Blog Archives | The Aesthetic Clinique

Lasers versus Radiofrequency Microneedling (RFM) for Acne Scars

Traditionally, lasers were the gold standard for acne scars. Specifically, ablative lasers, CO2 and Erbium, have been advocated over the nonablative lasers such as Fraxel 1550. In 2013, radiofrequency microneedling (RFM) was approved in the US and the dominance of lasers for acne scars has come under scrutiny. While there are indications for both technologies, this blog will elucidate the decision tree for which technology to use.

Fundamentally, ablative laser energy (heat) is generated outside the body and is driven into the skin at a temperature that causes ablation (vaporization) of the tissue ~ 100 C. Radiofrequency Microneedling generates it’s heat within the tissue by passing current through it. As the current encounters resistance (impedance), heat is produced to a level of coagulation ~ 65-70 C.

The number one concern with ablative laser is healing. While fractional technologies improve the downtime and risks, outcomes are sacrificed. Sometimes several treatments are recommended to match the results that fully ablative lasers would achieve. Downtimes are still around a week or longer with fractional CO2. More importantly, since the laser heats and ablates the most superficial skin layers, the risk of post inflammatory hyperpigmentation (PIH) is almost unavoidable in skin types 4-6. While PIH is reversible in most cases, it can take months in some cases. Wound care is essential with ablative lasers, particularly use of occlusive emollients, to maintain a moist wound for best healing. Unfortunately, occluding acne prone skin often leads to acne breakouts. When breakouts occur, there is risks of actually creating more acne scarring and becoming counter productive.

Healing with RFM is easier and less risky. While there are devices with uncoated needles, the author only advocates the coated or insulated needles. (Uncoated will have similar healing properties as the lasers). Using coated needles, the only injury to the superficial layers of skin are needle punctures. In essence, the device “bypasses” the epidermis. The heat generated from the RF will be in the deeper aspects of the skin, where there are no melanocytes, the pigment producing cells. While there is swelling, redness, and sometimes bruising, the downtime is less with RFM when compared to ablative lasers, usually 3-4 days (individuals do vary!). More importantly, the skin surface heals quickly (similar to microneedling) and there is no need for occlusive emollients.

The depths of acne scars is highly variable, and there can be superficial and deep scars in the same individual. This is probably the most important factor as to what technology to choose. RFM has the advantage for improving deep scars. While depths of RFM aren’t accurate in most devices, in the Genius they are. The Genius is able to reliably place coagulation zones down to 3.5mm. Of note, 3.5mm is typically much too deep to attack acne scars and typical settings are usually up to 2.5mm. Lasers can typically reach 1.5-1.7mm. The energy delivered diminishes as the pulse goes deeper because the energy is absorbed by the upper layers of the dermis. So for the superficial scars – boxcar specifically – give the advantage to the ablative lasers (Look up Dr. Lim 360 degree laser treatment). Keep in mind that the RFM devices can go superficial and treat boxcar scars too.

RFM

Positives:

Safer for all skin types
Less downtime
Deeper penetration
Less PIH risk
Less wound care
Safe on all areas of the body

Negatives:

Not as good with superficial scars but can still treat them
Doesn’t resurface so no pigmentation improvements

Ablative Laser

Positives:

Good for superficial scars – boxcar
Improves pigmentation

Negatives

Long(er) downtime
Higher risk of PIH in types 4-6
Doesn’t treat deeper scars as well
More wound care that can lead to more acne
Higher risks of infection/scarring than RFM
Can’t be used off-face as safely as RFM

Keep in mind that acne scars require multiple modalities such as TCA Cross, subcision, fillers, skincare, PRP, amniotic growth factors to achieve optimal results. Multiple treatments are always required upfront, but also as the aging process causes collagen and fat pad volume loss.

