Fractional Coagulation is in, Bulk Heating is out for Radiofrequency (RF) Skin Tightening

Ever since Rox Anderson suggested that treating a portion (fraction) of skin while leaving untreated healthy tissue behind as the basis for the Fraxel Skin resurfacing laser over 10 years ago, patients have been having less downtime, less risk, and less discomfort with their laser procedures.  Healing is dramatically improved because the adjacent nontreated dermis is able to provide the needed blood supply, nutrients, and local immune response much faster than the traditional treatments and results have been shown to be very similar in efficacy.

Until recently, all RF devices have applied heat to the skin/dermis in a nonfractionated approach, called “Bulk Heating”.  Whether the RF device is Bipolar or Monopolar, if the heating element does not penetrate the skin, the energy is pushed into the deeper layers using this method.  The implication of bulk heating is that all precision is lost.  Exact placement of the heat is impossible, with large opportunities for errors in depth of penetration and/or temperature control.  When treating skin, heat from the RF device using bulk heating can be placed too superficial, leading to burns or pigmentation changes, or too deep, leading to fat loss.  The dermis needs to be heated to 42 degrees C for 3 minutes to affect collagen stimulation. Only if skin temperature is measured can the operator be sure that the 42 degrees is reached with bulk heating, which is not the case for most bulk heating devices.  One last temperature issue is that bulk heating devices are unable to obtain coagulation of the tissue, which occurs at about 67 degrees C, which is needed for maximal tissue contraction and collagen stimulation.

The Infini uses microneedles to deliver the radiofrequency energy IN A FRACTIONAL manner.  Its unique array of needles allows the energy to flow between the needles, creating 49 coagulation points AT A SPECIFIED DEPTH in the dermis.  Surrounding tissue is sparred, which makes for very little downtime.  The superficial layer of skin is spared (because the needles are insulated), leading to no wound care, and markedly reduced risk of burns and pigmentation issues affecting the epidermis.  The temperature created in the areas between the needle is enough to create coagulation, for maximal tissue contraction and collagen stimulation.

(Not all microneedling RF devices are fractional.  Fractora uses microneedles, but because the energy is directed from the needles to the skin surface, the heating is in a fashion similar to bulk heating devices.  Also, because more tissue is affected using this heating method, discomfort is much higher and local anesthetic needs to be injected in most cases.)

It has taken a long time for RF devices to catch on to the fractional technology revolution.  The Infini has created much more precision in the delivery of RF energy to the dermis, allowing for higher degrees of skin tightening, while affording the safety and quick recovery time that fractional technology has created.

All Botox Providers are NOT the same. Choose carefully!

Botox injections are the most popular cosmetic procedure performed worldwide.  Millions of patients are injected each year with the wrinkle fighting drug.  Its popularity is attributed to:

  • There is minimal downtime – 15 minutes of bumps from the injection
  • The procedure is highly effective in improving wrinkles
  • Discomfort is usually minimal
  • Side effects are few and rare
  • Cost is fairly reasonably, but depends on how many areas are done
  • The time it takes to get a treatment is less than 10 minutes

So why is the “Was it Worth It” review on Realself.com for Botox only 69%?  This can be attributed to multiple reasons, which be further elaborated upon in this blog.  (A large volume practice should have a satisfaction rate in the >95%.)

Although the Botox procedure looks very routine to the observer/client, don’t equate this to being a simple procedure that all injectors can master easily.

All patients will age differently, so what areas need treating for optimal cosmetic results needs to be tailored specifically to each patient.  A cookie cutter approach to every patient will not work.  There are several areas of the face which can be considered advanced:  lips, corners of mouth, neck, gummy smile, under eye, bunny lines, inner eyebrows which require a highly trained and experienced injector, or you will live with a disfiguring facial appearance for 3 months.

The trend is moving away from the frozen, no movement, very obviously treated face to a more natural appearance.  Rather than blasting and overwhelming the forehead with Botox, a technique using very small, precisionly placed aliquots that  allows for movement but with diminished wrinkles.  This is a more difficult technique to master.

