The South Beach Symposium kicked off day three with a global aesthetics session and a management of surgical wounds and scars round-table. Afterwards the day was full with several live patient workshops on devices and treatments in aesthetics.
Non-CME: Devices and Treatments in Aesthetics: Advanced Live Patient Workshop
Glynis Ablon, MD; Steven Dayan, MD; Doris Day, MD; David Goldberg, MD, JD; Michael Gold, MD; Bruce Katz, MD; Stephen Mandy, MD; Mark Nestor, MD, PhD; Neil Sadick, MD; Yan Trokel, MD
Dr. Nestor began by discussing the topical radiofrequency devices Thermi 250 and ThermiSmooth. Both techniques are non-invasive and produce results through the selective heating of tissue (42 degrees Celsius), resulting in collagen stimulation and contraction, effects that have been histologically proven. The devices are excellent tools for skin tightening and are particularly useful around the eyes and mouth, abdomen, and thighs. As an added benefit, studies have shown a dramatic improvement in dry eye symptoms. The devices can be used to treat all Fitzpatrick skin types. Radiofrequency is safe and patients do not report pain – it feels like a warm massage. Typical treatment duration ranges from 5-15 minutes for facial skin to 30 minutes for abdomen and 40 minutes for bilateral thighs.
Dr. Nestor continued by discussing new innovations by Sensus Healthcare. Sensus is revolutionizing the laser industry with new, affordable pricing of outstanding devices. The Q-switched Nd:Yag (1064 and 532 nm) is a state of the art laswer with incredible abilities in the treatment of pigmentation, brown spots, tattoo removal, nevus of Ota, and solar lentigines. The price is $28,000, one-third of what we normally pay for a similar device. Also new from Sensus is a new IPL device with 5 handpieces for wrinkle reduction, pore refining, spot hair removal, acne, rosacea, telangiectasia. The IPL is also priced at $28,000. A new fractional CO2 device, 10,600 nm, has shown outstanding aesthetic effects in the treatment of fine lines and scars. Full-face resurfacing can be completed in under 10 minutes. These new devices from Sensus are “game-changers” and two can be bought together for $50,000. All devices include a 2-year warranty.
Dr. Yan Trokel discussed his revolutionary technique, the Y Lift: No incisions, no anesthesia, no downtime, and instant results in 30 minutes. As dermatologists, we’ve done well in improving facial color and texture, but size and form/shape have been the missing components. This new technique repairs the structural loss associated with aging. The revolumization technique requires 3 steps: expansion/lifting, filling, and sculpting. Results are instant and will last 3-4 years. Dr. Trokel will come to your office and train practitioners on your own patients.
NeoClear by Aerolase uses 650-microsecond technology for up to 255 J/cm 2 in a single pulse duration and has shown great efficacy in the treatment of acne on all skin types. Dr. Gold describes this as a painless, affordable procedure. He also reports efficacy in pseudofolliculitis barbae, skin rejuvenation and tightening, rosacea, telangiectasia, and even psoriasis. A full facial treatment takes 10 minutes.
Dr. Gold went on to discuss notable devices from Rohrer Aesthetics. The Spectrum is a multi-platform laser and IPL device. The 5 components are (1) a 810-Diode with cooling sapphire tip for hair removal that can treat an entire back in 15 minutes, (2) Erbium:Yag, which is efficacious in skin resurfacing and fine lip lines, (3) a Q-switched yag for tattoo pigment, (4) Long-pulsed Yag for hair removal, (5) and an IPL with 4 different filters for treating acne, pigmentation, and vasculature. The price is $54,995, an outstanding price considering just one component could be upwards of $80,000 by other manufacturers. Additionally, purchase of the device includes a free cooling system. Dr. Gold also mentioned the Phoenix CO2 laser that has cutting and scanning modes, rejuVAnate for vaginal rejuvenation, and Fraxis, which is a Fractional CO2 and microneedling in one system.
Dr. Doris Day introduced the SkinPen, the only class II FDA cleared microneedling device. This collagen induction therapy is minimally invasive, time efficient, and has little to no downtime. Patient satisfaction is incredibly high, exceeding 90%. Dr. Day recommends using 2 passes and a third for deeper acne scarring. The depth can also be adjusted for different treatment areas. Dr. Day emphasizes the importance of not just treating the visible scar; rather, treat the entire field. There are no risks of cross contamination between patients and each cartridge is validated for needle quality, sterility, and precision.
