and effective treatment for a number of benign skin conditions, including skin tags, seborrhoiec warts and syringomas. It involves the application of a high frequency, alternating electric current to biologic tissue, resulting the ablation of the tissue.

Prior to electrosurgery, topical anaesthetic or local anaesthetic is usually applied to the skin to minimize the pain of the procedure. During the treatment, the may be some minor discomfort but this is usually tolerable. Following the treatment, there may be some open wounds and crusting and superficial wounds.

After the treatment, you will be given some ointment to apply to the wound. Avoid rubbing and picking off the crust. It is also preferable to avoid sun exposure after the treatment to minimize post inflammatory hyperpigmentation.  The crust and wounds will usually take a few days or a few weeks to heal. There may be some redness and pigmentation during the healing phase but these will gradually lighten over the next few weeks to 1-2 months.

A mole, also known as a naevus, can be removed for medical or cosmetic concerns. If a mole shows signs of change, such as a rapid increase in size, bleeding and has irregular colours or borders, the mole should be removed and sent for histological analysis to rule out an underlying mole cancer or melanoma. It is important to see a dermatologist to get a proper evaluation of any pigmented skin lesion before removal.

Most moles can be removed by surgical excision. This is done under local anaesthetic and you do not have to fast prior to the procedure. The area around the mole is injected with local anaesthetic so that you will not feel any discomfort while the mole is surgically removed.  There will be stitches in place after the excision and it will take about 1 to 2 weeks before the stitches are removed. There is usually a line scar left in place of the mole. There may be some redness immediately after the stitches are removed but the will gradually lighten over the next few weeks or months. Other option for mole removal include laser surgery, shave excision and electrosurgery. It is best to consult us to discuss the diagnosis and the most appropriate option for mole removal.

Lumps and bumps are common occurrences on the skin.  There are many causes of lumps and bumps and the common causes include seborrhoeic keratoses, epidermoid cysts, dermatofibromas and syringomas. There are many other benign tumours that present as a lump or growth on the skin. In some cases, when the growth is rapidly increasing in size, bleeds or ulcerates, this may suggest an underlying skin cancer and the lesion should be biopsied to rule out malignancy.

Depending on the diagnosis, these growths can be either removed by electrosurgical or laser ablation, shave excision or by surgical excision. With excision, a sample of the lesion can be sent for histological confirmation of the diagnosis.

Electrosurgical or laser ablation is useful for treating superficial lesions like skin tags and seborrhoeic warts. A topical anaesthetic cream is first applied to the treatment area for about 30 to 60 mins. This is followed by the ablation or destruction of the lesion with laser or electrosurgery. During the procedure, you may experience some discomfort but this is usually bearable. Following the procedure, the treated area may have overlying crusts or erosions. You will be prescribed with an ointment to apply to the affected area. The wound will usually take about 1 to 2 weeks to heal. During the healing phase, the skin may darken but this will eventually resolve over several weeks.

Surgical excision involves the removal of the lesion with a blade and scalpel. This is done under local anaesthetic and you do not have to fast prior to the procedure. The area around the lump is injected with local anaesthetic so that you will not feel any discomfort while the lesion is surgically removed.  There will be stitches in place after the excision and it will take about 1 to 2 weeks before the stitches are removed. There is usually a line scar left in place of the mole. There may be some redness immediately after the stitches are removed but this will gradually lighten over the next few weeks or 1-2 months.

This is a new technology of skin resurfacing.  In this treatment, the laser creates multiple tiny puncture burns on the skin, and this is termed fractional photothermolysis. In so doing, a lot of areas of normal skin remain intact and this allows for quick recovery of the skin, whilst stimulating the underlying collagen to regenerate.  This is an excellent treatment for wrinkles and scars and pigmented spots on the skin.

This can be used to treat:

1. Acne scars

2. Small skin growths

3. Photoaging (this causes fine wrinkling and pigmentation of the skin)

A numbing cream will be applied to your face on the day of the treatment to reduce the discomfort.

During the treatment, you may experience some discomfort. This is usually bearable but this can be relieved with oral pain killers. Applying a cold compress to the skin after the treatment is helpful.

After the treatment, the face will be red and swollen with some fine crusting. This will clear up in the next 3 to 7 days. The redness can sometimes persist for weeks. You may notice a more tanned appearance of the skin as the scabbing improves.

During the post treatment, it is advisable to rest well and avoid sun exposure.  Avoid strenuous exercise and activities as this may slow down the recovery process. You can sleep with your face elevated after the procedure.

The skin will gradually return to its normal state over the next few weeks or months. As the treatment affects the deeper layers of the skin, the beneficial effects on the scar treatment and skin rejuvenation will be more lasting.

Usually 3 to 4 treatments are required very 4 to 6 weeks.

The main side effects are the pain, redness and crusting post treatment. Blistering and scarring may sometimes occur but is less common. A post laser hyperpigmentation can occur in about 10% of cases but this will clear after several weeks to 2-3 months.

IPL an advance light based delivery technology that is used to treat a number of skin conditions including skin pigmentation, fine blood vessels and  fine wrinkles.  It is not a laser device but delivers an intense broad spectrum of light, mostly in the visible spectrum, in pulses. This can target different lesions and different filters are used for the different skin types and condition that are being treated. The improvement with IPL is in general slower than laser treatment but the downtime with IPL is minimal compared with laser treatments.

Conditions that can be treated with the IPL include pigmentary disorders such as freckles, solar lentigines and some types of melasma. It can also be used to treat fine wrinkles and improve the skin texture.  It can also be used to treat fine blood vessels and rosacea. It is often used as a form of ‘Photorejuvenation’.  The IPL can also be used for hair removal treatment.

