It’s been touted for years by the aesthetic physicians – “Prejuvenation” – starting maintenance treatments in one’s late teens or early twenties. The Kardashians have popularized these minor cosmetic tweaks to stay youthful and refreshed with visits to their Beverly Hills physician, documented regularly on “Keeping Up with the Kardashians”. There is increasing pressure to get that perfect selfie for Instagram or to look cool and attractive on a “Snap”. Unfortunately filters don’t work well with videos unless you want to look like a cute puppy. Doctors are in agreement (for any disease process) that it is much easier to treat problems in their early stages than to reverse them after they have spiraled out of control. Small preventative treatments early on, can maintain and even enhance one’s looks for many years and avoid invasive surgical procedures in the future. The question is, which procedures should be considered for Prejuevenation?
Neuromodulators: These wrinkle improving injections take less than 5 minutes and have no downtime. Millions of these procedures are done each year and it is the most popular cosmetic procedure performed worldwide. Most often these are used in the younger population in the frown lines (glabella), forehead lines, and crows feet. Treating these areas before the lines set in at rest, known as “etched in” lines, is one of the fundamental concepts of Prejuvenation. (Suggestions: Dysport, Botox)
Dermal Fillers: Dermal fillers made from hyaluronic acid (HA) are used to improve the minor volume loss which occurs with age. In the more athletic patients, fat loss can be appreciated in the face as well as throughout the body. Supple enhancements can be added to the mid cheek and around the eye to stave off this premature volume loss. HA fillers are also used to plump up the lips to create a youthful appearance. (Suggestions: Restylane Refyne, Restylane L, Restylane Lyft, Sculptra)
Chemical Peels: To keep the skin in top notch shape and to reverse early sun damage, chemical peels can exfoliate the superficial layers of skin. This renews the texture and pigmentation and leaves a youthful and glowing quality to the skin. (Suggestions: Illuminize, Vitalize, ZO 3 Step Peel)
Skin care: Great skin care is the basis for good looking skin. Most would agree that some type of Retin A or Retinol is essential for maintaining youthful skin. These products lead to increased turnover of the skin cells, improve dyspigmentation (pigmentation problems), thicken the skin, and create a more hydrated skin. Sun protection with an SPF should be part of one’s daily regime. It is also highly recommended to apply growth factors to the skin to reverse the aging process. (Suggestions: ZO Skin Health, Lifeline Stem Cell Skincare)
Prejuvenation is a trend that is here to stay. Preventative maintenance will prolong the need for more aggressive corrections in the later years. With short, no downtime procedures such as neuromodulators, chemical peels, fillers, and a good skin care regime, youthful, natural appearances will persist for years. Stay ahead of the curve with Prejuvenation.
Acne affects millions of people in the US, and is the most common reason to seek medical attention from a Dermatologist. Billions of dollars are spent on medications to control the disease, both over the counter and prescription. Medications have potential side effects, and compliance is difficult. Even with aggressive medical therapy, acne can be difficult to control, which leads to frustration by patients, parents, and physicians. With prolonged cases of acne, scarring can set in, creating an even more difficult problem to treat.
It’s the early teen years, as one is experiencing puberty, when acne usually starts. This period coincides with high school, selfies, and an interest in dating. Acne can negatively impact social interactions and lead to depression, moodiness, negative self-worth, and isolation. Controlling acne is a top priority for large number of teenagers in the US.
A cascade of events leads to acne:
- A trigger: hormonal, emotional, stress, metabolic
- Increased sebum (oil) production from sebaceous glands
- Plugging of the follicles by the sebum
- Infection of the sebum by bacteria
- Inflammation related to the infection/immune response
Treating acne with lasers is not a new concept, but the Aerolase has made the process more effective and safer. Even the wavelength, 1064nm YAG laser, is not novel to the Aerolase. However, having a pulse width of 650 microseconds is unique. The Aerolase sits in the middle of the prior lasers used to treat acne, the Q Switched (nanosecond) and the Excel V/VBeam (millisecond). It has been shown that this pulse width is better tolerated than faster and slower lasers, and therefore more pulses and even stacking can occur. Deeper and more broadly-based heating occurs with the Aerolase. With the increased heating of the acne, the laser becomes more effective in its eradication. The 1064 wavelength is safe for all skin types, but settings are reduced for the darker skin patients. The Aerolase laser treats acne by:
- Heating up and shrinking the sebaceous glands leading to lower sebum output
- Killing the acne bacteria
- Reducing the redness associated with the acne
- Improving early scarring
- Reducing the inflammatory component of acne
Typically, a series of treatments are needed, 4-6, about a week or two apart. Touch ups are needed every 1-3 months. Flairs should be treated acutely, so they are controlled quickly. Continues use of topical therapy is usually recommended, such as Retin A and benzyl peroxide. The Aerolase gives patients a unique, no downtime, near painless 10-minute procedure to help control even the most difficult cystic acne.