The 5 Most Popular Instagram Cosmetic Procedures That Don’t Work

Instagram is being used as a marketing tool for all types of industries. Unfortunately, you can’t believe everything you see touted. This is especially true for aesthetic procedures. As with any, make sure you do your research, the before and after pictures are actually comparable and aren’t using lighting “tricks”, and the provider is experienced and reputable.

Lip flip with Botox – This procedure claims that the lip will turn up and make the lip fuller for very little money. If you weaken the muscles around the lips with Botox, there is no way this can end up lifting the lip. It also risks changing the smile, having difficulty with sipping and whistling.
Thread Lifts – The procedure consists of placing barbed sutures just deep to the dermis. The barbs engage into the skin and by pulling laterally and upward, they are supposed to lift and tighten. The posts on Instagram mainly show providers pulling on the sutures and watching the skin move. The problem is the sutures aren’t anchored in most cases and are attached to mobile skin. It’s impossible to lift when the entire are desiring lift is move. In addition, the barbs pull through their attachments very quickly, much sooner than collagen can be created to help anchor the suture. The side effects – visible threads, redness, puckering, pain – are as high as 34% in one study. In the same study, visible improvements were not apparent at 12 months. The noticeable changes in the author’s opinion are extremely mild and can be achieved with fillers in a more predictable and longer lasting correction.
Low Density PRP – PRP is short for platelet rich plasma. Unfortunately, there is no standard and the concentration for PRP is all over the map. In the majority of cases, 10-12cc of blood is being drawn to get 5-6cc of PRP. In these cases, the concentration is only about 2x (2 times the normal blood concentration) and all that has been done is the red blood cells have been removed by centrifugation. The benefits of PRP have been studied and optimal concentration levels to promote angiogenesis (new blood vessel growth) have been shown to be about 6X. If you are getting only a small test tube of blood drawn, you probably aren’t getting much benefit from the PRP.
MicroBotox for Necklace (“Tech Neck”) Lines: Horizontal neck lines are often called “Tech Neck” because some people believe they are caused by look down at your phone or computer. Providers are reporting improvements with injecting Botox in the lines in very small but multiple injections. In the author’s opinion, this is not the correct solution and these require filler +/- RFM (Genius) for optimal results. Static lines are not responsive to Botox. Dynamic wrinkles are what respond to Botox.
Using Radiofrequency That Doesn’t Penetrate Skin for Tightening: When an RF device is used to stimulate skin tightening, it must achieve 65-70 C to achieve coagulation. Anything short of coagulation causes temporary collagen contraction and denaturing but very minimal long-term effects. The epidermis needs to be kept at 42C or lower to avoid burns or hyperpigmentation. It is impossible to achieve coagulation in the dermis and still keep the skin surface at 42C or lower. So all the no downtime skin surface RF devices will need to be performed multiple times, have extremely variable results, and often very poor tightening effects. Optimal RF results require the energy to be introduced beneath the skin surface such as RF microneedling (Infini, Genius) or FaceTite/Accutite.

Remember, it all boils down to science whether a procedure works. If the science doesn’t make sense, the procedure probably doesn’t work.

Find Body Sculpting Options in Santa Rosa Beach

With summer in full swing, you want the best body possible to show off at the beach. All summer clothes reveal a lot of skin. For certain people, they may still be clinging to winter wear in order to hide certain areas of their body. Diet and exercise just don’t seem to work for them. They’ve lost weight, but they can’t seem to lose the stubborn fat and skin that continues to cling to their body. These individuals are not without hope. Body sculpting in Santa Rosa Beach can offer you a trimmed figure that diet and exercise aren’t providing. Through CoolSculpting®, Emsculpt®, and even Kybella®, you can receive a toned figure that you’ve always wanted. It’s time to remove winter clothes and embrace the sun and beaches at long last. This article will discuss body sculpting and the various treatments that you can select in Santa Rosa Beach.

Body Sculpting

There is often some confusion when it comes to body sculpting. Some people sign up for a body sculpting treatment expecting that their weight suddenly decreases. While some weight may be lost, body sculpting is not, in itself, a weight-loss treatment. Those who see the best results from body sculpting or body contouring are those who have already achieved their target weight.

