The concept of applying radiofrequency energy into the skin has changed in the past few years. The “older” methods use a process called “bulk heating” to apply the energy to the surface of the skin which will diffuse to the deeper layers of the dermis. The deficiencies of this method are:
- The heating is not precise, with the depths unknown.
- The epidermis is at risk for too much heat, leading to potential for scarring or pigmentation issues.
- Subdermal fat is at risk if the heating goes too deep.
- The heating is bulk and not fractional, so safety is less.
- The highest temperature achieved is about 45 degrees, enough to minimally stimulate collagen.
The progression of technology with RF heating of the skin has evolved to a process that is more precise. Using microneedles, RF energy is able to be placed at desired depths in the dermis. The deeper, fractional heating is much higher than if placed on the skin surface. It enables the temperatures to get to 65-70 degrees C, enough cause coagulation. Coagulation leads to maximal collagen stimulation and tissue contraction. In regards to the microneedles, there are 2 types of needles used: Insulated and Noninsulated. The noninsulated needles deliver energy only at the exposed tips, completely bypassing the more sensitive epidermis. On the other hand, noninsulated needles allow the energy to transmit along the entire length of the needle, creating a wound that includes the epidermis. When the epidermis is heated to point of coagulation, there is wound care and potential for pigmentation and scarring. The only way these uncoated needles get around potential safety problems is by delivering less energy. The advantages of microneedling insulated delivery of RF are:
- More precise level of RF energy delivery.
- Fractional heating of dermis, which is safer than bulk heating.
- Bypassing the epidermis so darker skin types are more safely treated.
- Higher energies can be placed leading to coagulation and better collagen stimulation.
- Insulation leads to better epidermal protection, less downtime, and potentially higher energies.
The main devices that deliver RF through microneedles with insulated needles are Infini and Profound. There are actually significant differences that might not be apparent to even the most informed providers.
- Infini uses 49 needles while Profound uses 10 needles.
- Infini can treat at 0.25 mm incremental depths between 0.1 – 3.5 mm while Profound has just 2 possible depths.
- Infini’s pulse durations are up to 500 milleseconds while Profound’s pulses are 3-5 seconds.
- Infini uses multiple passes to create thousands of coagulation zones whereas Profound uses only one pass.
What does this all mean? It means that the coagulation wounds placed with the Profound are less in number but much larger in size. The downside to larger wounds is that there is longer healing times because the unaffected tissue which is needed to assist in healing is further from the center of coagulation. With smaller coagulation zones as in the Infini, the wound healing is shorter in duration. In addition, the healing in the desired fashion (without scarring) is easier to control with multiple smaller wounds than it is for fewer, larger wounds. The concept of fractional ablation being safer and with less downtime (popularized by the Fraxel laser) loses it advantage as the wounds get larger.
It boils down to: The Infini creates smaller and many more coagulation zones than the Profound which creates larger and fewer zones. Safety and recovery are improved with the more plentiful, smaller coagulation zones of the Infini.
Tattoo removal is most effectively performed with lasers. The mechanism by which the laser works is by breaking up the larger ink granules into smaller particles. The body is unable to clear the larger particles but when smaller, the immune system is capable of clearing the ink. Successful clearance of a tattoo is dependent on several factors which will be highlighted in the remainder of the blog. While the experience of the physician performing the tattoo removal can’t be ignored, he/she is limited by the laser being used.
There are 3 aspects that need to be considered in a tattoo laser. They are power (and spot size), wavelengths, and pulse durations.
Power is a measure of how much energy can be delivered to the skin. What’s more important is how much is getting to the level of tattoo. It remains obvious, the more power delivered to a tattoo, the better clearance there should be. This is limited by the damage to the skin and surrounding soft tissue. Excessive energy to the superficial skin can lead to blistering, prolonged healing, scarring, and pigmentation changes. High-power lasers are able to use large spot sizes (10-15mm) to deliver the energy to the tattoo. Larger spot sizes give deeper penetration of energy and a safer treatment. Under-powered lasers need smaller spot sizes to get enough energy into the skin to cause an effect on the tattoo. This leads to the superficial skin heating up and potential for blistering/scarring.