“Get rid of that Instagram filter and show your true selfie.”
The addition of the CoolAdvantage handpieces, Zimmer Z Wave, and a 2nd Coolsculpting machine, treatments are faster, more comfortable, and with better outcomes.
(Dr. Weiner is one of the most experienced users of Restylane Refyne and Restylane Defyne in the US and has trained multiple physicians on his injection techniques of these new products.)
Late 2016, two new dermal fillers, Restylane Refyne and Restylane Defyne were FDA approved. Although new to the US, these fillers had approval in Europe in 2010 and in Canada in 2015 under the name Emervel. The announcement flew mostly under the radar and it wasn’t until early 2017 that Galderma officially launched the new fillers. Although these fillers are similar in composition, hyaluronic acid (HA), to many of the other fillers on the market, it is the technology behind them that set them apart from the rest.
Restylane Refyne and Defyne are made with XpresHAn technology which adds flexibility to the fillers – “think honey” – and makes them perfect for treating areas of expression. (Other Restylane fillers are based on NASHA technology, and are particulate in nature – “think sugar”.) Additionally, Refyne/Defyne have high crosslinking that lends to their ability to stretch and recoil. Refyne has less links, so it can stretch more, while Defyne is more tightly bound.
The clinical outcomes of using Refyne and Defyne are unique and directly related to their manufacturing process. With placement in the dermis using small aliquots (a different technique than other fillers) in areas of high muscle movement (expression), the filler will support the skin and soft tissue in unparalleled ways. In fact, muscle strain around the mouth was tested before and after Refyne/Defyne placement and was shown to revert a 55 year old’s profile to one similar to a 30 year old on average. The hyperactivity of the muscles was “constrained” by the filler, just as Botox or Dysport does in the glabella and crows feet. The previously difficult to treat radial cheeks lines (smile lines) can now be improved significantly with the new Restylane Refyne/Defyne fillers. Other fillers used to treat this area are more apparent and obvious due to their lacking the XpresHAn technology, and don’t look as natural with movements. Adding bulk/volume to the lower face is usually not desired because beautiful and youthful faces are V or heart shaped. The unique placement of Refyne/Defyne in the dermis does not add fullness in the lower face during corrections of the marionette lines, prejowl sulcus, and smile lines in Dr. Weiner’s experience.
Cohesiveness is the ability of a filler to “stick to itself” and integrate with the surrounding tissues. Both Refyne and Defyne have a high cohesivity. This equates to more blending of the filler with the tissues, and a more natural appearance. In clinical use, these new fillers can be injected into the mid/deep dermis (a dermal filler actually being injected in the dermis!) and still go unnoticed, without nodules or lumps.
One final highlight of Refyne/Defyne is their low degree of swelling associated with injections. This is beneficial for areas such as lips and tear troughs, where swelling can lead to social downtime, precluding some clients from doing these procedures. When comparing all the HA fillers available in the US, it’s been Dr. Weiner’s experience that Refyne/Defyne have the least amount of swelling.
Restylane Refyne and Defyne open up a new treatment paradigm for the perioral smile lines (radial cheek lines) where previous corrections were usually suboptimal. This area is often overlooked or discouraged, but is a frequent concern for a majority of dermal filler clients. The satisfaction rate with these corrections have been extremely high in Dr. Weiner’s experience. With the additional benefits of high conhesiveness and low swelling, Restylane Refyne and Defyne are a great addition to the filler armamentarium of the advanced injector.
The value of volume replacement in the aging face is now universally recognized as one of the most beneficial procedures to restore youthfulness. The combination of sun exposure, aging, and genetics leads to collagen, fat, muscle, and bone loss. Reinflating the cheeks, lips, and tear troughs are routinely done by physicians across the world on a daily basis. Most of these patients will have a week or more of downtime – swelling, bruising, discomfort – but that doesn’t have to be. Blunt cannulas can minimize most of these side effects associated with filler injections and has become standard practice for Dr. Weiner for the past 6 years.