Shortcuts are often routine in regards to Botox.  A majority of practices will draw up syringes of Botox in the morning, or the day before, by a nurse, medical assistant, or office staff.  That means the patient will need to get injected in multiples of what is contained in a syringe, leading to limited customization.  Also, errors in dilution and sterile technique are possible when filling the syringes is not done by the same person that is injecting the Botox.  (Botox comes in a powder form and needs to have saline added to reconstitute it to become an injectable solution.)  Dr. Weiner mixes all his Botox personally, and will draw up the appropriate amounts for each patient in the room, just prior to injection.

Discomfort related to the injection can be minimized using various techniques.  Using preserved saline has been shown to result in less pain than using regular saline.  Needle size, speed of injection, and using proper needle placement is also a key factor affecting comfort.  Dr. Weiner also uses several distraction techniques, capitalizing on the Gate Theory (the brain has difficulty processing more than one sensory input at the same time).

Varying the concentration of Botox is a technique Dr. Weiner has used for years.  Certain areas require different dilutions to lead to maximal cosmetic benefits.

Touch ups to correct minor imperfections require an advanced injectors experience.  They also need a responsive provider, easily available for a drop in or work in patient.

Getting injected by an unknown provider at someone’s Botox party, is never a good idea, and almost  always leads to problems that one has to live with for 3 months.  The “savings” never is worth it.

Although Botox is extremely popular, as the Realself.com stats show, there are many people that are not pleased with their experience.  This is not the norm for the high volume, experienced injector.  As explained above, there are many intricacies which can contribute to better results. Hopefully the public will understand that Botox should not be considered a routine cosmetic procedure, and they need to select their providers carefully.

The Most “Botched” Cosmetic Procedures Dr. Steven Weiner Is Asked on Realself.com

Realself.com is a public forum for asking questions about cosmetic procedures which patients have had or are thinking of undergoing to the website’s participating physicians.  The website allows doctors of the following specialties to respond:

  1. Plastic Surgeons
  2. Facial Plastic Surgeons
  3. Dermatologists
  4. Oculoplastic Surgeons

Unfortunately, experience and credentials are not always fully evaluated by the public, and undesired outcomes, often with long term repercussions, can result.  Sometimes with only a few weekend courses under their belt, Internists, Family Practitioners, Dentists, ER Physicians or OBGyns hang up a shingle Aesthetic Procedures.  An article by Tom Seery, CEO of Realself.com, points out that consumer satisfaction rates are about 30-35% higher when a specialist is performing Botox or Dermal Fillers vs. “all providers”.

Now for the most Botched Cosmetic Procedures:

1.  By far, the #1 most botched procedure is tear trough injection with fillers.  Complaints range from lumps, prolonged swelling, worsening of appearance, pain, prolonged bruising, vascular injury, numbness, and firm nodules.  The skin around the eye is very thin, and there is very little room for error in this procedure.  Dr. Weiner is a firm believer that this injection should be performed using blunt cannulas with Restylane.  There is less swelling, bruising, and significantly less vascular risk with cannulas.  Lesson:  Leave this injections to “the pros” for better outcomes and safety.

2.  Botox being botched is a close 2nd.  Common problems are eyebrow or eyelid droop, uneven smile, ineffectiveness, bruising or swelling, or “Dr. Spock” look.  Sometimes a touch up can improve these results, but often one has to wait for the Botox to wear off.  This can be 3-4 months.  So that deal on Botox that is supposed to improve ones looks becomes a nightmare where one looks abnormal and/or worse.  Lesson:  Botox deals aren’t usually worth it.

3.  Laser hair removal resulting in burns is fairly commonly asked about on Realself.  If the laser operator is not using the appropriate laser or settings for one’s skin type, permanent pigmentation problems can result.  Fortunately, most superficial burns will reverse over the course of several months.  In several states, rules for operating a laser are very lax, allowing techs without significant training to use the laser.  Florida is one of the strictest in the country.  The operator can only be a nurse practitioner, physicians assistant, doctor, or specially trained electrologist.  Lesson:  Get the most qualified person to operate the laser, preferably a physician with years of laser experience.  Dr. Weiner has over 25 years of laser experience.