Instead of being a way to lose weight, body sculpting helps trim away skin and remove stubborn fat that collects in certain areas of the body. This fat isn’t the kind of fat that helps your body. The good kind of fat stores energy for later use during periods of starvation or fasting. The bad kind of fat is primarily used for insulation or just exists because it has nowhere else to go.

It’s the bad kind of fat that is difficult to lose. Because it’s not being burned up and broken down for energy, it just sits there at your abdomen and hips doing nothing. You can restrict yourself to certain diets and try all of the crunches that you want, but it doesn’t mean that the stubborn fat is going to disappear.

Body sculpting helps remove that fat or makes it lose the content within the fat’s cells. As a result, your body is able to trim itself. The skin can press closer to the muscle rather than the barrier of fat that sits between the skin and muscle. Any muscle that you’ve developed through your exercises will be noticeable far easier.

There are a few different body sculpting treatments in Santa Rosa Beach that you might want to consider. Each one removes fat in a different way and can be used in certain areas of the body. Because body sculpting is a non-invasive treatment, you can receive these treatments numerous times over your life without consequence. Here are some of the treatments that you might want to consider and what they offer.

CoolSculpting®

Perhaps the biggest name in terms of body sculpting is CoolSculpting®. Before CoolSculpting®, most body contouring options began and ended with liposuction. Since liposuction is an invasive procedure, not many people were interested in trying it out. CoolSculpting® changed the body sculpting game.

It relies on the concept of freezing fat cells until they die. It was discovered by two researchers who noticed that children who ate a lot of popsicles had dimpled cheeks. The belief was that the consistent exposure to the cold destroyed the fat cells in certain areas of their cheeks. As a result, dimples were formed. The researchers continued to look into this and discovered that extremely cold temperatures could, in fact, destroy fat cells.

The process is quite simple. A device is used atop your body in the key area that you want to have toned. This device then uses liquid nitrogen or other freezing agents to deliver a cold temperature against your skin. Eventually, it seeps through the skin and the fatty layer. The cold temperatures damage the cells. Your body then targets them for death, and they’re destroyed. The content that resides within the fat cells is released into the body. This content can be used for energy or it can be transferred into waste.

With the removal of the fat cells, the skin is then able to cling to the muscle layer below it. Sometimes results can be noticed immediately. Other times, you may need a few treatments to receive a full effect. Fat cells are not gone forever either. So, if you’re worried about what the destruction of fat cells does to your body, you have no need for concern. As you eat, you will eventually create new fat cells. That also makes touch-ups necessary if you do not regularly exercise and eat well to limit the number of fat cells that are created.

After only a few minutes, the device is removed, and you’re finished with the treatment. Your physician might offer a few suggestions on how to take care of the area after the treatment is over. By and large, however, because the treatment is non-invasive, you’re able to simply return home or back to work without any issues.

You may wonder if you’ll feel the cold. This isn’t the case. Before the procedure begins, you’ll have either a thick cloth or some ointment placed on the target area. This dispels the temperature, so you don’t feel it. In fact, the treatment is quite relaxing. All you do is lay back and let the professionals run the device over your skin.

Because the treatment is so quick, it’s easy to fit CoolSculpting® into your schedule. You can do it right after work or even on your lunch break. Since it’s easy on the body, you don’t have to worry about skipping out on social engagements afterward either.

CoolSculpting® can be used in many different parts of the body. Although it is most commonly used in the abdominal area, it can be used on the arms and legs area, too. With more devices being made for CoolSculpting® technology, there is practically a device for any area that you might want to have worked on.

If you want an easy way to body sculpt your body in Santa Rosa Beach, then you should consider CoolSculpting®.

Emsculpt®

Another exciting way to trim the body is through Emsculpt®. This body sculpting option is quite different from CoolSculpting®. While CoolSculpting® was focused solely on the removal of fat cells, Emsculpt® actually helps build muscle while destroying fat. Instead of cold temperature, Emsculpt® uses contractions.

