acne-scars 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.

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.

2019 UPDATE: State-of-the-Art Acne Scar Treatments

Acne scarring has significant debilitating effects on one’s overall self-worth and confidence. Millions in the US are affected. There have been improvements in techniques and energy devices in past few years which have led to better outcomes for acne scar treatments.

Subcision – This is process of breaking up deeply tethered scar bands associated mainly with atrophic/rolling scars. Subcision has be performed for acne scars for decades and just using this procedure alone has proven to lead to significant acne scar improvements. Recently there have been a couple publications suggesting that cannula subcision had better outcomes, less downtime, and less discomfort than the traditional method of using a Nokor needle. A cannula has a blunt tip so it is also safer – less chance for cutting a nerve or blood vessel than the knife-like edge of the Nokor needle. In the study, both patients and the performing doctor rated the results better when using the cannula. Subcision is particularly important, in Dr. Weiner’s opinion, to be performed prior to any energy device for tethered scars. This is based on the fact that RF and laser will preferentially travel through collagen – which is high is water content – than fat or most other tissue. Scars are predominantly collagen, so it makes sense to cut the connection of the scar to the deeper tissue. Through personal communication with Dr. Davin Lim, biopsies he performed have shown scar band that reach the deeper fat pads from tethered acne scars. Transmission of the energy through the scar can theoretical lead to collagen contraction and deepening of the tethered scar. Sometimes fillers are placed at the time of the subcision to improve the volume loss associated with the scarring. Some hypothesize that putting a “spacer of filler” might improve results as well. Dilute lidocaine during the initial passes allows for this procedure to be well tolerated.

TCA CROSS – TCA (Trichloroacetic Acid) is a chemical peel used to improved acne scarring by placing minute quantities in the scar using a toothpick. CROSS stands for Chemical Reconstruction of Skin Scars. The most common use of this procedure is for ice pick and small boxcar scars. The process of causing a controlled chemical burn, allows for the body to heal from the deepest part of the scar towards the skin surface. This makes the scar smaller in diameter and shallower. Usually a series of 3-6 treatments are needed, with 3-4 weeks between treatments. There will be some mild scabbing for a few days which needs to be kept moistened for best results. Risk include widening of the scar or post inflammatory hyperpigmentation (PIH).

Radiofrequency Microneedling – This technology (RFM) has been available in the US for about 6 years and has revolutionized acne scar treatment. Using needles which are insulated, energy is delivered into the scar tissue directly and bypassing the epidermis, for the most part. The insulation protects the skin surface from heating so darker skin type individuals are at much less risk of PIH (post inflammatory hyperpigmentation) vs a laser treatment. The needles allow for deeper penetration than lasers as well. Overall, downtime is less than ablative lasers in most individuals (when insulated needles, proper technique, and appropriate settings are used). With acne scarring affecting darker skin types disproportionately, this is an excellent alternative to lasers. The Genius has recently been FDA approved and is now the “best of bread” RF microneedling device. There is now impedance feedback from the needles which allows for improved and exact energy delivery. The resistance in the tissues being treated is measured and this is important because throughout one’s face, there are differences, as well as between different individuals. Also, as tissue are heated or subcised, the resistance changes. Prior to Genius, there was no idea of how much energy was being delivered. There is now an accurate total energy for each pulse and a cumulative total. Other improvements include needle design-sharper, stronger motor, and feedback regarding quality of each pulse fired.

There is a myth that needs to be busted. Deeper does not mean better for acne scars.

The needles must stay within the scar for best results. If the needles go beneath the dermis, there is a risk for heating the fat and fat loss. Let it be known that the actual depth of the needles in most RFM devices is less than the settings, and becomes less accurate, the deeper the settings are. There is inherent resistance of the skin to penetration and many needles aren’t sharp enough or motors aren’t strong enough to get to the desired levels in the time required. This has also been addressed with the Genius and it’s depths are very accurate after extensive testing.

In addition, higher energy levels on any device which doesn’t monitor impedance, can actually result in very little energy delivered. Once the tissue is heating beyond a critical level, the resistance becomes so high that energy output cuts off. However, when higher energy levels are desired when using the Genius, the energy is adjusted to the increasing impedance and it is successfully delivered.