When comparing energies between lasers, most companies measure the output from the laser. What is not discussed is how much the energy is diminished while going through the arms, mirrors, and handpiece. This can account for 20-30% less energy at the skin than what is the measured output of the laser in the lab. (The energy measured by the Piqo4 system is to the skin while all other systems is output from laser.)
The wavelength of a tattoo laser determines what colors it can treat. The most common color in tattoos is black. The best wavelength for treating black inks is 1064nm. This wavelength also is the safest for darker skin type. Even if the tattoo doesn’t look like it has black ink, over 95% have some component of black ink. It is imperative that the laser chosen for tattoo removal has a 1064 wavelength. The next most common ink is red. This is best treated with a 532 wavelength. Almost always, the 532 and 1064 wavelengths are packaged together in the same laser. It requires a doubling of the frequency to go from 1064 to 532 (double frequency means halving wavelength). The remaining colors require a variety of wavelengths so it is essential to have multiple wavelengths to treat colored tattoos. The lighter the color – pink, yellow, white, light blue – the harder it is to treat.
The lasers for tattoo removal are much faster than lasers used for hair removal, photofacials, telangiectasias, and leg veins. Where as the typical pulse duration is measured in milliseconds for the dermal treatments, tattoo lasers are measured in either nanoseconds or picoseconds (1000x – 1,000,000x). These extremely short pulses lead to extremely high energies being placed into the tattoo. This energy leads to a shock wave hitting the ink and breaking it up. The faster the pulse, the higher the energy and the more directed the energy is to the ink and less to the surrounding tissues. The longer the pulse, the more time the energy has to spread to the tissues. In the author’s opinion, initial treatments for tattoos are best performed with nanosecond pulses (to break up the larger ink particles) while the later treatments need picosecond pulses to clear the remaining ink particles which are smaller in size. It is most effective to have a laser with both nano and picosecond capabilities for treating tattoos.
The Best Laser for Tattoo Removal
After understanding the important qualities required in a laser for optimal treatment of a tattoo, it becomes fairly easy to see the obvious best laser. The Piqo4 has the highest energy (to the skin) of all nano/picosecond lasers. As a corollary, it has the largest spot sizes on the market – meaning safer, deeper, and faster treatments. With it’s 4 wavelengths, it has the capabilities to treat the 9 most common colors. It has 4 different pulse durations – 2 and 8 nanosecond and 600 and 800 picosecond. In conclusion, the Piqo4 combines high power, 4 wavelengths, and multiple pulse durations to enable it’s lasers to be the most effective option available on the market.
The ideal facial shaped has been described as “heart shaped”, “V shaped”, or “Upside Down Egg”. A youthful face draws attention to the upper face and eyes. With aging, the lower face becomes “heavier” and more dominant, as laxity and volume loss set it. Instead of round or oval, the shape of the face becomes closer to square. The underlying cause for these changes is primarily loss of fat, muscle, and bone.
The upper face’s width is determined primary by the temples. Fat pads in this area are particularly susceptible to atrophy associated with aging and exercise. To reestablish the youthful facial shape, it is essential to reflate the temples. There is a contiguous fat pad in the preauricular area which follows similar volume loss as the temples and should be volumized simultaneously. When the lateral cheeks are given filler, the temporal deficits become exaggerated and more obvious. Patients must be counseled on their temples whenever cheeks injected.
Besides the overall facial shape change, the benefits of filling the temples are the lift given to the surrounding tissues. The brow, and upper eyelid will be elevated with temporal filler. Placement of filler along the orbital rim and lower forehead further enhances this effect. The ideal temple should be convex in a women and slightly concave in the male.
The filling of the temples is reserved for the experienced injector. Dr. Weiner’s choice for this area is Sculptra because of its safety and natural appearance. The only downside to Sculptra is that when placed along the bone in the deepest aspect of the temporal fossa, a large volume of product is needed for complete correction. To finish corrections after the deep Sculptra placement, a superficial layer of HA filler (Restylane, Juvederm) can be safely placed using large bore cannulas. The filler is placed immediately below the dermis in the subcutaneous layer or just below the superficial layer of the temporalis fascia.
To reverse the signs of aging and restore the upper face dominance, temple volumization is required. It must be considered for patients that have brow and eyelid heaviness as well. This is an area that is difficult to treat with higher than average safety risks, and should be reserved for the most experienced injectors.