When you work out, you’re essentially contracting your muscles. You perform some form of damage to them. This forces the body to break down fat and build muscle. The more that you work out, the more muscle is created in order to deal with the strain. Emsculpt® takes that up to a few notches. When you go in for an Emsculpt® treatment in Santa Rosa Beach, you’re basically going to receive an easy workout for your muscles.

By using a device that invokes contractions in your muscles, your body works fast to destroy the fat cells. Because your muscles are being contracted quickly, the body has to break down the fat in that area in order to have the energy to build up the muscle. The fat is also removed simply because of the movement. As muscle builds up, it needs space. That space is created through the removal of fat.

The procedure lasts about a half-hour. However, to receive the best results, you have to schedule at least four sessions. These sessions should take place every two to three days. Like with working out, if you don’t work the muscle out continuously, then the muscle is eaten away, and you’re back with fat. In order to remove the fat entirely, a series of contractions is required. That’s why four sessions seem to be the optimal amount for the best results. Of course, your provider will take an examination of the area and determine just how many sessions you will need. These treatments are always relative to the individual.

Considering that a lot of contractions are being used, you may wonder what the treatment itself will feel like. More than anything, it will just feel like you had an intense workout. You’ll be laying down while the device is moved over your body. You can even relax. It’s only after the treatment is complete that you may feel as though you did a bunch of crunches or ran a few miles.

Just like CoolSculpting®, Emsculpt® does not require any downtime after the procedure is over. While you may want to take it easy with working out just to give your muscles a break, you can likely hit the gym again the day after. In fact, you really get the most of Emsculpt®, it doesn’t hurt to work out lightly to continue to build muscle in those target areas.

You don’t have to worry about doing anything before the treatment either. Because the device doesn’t interfere with your skin, you don’t have to worry about shaving or showering or doing anything else to prepare. You can come as you are.

Emsculpt® is similar to CoolSculpting® in that it can be used on most areas of the body. People typically receive treatment on their abdomen to help promote abs. However, it has also been used on arms, legs, and even on the backside for firm glutes.

It can sometimes take up to two to four weeks for results to be noticed. Yet those results continue to be shown and even become better and better as time goes on. For a body sculpting option in Santa Rosa Beach that helps you build muscle as well as to trim the fat, you should consider Emsculpt®.

Kybella®

For those who dislike their double chin, then Kybella® is the body sculpting option for you. For many, a double chin can make them bigger than they are. It can also make an individual look older. A key sign of aging is sagging skin. A double chin is essentially sagging skin. They’re also difficult to keep from forming. Even if you’re incredibly fit, you can still suffer from a double chin simply through your genetic makeup.

Kybella® is a body sculpting option in Santa Rosa Beach that is specifically designed to remove double chins. The procedure is just as simple as CoolSculpting® and Emsculpt®. Instead of having a device ran over the treatment area, however, Kybella® is actually an injectable treatment.

Initially, you’ll meet with your doctor and go over the problem area. They’ll assess your chin and come up with a treatment plan that will determine how many injections you’ll need and where they need to be injected. Once the plan is set, you’re able to receive treatment. The procedure itself is easy and quick. A naturally-occurring molecule known as Deoxycholic acid is what’s injected into the body. In your body, Deoxycholic acid actually works to naturally dissolve fat. It absorbs the contents within the fat to bring to the rest of your cells that require it for energy.

In terms of Kybella®, Deoxycholic acid is used to dissolve the fat that resides within the double chin. Once they’re gone, fat content can no longer be stored there. Your double chin will disappear, and you’ll no longer suffer from a dreaded double chin.

During the procedure, you’ll receive multiple injections. You will likely need a few different sessions in order for the fat cells to be destroyed completely. It’s most common for six treatment sessions to be needed in order to have the best results. These sessions are scheduled at least one month apart. This allows the Deoxycholic acid plenty of time to work through the area and remove fat cells.