Fillers – Fillers are a very integral part of improving acne scars. They are extremely useful for the atrophic scars and the lipoatrophy associated with these scars. The aging process leads to dermal thinning and fat atrophy, which makes the acne scars appear worse, even if active acne has long been controlled. Fillers need to be injected deeply for correcting large areas of volume loss and superficially in minute quantities for focal defects. A hyaluronic acid filler will give about 12 months of improvement vs Bellafill which can give near permanent improvements. Bellafill does require a skin test to see if one has a allergy to the bovine collagen (0.5% chance) which needs 3-4 weeks to determine. There is some who feel fillers in areas of subcision will prevent re-adhesion of the scars. Most failures from other treatments are related to not recognizing the need to fillers to improve the acne scars.

Lasers – Erbium/CO2 ablative lasers still are beneficial for acne scars but have more downtime and risks vs RFM. Deeper skin imperfections are not improved with lasers and require fillers. These devices are best reserved for more superficial scars, mainly boxcar scars. Non ablative lasers are less affective but safer and in the author’s opinion give very minor results.

Microneedling – Also know as “Collagen Induction Therapy” CIT, has become popular in recent years. There are rollers available for home use and then there are medical grade devices which go to depths of 2mm or deeper and create thousands of penetrations per second. Rollers should be not be used at home for 2 reasons – questionable sterility at home and they tear tissue more than the in-office devices. Often these treatments are combined with topicals and PRP. It is highly recommended to not use any products on the skin which would normal not be injected. There have been many cases of infection and granulomas from these practices. Even when done in the office with PRP or amniotic membrane products, the efficacy of this procedure is minimal, and should be reserved for only mild acne scarring.

PRP/Amniotic membrane products – There is some date to support that better results and faster recovery with less side effects if PRP or amniotic membrane products are used during acne scar treatments. There is a movement more towards amniotic/placental products and away from PRP because there are more growth factors/healing properties in these vs PRP.

LLLT – There is a plethora of studies to suggest that using low level laser light (LLLT) is beneficial to results and healing times. The most researched device is Healite, and this should be performed immediately following all acne scar procedures which use energy devices. It calms the skin and improves circulation.

Acne scarring procedures are continuing to improve as technology and techniques evolve. One must understand that results require months to fully appreciate and multiple treatments (3-5 or more) are often needed to optimize results. Expectations need to discussed with providers/patients so that all are on the same page as to what one can achieve with treatments.

Dr. Weiner is an Acne Scar Center of Excellence designated by Bellafill and is a specialist on acne scars. He is a lecturer and trainer for Bellafill. He has become one of the leading authorities on Radiofrequency Microneedling and travels the globe lecturing on this technology. He performed the FDA trails for the Genius. He recently authored a chapter on RF Microneedling which soon will be published in the Facial Plastic Clinics of North America. He also wrote a recent chapter on Radiofrequency Safety and Complications which will be part of a book titled “Complications in Minimally Invasive Facial Rejuvenation: Avoidance and Management” by Paul Carniol, MD

Subcision of Acne Scars – Revisiting an Old Technique

Acne scarring is a significant psychologically debilitating disease affecting millions in the US, approximately 1% of the adult population in one study. Treatments for acne scars include:

Lasers
RF Microneedling
Fillers
TCA Cross
Subcision
Microneedling
PRP (Platelet Rich Plasma)
PDO Threads (?)

Most of these techniques are based on trying to make the disorganized collagen in the scar to be more organized and natural. Using carefully induced tissue trauma with heat or microneedles (mechanical), the body initiates a healing process to smooth the scars.

Acne scars will often affect tissues deeper than the dermis. Fibrosis/scarring can affect the subcutaneous tissues and fat and lead to tethering of scar to the deeper structures. Lipoatrophy (fat loss) can occur as the result of the inflammatory mediators released from the acneic process. When heating from lasers and RF is applied, it is preferentially conducted through the collagen because the water content of collagen is high. Heating collagen will lead to collagen remodeling but also collagen contraction. If the collagenous attachments to the deeper tissue are not cut (subcised), there is actually potential for worsening the appearance of the scars with these heating devices.

A recent paper suggested that using a cannula to subcise acne scars is better tolerated, with less adverse events, and judged to have better results by the patients. This is Dr. Weiner’s (and acne scar expert Dr. Davin Lim’s per personal communication) preferred method of subcision vs using a Nokor needle. By subcising, the energy flow to the deeper structures is severed and harm to fat is less as is the risk of pulling some scars deeper. Placement of filler (Restylane Defyne, Bellafill) is often done simultaneously with the subcision to help elevate the scars and prevent reattachment of the scars.