The benefits of blunt cannlas are:
- There is only one insertion point to treat multiple areas. This equates to less intrusions through the skin and therefore a more comfortable procedure.
- The tip is rounded and blunted. This very fact accounts for less bruising/swelling. When a blood vessel is encountered with the end of the cannula, the vessel is more likely to be gently displaced rather than punctured.
- There is increased safety. A phenomenon termed “vascular occlusion” occurs when a filler is injected into a blood vessel. The filler then blocks the blood flow and can lead to necrosis (death of skin) or even blindness. It is much less likely to occur with blunt cannulas, particularly larger cannulas (23 or 25 guage), because they don’t enter blood vessels as easy as needles do.
- Allows treatment in areas otherwise not easily accessible. Due to the safety of the cannulas, there are now areas of the face which are more easily treated. The superficial temporal area, supraorbital, forehead, piriform, periocular and lower eyelid are now routinely treated with cannulas whereas with needles, these areas were very precarious to inject.
- Downtime is minimize. As a result of all the benefits listed above, most patients have significantly less healing time and are much happier after receiving their filler treatments with blunt “safety” cannulas.
If blunt cannulas have so much benefits, why are only 5% of the providers using them for dermal fillers? The art of using cannulas is not an easy one. Patience is required because directing the tip to the exact spot it is needed is not always easy. Remember, when the tip encounters an obstruction (vessel, ligament, collagen), it will need to traverse around it and not pierce it (as needles would do). This can be frustrating and lead to longer and less satisfactory results for the inexperienced cannula injector.
Dr. Weiner is one of the leading authorities on cannula injections of dermal fillers and has used them for over 6 years for nearly all of his injections. The cannulas provide a safe, comfortable, minimal downtime technique for volumizing the aging face, even with multiple syringes being used simultaneously.
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.
Melanocytes are the cells responsible for the pigmentation in the skin. Their activity can be increased in response to inflammation. When skin becomes hyperpigmented from an injury, it is called “post inflammatory hyperpigmentation” or PIH. This is particularly prevalent in darker skin individuals, where there is more melanocytic activity, but can occur in lighter skin individuals as well.
The widely accepted scale for skin pigmentation types is the Fitzpatrick Scale. The Fitzpatrick Skin Type 1 are extremely light skinned, have blue eyes, and burn extremely rapidly with sun exposure. Type 6 individuals have very dark skin, dark eyes, and tolerate prolonged sun exposure without burning. In general, the type 4-6 skin types are the ones at risk for PIH.
PIH is possible after the following:
- Laser procedures (mainly laser resurfacing)
- Surgical incisions
- Chemical peels
- Radiofrequency (Infini is low risk)
The best way to treat PIH is prevention, if possible. Prevention consists of calming down the melanocyte metabolism. The standard recommendations are Retin A and hydroquinones. If there is a procedure a darker skin individual is planning that has risks of PIH, this regime should be started at 3 weeks prior to the procedure. It should be continued at least a month and up to 3 months afterwards. These 2 topicals are also standard therapy for patients with PIH.
Prolonged inflammation after a procedure (more than a week) in a darker skin individual, is a risk for PIH. The practitioner needs to recognize this and treat the inflammation appropriately. If there is prolonged redness of the skin, steroids and/or vascular lasers are needed to reduce this. If infection suspected, antibiotics are needed. Calming the skin is essential to prevent PIH.
The timing of PIH is very predictable. It almost always occurs about 3 weeks after a “at risk” procedure is performed.
If there is already PIH, treatments which can be used are:
- Topicals such as Retin A, hydroquinone, and steroids; Triluma contains all 3
- Chemical Peels
- Gentle laser treatments with a 1064 laser (nanosecond or picosecond)
- Possibly PRP with microneedling (experimental but minimal risk)
- Antibiotics for ongoing infections
- Laser hair removal for PIH associated with folliculitis
In general, PIH is best prevented then trying to treat after it occurs. Recognizing risk factors with certain procedures is the key to success. Treating prolonged redness is often overlooked and must be treated aggressively rather than taking a “wait and see” approach.
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.
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.