Traditionally, lasers were the gold standard for acne scars. Specifically, ablative lasers, CO2 and Erbium, have been advocated over the nonablative lasers such as Fraxel 1550. In 2013, radiofrequency microneedling (RFM) was approved in the US and the dominance of lasers for acne scars has come under scrutiny. While there are indications for both technologies, this blog will elucidate the decision tree for which technology to use.
Fundamentally, ablative laser energy (heat) is generated outside the body and is driven into the skin at a temperature that causes ablation (vaporization) of the tissue ~ 100 C. Radiofrequency Microneedling generates it’s heat within the tissue by passing current through it. As the current encounters resistance (impedance), heat is produced to a level of coagulation ~ 65-70 C.
The number one concern with ablative laser is healing. While fractional technologies improve the downtime and risks, outcomes are sacrificed. Sometimes several treatments are recommended to match the results that fully ablative lasers would achieve. Downtimes are still around a week or longer with fractional CO2. More importantly, since the laser heats and ablates the most superficial skin layers, the risk of post inflammatory hyperpigmentation (PIH) is almost unavoidable in skin types 4-6. While PIH is reversible in most cases, it can take months in some cases. Wound care is essential with ablative lasers, particularly use of occlusive emollients, to maintain a moist wound for best healing. Unfortunately, occluding acne prone skin often leads to acne breakouts. When breakouts occur, there is risks of actually creating more acne scarring and becoming counter productive.
Healing with RFM is easier and less risky. While there are devices with uncoated needles, the author only advocates the coated or insulated needles. (Uncoated will have similar healing properties as the lasers). Using coated needles, the only injury to the superficial layers of skin are needle punctures. In essence, the device “bypasses” the epidermis. The heat generated from the RF will be in the deeper aspects of the skin, where there are no melanocytes, the pigment producing cells. While there is swelling, redness, and sometimes bruising, the downtime is less with RFM when compared to ablative lasers, usually 3-4 days (individuals do vary!). More importantly, the skin surface heals quickly (similar to microneedling) and there is no need for occlusive emollients.
The depths of acne scars is highly variable, and there can be superficial and deep scars in the same individual. This is probably the most important factor as to what technology to choose. RFM has the advantage for improving deep scars. While depths of RFM aren’t accurate in most devices, in the Genius they are. The Genius is able to reliably place coagulation zones down to 3.5mm. Of note, 3.5mm is typically much too deep to attack acne scars and typical settings are usually up to 2.5mm. Lasers can typically reach 1.5-1.7mm. The energy delivered diminishes as the pulse goes deeper because the energy is absorbed by the upper layers of the dermis. So for the superficial scars – boxcar specifically – give the advantage to the ablative lasers (Look up Dr. Lim 360 degree laser treatment). Keep in mind that the RFM devices can go superficial and treat boxcar scars too.
- Safer for all skin types
- Less downtime
- Deeper penetration
- Less PIH risk
- Less wound care
- Safe on all areas of the body
- Not as good with superficial scars but can still treat them
- Doesn’t resurface so no pigmentation improvements
- Good for superficial scars – boxcar
- Improves pigmentation
- Long(er) downtime
- Higher risk of PIH in types 4-6
- Doesn’t treat deeper scars as well
- More wound care that can lead to more acne
- Higher risks of infection/scarring than RFM
- Can’t be used off-face as safely as RFM
Keep in mind that acne scars require multiple modalities such as TCA Cross, subcision, fillers, skincare, PRP, amniotic growth factors to achieve optimal results. Multiple treatments are always required upfront, but also as the aging process causes collagen and fat pad volume loss.
Instagram is being used as a marketing tool for all types of industries. Unfortunately, you can’t believe everything you see touted. This is especially true for aesthetic procedures. As with any, make sure you do your research, the before and after pictures are actually comparable and aren’t using lighting “tricks”, and the provider is experienced and reputable.
- Lip flip with Botox – This procedure claims that the lip will turn up and make the lip fuller for very little money. If you weaken the muscles around the lips with Botox, there is no way this can end up lifting the lip. It also risks changing the smile, having difficulty with sipping and whistling.