4.  Lip augmentation with dermal fillers is another highly botched procedure.  The most common lip problem is uneveness and lumpiness.  These are a direct result of poor technique by the injector.  Hyaluronidase to dissolve the filler is usually required, and then you are back to where you started (so 2 procedures to get back to square one).  Bruising, swelling, and prolonged downtime is seen when lips are injected using needles in combination with injector inexperience.  Dr. Weiner is a huge fan of using blunt cannulas for the lips to minimize the recovery time and bruising.  Overfilled, and unnatural lips are also a problem, mainly due to lack of knowledge of the natural anatomy of lips by the provider.  Lips should have a ratio of about 40% upper to 60% lower.  When the upper lip is larger, or the natural landmarks (tubercle, cupids bow, shape) are not preserved, the lips become obviously “done” and unattractive.  The sausage lip is when the lips appear tube like (like a sausage link) which is another common error by the inexperienced injector.  Lesson:  Lips are another area with several intricacies  that require an experienced injector.  Cannulas limit bruising, swelling, and downtime so you can enjoy your lips without interrupting your social life.

 

The take home message is that all providers are not equal.  Please do the homework, look at reviews, ask friends, and ask the facility “Who is actually doing my procedure?”.  In general, specialty trained physicians will give better outcomes with higher satisfaction rates.

Beauty and Skin Tips for those on a budget.

This blog will elucidate that small changes to one’s lifestyle and a small investment in skin products, will lead to significant improvements in one’s skin health and beauty.

  1. Protect from the sun with daily sunscreen, sun protection, and Heliocare.  The number one enemy to skin is sun exposure.  The sun’s UVB rays lead to activation of enzymes that destroy the skin’s collagen leading to wrinkling and thinner skin.  Skin pigmentation problems (melasma, solar lentigos) are exacerbated by the sun.  Skin cancers are almost always related to exposure to the sun’s damaging rays.  Studies have shown that just using sunscreen can improve ones looks.  Heliocare contains Polypodium leucotomos which is a fern extract that is an antioxidant that reverses and protects against the radiation effects of the sun on skin cells.  Heliocare has also been shown to improve melasma, because even indoor artificial light can exacerbate this condition where sunscreens don’t offer protection.  Wearing a large brimmed hat, SPF rash guard (if at the beach), and staying under an umbrella/shade should be considered during periods of prolonged outdoor sun exposure.
  2. Stop smoking.  Smoking is probably a close second to the sun as a factor affecting skin health and beauty.  The toxins in smoking cause contraction in vessels in the skin, leading to poor oxygenation of the skin cells.  Smoking essentially strangulates one’s skin causing loss of elasticity, viability, and thickness.  Other side effects include increased wrinkles, a change in the color of the skin, thinning of the hair, halitosis, and dental disease.
  3. Apply topical Retin A or Retinol.  It has been well established with research dating back over 25 years, that Retin A has anti-aging qualities.  It has been shown to increase cellular turnover in the skin, thus creating skin cells that are younger and more vibrant.  It increases collagen in the skin and improves hydration in the skin by increasing the GAG’s.  Pigmentation abnormalities are improved as well.  Precancerous changes are reversed and prevented to a certain extent.  Wrinkles and photodamage have been shown to improve with just using Retin A.  One word of caution.  If you choose to use Retinol because it has less peeling, you have to use a strength that is higher than what is found in most OTC cosmetics.
  4. Maintain hydration, drink plenty of water.  This is somewhat controversial, but there are anecdotal reports of improvements in overall looks with just making sure you are fully hydrated.  There are obvious other benefits as well including kidney, bladder, blood pressure and circulatory health.
  5. Topical Growth Factors and Antioxidants.  Growth factors stimulate skin cells to become more youthful and recruit stem cells which may lay dormant in the skin.  Antioxidants help the skin fight off the environmental stress that attacks the skin, including the sun’s damaging radiation.  Products that fall into this category are:  TNS Essential Serum, Lifeline Day and Night Cream, and Neocutis Journee.