The best aspect of Kybella® is that once the fat cells are destroyed, you likely won’t need another treatment again. As long as you mind your food and stay up on your weight, fat cells won’t need to be produced under your chin again. Kybella® provides lasting results that you can be proud to show off.

Practically everyone is able to receive Kybella® treatments. As long as you’re tired of having a double chin and don’t want to see pricier surgical options, then you’re likely a good candidate for Kybella®. The treatment only lasts for about a half-hour, and you’re able to return to work and other activities following treatment.

Kybella® is a body sculpting option that is only used on the area below the chin. It cannot be used in other areas of the body as of yet. So, if you suffer from a double chin and want to stop looking older or fatter than you actually are, then you should consider scheduling a body sculpting treatment with Kybella® in Santa Rosa Beach.

Who Are The Best Candidates?

If you’re thinking about body sculpting, then you might wonder if you make for a good candidate. The good news is that since body sculpting in Santa Rosa Beach is noninvasive, practically everyone is a good candidate for the treatments. The key factors are to ensure that you are already at your target weight and have done everything you can to achieve a good level of fitness. These are the individuals who experience the best results with body sculpting because they’ve already put in the hard work of maintaining a good weight and developing muscle.

They have a trim figure in the making. Their stubborn fat just keeps them from being able to see the bulk of the results. Good candidates are also of good health. They don’t have any infections or problems with their blood or heart. While these treatments shouldn’t exacerbate any of these problems, it’s always a good idea to be of good health before undergoing any treatment.

Finally, body sculpting does not require you to be a certain age or skin color. The treatments listed above can work on you just as well as if you were 20 or 70. Whether you have light or dark-colored skin, the devices and injections will work on you just the same. That makes body sculpting available for almost everyone.

What to Look for in a Clinic

One last aspect to consider with body sculpting is to use a clinic that is experienced with the treatments. These are professionals who have delivered the treatments countless times before. They’ve seen everything and know how to handle everything. They can answer any questions that you have with informative answers. More than that, however, they can take a look at your case and understand exactly what kind of treatment you need and how many sessions of that treatment you’ll need.

Experience and professionalism matter when it comes to body sculpting. That’s why you should consider The Aesthetic Clinique in Santa Rosa Beach. We offer numerous body sculpting treatments that can help you achieve the trimmed body you’ve always wanted. Contact us today to schedule your consultation!

“How I Treat Axillary Hyperhidrosis” Using RF Microneedling (Genius/Infini)

Consent – include pain, tenderness, infection, inadequate improvement, need for further treatments, PIH, scarring, compensatory sweating elsewhere, hair loss
Starch-iodine sweat test and mark treatment area. Hair must be shaven.
Apply 23%/7% lidocaine/tetracaine topical from Central Ave Pharmacy, Lipothene for at least 1 hour – 1.5 hours. Use 30% lidocaine ointment for darker skin types.
Subsequent analgesia might be needed with either injections using mesoram device and lidocaine with epi mixture (5cc lido w epi/5cc saline/1cc bicarb) or just inject
Pronox (Nitrous oxide mixture “Laughing Gas”) can be used as well.
Clean off ointment with alcohol and clean skin with Hibiclens
Use Zimmer air chiller and/or ice, ice roller, or Frozen C
Perform 1-2 passes with each depth of Genius with breaks after each pass to chill and go to opposite side.
3 depths – 3.5, 3.0, 2.5mm – go deep to superficial with subsequent passes
Energy/pin 40-60mj. Lower energies in darker skin types, poor pain tolerance
(For Infini – Treatment level 3-5, 300-400msec if tolerated)
Use sterile technique throughout – sterile gauze, sterile gloves, sterile saline
Keep eye on skin reaction – avoid excessive heat build up, redness. Abort procedure if skin not tolerating energies.
Infrared camera, if available, to monitor skin surface temperature – stay below 42C
Clean skin with sterile gauze and saline.
Apply Clindamycin gel.
In darker skin types, consider 4% hydroquinone 1 week prior and for 4-6 weeks after.
Expect decreased sweat in less than one week.
Repeat treatment in 6 weeks or longer.
2-3 treatments needed to have “controllable sweating”.