There are now several procedures to make those private moments even better. There is no downtime and minimal discomfort with these procedures and they should boost your self confidence.
- Botox for sweating: Most people are familiar with Botox for wrinkles. What most don’t know is that it also stops sweating. It works by inhibiting the nerves to the apocrine and eccrine glands from secreting sweat. Botox can be injected in the pubic area to improve the sweat and the odor associated with it. It can be done in less than 5 minutes and should last 4-6 months. Dr. Weiner has developed a technique that makes it go faster and gives less discomfort than standard injections. The results are apparent about 3-4 days after treatment. Men and women can benefit from this procedure.
- Fillers for the labia: Just as with the face, as we age, the labia (majora) loses fat. This can easily be improved with fillers. Dr. Weiner uses cannulas for this so the amount of insertion points is either 1 or 2 per side maximum. All the fillers can be used here but Radiesse and Sculptra are the preferred choice.
- ThermiVa for rejuvenation: ThermVa is able to improve multiple different problems with a series of painless 45 minute procedures. It uses a temperature controlled wand that cause collagen stimulation, tissue contraction, and rejuvenation of the vaginal mucosa. The treatment improves: dryness, laxity, labial (minora) hypertrophy, urinary incontinence, and in some cases, orgasmic dysfunction.
Build you confidence and pleasure under the sheets with these 3 easy procedures. Downtime, side effects, and discomfort are minimal. These are procedures both you and your partner can enjoy.
It doesn’t matter how long you spend in the gym. Most women still want a more rounded, lifted buttocks and legs with less cellulite. Wouldn’t it be nice if both of these could be improved with just injections?
There is a new procedure that uses a long term filler for a new purpose. Sculptra has been FDA approved since 2004 for use in the face for volume loss. It works by stimulating one’s own body to produce collagen in response to the PLLA (Poly L Lactic Acid), it’s main component. It takes 2-3 months to appreciate the correction from Sculptra. The result of Sculptra should last years because newly formed collagen lasts 7 years in other areas of the body.
How the procedure works is by filling in the dimples and creases associated with the cellulite with injections. The correction is seen immediately but that subsides rather quickly because it is mostly saline. Over the next several weeks, collagen is gradually built up from the PLLA injected, and the cellulite appearance improv es. Severe laxity and “cottage cheese” of the skin is not correctable.
Creating a Brazilian Butt Lift with Sculptra is an extremely easy procedure to get done. There is no liposuction required, no healing/soreness from fat harvest, no need to sit on donuts or in some cases “avoid sitting at all costs”. It can be done in 15 minutes and is nearly painless. Dr. Weiner prefers to do the procedure in a series of 3-4 treatments. Each injection is done using cannulas for minimal bruising and discomfort. Approximately 4 vials are used per treatments. Long lasting improvements in lifting and fullness should be expected from Sculptra which appears gradually over several months.
Having a minimally invasive alternative to these traditionally difficult to treat “problems” is a breakthrough for those patients “on the go”. In contrast, a formal BBL requires weeks to recover, restrictions on exercise/sitting and sometimes need “redos”. These Sculptra injections can be done in about 15 minutes and have no downtime except for bruising, with results lasting for years.
Dr. Weiner’s “Superficial Skin Block” to Numb The Face for Aesthetic Procedures – Infini and Laser Resurfacing
Some of the fastest growing and most popular procedures in the Aesthetic Industry are radiofrequency and laser procedures. The most sighted obstacle for patients doing these procedures is pain. Dr. Weiner has develop and perfected a method to numb the face fairly thoroughly that is fairly quick and simple. The “Superficial Skin Block” takes about 3 minutes to administer for the entire face. It requires no knowledge of neural anatomy and is less invasive/more comfortable than nerve blocks. The anesthesia kicks in within minutes and will last at least a couple hours. It is ideal for improving comfort when undergoing the Infini, CO2, Erbium, or Fraxel laser resurfacing. Dr. Weiner’s mixture for injection is:
- Lidocaine 1% with 1:100,000 Epinephrine (Standard premixed from most medical suppliers)- 5cc
- Bacteriostatic 0.9% Sodium Chloride with Preservative – 5cc
- 8.4% Sodium Bicarbonate – 1cc
- All this is drawn up in a 10cc syringe
The “Superficial Skin Block” starts with placement of topical numbing cream. Dr. Weiner uses “Lipothene” from Central Avenue Pharmacy which contains 23% Lidocaine and 7% Tetracaine. It is left on the face for at least 1 hour. Do not place on face and neck simultaneously. This is too large a surface area for the topical. The neck doesn’t require this strong a topical in Dr. Weiner’s experience.