These recommendations are a good start to improve skin health for all individuals, regardless of budgetary concerns.  The younger these are implemented, the less correction that will be needed in the future.  Consider following these guidelines as an “investment in the future”.

New Handpieces From Coolsculpting Help Create an “INNER THIGH GAP”

 

Inner Thigh Gap from Coolsculpting

Coolsculpting of Inner and Outer Thighs showing the Thigh Gap. 5 weeks after treatment.

  It seems that women are going to great lengths to try to achieve the elusive “inner thigh gap”.  According to Nik Richie, the founder of the website “The Dirty” who claims to be the  first to coin the phrase “inner thigh gap”, the space between the thighs needs to ideally be 5 finger breadths.  Many people, including physicians, argue that women are genetically predisposed as to whether they have the ability to obtain an ITG.  If one’s hips are narrow, the argument is that the legs are too close together and having a gap is not possible.  Nik’s reply is that it is possible in all women with harsh dieting and exercise, with particular attention to the thigh abductor weight machine (I think he meant adductor machine).  Most women would probably be satisfied with an ITG of any dimension, and  feel that Nik’s definition is at the far end of the spectrum.

Coolsculpting has just made it easier for women to improve their inner thighs.  Whether or not one achieves the perfect “5 finger breadth” gap is really dependent upon what status the thighs are before starting the procedure, their anatomy (genetics) and how much is related to excessive fat deposits.  Each Coolsculpting treatment is able to decrease fat in the treated area by about 25%.  Results can be visible at only 5 weeks but take about 3 months to fully appreciate the change.  The procedure can be repeated if more fat reduction is desired.

Although Coolsculpting was initially FDA approved in 2009  (2010 approval to treat flanks), the handpieces to treat the thigh area were only recently developed and approved.  Both the Coolsmooth and Coolfit handpieces are able to treat the thigh area.  Treatments are nearly painless and take approximately 1-2 hours per thigh.  There is no downtime and no restrictions on activity after the procedure.  Risks are minimal and include bruising, numbness, and need for more treatments.   Dr. Weiner feels that Coolsculpting offers a healthy method for reducing thigh fat and does not endorse the alternative, that being extreme dieting.  In addition, Dr. Weiner stresses that patients must have realistic expectations as to what the Coolsculpting procedure can achieve, and have an appropriate body image before commencing treatment.

Certainly the “inner thigh gap” is a controversial subject.  Dr. Weiner’s stance is that many people will not be able to achieve the gap with the Coolsculpting procedure, but they should expect improvement.  There are some people who have  an actual physical need to reduce their inner thighs – those who have thighs that rub during exercise or walking – who are particularly good candidates for this treatment.  The bottom line is that Coolsculpting is a noninvasive, no downtime, permanent way to improve one’s inner thighs with it’s newly approved handpieces, gap or no gap.

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Off Label Uses of the Infini – A Plethora of Potential Treatment Options – Scars, Sweat, Cellulite, Acne, Fat, Breast Lift, Knees, Tattoos

Sweat reduction with the Infini

Dr. Weiner Infini Hyperhidrosis treatment

The Infini is quickly being recognized by the aesthetic physicians as a very powerful tool to tighten facial and neck skin with very little downtime (less than 36 hours).  It has also proven to have an extremely low risk profile, with very few long term side effects noted, even in tan or dark skinned individuals.  For those unfamiliar with the Infini, please read this blog.  In a nutshell, the Infini is a microneedling fraction radiofrequency (MFR) device that coagulates the dermis at various depths (o.25mm – 3.5mm) leading to tissue contraction, new collagen and elastin formation, and overall skin tightening and wrinkle improvement.  Dr. Weiner has been using the Infini soon after it was FDA approved and has become the largest user of the device in the US.  There have been several off label (non FDA approved) uses of the Infini that Dr. Weiner has been studying that will be discussed below.