https://stevenfweinermd.wordpress.com/2015/10/09/hyperhidrosis-of-face-body-and-axilla-can-be-treated-permanently-using-the-infini/

Does Radiofrequency, RF Microneedling, or Lasers Affect Hyaluronic Acid Fillers?

While there are number of studies suggesting that lasers and RF do not affect fillers, a recent article by Dr. Weiss opened up the debate again. In his paper he stated that biopsies showed evidence of heating around the filler. It did not evaluated the changes in the filler volume over time. He concluded that the filler was at risk to be affected by the heat. Dr. Davin Lim’s recently published study contradicts Dr. Weiss, and showed with RFM, there was no affect on fillers (biopsy proved) at multiple different energy levels.

The heat from RF Microneedling reaches approximately 65-75 C for 100 msec to up to 3-4 seconds depending on the device and parameters used. This is the “hottest” version of RF delivery used in aesthetics. This compares to the sterilization process of the fillers at the (Galderma) manufacturing plant of 110-120 C for 15-20 minutes.

Lasers can heat the tissue to a higher level, up to 100 C, but again, it is for milliseconds at best.

Conclusion: There should be no concern regarding placement of HA fillers with RF Microneedling or lasers, at any level of the dermis or subcutanous planes on the same day. Furthermore, there will be no effect on previously placed HA filler. As a side note, PMMA has to be heated to 160 C to cause changes to it’s structure. While the exact temperature is unknown for calcium hydroxyapatite, it is significantly higher than HA, so it too is safe from RF and lasers.

What’s More Accurate – Cannulas vs Needles For Dermal Fillers?

There is an ongoing debate among injectors as to what method of injecting fillers is more accurate. The needle pundits state that the needle can inject in any tissue, at any depths. While this is true, is the filler actually placed where they think it is? Cannulas aficionados argument is that cannulas will stay in the plane which they are placed, and are therefore more accurate.

In a paper titled “Precision in Dermal Filling: A Comparison Between Needle and Cannula when Using Soft Tissue Fillers.” by Pavicic, Frank, Cotofan, et all, the debate was studied. There were 10 cadavers studied for supraperiosteal injections. The filler injected was radiopaque. Needles were placed in position using a perpendicular transcutaneous approach. The cannulas were placed in a similar position in the supraperiosteal plane. Using fluoroscopy, the injected material was analyzed in the horizontal and vertical planes.

The results show that in over 60% of the needle injections, the material changed planes (became more superficial) and this was not found in the cannulas group.

The conclusion was that cannula filler placement is more precise because the filler remains in the plane of the intended implantation much more so than needle placement.

Article Link

Why Subcision is Needed When Treating Acne Scars with Lasers or Radiofrequency (RF)

Acne scars are routinely treated with laser and RF or RF microneedling. However, the optimal benefits are probably not achieved unless subcision is performed. Here’s why –

Acne scars frequently will have collagen scar fibers extending to the subcutaneous fat, fat pads, or fascial layers. These fibers cause tethering of the dermis, leading to the appearance of an atrophic scar.

FACT: RF and laser energy has a propensity to travel through collagen.

FACT: As energy/heat travels through collagen, it heats the collagen and leads to collagen contraction

Theory: When treating tethered scars, there is a possibility that the collagen contracts and actually makes the atrophic scars appear deeper

Theory: When energy/heat travels down the collagen fibers, some of it might be transferred to the surrounding fat and lead to fat atrophy.

