After nearly three decades of use of ablative lasers, “The pendulum swung and we went to non-ablative laser technology, and over the last decade or more we’ve been doing fractionated technology and mixing and matching those,” observes Tina Alster, MD in a recent episode of Device Talk from Practical Dermatology® magazine’s sister site ModernAesthetics.com. “But what I’m finding is that because fractionated technology wasn’t giving us quite the ‘oomph’ that we wanted, people are mixing and matching lasers again.”
Citing too much downtime and risks for infection, scarring, and/or pigmentation changes, Arisa Ortiz, MD notes that fully ablative resurfacing is uncommon in her practice. However, she says, “I’m focusing my fully ablative lasers just around the mouth, because it’s really a stubborn area, and I’m disappointed when I do just fractional ablative. I do fully ablative around the mouth and then fractional ablative on the rest of the face. I think patients are really able to tolerate that downtime a little bit better and then they’re happier with the results.”
Click here to watch Dr. Saedi and Dr. Stankiewicz discuss radio frequency devices and the popularity of “prejuvenation.”
Initial healing from the fully ablative treatment takes about two weeks, Dr. Ortiz says, during which there could be bleeding and crusting. Prolonged erythema can persist for several months but can be camouflaged with makeup. “You definitely have to find the right patient, because it does take a long time for them to heal,” Dr. Ortiz acknowledges, “but I think they’re pretty happy with the results when you mix and match.”
“It’s true that the fully ablative lasers really pack more of a punch and are much better for the stubborn scars or rhytides,” Dr. Alster concurs. “The problem is most patients really have lives outside of our office and getting them to take that time off is tough.”
Dr. Alster will mix and match devices, and also considers, “microneedling around the mouth because that ‘tills the land,’ for lack of a better term, to break apart those rhytides. I think that all of us are getting more comfortable with mixing and matching whatever lasers are out there.”
RadioFrequency is Ramping Up
“Radiofrequency with microneedling has become the most popular treatment in our practice just because it’s getting so much buzz recently—no pun intended. So many patients are coming in either asking for it or curious about the technology,” says Nazanin Saedi, MD in a conversation with Kelly Stankiewicz, MD. She explains that microneedles create a mechanical injury in the skin but that they also release radiofrequency energy either throughout the whole needle with a non-insulated tip or just at the base with an insulated tip. “It protects the epidermis [which is beneficial] for patients who are darker skinned.”
Dr. Alster and Dr. Ortiz discuss tattoo removal advancements, as well as resurfacing, for Device Talk. Click here to watch now.
There are multiple potential applications for RF microneedling. “You can use it for so many things: for tightening, for acne scars, for enlarged pores, and for improvement in skin texture. So it is popular in a huge age range,” Dr. Saedi offers. Although in some cases she will do conventional microneedling, she tends to offer microneedling with RF. “In most cases I feel like it just offers the benefit of tightening in addition to the textural changes.”
Downtime is minimal with RF microneedling, and patients can use makeup after 24 hours, Dr. Saedi says. However, there is some discomfort associated with treatment. Dr. Saedi has her patients apply topical anesthetic 30 minutes before treatment. “With some of the devices, you have to use a topical anesthetic. Some people do nerve blocks; it really is device dependent,” she says.
From patient demands to the latest in cellulite treatment, Dr. Green and Dr. Avram share insights for aesthetic practices. Click here to watch the videos.
Advancements in Cellulite
When it comes to treatment of cellulite, “Many different devices over the years that have promised improvement really haven’t delivered,” observes Mathew Avram, MD. “Part of that has to do with the architectural components of cellulite. Cellulite is present in almost all females and almost no males…Addressing that architectural component over the years has been very difficult. We’ve seen radio frequency devices. We’ve seen endermology. We’ve seen lotions, potions. The bottom line is over the years, many of them have been very disappointing. There’s a distinction between treating individual dimples and treating the undulating appearance of cellulite.”
Affirming that there are different types of concerns associated with cellulite, Jeremy Green, MD says, “For the last few years in my practice, I’ve had a great answer for dimples as well as short horizontal lines on the thighs and buttocks. And that’s Cellfina, tissue stabilized, guided subscision. That’s approaching the underlying anatomy, which are these fibrous septae, these tethers which are oriented predominantly perpendicular to the skin surface.”
Dr. Avram notes that there are now five-year data for Cellfina (and an associated FDA label clearance), “that shows that the benefits are not temporary, like they were with some other devices devices, but really go out five years and beyond showing a rate in the high nineties in terms of retention of the benefit.”
An injectable collagenase in development is showing promise to address the dimpling of cellulite, as well. When it comes to the undulating appearance of cellulite, the use of injectables biostimulators helps. “When you hyper-dilute these products and inject them subcutaneous, just subdermal in the buttocks and thighs, we’ve seen some very nice benefits as far as addressing the laxity, the skin quality of patients with cellulite,” Dr. Green notes.