The injection requires a mesotherapy apparatus from Mesoram.com. The exact device used is found at: Dr. Weiner’s Preferred Mesoram Needles . The needles are 4mm, 30g and the plate is circular with 7 needle connectors. Plates can also be purchased without needles and 32g needles can be purchased from the site and attached manually.
The topical is wiped off and the face is cleaned with alcohol and hibiclens. The injection is started on the cheeks with 0.5 ml aliquots placed in each injection. The areas injected are slightly overlapped. A small amount of the mixture is placed above the upper lip with a needle that is removed from the device. A few minutes are allowed before starting the procedure to allow for the small blebs to diffuse into the skin tissues. You will notice areas injected become pale and this is the epinephrine effect. This helps in controlling bleeding and bruising.
Dr. Weiner’s Superficial Skin Block has been used by multiple practitioners with great success. It’s effectiveness, ease of use, and limited downside make it perfect for many aesthetic procedures, particularly Infini and laser resurfacing.
Until recently, the dreaded double chin has been fairly difficult to treat. Liposuction was the mainstay of treatment. This can be performed under local anesthetic, but there is downtime, bruising, need to wear a chin strap, and some risks. Now, there are 3 non surgical options to treat this area and along the jawline (with 2 of them) which have no or minimal downtime.
Kybella is a bile salt (deoxycholic acid) that is found in the gallbladder. It is natural secreted to assist the body in digesting consumed fat. It is now available in an injection form and can be used in the submental area to permanently reduce fat. It typically requires 1-2 vials per session, and about 2-4 session. This is all dependent on the amount of fat in this area. 1 month to 6 weeks in the recommended period between treatments. The procedure takes about 15 minutes. There is very minimal pain at first. It then starts burning and this lasts for up t0 30 minutes. Swelling occurs for the first 3 days that is significant. Most of the swelling is gone by a week. All swelling is gone by about 3-4 weeks and results are seen at this time. Areas other than the submental area are being investigated
Pros: short procedure, effective for submental area, long lasting results
Cons: swelling, can’t be used along lateral neck – only central portion, multiple treatments
CoolMini from Coolsculpting is a new handpiece that is designed to treat the upper neck area. At this point, most people have heard of Coolsculpting. This technology cools fat down to a certain temperature to where it will partial die, but leave the other structures intact. The CoolMini is a newer technology from Coolsculpting that uses more uniform cooling, and doesn’t require the full one hour to get treated. It’s suction grabs onto the fatty area and stays attached for the 45 minute cycle. It can be used to the central and lateral portions of the neck. If there are large areas needing treatment, more than one session is needed and more than one attachment is needed per session.
Pros: minimal or no downtime, can treat lateral as well as submental fat, proven technology that is permanent
Cons: treatment times are 45 min per application, might need more than one application and more than one session
Infini uses high intensity radiofrequency to treat excessive fat in the neck. It gets to the fat by use of the microneedling delivery system. It can go up to 3.5 mm which is into the superficial layer of fat. By adjusting the power and pulse duration, fat along the jawline, jowls, and submental areat can be treated. It is usually a series of 3 treatments, spaced about 4-6 weeks apart.
Pros: can treat all areas of fat in the neck and jowls, tightens skin as well and improves wrinkles
Cons: requires topical anesthetic (more painful than others), requires 3 treatments usually, mild redness and swelling afterwards for a couple days
There are now a few ways to treat the neck and double chin area. Which one is best for you is based on your desires, lifestyle, and anatomy. All are effective with minimal or non invasive techniques.
Coolsculpting has established itself as the worlds #1 noninvasive fat reduction treatment. It has over 3 million treatments worldwide and has been found to be a safe, well tolerated, and reliable procedure. It was FDA approved to cool skin to allow for anesthesia in 2009 and later in 2010, it was given the permanent fat reduction approval.