Dr. Katz closed out the live patient workshop by discussing vaginal rejuvenation. This used to be a taboo topic that was underreported and undertreated. Treatment traditionally consisted of non-surgical, injectable, and surgical approaches. The UltraFemme 360 is a new non-invasive procedure that has excellent results. The radiofrequency device uses volumetric heating of a 360-degree tip at temperatures of 40 degrees Celsius or greater. The device results in increases in circulation, collagen stimulation, and thickening and tightening of vaginal mucosa. Studies have also shown 96% improvement in urinary leakage.
Let’s Be Real: Ethical and Valuable Marketing
Steven Dayan, MD
Dr. Dayan noted his presentation will focus on marketing in today’s age. The media of today presents unrealistic messages, which take advantage of 4 primitive instincts we all need to survive: S.A.F.E. = sex, appetite, fear, ego. The desire to be beautiful is innate in every culture and extends across all millenniums and ages. Beauty makes us feel euphoric and good. Beauty serves a purpose as it communicates we are healthy, well and fertile. Beauty is something we are born with.
The media appeals to our primitive instinct to be beautiful but presents perfection, which is not obtainable. Similarly, physicians have unique privileges which allow us to sell the dream if we choose. However, this becomes problematic when we guarantee things we cannot necessarily delivery. Social media particularly makes this easy and caution is advised if utilized. Always keep in mind that with the privilege of being a physician comes responsibility. We should not try to sell or promise the ideal as the margin for error is very small and thus difficult to deliver. It is key to understand what is important to each individual as everyone perceives one another differently.
Dr. Dayan concluded that we should instead try to improve the mind and mood. Instead of promising someone beauty, as physicians we can make patients attractive. Attractive is improved self-esteem and confidence. Beauty is a pinpoint target and difficult to hit while self esteem is a large target that sends the message of empowerment.
Z. Paul Lorenc, MD
Dr. Lorenc commented that injectable radiofrequency (RF) is a game changer in his practice and an option in-between surgical and non-invasive treatments. Dr. Lorenc presented his 2 year experience with injectable RF. The device delivers internal subdermal energy that allows for a maximum temperature of 90 C. The temperature underneath the skin is measured and a feed back loop is provided. An image is presented on the screen as the device uses an infrared camera. Thus, the components of the RF device allows the physician to control energy in a predictable way. Dr. Lorenc states the temperature goals he uses in practice are: Sub-dermis : 50-70C and Epidermis 41-43C. A better result is achieved by increasing surface temperature but this needs to be done in a slow, mechanical manner. It is critical to not have temperature spikes and be aware of the heat sink phenomenon in which a delay in temperature peaks occurs.
The energy of injectable RF can be focused to deliver energy to a targeted depth for tightening: collagen remodeling (40-42C), septal collagen tightening (50-60C), lipolysis sculpting (60-70C), and nerve (85C).
Dr. Lorenc stated he especially loves using injectable RF to treat the platysma muscle as one can denervate the muscle and decrease hypertonicity. However, it is crucial to know the anatomy (i.e. the marginal mandibular nerve usually is 1-2 cm below the mandibular border but there are variations) and the only way to ensure safety and prevent paralysis is to map the critical structures and use a nerve stimulator to coarse the nerve. In treating the platysma, the medial border of the platysma is the target for denervation. Dr. Lorenc comments he does not think injectable RF should be used for subplatysmal fat but is quite applicable for treating supraplatysmal fat which will improve the angle of the jaw. Throughout any procedure the surface temperature should be monitored. A 22 gauge needle is hooked up to device, the nerve is stimulated to ensure you are entering in correct location, then infiltrate with plain lidocaine, and subdermal energy can be delivered. Dr. Lorenc states his results have lasted 2 years. The full result can be appreciated in about 6 months. Swelling lasts for about 2-3 days.
Dr. Lorenc concluded that injectable RF and can be used to address skin, fat, platysma muscle, etc. Injectable RF can be combined with surface therapy to improve the quality of skin. It is a versatile technique!