- Thread Lifts – The procedure consists of placing barbed sutures just deep to the dermis. The barbs engage into the skin and by pulling laterally and upward, they are supposed to lift and tighten. The posts on Instagram mainly show providers pulling on the sutures and watching the skin move. The problem is the sutures aren’t anchored in most cases and are attached to mobile skin. It’s impossible to lift when the entire are desiring lift is move. In addition, the barbs pull through their attachments very quickly, much sooner than collagen can be created to help anchor the suture. The side effects – visible threads, redness, puckering, pain – are as high as 34% in one study. In the same study, visible improvements were not apparent at 12 months. The noticeable changes in the author’s opinion are extremely mild and can be achieved with fillers in a more predictable and longer lasting correction.
- Low Density PRP – PRP is short for platelet rich plasma. Unfortunately, there is no standard and the concentration for PRP is all over the map. In the majority of cases, 10-12cc of blood is being drawn to get 5-6cc of PRP. In these cases, the concentration is only about 2x (2 times the normal blood concentration) and all that has been done is the red blood cells have been removed by centrifugation. The benefits of PRP have been studied and optimal concentration levels to promote angiogenesis (new blood vessel growth) have been shown to be about 6X. If you are getting only a small test tube of blood drawn, you probably aren’t getting much benefit from the PRP.
- MicroBotox for Necklace (“Tech Neck”) Lines: Horizontal neck lines are often called “Tech Neck” because some people believe they are caused by look down at your phone or computer. Providers are reporting improvements with injecting Botox in the lines in very small but multiple injections. In the author’s opinion, this is not the correct solution and these require filler +/- RFM (Genius) for optimal results. Static lines are not responsive to Botox. Dynamic wrinkles are what respond to Botox.
- Using Radiofrequency That Doesn’t Penetrate Skin for Tightening: When an RF device is used to stimulate skin tightening, it must achieve 65-70 C to achieve coagulation. Anything short of coagulation causes temporary collagen contraction and denaturing but very minimal long-term effects. The epidermis needs to be kept at 42C or lower to avoid burns or hyperpigmentation. It is impossible to achieve coagulation in the dermis and still keep the skin surface at 42C or lower. So all the no downtime skin surface RF devices will need to be performed multiple times, have extremely variable results, and often very poor tightening effects. Optimal RF results require the energy to be introduced beneath the skin surface such as RF microneedling (Infini, Genius) or FaceTite/Accutite.
Remember, it all boils down to science whether a procedure works. If the science doesn’t make sense, the procedure probably doesn’t work.
- Consent – include pain, tenderness, infection, inadequate improvement, need for further treatments, PIH, scarring, compensatory sweating elsewhere, hair loss
- Starch-iodine sweat test and mark treatment area. Hair must be shaven.
- Apply 23%/7% lidocaine/tetracaine topical from Central Ave Pharmacy, Lipothene for at least 1 hour – 1.5 hours. Use 30% lidocaine ointment for darker skin types.
- Subsequent analgesia might be needed with either injections using mesoram device and lidocaine with epi mixture (5cc lido w epi/5cc saline/1cc bicarb) or just inject
- Pronox (Nitrous oxide mixture “Laughing Gas”) can be used as well.
- Clean off ointment with alcohol and clean skin with Hibiclens
- Use Zimmer air chiller and/or ice, ice roller, or Frozen C
- Perform 1-2 passes with each depth of Genius with breaks after each pass to chill and go to opposite side.
- 3 depths – 3.5, 3.0, 2.5mm – go deep to superficial with subsequent passes
- Energy/pin 40-60mj. Lower energies in darker skin types, poor pain tolerance
- (For Infini – Treatment level 3-5, 300-400msec if tolerated)
- Use sterile technique throughout – sterile gauze, sterile gloves, sterile saline
- Keep eye on skin reaction – avoid excessive heat build up, redness. Abort procedure if skin not tolerating energies.
- Infrared camera, if available, to monitor skin surface temperature – stay below 42C
- Clean skin with sterile gauze and saline.
- Apply Clindamycin gel.
- In darker skin types, consider 4% hydroquinone 1 week prior and for 4-6 weeks after.
- Expect decreased sweat in less than one week.
- Repeat treatment in 6 weeks or longer.
- 2-3 treatments needed to have “controllable sweating”.
While there are number of studies suggesting that lasers and RF do not affect fillers, a recent article by Dr. Weiss opened up the debate again. In his paper he stated that biopsies showed evidence of heating around the filler. It did not evaluated the changes in the filler volume over time. He concluded that the filler was at risk to be affected by the heat. Dr. Davin Lim’s recently published study contradicts Dr. Weiss, and showed with RFM, there was no affect on fillers (biopsy proved) at multiple different energy levels.