Subcision has been around for decades for acne scar treatment. It is now even more important when energy devices are used to maximize the benefits of these treatments. The use of cannulas for this procedure leads to more comfort, less risks, and better satisfaction.

The Aesthetic Clinique has been designated an Acne Scar Center of Excellence by Suneva (Bellafill) and is considered an acne scar expert.

**(Subcision is also useful for treating cellulite as there are fibrous attachments from the skin which cause the dimpling.)

Acne is NO Longer A Problem with The Aerolase Neopod Laser (Neoclear)

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.”

3 Year Experience with Infini – High Intensity Focused Radiofrequency

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It’s been a little over 3 years since the Infini was introduced in the United States in August, 2013 by Lutronic. It was developed in Korea, and had been used in the prior 2 years in Asia and Europe. Infini brought a significant evolutionary change to treating the skin with radiofrequency (RF). Although RF has an over 50 year history of medical uses, Lutronic’s Infini innovations has elevated the precision in which the RF energy is delivered to an entirely new level.

It been long established that heating skin causes an inflammatory response that results in collagen stimulation, tissue contraction, and skin rejuvenation. While 42-45 C (denaturing) has shown to be enough to create this cascade, 65-70 C (coagulation) has been shown to lead to maximum collagen deposition. Radiofrequency devices which push their energy through the skin without penetration are limited to temperatures of 45 C because of the risk of harming the skin surface (blisters/scarring). Bypassing the surface with microneedles, as Infini does, temperatures can go up to the coagulation point with very little risk. In addition, Infini can place this energy at the “sweet spot” of the skin, the mid to deep dermis. The depth of most of the predecessor RF devices was always in question, and was often too deep (fat necrosis risk).

Over the last several months, there have been significant treatment innovations with Infini. With diligent research and histological evaluations, optimal settings were further enhanced. These settings lead to larger zones of coagulation during each pulse. This translates into fewer pulses needed (shorter treatment times), and better results. In addition, the treatment tip was modified to allow for a more even distribution of energy, which also leads to better outcomes. The “price to pay” for these innovations is slightly more prolonged redness, possibly up to a week. Also, “microdots”, the grid-like white marks from the needle tips, might last for more than a couple weeks. These have always resolved without scarring or complications.

Dr. Weiner has performed approximately 1000 cases in the past 3 years with Infini. (Cases = areas treated, i.e face, neck, chest). A summary of his findings:

There have been no long term complications in his patients. There have been no incidences of scarring, unwanted fat loss, or pigmentation issues.
Infini is safe to use on all skin types.
Infini is the most effective device available for acne scarring when compared to ablative, non ablative lasers, and other RF devices.
Significant improvements can be established in the neck wrinkles, necklace lines, and creepy skin of the neck.
Superficial fine lines on the face are well treated.
Jawline and submental definition are improved in most cases. Purposeful fat loss is possible in these areas with deeper, more aggressive settings.
Infini is an option for axillary hyperhidrosis with proven long term results.
Infini can be safely used all over the body but the small footplate limits treatments on large surface areas.
Treatment of stretchmarks is only mildly effective. Further refinements in settings and combination therapies are still being researched.
Treatment of malar festoons (fat pads) is moderately effective with Infini (and will soon be even better with new protocols).
Over 95% of patients can be treated with only topical anesthesia. With the addition of the Superficial Skin Block, treatments are extremely well tolerated by the remaining patients.
For optimal results, some patients need volumization and Sculptra can be done simultaneously with Infini treatments.

Infini has already established itself as a low risk, low downtime, skin tightening procedure. Expect better results, less number of treatments needed, and new indications in the future. Significant resources at Lutronic will build upon the Infini platform to maintain its market dominance in the Aesthetic RF market.

Bellafill is a Unique, Safe, Long Lasting Filler

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Bellafill is a one of a kind dermal filler. What makes it unique is its longevity, composition, and FDA approved indications. Although FDA approved in 2006 for improving the nasolabial folds, there have been 2 recent studies that have expanding its indications. These are the use of Bellafill for acne scars and data which shows at least 5 years of correction from a Bellafill treatment. Both of these studies are ground breaking, with no other fillers able to make these claims.