Management of Surgical Wounds & Scars Roundtable Discussion
Panelists: Brian Berman, MD; Michael H. Gold, MD; David J. Goldberg, MD, JD; Z. Paul Lorenc, MD
Dr. Berman first discussed the use of Silicone for scars. He noted a 12 week randomized study in which 100% Silicone Gel applied BID is compared to Onion extract gel applied daily to 2-4 month old surgical scars. The cosmetic benefit was assessed using the Vancouver Scar Scale (VSS) which noted improvement with both gels; however those randomized to the Onion extract gel experienced symptoms of itching. Dr. Berman continued by discussing Hypchlorous Acid (HOCL) and its benefit on scars. HOCL is natural molecule produced during immune reactions. It is anti-inflammatory, inhibits histamine, and aids in the remodeling of wounds. A double-blind study of 40 adults with keloids or hypertrophic scars was performed comparing Silicone + HOCL vs. Silicone gel alone applied TID x 8 weeks. In all, pain and itch were noted to improve however greater improvement was demonstrated with the combination gel as well as better appliance of the scar as assessed by VSS. Lastly, Dr. Berman discussed self-drying, flexible silicone/polysiloxane Gel OD for scars applied daily. An observational study showed the gel achieve good or very good results by both physician and patient evaluation.
Dr. Gold next discussed fractional CO2 lasers as being popular for treating hypertrophic scars. He notes a study in which the treatment of hypertrophic scars with combination CO2 and pulsed dye lasers compared to CO2 alone. Results indicating the combination laser therapy appears to be better than using a single modality in most patients. Dr. Gold then also discussed the benefit of HOCL for scars. He reiterates HOCL has an effect on inflammation, proliferation and remodeling in wound healing. HOCL also eradicates microorganisms, breaks down biofilm, reduces itch & pain, and increases oxygenation to wound sites to improve healing. He notes the application of using HOCL as prep to pre-cleanse patients before procedures due to its ability to eradicate microorganisms. Next, Dr. Gold discussed Silicone gel sheeting to achieve rapid epithelialization of wounds. Now there are silicone gel sheets which can be used on open wounds and the results on healing are remarkable. Other Silicone gels are better for resurfacing or for those with sensitive skin.
Dr. Goldberg stated there is tremendous interest in Silicone gels and its application to open wounds. There are many properties required for optimal wound healing including: semi-occlusive, hydrophobic, sterile, antiomicrobial/bacteriostatic, pH that mimics fragile acid mantle, pain free, and simple to apply. There are several options: film forming gel for scar management (Strataderm) and those which are innovative as they can be used in open wounds: Stratamed for incisions and following fully ablative procedures and Stratacel for fractionated wounds. A randomized open label, split face study comparing the use of Aquaphor vs. Silicone in 20 subjects who underwent Erbium:YAG were evaluated at days 7 and 60. It was noted after 60 days there was no difference in signs/symptoms but those randomized to Silicone had less post-treatment erythema and post-inflammatory change.
Dr. Lorenc noted from a plastic surgeon perspective, the only thing patients will see is their scar and historically not enough attention has focused on scars. Prevention is more important than treatment. To prevent scar formation, tension needs to be presented during wound closure. Dr. Berman provided the scientific basis that in wounds under tension, kinase is activated leading to scar formation. Silicone gel sheets such as Stratamed should also be used directly following sutures as it is occlusive and flexible. Dr. Lorenc also stated he will have his patients numb with Stratamed and Lidocaine mix prior to laser therapy.
Combination Therapy of Surgical vs. Non-Surgical Techniques
Julius Few, MD
Dr. Few stated he is a believer of blending surgical and non-surgical modalities. By implementing non-surgical techniques, you can enhance an incomplete surgical correction, salvage a complication, create a road map to a surgical outcome, and buffer a normal post-surgical resolution or maintain the result.
The 3 core components of aging are: variables in skin change, volume loss, and ptosis of facial anatomy. The goal is to maintain the inverted triangle of youth. In addressing the face, you need to divide it’s anatomy into thirds. The concept of composite rejuvenation also needs to be applied (skin, muscle, fat, and bone projection).
The skin of the periocular area is quite thin (0.5 mm) in comparison to the thickness of the cheeks. Additionally, the neck is another thin cosmetic unit. In dealing with delicate, thin skin, the impact is large and any error will be obvious. In targeting the skin many modalities can be used including chemical peels, ablative and cosmeceutical therapies. Neuromodulators can be a powerful tool for periocular rejuvenation. Dr. Few noted he is treating the frontalis muscle much less than in the past because it works against your effort to accentuate the natural brow. He finds treating the orbicularis oculi most effective in terms of correcting a low brow, as a major function of this muscle is depressing the brow. You can also elicit different effects by targeting the various rings of the orbicularis oculi. Dr. Few stated that treating the pre-tarsal area with a neuromodulator functions to diminish the appearance of lower lid bags. He described his 3 point injection technique, where he works lateral to medial and uses a 0.3 ml insulin syringe, assesses for fine veins and injects superficially using a very concentrated solution of product (Botox/Xeomen: reconstitute with 1 cc bacteriostatic NS – 1 u/gr; Dysport: reconstitute with 1.5 cc of bacteriostatic NS – 2 u/gr) with little discomfort.