The heat from RF Microneedling reaches approximately 65-75 C for 100 msec to up to 3-4 seconds depending on the device and parameters used. This is the “hottest” version of RF delivery used in aesthetics. This compares to the sterilization process of the fillers at the (Galderma) manufacturing plant of 110-120 C for 15-20 minutes.
Lasers can heat the tissue to a higher level, up to 100 C, but again, it is for milliseconds at best.
Conclusion: There should be no concern regarding placement of HA fillers with RF Microneedling or lasers, at any level of the dermis or subcutanous planes on the same day. Furthermore, there will be no effect on previously placed HA filler. As a side note, PMMA has to be heated to 160 C to cause changes to it’s structure. While the exact temperature is unknown for calcium hydroxyapatite, it is significantly higher than HA, so it too is safe from RF and lasers.
There is an ongoing debate among injectors as to what method of injecting fillers is more accurate. The needle pundits state that the needle can inject in any tissue, at any depths. While this is true, is the filler actually placed where they think it is? Cannulas aficionados argument is that cannulas will stay in the plane which they are placed, and are therefore more accurate.
In a paper titled “Precision in Dermal Filling: A Comparison Between Needle and Cannula when Using Soft Tissue Fillers.” by Pavicic, Frank, Cotofan, et all, the debate was studied. There were 10 cadavers studied for supraperiosteal injections. The filler injected was radiopaque. Needles were placed in position using a perpendicular transcutaneous approach. The cannulas were placed in a similar position in the supraperiosteal plane. Using fluoroscopy, the injected material was analyzed in the horizontal and vertical planes.
The results show that in over 60% of the needle injections, the material changed planes (became more superficial) and this was not found in the cannulas group.
The conclusion was that cannula filler placement is more precise because the filler remains in the plane of the intended implantation much more so than needle placement.
Acne scars are routinely treated with laser and RF or RF microneedling. However, the optimal benefits are probably not achieved unless subcision is performed. Here’s why –
Acne scars frequently will have collagen scar fibers extending to the subcutaneous fat, fat pads, or fascial layers. These fibers cause tethering of the dermis, leading to the appearance of an atrophic scar.
FACT: RF and laser energy has a propensity to travel through collagen.
FACT: As energy/heat travels through collagen, it heats the collagen and leads to collagen contraction
Theory: When treating tethered scars, there is a possibility that the collagen contracts and actually makes the atrophic scars appear deeper
Theory: When energy/heat travels down the collagen fibers, some of it might be transferred to the surrounding fat and lead to fat atrophy.
Subcision is a process where the tethered collagen fibers are transected. By cutting these fibers, the energy can’t progress to the deeper layers of tissue and thus not cause possible fat atrophy or further deepening of the scars. I perform this on most patients undergoing laser or RF for acne scarring if I feel there is any degree of deeper scarring or tethering. There is also the benefit of subcision even without using energy based devices in improving acne scars.
Cannulas, specifically, blunt microcannulas, can be used to administer fillers by advanced injectors. They a favorable over needles because they have a blunt round tip and are flexible, leading to the following advantages:
- Less discomfort – one entry point can serve a large area, thus avoiding multiple dermal penetrations which is more uncomfortable.
- Less bruising – the rounded/blunt tip tends to bend around blood vessels rather than nick or penetrate them.
- More accurate – a recent study shows that the filler is most likely to be deposited in the area of the exit port vs a needle which has been shown to have filler travel up the shaft (back flow)
- Safer – cannulas are less likely to give intraluminal vessel injections because of the blunt tip and therefor less possibilities of vascular compromise and blindness.
However, a recent publication by Drs Pavicic, Cotofana et al. has shown that #4 comes into question with certain cannulas. There study consisted of a total of 294 penetrations of the superficial temporal artery in cadavers using 22, 25, and 27 gauge cannulas and needles. The force applied to enter the vessel was measured for each. The cannulas had statistically higher forces needed to enter the vessel for the 22 and 25 gauge cannulas.
Interestingly, there was no difference in the forces when comparing 27g cannulas and needles.