Bellafill is a mixture of 20% PMMA (Poly Methyl Methacrylate) and 80% Bovine Collagen. PMMA has been used medically for over 50 years as an implant. The PMMA in Bellafill is uniform smooth spheres of 40 micron diameter. The spheres elicit an inflammatory response, which stimulates the body to create a collagen capsule around these spheres. The size of the spheres is important, because at 40 microns, the body is unable to phagocytize the PMMA (digest), leading to the prolonged longevity of the product. Being smooth, the inflammatory response is subdued, minimizing the uncontrolled inflammation found in granulomas. Prior to Bellafill injection, a dermal test is needed to see if the patient is allergic to the Bovine collagen and this takes 28 days to determine the results. The Bovine collagen in Bellafill provides a temporary correction for about 2-3 months, until the body’s own collagen is created.

Acne scarring causes significant psychosocial problems for millions of Americans. Isolation, depression, suicidal thoughts, and poor self-esteem are just some of the many issues these individuals suffer from. Bellafill is used to improve the appearance of the rolling type (scars that flatten when stretched) of acne scars. It is injected into the dermis, to elevate the scar. The results are immediate, but improvement is noted over the next 12 months. The FDA study showed that approximately 0.1cc was needed per scar, and most patients required 2 treatment sessions. There were no major complications noted and everyone was followed for 12 months. Satisfaction rated by the patients was over 90% at 12 months.

No filler on the market has published data showing persistent corrections at the 5 year mark. Bellafill studied 1008 patients for 5 years. Retention rate was 87%. Satisfaction rates at every year including the 5^th year was 80% or higher. The granuloma complication rate was 1.7%, which is comparable or better than all other fillers. With treatment, the granuloma rate was less than 1%. With corrections lasting at least 5 years, it is easy to see how Bellafill is actually a very economical filler as well.

Bellafill truly is unique amongst the dermal filler in regards to its longevity and use for acne scars. It is currently only available from a select group of physicians who have been trained by the company. Dr. Weiner is a physician trainer, lecturer, Key Opinion Leader (KOL) and on the physician advisory board for Bellafill. Dr. Weiner is actually a Bellafill patient as well, having been recently injected with 8 syringes of the product.

Comparing Infini to Ulthera and Why Infini’s Technology is Superior for Laxity, Wrinkles, and Acne Scars

When it comes to skin tightening and wrinkles, there has been an increasing trend for the consumers to choose the less invasive approaches and opting out of surgery. Although results aren’t as dramatic, nonsurgical treatments offer less downtime, less risk, and less cost. These treatments are great for the people who are not quite surgical candidates because of very mild signs of aging as well as those that just want to delaying the sagging before it is even apparent. Then there are those who really are surgical candidates but can’t afford the downtime or are concerned about the looks of some of their peers who have had face/neck lifts.

The most recognized name for noninvasive skin tightening currently is Ulthera (Ultherapy). This technology uses highly focused ultrasound to cause a thermal coagulation zone beneath the skin without affecting the surface. This technology is akin to the one used to break up kidney stones or gall stones with ultrasonic energy (lithotripsy). The coagulation zones elicit an inflammatory response leading to collagen stimulation and contraction. This results in tissue tightening and wrinkle improvement. Ulthera was brought to market in 2009, with Dr. Weiner being one of the first 20 adopters in the US. Dr. Weiner has had significant experience with this device and with all the changes in protocols.

In 2013, the Infini was FDA approved and introduced in the US. This was a novel technology for the US, but it had been used in Asia for at least 1.5 years prior. Infini uses radiofrequency attached to microneedles to cause similar thermal coagulation zones as the Ulthera, below the surface of the skin. Dr. Weiner is the largest user on the Infini in the US and now lectures and precepts other physicians in it use.

The similarities of the 2 technologies:

Both are fractional treatments (only treat a portion of tissue) which is safer and leads to faster healing.
Both can treat at multiple different levels. While Ulthera is restricted to 3 levels, it is not uncommon for Dr. Weiner to treat at up to 5 levels with the Infini.
Both have very little downtime – Ulthera has potential for bruising but otherwise no downtime. Infini has about 24-36 hours of redness and swelling. There are no activity or sun restrictions for either treatment.
All skin types can be treated with both technologies.
Both can be performed in the office with just topical – Patients who have had both technologies report that Ulthera had more discomfort in Dr. Weiner’s office.
Both can improve skin laxity, particularly in the jawline. It is Dr. Weiner’s opinion that this is primarily due to fat destruction by both technologies. Both can reach into this layer (the Infini only if desired, Ulthera almost always by default with the deeper transducers).
Both mechanisms of tightening are similar – create a controlled injury that leads to tissue contraction, tightening, collagen stimulation BUT the way the injury is produced is different.
Both can be safely off the face – neck, chest, extremities, under arms (hyperhidrosis)
Both are extremely safe technologies with very little side effects and don’t use lasers (so safer for the eyes).
Both have better results with multiple treatments. Although Ulthera states one treatment is needed, the experience Dr. Weiner had with the technology was that better outcomes were seen with multiple treatments.