  1. Scar Improvement – The Infini causes disruption of the abnormal/pathologic collagen deposition and stimulates new and more organized collagen that more closely resembles the body’s normal collagen.  Acne scars have been treated, even in darker skin individuals, with improvements noted.  A physician in Korea has a large series of acne scarring patients who have been treated with the Infini showing dramatic improvements.  Other scars being studied are stria (stretch marks) and surgical scars (such as tummy tuck and skin cancers).
  2. Hyperhidrosis (Excessive sweating) – The sweat glands lay in the lower part of the dermis and just below it.  By heating these areas up to a certain temperature, they can be destroyed permanently.  This has been proven by the Miradry device, which uses microwaves to heat up the tissue.  There is a very high long term satisfaction rate using this device after undergoing 2 treatments.  It’s drawback has been discomfort (requiring blocks with injections) and cost ($3000 for 2 treatments).  The Infini can be set to a depth that targets the area of the sweat glands and heat this area up to a point of coagulation (gland destruction).  In preliminary studies in axillary (underarm) sweating, Dr. Weiner’s patients have seen improvements with the Infini with less discomfort, no downtime, and at a fraction of the cost.  Dr. Weiner’s Press Release about using Infini for Hyperhidrosis.
  3. Acne – Dr. Weiner had been noting that patients whom were undergoing Infini for skin tightening/wrinkles were also noting improvement with their acne.  It was postulated that the sebaceous glands, the glands responsible for sebum production (the root cause of acne) were being injured with the Infini treatment.  An acne flair is not uncommon after an Infini treatment, and this is caused by inflammation of the sebaceous gland temporarily.  Over time, the glands will involute (becomes smaller with less secretions) and lead to the acne improvements noted.  Eventually sebaceous glands can enlarge again (unlike sweat glands with don’t have the ability to regrow), so the treatment with Infini turns out to be a potential long term but not permanent solution for acne.
  4. Body Skin Tightening – Areas such as knees and arms are a concern for many patients.  Other than surgical correction, which leaves large undesirous scars, there hasn’t been a good solution.  Perhaps the Infini can create similar skin contraction and thickening in these areas as it does on the face. Dr. Weiner is studying this on a few select patients.
  5. Fat Reduction – The depth of 3.5 mm is below the dermis in most areas of the body.  Using this depth with the Infini, it is possible to target fat, particularly in the submental (below the chin) area and along the jaw line.  Many patients have seen improvements in these areas with their Infini treatments for wrinkles on the face and neck.  Dr. Weiner purposely will go deep in these areas to coagulate and destroy fat and then go more superficial to tighten the dermis.  Slimming the mid and lower face for patients with excessive fat tissue can be manage with the deep depth Infini treatment.
  6. Cellulite Improvement – Using the same rationale as targeting fat, it seems logical that destroying the fat that is herniating would improve the appearance of cellulite.  This is still an area of treatment that is more speculation and research is being conducted by Dr. Weiner on a few select patients.
  7. Tattoo Removal – There is evidence that combining fractional ablative lasers with the Q-Switched laser has benefit in removing tattoos.  If this is merely causing more of an inflammatory response to enhance the ink removal, then Infini can cause a similar tissue coagulation, but with less risk and downtime than the lasers do.
  8. Breast Lifting – If the Infini can cause tissue contraction in the area of the breast, is it enough to see a noticeable improvement in the position of the breast?  A no scar breast lift sounds extremely appealing.  Studies will need to be done to see if the Infini can work for this and if so, how many treatments are needed, are touch ups required, and is it’s price justified.

Dr. Weiner is carefully studying the Infini for these off label uses and trying to develop standardized protocols for the medical community.  It seems like the Infini’s potential is just starting to be recognized and its future is very promising.