Coolsculpting treatments involve attaching a handpiece to the area of desired fat removal. There are various sizes of handpieces to assist in reaching all the different areas of the body where there is excessive fat. Most of these handpieces use a suction to pull/draw the tissue and fat into the handpiece, so a requirement (except for the outer thigh where a flat handpiece is used) is that there is “pinchable” fat. These handpieces gradually cool the area treated to the optimal temperature where the fat is killed but the surrounding tissues (skin, blood vessels, nerves) are kept safe. The attachment duration has been 1 hour until recently. It has been proven that about 25% of the fat treated will be removed during this process. It has also been shown that massaging the area treated immediately after handpiece removal improved the outcomes too. There was more fat loss and less post procedure discomfort.
There was a study last year that showed the Zimmer Z Wave treatment, done in place of the massage, lead to a 65-100% improvement in outcomes. In large volume practices, including Dr. Weiner’s office, this is now routinely performed on all Coolsculpting patients immediately when the handpieces are removed. The Z Wave uses radio pulsed technology that send shock waves through the tissues. When these waves bump against newly frozen fat cells, the already compromised cell is further damaged. This increases the amount of fat cell death from the Coolsculpting treatment. Another way to explain how it works is that with Coolsculpting, there are cells that are killed, cells that aren’t, and cells that are undecided. The Z Wave pushes some of these undecided cells to the point that they will die.
A recent advancement in the handpiece technology has been developed. This is the found in the CoolAdvantage and CoolMini handpiece. The changes consist of a more uniform cooling of the area treated. Older handpieces had cooling elements only on the sides of the handpiece cup but the newer has cooling throughout. What does this do to change the treatments? It lowers the treatment time from 1 hour to 35 minutes (45 min with the CoolMini). The newer handpieces have less depth, so more fibrous, less flexible skin areas can now be treated. This also translate into a much more comfortable treatment because there is less pulling in of the tissues. It has been found that post treatment discomfort is also less. There are reports that these handpieces are more effective because there are no longer fat pockets that might not get to the critical temperature need for death.
With the addition of CoolAdvantage technology and the Zimmer Z Wave, Coolsculpting treatment times are almost cut in half, treatments are more comfortable (during and after), and most importantly, the procedure is significantly more efficacious. When researching providers, make sure they use these new technologies.
It’s been a little over 3 years since the Infini was introduced in the United States in August, 2013 by Lutronic. It was developed in Korea, and had been used in the prior 2 years in Asia and Europe. Infini brought a significant evolutionary change to treating the skin with radiofrequency (RF). Although RF has an over 50 year history of medical uses, Lutronic’s Infini innovations has elevated the precision in which the RF energy is delivered to an entirely new level.
It been long established that heating skin causes an inflammatory response that results in collagen stimulation, tissue contraction, and skin rejuvenation. While 42-45 C (denaturing) has shown to be enough to create this cascade, 65-70 C (coagulation) has been shown to lead to maximum collagen deposition. Radiofrequency devices which push their energy through the skin without penetration are limited to temperatures of 45 C because of the risk of harming the skin surface (blisters/scarring). Bypassing the surface with microneedles, as Infini does, temperatures can go up to the coagulation point with very little risk. In addition, Infini can place this energy at the “sweet spot” of the skin, the mid to deep dermis. The depth of most of the predecessor RF devices was always in question, and was often too deep (fat necrosis risk).
Over the last several months, there have been significant treatment innovations with Infini. With diligent research and histological evaluations, optimal settings were further enhanced. These settings lead to larger zones of coagulation during each pulse. This translates into fewer pulses needed (shorter treatment times), and better results. In addition, the treatment tip was modified to allow for a more even distribution of energy, which also leads to better outcomes. The “price to pay” for these innovations is slightly more prolonged redness, possibly up to a week. Also, “microdots”, the grid-like white marks from the needle tips, might last for more than a couple weeks. These have always resolved without scarring or complications.
Dr. Weiner has performed approximately 1000 cases in the past 3 years with Infini. (Cases = areas treated, i.e face, neck, chest). A summary of his findings:
- There have been no long term complications in his patients. There have been no incidences of scarring, unwanted fat loss, or pigmentation issues.
- Infini is safe to use on all skin types.
- Infini is the most effective device available for acne scarring when compared to ablative, non ablative lasers, and other RF devices.
- Significant improvements can be established in the neck wrinkles, necklace lines, and creepy skin of the neck.