Subcision is a process where the tethered collagen fibers are transected. By cutting these fibers, the energy can’t progress to the deeper layers of tissue and thus not cause possible fat atrophy or further deepening of the scars. I perform this on most patients undergoing laser or RF for acne scarring if I feel there is any degree of deeper scarring or tethering. There is also the benefit of subcision even without using energy based devices in improving acne scars.

New Research Suggests that Not All Cannulas are Safe!

Cannulas, specifically, blunt microcannulas, can be used to administer fillers by advanced injectors. They a favorable over needles because they have a blunt round tip and are flexible, leading to the following advantages:

Less discomfort – one entry point can serve a large area, thus avoiding multiple dermal penetrations which is more uncomfortable.
Less bruising – the rounded/blunt tip tends to bend around blood vessels rather than nick or penetrate them.
More accurate – a recent study shows that the filler is most likely to be deposited in the area of the exit port vs a needle which has been shown to have filler travel up the shaft (back flow)
Safer – cannulas are less likely to give intraluminal vessel injections because of the blunt tip and therefor less possibilities of vascular compromise and blindness.

However, a recent publication by Drs Pavicic, Cotofana et al. has shown that #4 comes into question with certain cannulas. There study consisted of a total of 294 penetrations of the superficial temporal artery in cadavers using 22, 25, and 27 gauge cannulas and needles. The force applied to enter the vessel was measured for each. The cannulas had statistically higher forces needed to enter the vessel for the 22 and 25 gauge cannulas.

Interestingly, there was no difference in the forces when comparing 27g cannulas and needles.

The conclusion was that a 27g cannula was not safer than a 27g needle when used for filler injections. While 27g cannulas can be used, it is up to the injector to realize these are not safer than needles and to take the appropriate safety measures during treatments.

(Article: Plast Reconstr Surg. 2019 Mar;143(3):504e-512e. doi: 10.1097/PRS.0000000000005321)

Duration of Neuromodulators – What You Need to Know

There is renewed interest in neuromodulator/neurotoxins because of 2 newcomers to the US aesthetic market. Jeuveau is FDA approved and Revance will be approved early 2020. To differentiate themselves, these 2 have focused on duration of action of their products. Here’s the lowdown on what patients need to know about these wrinkle eradication injections.

There is a well-recognized scale that grades the glabellar lines at full contraction. Grade zero being no lines and 4 being the most severe dynamic lines. Keep in mind that this scale references only lines which appear during motion, not the static lines found at rest. In order for the FDA to approve injectable neuromodulators for the glabellar lines, there must be a demonstrable 2 point improve in this scale after 30 days. The take home messages of these FDA studies are:

The FDA considers a one-point improvement a failure, but the companies do not. There is literature and marketing by several companies stating their 4 or even 5 month duration for one-point improvements.
At FDA approved dosing, most grade 4 glabellar lines will not relax to the grade-zero score. In fact, with any dosing, grade 4 patients will most likely still have movement and wrinkles after treatment.
Not all patients had a 2 grade improvement in the FDA trials of any of the neuromodulators. Approximately 88-92% of patients responded to the FDA approved dosing.
The effect of muscle relaxation peaks at about 2-4 weeks, and then gradually tapers off. Muscle strength eventually returns to baseline at 3-6 months, depending on the dosing and the product used.
At 3-4 months, the FDA approved duration of the current modulators, a minority of patients still have 2 grade improvements in their glabella grade.

A well-established phenomenon with all the neuromodulators is the dose-response curve. The higher the dosing, the more effective the relaxation of the muscle injected. Additionally, the higher the dosing, the longer duration of the relaxation. Dr. John Josephs has performed studies on Dysport using dosing of 120 units (FDA approval is 50u) and has shown up to 6 months of 2 grade improvements in a significant proportion of patients. One “trick” he used when using these higher doses was to minimize the reconstitution volume to only 1cc. (Most practitioners use 1.5-3cc). Dr. Joseph refers to this technique as “A big dog on a short leash”. In other words, high dosing with limited spread in order to limit adverse events.