Slimming Ones Facial Appearance with Botox/Dysport

The ideal shape for an aesthetically pleasing face has been referred to as “an upside down egg” or heart-shaped.  It is desirous to have the upper face wider than the mid/lower face.  It brings more attention to the eyes, the center of beauty.  Widening of the lower face can give a female a more masculine appearance, and also is a sign of aging. The causes of enlargement of the mid/lower face are:

  1. Enlarged masseter muscles.  Often caused by bruxism (grinding one’s teeth)
  2. Obesity
  3. Genetics.  Asian females tend to have this issue
  4. Jowling associated with the aging face

By injecting the masseter muscles with Botox or Dysport, the muscles can diminish in size and atrophy over time.  If the procedure is repeated and regularly administered, a long-term slimming of the mid and lower face can be achieved.  Candidates for this procedure are people who fall into the #1 and #3 category. Risks are minimal, but this can affect your smile if not done by someone who has experience with the anatomy and performing this procedure.

Many people would also benefit from injecting the temples simultaneously with filler to help create the upside down egg-shape to the face (from a square-shaped face).

For the person that falls into the #2 and #4 category, there is some literature that suggests that Ulthera might be helpful.  Although a much newer technology, Infini might work for this as well, time will tell.  By going to depths that are much deeper than the skin, into the fat layer, it might be possible to decrease the amount of fat in these areas and thereby slim the face.

Coagulation is Necessary For Maximum Skin Tightening; Science and Experience Prove This – INFINI is the Best Solution

It is fundamental that my patients understand the science behind their treatments.  There is too much “quasi science” in the aesthetic industry that is fooling the general public.  As a result, many patients are dissatisfied with their outcomes and have buyer’s remorse.  Perhaps the most controversial area of the industry is with “skin tightening” procedures.  After reading this and my previous blog on the Infini, hopefully you will recognize the reasons why most of the devices/procedures for skin tightening don’t work well and why the Infini stands out from the crowd.

To achieve skin tightening, the deeper layer of the skin, the dermis, needs to create new collagen.  It has been found that heating this layer of skin can stimulate neocollagenesis (new collagen production).  The threshold is 42 degrees centigrade to impart a stimulus to the dermis, because at this temperature collagen denaturing occurs (the bonds holding collagen together break down).  The body senses the injury, and during the repair of this area, new, youthful collagen is produced.  The response is very mild at these temperatures.  At higher temperatures, 55-70 degrees centigrade, coagulation of the collagen and surrounding tissue occurs, with more coagulation seen in the higher range of those temperatures.

WHEN COAGULATION OCCURS, THE BODY’S RESPONSE TO THE INJURY IS MUCH MORE INTENSE.  TO ACHIEVE MAXIMUM SKIN TIGHTENING AND COLLAGEN FORMATION, COAGULATION IS NEEDED IN THE DERMIS.

Digression:  The long standing “gold standard” for wrinkle control and skin tightening (without surgery) has been considered the fully ablative CO2 laser.  It has been determined that its efficacy is based primarily on its significant coagulation effect.  The risks associated with complete removal of the upper layer of the dermis – prolonged healing, redness, scarring, infection, and hypo and hyperpigmentation – have significantly curtailed its use.  Recent technology improvements that have made the CO2 laser fractional (treating only a fraction of the skin) has greatly reduced the risks, but they are still present.  Erbium laser resurfacing, which traditional has very little coagulation, has not been shown to have the same results as the CO2 laser.  Changes in the Erbium to give it more of a coagulation effect on the skin have lead to better results.

The ideal skin tightening device would cause tissue coagulation in the dermis, but have very little of the risks and downtime associated with the CO2 laser.  Radiofrequency devices have been trying for over 10 years to do this without success.  They try to heat the dermis, but not the epidermis (upper layer of the skin) to the 42 degrees needed to get a mild neocollagenesis.  THE PROBLEM IS THAT ALL THE NON PENETRATING RF DEVICES CAN DO, AT THEIR VERY BEST, IS HEAT, BUT NOT COAGULATE, TISSUE IN THE DERMIS.