Comparing the differences of Infini versus Ulthera:

Infini treatment of the face/upper neck lays down over 50,000 thermal coagulation zones VS Ulthera’s 16,000. It only makes sense that the more zones, the more results.
Infini depths can be adjusted from 0.25 mm to 3.5 mm in increments of 0.25 mm. Ulthera has 3 depths: 1.5, 3.0, 4.5 mm. Using the ultrasound of the Ulthera, Dr. Weiner was able to measure skin depths over the face and neck. There were no areas of skin thickness greater than 2.5 mm in the entire face and neck (except in very thick skinned males in the upper cheeks). Therefore, MOST OF THE TREATMENT FOR ULTHERA IS BELOW THE LEVEL OF EVEN THE DEEP DERMIS. Only the 1.5mm transducer causes coagulation in the dermis. This is not included in most protocols, or if it is, is only a minor component. Studies have shown that the area of greatest collagen formation is in the deep dermis. Infini is able to lay the coagulation zones all throughout the dermis, including the deep dermis because of its ability to change it’s depths. The Infini can even treat different areas of the face at different depths, which is important because the face has significant variability of thicknesses between the forehead, eyes, cheeks, lips, jawline, submental, and chin area. Depths below the dermis injure the subcutaneous tissue, which is mostly fat. Fat is what we want to preserve, not destroy, except along the jawline and submental area.
The treatment cost (consumable) of Ulthera for the physician is more than 10 times greater than for the Infini. The purchase price to the physician is also about 50% more for the Ulthera. The treatment time is also longer, sometimes up to 50% more for Ulthera. This all gets passed on to the patient resulting in Ulthera being about double the price of the Infini in most offices.
Although Ulthera touts that deeper penetration causes contraction of the SMAS, to Dr. Weiner’s knowledge, this has yet to proven histologically. The deeper penetration does lead to more discomfort as well as potential for fat destruction. The Infini targets the dermis, particularly the deep dermis, the area for maximal collagen creation.
Results seem to be more consistent with the Infini versus Ulthera. This seems to follow the science. More coagulation points in the correct zone of the dermis should lead to more collagen, more tightening.
Superficial fine lines can be treated with the Infini but not Ulthera. In certain cases with skin type 1-3, shallow treatments of less than 1 mm can be used to treat these wrinkles and etched in lines. Ulthera doesn’t have this capability.
Although there are some reports of Ulthera treating acne scars, Infini seems to be the best technology to treat these. It is probably the combination of the microneedles, RF energy, and adjustable depths that make it a superior technology to treat this difficult problem.

From about 2005 – 2009, Thermage was the most advanced noninvasive skin tighten device. This was replaced with Ulthera in 2009, which offered better, safer, and more predictable results because of precisely placed coagulation zones (albeit, maybe too deep). In 2013, Infini was introduce and it has been slow to catch on. However it is finally being adopted by the key thought leaders in the Aesthetic Industry. It will soon be recognized as the most efficacious noninvasive skin tightening technology on the market.

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State of the Art in Acne Scar Treatment – 2015

Dr. Weiner: Acne Scarring after 2 Infini treatments.

Acne affects 85% of people between the ages of 12 – 24. There are various types of acne that range from simple black/white heads, papules/pustules, to the cystic breakouts. It’s the cystic acne that leads to most of the scarring. Acne scarring can have a impact on one’s appearance leading to a significant emotional toll. Lack of self esteem, social withdrawal, negative self image, and depression have all been described by acne scarring sufferers. Acne scarring questions are one of the most frequently asked questions to the experts on Realself.com. It’s important for the medical community to address this problem for the overall well being of a significant segment of the population.

It might seem obvious, but in order to treat acne scarring, the active acne must be controlled. It’s the author’s opinion that acne can be controlled with topical medications combined with lasers. A newer treatment, recently popularized by Dr. Weiner, has been the use of Botox/Dysport for controlling the sebum production in the skin. Please see my blog for more details about acne treatments.