The conclusion was that a 27g cannula was not safer than a 27g needle when used for filler injections. While 27g cannulas can be used, it is up to the injector to realize these are not safer than needles and to take the appropriate safety measures during treatments.
(Article: Plast Reconstr Surg. 2019 Mar;143(3):504e-512e. doi: 10.1097/PRS.0000000000005321)
There is renewed interest in neuromodulator/neurotoxins because of 2 newcomers to the US aesthetic market. Jeuveau is FDA approved and Revance will be approved early 2020. To differentiate themselves, these 2 have focused on duration of action of their products. Here’s the lowdown on what patients need to know about these wrinkle eradication injections.
There is a well-recognized scale that grades the glabellar lines at full contraction. Grade zero being no lines and 4 being the most severe dynamic lines. Keep in mind that this scale references only lines which appear during motion, not the static lines found at rest. In order for the FDA to approve injectable neuromodulators for the glabellar lines, there must be a demonstrable 2 point improve in this scale after 30 days. The take home messages of these FDA studies are:
- The FDA considers a one-point improvement a failure, but the companies do not. There is literature and marketing by several companies stating their 4 or even 5 month duration for one-point improvements.
- At FDA approved dosing, most grade 4 glabellar lines will not relax to the grade-zero score. In fact, with any dosing, grade 4 patients will most likely still have movement and wrinkles after treatment.
- Not all patients had a 2 grade improvement in the FDA trials of any of the neuromodulators. Approximately 88-92% of patients responded to the FDA approved dosing.
- The effect of muscle relaxation peaks at about 2-4 weeks, and then gradually tapers off. Muscle strength eventually returns to baseline at 3-6 months, depending on the dosing and the product used.
- At 3-4 months, the FDA approved duration of the current modulators, a minority of patients still have 2 grade improvements in their glabella grade.
A well-established phenomenon with all the neuromodulators is the dose-response curve. The higher the dosing, the more effective the relaxation of the muscle injected. Additionally, the higher the dosing, the longer duration of the relaxation. Dr. John Josephs has performed studies on Dysport using dosing of 120 units (FDA approval is 50u) and has shown up to 6 months of 2 grade improvements in a significant proportion of patients. One “trick” he used when using these higher doses was to minimize the reconstitution volume to only 1cc. (Most practitioners use 1.5-3cc). Dr. Joseph refers to this technique as “A big dog on a short leash”. In other words, high dosing with limited spread in order to limit adverse events.
An as yet to be approved neuromodulator from Revance will be after a 6 month approval of their product. While at first glance, their 40 unit dosing will appear to be using the phenomenon of higher dosing – longer duration, this is not the case. Neuromodulators units, unfortunately, are not uniform between companies. A study Revance performed on the actually molecular weight of the active neurotoxin in their dosing showed that it was equal to that of the 20 unit dosing of Botox. They also evaluated Dysport’s weight, which was shown to be 50% higher than Botox and Revance, while Xeomin was actually 50% less than Botox/Revance.
What makes Revance’s neuromodulator last longer? It’s an associated proprietary protein that does not dissociate upon reconstitution. It is hypothesized that this protein’s ionic charge leads to better attraction to the receptor at the neuromuscular endplate. Revance’s product is essentially “more efficient” at binding, and therefore blocks more of the muscle movement than the other neuromodulators on the market at FDA approved dosing. Normally, there is some “wasted” neuromodulator which doesn’t bind and is swept away by the lymphatics and blood stream. The proprietary protein mimics what higher dosing would accomplish.
Neuromodulators work by blocking the release of acetylcholine at the neuromuscular endplate of the nerves. Return of function of the muscle is established when new nerve fibers are grown and re-establish contact with the muscle. If more nerves are blocked, it will take longer for the return of muscle function. If all the endplates were blocked to a muscle, studies have shown it takes 9 months for return of function.
After explaining all the numbers, it must be remembered that each patient reacts differently to the neuromodulators. As previously explained in another blog, once water/saline is added to the vials of Botox/Dysport/Xeomin/Jeuveau, there is only active protein in the vial within about a minute. The differences between the products are related to dosing, spread, and experience of the injector. As previously mentioned, Dysport has the highest weight of active neurotoxin in its FDA approved dosing and is the author’s choice amongst the current FDA approved neuromodulators.