So what devices can coagulate tissue is the dermis aside from the CO2 laser:  Microneedling RF devices (like Infini) and Ulthera (High Frequency Ultrasound).  In this category, Infini wins hands down.  All of the other microneedling devices currently on the market have one or more of the following downfalls:

  1. The needles are not insulated so the epidermis is at risk for injury (pigmentation or indentation risks)
  2. The needle depth is fixed and not variable.  The facial skin has a huge variation in depth, from 0.38mm to 3mm.  Ideally, the coagulation is placed at the deep dermal layer.  If it is too deep, there will be minimal collagen response.
  3. The themal injury is not fractional.  Treating fractionally is the way to treat in 2014.  This allows for accelerated healing, minimal risks, without compromising results.
  4. Their temperatures don’t reach the level high enough for coagulation.  Without coagulation, results won’t be as good.

THE INFINI USES INSULATED NEEDLES, HAS VARIABLE NEEDLE DEPTH (0.5mm-3.5mm), AND CAUSES A FRACTIONAL COAGULATION INJURY IN THE DERMIS.

Infini Skin Tightening

Infini Coagulates the Dermis

Ulthera has been a great tool in our office for the past 5 years.  When comparing the Infini to the Ulthera, the following deficiencies in skin tightening have come up:

  1. Ulthera currently only has 3 depths – 1.5mm, 3mm and 4.5mm.  For most of the face, only the 1.5 is at the level of the dermis.  Ulthera reportedly tightens at the deeper muscular layer, the SMAS, but this has yet to be a proven mechanism by histological samples (looking under the microscope at biopsies).  Much of the coagulation from Ulthera is in the subcutaneous fat or fat layer, an area that produces very little or no collagen.  It does explain the improvement in the jawline and upper neck though, the areas where there are fatty deposits.
  2. Ulthera lays down about 15,000 thermal coagulation points (TPC’s) during a treatment.  The Infini will create 50,000 or more of these TPC’s during a treatment.  More TPC’s probably mean more results because Ulthera has proven that going from 7500 TPC’s to 15,000 TPC’s gave them better results.
  3. Ulthera is more expensive for the physician to use, so the costs get passed on to the patients.

To summarize, skin tightening requires a coagulation injury in the deeper dermis.  The discussion above has tried to show that besides the Infini, all other RF devices fail to deliver a predictable, safe, thermal injury to the point of coagulation in the dermis.  Without the coagulation in the dermis, results will be unsatisfactory.   In essence, the Infini has made Thermage, Venus Freeze, Exilis, Pelleve, Tripolar, Titan – all OBSOLETE.  

To get a better grasp of the RF skin tightening Industry, please read the blog:  “FINALLY…A Radiofrequency (RF) Skin Tightening Device that Makes Sense.  Infini by Lutronic.” Includes an overview of the RF skin tightening industry.

Recent Advances in Coolsculpting – 2014

 

Coolsculpting is a noninvasive technique to permanently reduce unwanted fat.  It was FDA approved in 2009 for treatment of the flanks.  It has subsequently been FDA approved for abdominal fat and, as of April, 2014, has the indication for treating thighs.

Up until this point, all the handpieces required a suction to adhere to the area that was going to be treated.  There needed to be a roll of fat that could be “grabbed” by the suction or the area couldn’t be treated.  The development of the newest handpiece, the Coolsmooth, allowed for areas to be treated without the use of the suction, such as the thigh area.  It also enabled the person with smaller amounts of fat or tighter skin to be treated.  At the present time, each application of the Coolsmooth handpiece requires 2 hours but this will most likely be reduced to 1 hour in the future.

“Treatment to transformation” is a technique whereby multiple applications of the Coolsculpting machine are applied in either one or several sittings.  By overlapping areas treated or by treating some areas 2 or 3 times, results are now approaching what liposuction can achieve – without the downtime or risk associated.  The technique has been pioneered by Dr. Grant Stevens, from Marina del Ray, California.

