What’s new in facial rejuvenation

From single devices that perform a spectrum of rejuvenation procedures, to older devices that are re-emerging, to new combinations using tried-and-true technologies, dermatologists are at the forefront of what’s new and exciting in facial rejuvenation. Two dermatologists weigh in with their favorites.

Microneedling 

Tina S. Alster, M.D., director, Washington Institute of Dermatologic Laser Surgery and clinical professor of dermatology, Georgetown University Hospital, Washington, DC, said she is a laser user and abuser, but her top pick is no laser at all. It’s micro-needling, which she says is affordable for dermatologists and patients, and is an effective wrinkle reducer.

“I’m using microneedling every day to minimize perioral rhytides and large pores. I’m seeing impressive results-similar to those that are achieved with fractionated laser treatment. Unlike lasers that produce heat during treatment, the microneedling device produces micro injuries in the skin without heat; thereby, stimulating new collagen production without risk of postinflammatory hyperpigmentation,” Dr. Alster says.

Tina S. Alster, M.D.

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Dr. Alster recommends that dermatologists who don’t have much or any experience with microneedling use it initially on small areas, such as on patients’ upper lips, until they get comfortable using the devices.

“You want to produce pinpoint bleeding indicating dermal penetration, which will kickstart the wound-healing cascade,” says Dr. Alster. “Until you see how these devices work in your hands, keep the treatment confined within cosmetic units. When treating the perioral region, use the nasolabial folds as your lateral border and treat very lightly over the vermillion border.”

More experienced dermatologists can venture beyond the cosmetic units, without having to worry as much about discoloration as with laser treatment.

When using microneedling on the face to treat large pores, Dr. Alster avoids the nasal bridge.

“The skin in that area is much thinner and more prone to bruising,” she says.

NEXT: Combination microneedling approach

Combination microneedling approach

Dr. Alster often combines microneedling to treat stubborn wrinkles on the upper lip with light fractionated resurfacing on the rest of the face. For the task, Dr. Alster says she uses the Clear + Brilliant (Solta Medical). Posttreatment healing is typically a couple of days of skin redness.

READ: Laser and light devices: What's trending?

“I instruct patients to ice the treatment areas for the remainder of the day after the procedure. I recommend the use of a soothing balm that contains small amounts of hydrocortisone under a medical barrier cream and a non-chemical (physical) sunscreen. Patients should apply the creams at least four times a day for the first couple of days after treatment,” she says.

Dr. Alster says she likes the Clear + Brilliant because, even though it’s not as effective as the deeper lasers on wrinkles and scars, it offers a relatively easy postoperative recovery and it’s less expensive for patients.

“It’s the one laser that my physician extenders perform. That being the case, the patients save a little bit of money and still get a very nice cosmetic outcome,” Dr. Alster says.

NEXT: One intraoral device;Three lasers in one platform

One intraoral device; three lasers in one platform

Min-Wei Christine Lee, M.D

Min-Wei Christine Lee, M.D., a dermatologist and cosmetic dermatologic surgeon who practices Walnut Creek, Calif., spoke at this year’s American Academy of Dermatology (AAD) annual meeting on Emerging Lasers and Aesthetic Technology. Dr. Lee’s favorite emerging technologies for facial rejuvenation? The Fotona SP Dynamis and Elixis.

Fotona SP Dynamis Pro (Fotona) is based on an intraoral technology used for years in dentistry. It was later discovered that what dentists were doing to treat the inside of the mouth had a skin tightening effect on the outer face. Today, the combination intraoral and outer laser procedure for skin rejuvenation is called Fotona 4D, using the SP Dynamis Pro, according to Dr. Lee.

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“Fotona SP Dynamis is like having 20 different lasers in a dermatology practice, because it has so many different applications,” says Dr. Lee, who helped develop the procedure and is a consultant and researcher for the company that makes it. “The reason it can effectively perform so many different applications is because of [the platform’s] longer pulse durations and higher energy than other devices, as well as the unique application of wavelengths.”

