Chilukuri’s Approach to Safer Aesthetic Treatments

At the 2025 South Beach Symposium, board-certified dermatologist Suneel Chilukuri, MD, FAAD, FACMS, discussed strategies for preventing complications in minimally invasive dermatological procedures, particularly energy-based devices and injectable treatments. He emphasized the importance of recognizing patients' predisposition to hyperpigmentation and employing pre-treatment protocols to minimize risks.

Recognizing and Managing Hyperpigmentation Risk

Chilukuri highlighted a technique learned from Hector Leal Silva, MD, PhD: "Look at the palm, and if you can see those lines are actually darker, even for a very fair-skinned person, you realize that that person has a genetic predisposition to hyperpigmentation." To mitigate this risk, he recommends oral tranexamic acid and skin preparation using products that support skin health. He also pointed out that while hydroquinone has no proven effect on energy-based device outcomes, other measures such as reducing transepidermal water loss are beneficial. A key product in his regimen is a probiotic-based skincare product utilizing "Zykrob technology, that then activates the healthy bacteria called C. acnes defenders, to actually repair the skin." Additionally, he advocates for pre-treatment with retinols for at least 6 weeks, ideally 3 months, before procedures to enhance skin turnover.

Addressing Injectable Treatment Complications

Chilukuri expressed concern over the increasing number of undertrained practitioners performing injectable treatments. "The biggest complication that I see is that the person behind the needle doesn’t recognize that there’s a complication," he stated, noting that vascular occlusion is often mistaken for infection. He explained that sterile pustules appearing 3 to 4 days post-procedure indicate vascular compromise rather than infection or herpes.

To prevent vascular occlusion, Chilukuri follows a meticulous technique, noting that "if somebody has more pain in 1 spot versus the other, there’s a very good chance that you pass by 1 of the nerves that’s closely associated to a blood vessel." If increased pain occurs, he withdraws the needle and repositions it, ensuring a safer injection site.

Product Selection and Monitoring for Complications

Understanding product properties is crucial in injectable treatments. Chilukuri explained that some fillers have lower expansion potential, reducing the risk of vascular compromise. Conversely, "products that can expand, you’re talking about Juvederm Ultra, Ultra Plus, RHA 2 products, and Defyne," which may cause delayed vascular occlusion due to their hydrophilic nature.

He emphasized proactive patient monitoring, particularly in high-risk areas such as the nasolabial folds and lower face. "I make it routine that we do preventative care by calling the patient. If somebody has any kind of achiness, I want a photo," he said. He instructs patients to send images at 1, 3, and 6hours post-procedure to detect early signs of vascular compromise, which appears as "a faint pinkish-purple color, and it looks like rivers or streams coming out from that skin area."

Treatment and Wound Healing Approaches

Chilukuri detailed strategies for improving blood flow and preventing delayed vascular compromise. He recommends aspirin and mechanical devices such as bulk heating radiofrequency but avoids nitroglycerin due to its transient vasodilation followed by vasoconstriction. While the use of ice is controversial, he noted that "2 minutes of ice on, 2 minutes off" may induce idiopathic vasodilation, improving blood flow.

For wound healing, he employs exosomes, polynucleotides, and platelet-derived growth factors. At 3 to 4 weeks post-procedure, he addresses hyperemia and post-inflammatory pigmentation. His comprehensive approach underscores the importance of education, experience, and vigilance in minimizing dermatologic treatment complications.