Massaging immediately after removal of the handpiece has been shown to increase the fat loss in a recent study.  This has been done in our office for at least 4 years.

Although loose skin is a theoretical risk after losing fat underneath it, Dr. Stevens has shown that this is absolutely not the case.  He has seen skin contraction with his patients and has not seen cases of excess skin.

A recent study presented at ASLMS 2014 showed effectiveness in patients with gynecomastia.  Two treatments were required and most patients were satisfied with their results.

Future handpieces are being developed to work on the neck/chin area, ankles, and one specifically for breast tissue.  Cellulite reduction is also being studied and it looks promising.  Treatment for uneven results after liposuction seems to be greatly improved with Coolsculpting as well, and the new Coolsmooth handpiece will be a huge advance in this treatment.

 

Hyaluronidase – The “Magic Eraser” for Hyaluronic Acid (Juvederm, Restylane) Dermal Fillers

Hyaluronic Acid dermal fillers are the most popular fillers used worldwide.  In the United States, the commonly used HA fillers are:

  1. Juvederm Ultra and Ultra Plus
  2. Voluma
  3. Restylane
  4. Perlane
  5. Belotero

The beauty of HA fillers is that they are very well tolerated because hyaluronic acid is a component of skin, so it is a naturally occurring substance.  It’s a soft product, and will last anywhere from 4 months, to up to 2 years, depending on the brand used, and the location it is placed.

Another key attribute to the HA fillers popularity is that it can be completely dissolved with an enzyme called hyaluronidase.  It is manufactured from either bovine (cow) or ovine (sheep), so there is a remote possibility of having an allergic reaction to the commercially available products (Vitrase, Hydase, and Amphadase).  There seems to be a crossover with people that are allergic to bees for these animal derived products.  (Hylenex is a recombinant form of hyaluronidase that is the human form that is rarely used due to its expense.)

Hyaluronidase is useful for dissolving HA filler in the following instances:

  1. The filler was over done/”over filled” and it is not aesthetically pleasing
  2. There is prolonged swelling, particularly around the eye and most often with Juvederm
  3. An infection has occurred in the area of prior filler
  4. The filler is lumpy or has nodules and doesn’t respond to massage and time (especially lips)
  5. Rare possible allergic reaction to the HA filler
  6. When there is vascular compromise secondary to the HA filler injection which can be caused by external compression on a vessel or intraluminal (within the vessel) injection

My experience with hyaluronidase has been mostly with patients that have had Juvederm injected in the tear trough area from another facility.  I strongly recommend that Juvederm not be injected in this area because of the risk of prolonged edema.  The reason this happens more with Juvederm is speculated to be due to its ability to attract more water, and because it spreads more diffusely than the other fillers.

When injecting hyaluronidase, it is mixed with lidocaine by the physician, so it is a fairly comfortable procedure.  There are a couple limiting factors with the injection.  It is not as precise as the filler injection, so it can remove some of the filler that you wanted to stay along with the unwanted filler.  Also, dosing/how much to use, is not an exact science.  It may take more than one treatment to dissolve the HA filler.  The results can occur within minutes, but usually take about a day to fully appreciate.  Also, Juvederm tends to be the hardest to dissolve, and it thought that this is related to the way it is cross linked (manufacturing process).  I imagine that Voluma would be similar to Juvederm or maybe even harder to dissolve, but I don’t have any experience with it yet.

The bottom line is that you don’t have to live with HA filler that you are not happy with.  You can easily reverse lips that are lumpy or too big, swelling around the eye from filler, or dissolve an over correction or asymmetry with hyaluronidase.  An injection with hyaluronidase can get you back to where you used to be in about 24 hours.  Also, it’s nice to have a little piece of mind when getting injected with an HA filler that the process can be completely reversed with a small procedure.

Dr. Steve Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and concentrates solely on non invasive and minimally invasive cosmetic procedures at The Aesthetic Clinique.   His website is http://www.theclinique.net .  Call for a consultation:  850.622.1214

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

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