The aging phenomenon affects all the areas of the face and body. Sun exposed areas will be most affected due to the collagen destroying effects of UVA and UVB light. Dr. Weiner has developed a technique which addresses many different aspects of the aging neck, and, better yet, it’s all minimally invasive.
Hyperpigmentation is a sign of UV damage and aging. It can be addressed with nonablative lasers, such as the Thullium 1927nm laser (Fraxel Dual/LaseMD). In some patients, there is also an associated redness, such as in poikiloderma. Redness needs a vascular laser such as the Excel V + laser. Skincare products are essential in maintaining results and must include a retinol, growth factor, and SPF.
Much has been written about fat loss in the face, but this process will also affect the neck. Recent articles have validated safety with collagen stimulating fillers in the neck if done with careful technique. Deeper lines and wrinkles might also require a hyaluronic acid filler (HA) for improvement
Loss of collagen, elastin, and gravity contribute to skin laxity in the neck. Radiofrequency seems to be the leader of the pack for tightening skin and building collagen and elastin. There are a couple different methods to use RF in the neck such as The Genius, FaceTite/NeckTite/AccuTite.
There is more literature supporting the platysma muscle becomes stronger as one ages. This leads to neck bands, jawline sagging, and corners of the mouth drooping. Strategic placement of a neuromodulator in the platysma can improve the appearance of the jawline and neck.
Fat can accumulate in the chin area (double chin) and along the jawline. Methods used to improve the appearance of the fat in these areas includes: Kybella, Genius, FaceTite/NeckTite/AccuTite. If these procedures are done, the other procedures listed above will have to done on a different treatment day. Jowling can also be improved with these methods.
By combining these treatments, usually done in a series, multiple areas of the aging process can be addressed. Upkeep with future treatments and skincare is essential to maintain long-term results. To see if Dr. Weiner’s “TriNECKta” treatment is right for you, please call the office: 850-622-1214.
The aging process leads to hyperactivity of the muscles of the face. This movement leads to increased wrinkles and loss of the smooth, youthful appearance of the skin. In the upper face, neuromodulators such as Dysport and Botox, do a great job at relaxing this hyperactivity. What’s trending with aesthetic providers is dampening the muscle movement but not complete relaxation, leading to a more natural expression without “freezing” the patient.
Unfortunately, the neuromodulators can’t be administered throughout the entire face. In the lower face, low doses of neuromodulators are safe for the lips, chin, gummy smile, and DAO (AKA RBF) muscles for the most part. Inhibiting the lower face too much leads to changes with expression and smiling. What can be done to control the muscles in this area? Filler!
(Side note: Hyperactivity of the lower face has been described by Dr. Weiner in gum chewers in a previous blog. It leads to accelerated aging in the lower face and should be discouraged by aesthetic providers.)
An interesting study by Dr. Nowell Solish supports this concept. Using a rather large and sophisticated machine, Dr. Solish was able to determine muscle strain in the lower face during facial expressions. He compared patients in their 50’s to ones in their 30’s. As expected, the older patients had more muscle strain than the younger patients. He then injected the older population with Restylane Refyne and Defyne, 3-4cc in the perioral area. These fillers have XPresHAn technology and have flexibility – stretch capabilities. After the injections, the older patients were restudied for muscle strain. The findings: The muscle strain of the 2 groups (older vs younger) were basically the same. The filler was able to reduce the muscle strain about 15 – 20 years!
What’s the explanation? Dr. de Maio has coined the term myomodulation. His theory is that filler placed around hyperactive muscle leads to stretching and relaxation of the muscle. While this is plausible, there is probably a better way to describe this phenomenon.
Dr. Weiner’s theory: Think of an Aston Martin that has a top speed of 230 mph or more. However, in the US, to conform to the laws and regulations, governors are placed on the car to keep its top speed at 180 (This is purely hypothetical and used for illustrative purposes only). Dr. Weiner feels the fillers Refyne/Defyne limit the full range of movement of the hyperactive muscle, akin to a governor on the muscle. Why these fillers work so well at doing this is because they can stretch and recoil (akin to a tether), leading to some, but not excessive muscle movement. Other fillers would work but with a different and less natural mechanism. Think of the non-flexible fillers as acting as a wall, and not as a governor or tether.
With the new XPresHAn fillers, Refyne and Defyne, we now have a new treatment modality for the lower face which is highly effective. Myomodulation is real, exactly what is the underlying mechanism is still debatable.