For best result,  a number of IPL treatments ( about 4 to 6 treatments) are required, spaced every 4 to 6 weeks.

Prior to the IPL treatment, anaesthetic cream is applied to the face to reduce the discomfort during the procedure.  During the procedure, you may feel a mild prickling or burning sensation. This is usually bearable and well tolerated.

After the IPL procedure, you may experience some transient redness. This usually settles in hours. There is little downtime with the treatment and you can resume your normal activities.  If there is marked redness, a steroid cream or moisturizer might be applied for a short duration. It is best to avoid excessive sun exposure for a few days after the IPL treatment.

IPL is generally a very safe treatment and the risk of side effects is very low. There is little down-time with this treatment.  Some possible complications include a sunburn reaction and blister formation.  This will usually settle down in a few days to 1-2 weeks but can leave a residual pigmentation which may take several weeks or months to clear. This risk of hyperpigmentation is more common in darker skin individuals and with sun exposure.

The effectiveness of IPL depends on the underlying condition being treated. Your dermatologist will assess and discuss with you about the suitability of IPL for you skin condition. In general, conditions such as freckles and fine blood vessels do respond well to IPL treatment.   However, the response to treatment can vary depending on the depth of the pigmentation and size of the blood vessels.  The response may also vary according to each individual.

IPL cannot be used to treat deep, dynamic wrinkles such as crow’s feet and frown lines. For these conditions, treatment with botulinium toxin is the better option.  You can discuss this with your dermatologist.

The pigment laser is used to remove pigmentation such as birth marks, tattoos and unwanted pigmentation such as sun spots and freckles. The Q-switched Nd: YAG laser is a one of the most commonly used pigment laser. The number of treatments required varies from a single treatment to multiple repeat treatments, depending on the condition to be treated. Not all types of pigmentation can be treated by the pigment laser and your dermatologist will assess you and advise you on your suitability for the treatment.

The following pigmentation can be treated with the Q-Switched Nd-YAG laser

Type of Pigmentation                                 Number of treatment sessions

Freckles/Lentigines                                                 1 to 3

Eyebrow tattoos                                                       2 to 3

Cafe-au-lait macules                                               3 to 5

Amateur tattoos                                                       4 to 6

Hori’s naevus                                                            7 to 10

Naevus of Ota                                                           7 to 10

Professional tattoos                                                 7 to 10

The number of treatments depend on the type of pigmentation to be treated. The results can vary from patient to patient and it is difficult to predict if all the pigmentation can be cleared with the treatment.

First, a topical anaesthetic is applied to the face. This is usually left on for about an hour and this will reduce the pain and discomfort of the laser treatment.

When the laser is applied to the skin, you may feel a burning or prickling pain.  This discomfort is usually tolerable. An ice pack may be applied after the treatment to reduce the redness and swelling.

After the laser treatment, you will notice that your face will be red, swollen with some crusting on the surface. You may continue to experience some burning discomfort and this can last for several hours. If this persists, you can take oral analgesics like panadol to relief the pain. You will be prescribed with some sterile normal saline to cleanse the wound and this should be done gently. Do not scrub off the crusts on the skin. Topical antibiotics or emollients like white soft paraffin will also be prescribed and this should be applied to the wound twice a day. The redness and crusting will usually take about a few days to 1-2 weeks to settle. The scabs on the face will slowly drop off by themselves so do not remove them forcefully as this can damage the skin and lead to infection and scarring.

In some cases, the skin may bruise more than crust. This occurs when we are treating pigmentation that is present in the deeper layers.  This will usually resolve in 3 to 5 days. In general, it is best to avoid applying make-up and partaking in sports like swimming till the crusting has dropped off.

Often, during the recovery phase, the skin may gradually darken again.  Do not be alarmed as this is a natural part of the healing process and this should gradually settle within1 to 3 weeks, although in some cases, it can be very dark and take up to 6 months to fade away. It is best to avoid excessive sun exposure after the treatment as this reduces the risk of developing the darkening during the healing phase and also prevents recurrence of the skin pigmentation.

Overall, the pigment laser is a safe and effective treatment for pigmentation. However, you must expect a period of downtime immediately post laser. The most common risk of post-inflammatory hyperpigmentation will fade off.  Permanent scarring and textural change and skin hypopigmentation are rare complications of the laser treatment.

Skin tags are brownish or skin-coloured growths, commonly affecting the neck, armpit area, eyelids and groin. They can vary in size from less than 1mm to as large as 10mm. In some individuals, the lesions may be numerous. Fortunately, skin tags are harmless and can be removed if there are cosmetic concerns.

Skin tags can be easily removed by laser or electrosurgical ablation. Electrosurgical ablation is one of the most commonly employed treatment to remove skin tags. Prior to the surgery, a topical anaesthetic cream is applied to the treatment area.  After the surgery, there will be scabbing and superficial wounds. These may take up to 1-2 weeks to heal. There is often some darkening as the wound heals. This will gradually fade over a few weeks to 1-3 months.

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are the most common skin cancers. They are more common in the Caucasian skin type. People with excessive sun exposure are at a higher risk of developing them.

It is best to avoid rigorous activities after the surgery to prevent the sutures from coming apart. You will be prescribed with an ointment to apply over the wound. The stitches will be removed after 1-2 weeks. There will be a line scar at the site of the excision. This will be red initially but will gradually resolve over the next few weeks or months. You should continue to go for regular follow-ups to monitor for recurrence of the skin cancer.