The four steps in the procedure include:

Step 1: The intraoral procedure using the Erbium PS03 smooth mode. This is a unique nonablative fractional erbium with a long pulse duration of 250 milliseconds, according to Dr. Lee. The intraoral laser can be used on the skin, as well, she says.

“It can actually cause heating of the oral mucosa without any injury or burning,” Dr. Lee says. “This should never be attempted with another erbium system because it would cause severe burns.”

Step 2: When applied to the skin’s surface, the Frac3 nonablative fractional Nd:YAG in the SP Dynamis platform cleans debris from the pores, helps to shrink the sebaceous glands, kills propionibacterium acnes, or P. acnes and makes skin smoother, according to Dr. Lee.

Step 3: The Piano mode Nd:YAG is the only Nd:YAG laser on the market that has long pulse durations of 6 seconds, which results in deep volumetric bulk heating and skin tightening, according to Dr. Lee.

Step 4: This step involves an ablative erbium laser. The one that is part of the Fotona SP Dynamis allows dermatologists the versatility of changing settings-from light, superficial ablation to fully ablative with thermal coag.

Because of the ability to customize, dermatologists can use the Fotona 4D procedure on anybody, any skin type and at any age, according to Dr. Lee. She adds that there are no contraindications.]

Next: Exilis for skin tightening, lifting

Exilis for skin tightening, lifting

Exilis (BTL Aesthetics) is a focused, continuous monopolar radiofrequency (RF) device, which has face and body applicators, according to Dr. Lee.

“It provides uniform volumetric deep bulk heating (reaches a depth of 2.5 cm), resulting in skin tightening,” she says.

Exilis has controlled contact cooling and real-time temperature monitoring, impedance intelligence and energy flow control, which measures impedance and temperature of the tissue and adjusts current accordingly, according to Dr. Lee.

“This eliminates the chance of over treatment, while providing uniform energy delivery at optimal levels,” Dr. Lee says. “RF energy is color blind, making it safe for treating all skin types.”

READ: Rejuvenation and Scars: tips you need to know for laser technologies

Researchers reported in September 2014 in the Journal of Drugs in Dermatology on 24 females who received two treatments with bilateral monopolar RF to the mid and lower face. Their assessments revealed a 35% reduction in skin laxity, 42% reduction in fine lines and wrinkles and 33% decreased appearance of photo damage. At three months post-treatment, 92% of the women showed at least mild skin laxity improvement. Ultrasound testing in 12 women showed a 19% improvement in skin density, and histology showed a notable increase in dermal collagen and elastin fibers in two women. They found no significant adverse events.¹

The ideal Elixis candidate, according to Dr. Lee, is a patient who has mild to moderate facial skin laxity.

“It is not a substitute for a facelift, but it is painless, has no downtime or side effects and can provide 30% to 40% skin tightening in all skin types, safely,” she says. “Patients with severe skin laxity would not be good candidates. These patients would not do well with any laser procedure, they would require surgery.”

An advantage of the Elixis, compared to Thermage (Valeant) and Ultherapy (Ulthera), is that it does not require expensive consumables, according to Dr. Lee.

Dr. Alster, however, who says she used Elixis and offers Thermage and other skin tighteners in her practice, favors Ulthera micro-focused ultrasound for skin lifting and tightening.

“I routinely recommend Ulthera because I think it provides optimal non-invasive lifting due to its deep penetration and focused tissue effect. It can be used alone to tighten the jawline and lift the brow, but I often use it in conjunction with other treatments, including the Fraxel Clear + Brilliant and/or microneedling in order to minimize rhytides in the same treatment session,” Dr. Alster said.

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Disclosures:

Dr. Lee has served as consultant and investigator to: Lumenis, Cutera, Syneron, Iridex, Solta, Ulthera, Cynosure, Fotona, BTL

Dr. Alster is a consultant to Merz.

References:

1.     Mcdaniel D, Weiss R, Weiss M, Mazur C, Griffen C. Two-treatment protocol for skin laxity using 90-Watt dynamic monopolar radiofrequency device with real-time impedance intelligence monitoring. J Drugs Dermatol. 2014;13(9):1112-7.