An as yet to be approved neuromodulator from Revance will be after a 6 month approval of their product. While at first glance, their 40 unit dosing will appear to be using the phenomenon of higher dosing – longer duration, this is not the case. Neuromodulators units, unfortunately, are not uniform between companies. A study Revance performed on the actually molecular weight of the active neurotoxin in their dosing showed that it was equal to that of the 20 unit dosing of Botox. They also evaluated Dysport’s weight, which was shown to be 50% higher than Botox and Revance, while Xeomin was actually 50% less than Botox/Revance.

What makes Revance’s neuromodulator last longer? It’s an associated proprietary protein that does not dissociate upon reconstitution. It is hypothesized that this protein’s ionic charge leads to better attraction to the receptor at the neuromuscular endplate. Revance’s product is essentially “more efficient” at binding, and therefore blocks more of the muscle movement than the other neuromodulators on the market at FDA approved dosing. Normally, there is some “wasted” neuromodulator which doesn’t bind and is swept away by the lymphatics and blood stream. The proprietary protein mimics what higher dosing would accomplish.

Neuromodulators work by blocking the release of acetylcholine at the neuromuscular endplate of the nerves. Return of function of the muscle is established when new nerve fibers are grown and re-establish contact with the muscle. If more nerves are blocked, it will take longer for the return of muscle function. If all the endplates were blocked to a muscle, studies have shown it takes 9 months for return of function.

After explaining all the numbers, it must be remembered that each patient reacts differently to the neuromodulators. As previously explained in another blog, once water/saline is added to the vials of Botox/Dysport/Xeomin/Jeuveau, there is only active protein in the vial within about a minute. The differences between the products are related to dosing, spread, and experience of the injector. As previously mentioned, Dysport has the highest weight of active neurotoxin in its FDA approved dosing and is the author’s choice amongst the current FDA approved neuromodulators.

Dr. Weiner’s New Treatment for the Aging Neck – “TriNECKta”

The aging phenomenon affects all the areas of the face and body. Sun exposed areas will be most affected due to the collagen destroying effects of UVA and UVB light. Dr. Weiner has developed a technique which addresses many different aspects of the aging neck, and, better yet, it’s all minimally invasive.

Pigmentation

Hyperpigmentation is a sign of UV damage and aging. It can be addressed with nonablative lasers, such as the Thullium 1927nm laser (Fraxel Dual/LaseMD). In some patients, there is also an associated redness, such as in poikiloderma. Redness needs a vascular laser such as the Excel V + laser. Skincare products are essential in maintaining results and must include a retinol, growth factor, and SPF.

Volume Loss

Much has been written about fat loss in the face, but this process will also affect the neck. Recent articles have validated safety with collagen stimulating fillers in the neck if done with careful technique. Deeper lines and wrinkles might also require a hyaluronic acid filler (HA) for improvement

Laxity

Loss of collagen, elastin, and gravity contribute to skin laxity in the neck. Radiofrequency seems to be the leader of the pack for tightening skin and building collagen and elastin. There are a couple different methods to use RF in the neck such as The Genius, FaceTite/NeckTite/AccuTite.

Hyperactive/hypertrophic Platysma

There is more literature supporting the platysma muscle becomes stronger as one ages. This leads to neck bands, jawline sagging, and corners of the mouth drooping. Strategic placement of a neuromodulator in the platysma can improve the appearance of the jawline and neck.

Excessive fat

Fat can accumulate in the chin area (double chin) and along the jawline. Methods used to improve the appearance of the fat in these areas includes: Kybella, Genius, FaceTite/NeckTite/AccuTite. If these procedures are done, the other procedures listed above will have to done on a different treatment day. Jowling can also be improved with these methods.

By combining these treatments, usually done in a series, multiple areas of the aging process can be addressed. Upkeep with future treatments and skincare is essential to maintain long-term results. To see if Dr. Weiner’s “TriNECKta” treatment is right for you, please call the office: 850-622-1214.