- Superficial fine lines on the face are well treated.
- Jawline and submental definition are improved in most cases. Purposeful fat loss is possible in these areas with deeper, more aggressive settings.
- Infini is an option for axillary hyperhidrosis with proven long term results.
- Infini can be safely used all over the body but the small footplate limits treatments on large surface areas.
- Treatment of stretchmarks is only mildly effective. Further refinements in settings and combination therapies are still being researched.
- Treatment of malar festoons (fat pads) is moderately effective with Infini (and will soon be even better with new protocols).
- Over 95% of patients can be treated with only topical anesthesia. With the addition of the Superficial Skin Block, treatments are extremely well tolerated by the remaining patients.
- For optimal results, some patients need volumization and Sculptra can be done simultaneously with Infini treatments.
Infini has already established itself as a low risk, low downtime, skin tightening procedure. Expect better results, less number of treatments needed, and new indications in the future. Significant resources at Lutronic will build upon the Infini platform to maintain its market dominance in the Aesthetic RF market.
There are currently 2 dermal fillers FDA approved for enhancing the cheeks – Voluma and Restylane Lyft. These are both HA (Hyaluronic acid) fillers which are injected into the deeper tissues of the cheek to volumize and lift the cheeks. By lifting the cheeks, the entire lower face is lifted as well, including the jowl area, nasolabial folds, and jawline. It is well known that for an aging face with volume loss, the mainstay of treatment starts with the cheek area.
There are 2 main distinctions between Voluma and Lyft. The first is G prime, which is a measure of resistance of a fluid to flow. What this translates into when injected into the body is it’s “lifting ability”. There is huge difference between the 2 with Lyft at 531 and Voluma at almost 1/2 of Lyft at 274. Although this is not important according to Allergan, the makers of Voluma, this was found to be significant in our challenge. The other factor is cohesivity. This has only been popularized since Voluma was introduced and it the pressure needed to “flatten” the filler. What this translate in the body is the amount of spreading of the filler in the body. Voluma is higher in this category (less spreading) when compared to Lyft, but it’s importance is not known.
When Voluma was introduced to the market, there was significant marketing on it’s “2 year duration”. What wasn’t discussed was how this FDA designation was obtained. Most people in the study were injected at 2 different times. Also, the average amount of filler injected was over 6 syringes. Lastly, only a minority of subjects had evidence of some correction at the end of 2 years. These important details are left out of most discussions with physicians, and certainly not what the public understands about Voluma. In addition, Voluma’s pricing is much higher than all the other fillers on the market, but justifies these prices due to it’s longer duration.
The “Cheek Challenge” was performed by Dr. Weiner to try to vet out whether there are significant differences between Restylane Lyft and Voluma. To try to keep the study similar to the FDA study, a total of 6cc was injected, 3 of Lyft on the right cheek, and 3 of Voluma on the left cheek. Follow ups and photos were taken at 1-2 month intervals for 1 year. There was no secondary injections because this is what most closely represents a real patient’s experience. Keep in mind this is only one patient but Dr. Weiner did challenge other physicians to do the same, similar to the “Ice Bucket Challenge”. There were about 4-5 other physicians which have also done the “Cheek Challenge”. Their findings have been similar per private discussions with them.
- Duration of improvement was the same. AT 12 MONTHS, THERE WAS NO DIFFERENCE BETWEEN THE RESTYLANE LYFT AND VOLUMA TREATED SIDES AND THE BASELINE PRE PROCEDURE PICTURES.
- During the year, the patient noted that the Restylane Lyft cheek felt higher than the Voluma side.
- During the year, the patient felt that the Voluma cheek dropped slighted.
- During the first 1-2 weeks, more swelling was noted on the Lyft side.
- There was no difference in pain between the 2 sides.
- Noted improvements were seen in jowls, jawline, NLF, cheeks, and periocular area on both sides of face.
Although this is only a single patient, these results support multiple clinicians findings that Voluma’s duration is very similar to other HA products. Even with the use of 6 syringes, which is rarely used in a single patient, the duration did not exceed 12 months. Patients need to be counseled that 12 months is what can be expected for Voluma’s longevity. Less expensive and higher G prime filler, Restylane Lyft, seems to be a better choice for volumizing the cheek complex.