In targeting the periorbital fat, it is imperative to recall the anatomy of the orbiculares retaining ligament (ORL) which separates fat into different compartments. You should be cautious to not place filler into this ligament. Tear troughs are treated quite superficially in comparison to the palpebro malar groove and the nasojugal groove.
In regards to the non-surgical approach, when treating a surgical complication, fillers can be used. Dr. Few stated Ulthera is a powerful tool and an example of a road map to a surgical outcome. He provided the example of a patient resistant to neuromodulators who benefitted from the use of Ulthera to correct the depression of the medial brow. He then used a surgical approach with browpexy and transpalpebral corrugator resection. In buffering surgical results, Dr. Few is a fan of using RF to reduce edema around the eyes. His preference is a multi-polar combined with magnetic field pulse. Lastly, hyaluronic acid filler can be used to camouflage a surgical procedure with poor results. Dr. Few accomplished this in a patient who had poor fat grafting, which left her with facial bumps. The HA filler camouflaged some of the irregularity and as a result, the patient regained confidence in the potential for the issue to be corrected and was later open to having a lower lid blepharoplasty to obtain her desired result.
Panel Discussion: Combining Surgical and Non-Surgical Approaches from the Dermatologists’ and Plastic Surgeons’ Perspective
Moderator: Z Paul Lorenc, MD
Panelists: Julius Few, MD; Steven Dayan, MD; David Goldberg, MD, JD; Michael Gold, MD
There were three questions posed by Dr. Lorenc:
- What percentage do nonsurgical procedures make-up in your practice?
- In the last 2-3 years, give one device/modality that changed your practice?
- What do you think will be a huge change in the future?
Dr. Few’s comments included:
- There has been exponential growth towards nonsurgical procedures. Patients are younger and more educated than ever and often leading with what treatment options are available. In my practice, surgical and non-surgical procedures are almost split evenly.
- By large, the collaboration of dermatology. It forced us to come together on the technology and we challenge one another to make things better and revolutionize practice. At the end of the day, this is a new specialty, “the hybrid” and we get to be at the forefront.
- Aesthetics has exploded. Less is more. Patients are afraid of filler because in the past, too much was used. But an exponential growth towards these procedures will occur as the technology will continue to improve and modalities will be combined. Soon patients will get a treatment and go out to lunch.
Dr. Dayan’s comments included:
- Nonsurgical has surpassed in terms of bringing in revenue, and it feeds surgery as well.
- It is multifaceted and not one modality. PRP has been incredibly successful. The new way of thinking now is “dermaplastics.” In the future, psychiatry may be a component because there are multi-dimensions of what we do.. skin, below skin, nutrition and how the patient feels. Dr. Dayan echoed that Silicone post-surgical is great.
- In 2075 : We will redefine what natural is, the current toxins and fillers will work better, devices to diminish vascular injury will be available, the practice will become multifaceted with a collaboration between dentists, psychiatrists, and genetic medicine. In the future, we may be able to analyze genes to determine what treatment is appropriate for that patient.
Dr. Goldberg comments included:
- There is a challenge for dermatologists who do not have collaboration with plastic surgeons. The population is adamantly against surgery and we can’t get them to consider it when they need it. Patients who really are not candidates for fillers and need surgery, can have bridge procedures such as InstaLift and Kybella performed.
- Two – InstaLift and recreating the face with fillers. The idea of treating scars (SRT for keloids, Silicones to lessen scarring) is also a practice changer.
- The photoactivation of new substances such as silver. Also the potential for growth factors to be loaded onto InstaLift. And definitely less and less surgery.
Dr. Gold’s comments included:
- I never did cutting procedures and there is a continued growth of nonsurgical rejuvenation treatments and devices (energy based), InstaLift. I have plastics in practice who does hair transplants but now does a lot of PRP for hair loss.
- IPL changed my career because at first no one thought it worked. It has enhanced my practice and I use it every day. Thermatight and InstaLift , Silicone gel are fantastic. Silicne has the healing properties of using it post procedures. People hate scars and we have the tools to prevent this.
- What does ultimate device look like? I envision one that looks like a CT scanner, that we can program and have it perform what we need and want it to do. It may be able to provide suggestions of techniques the patient will benefit from.