Fresh Acne Scarring Treatment

When acne scarring is still red, treatment is easier and results are better. The primary treatment for scars in this stage is vascular lasers. It has been found that early scar formation can be reversed using these lasers over several sessions. The author’s choice of lasers is the Spectra Q Switched Laser – Gold Handpiece. This offers a quick (5 minute) nearly painless treatment. It should be done 4-6 times in general. Other laser options are the Excel V or the VBeam. Some small smoldering areas of acne are treated simultaneously with these lasers as well.

Long Standing/Persistent Scarring Treatment

Longer standing scars are harder to treat than early red scars. Collagen has been laid down in an inappropriate, disorganized manner. Treatments are directed at breaking up this collagen and for it to reorganize in a more natural manner. There are a few ways this can be done:

Lasers: There are ablative (tissue is removed) and non ablative (tissue is heated) lasers. There is more downtime, more risk, and more results with the ablative lasers. Darker skin types are at risk for darkening of their pigmentation (hyperpigmentation)
Subcision: Using a needle or similar, the physician goes under the scars and cuts them from their deeper attachments. This process has been used for decades and has minimal risk and downtime. It’s the authors opinion that unless something is placed in the area where scarring was cut, the scar will reform between the “sticky edges” as it does in all other surgical wounds. Bellafill is a permanent filler that was recently FDA approved for acne scars. Dr. Weiner suggests placement of Bellafill in these subcised scars to keep the edges from tacking back down, and to fill lost volume in the rolling acne scars.
Microneedling Fractional (Controlled Depth) Radiofrequency: This technique uses RF energy to break up and reduce the scarring with coagulation. The healing process leads to a more organized collagen matrix. The best in class device for this category is the Infini from Lutronic. The insulated needles, variable depths, and fractional delivery make it extremely safe for all skin types with minimal downtime and risk.
Platelet Rich Plasma (PRP): PRP has been shown to improve healing times and results in many areas of orthopedics. As of yet, there are no studies that definitively say that PRP can help acne scarring but there are several case reports that it improves outcomes. It is probably an effective addition to laser or RF procedures when treating acne scars with no known detrimental side effects.

Dr. Weiner Recommendations for Mature/Long Standing Acne Scars:

The most effective energy based treatment for acne scars seems to be the Infini. Results from ablative lasers (CO2), and non ablative lasers (Fraxel 1550) don’t seem to match the Infini’s results in his clinical experience. Patient satisfaction is higher with Infini, with much less downtime and a safety profile, particular in darker skin types, unmatched by the lasers.

For persistent defects after 3 or more treatments with the Infini, subcision with Bellafill administration is then recommended. It typically will take about 2 treatments, 2 months apart, to get optimal results with this method. This is only practical on about 10 – 15 lesions at a single session.

PRP can improve healing times and may improve results.

Remember that acne scars “won’t go away” but will be improved with the treatments mentioned.

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Most Frequently Asked Questions about Infini, RF Skin Tightening from Lutronic

What makes Infini different than other RF devices? The long answer can be found at my blog post. The short answer is: fractional not bulk heating, needles are insulated, needle depths are variable, coagulation occurs for maximal collagen stimulation, and the epidermis is safely protected from the heat. This allows for a very safe treatment for all skin types, that is also very effective.
What long term complications have you (Dr. Weiner) seen? With over 1000 treatments, I have seen no long term complications. No skin atrophy, no unintended fat loss, no scarring, and no pigment changes.
How long does a treatment take? With an experienced provider, the face treatment takes about 45 minutes, and if the neck is included, add another 15 minutes.
How long is recovery? The initial redness subsides very rapidly in the first hour. It takes about 24-36 hours to resolve, as does the swelling. Rarely, patients report extend redness for a few more days.
What are the restrictions after the Infini? Skin care must be only the prescribed creams. No make up until the morning and care with touching the skin with unclean hands or towels. There are no activity or sun restrictions!
Is ice or steroids used after the treatment? It is not recommended to use either of these after Infini. Although there is no data, it is Dr. Weiner’s opinion that the results can be compromised if ice or steroids are used. The results are dependant on inflammation, and “heat shock proteins”, both of which are inhibited with ice and steroids.
How many treatments are needed? Good question. It is variable. To get maximum benefit, the general consensus is 3. Some people might be happy with only one, but that is uncommon. Younger patients wanting only preventative treatments can get one yearly. Acne scarring clients should consider at least 3, and might be more satisfied with 5 or 6.
How does Infini affect fillers? If the fillers are injected deeply below the skin (sub Q, or deeper), such as is done by Dr. Weiner using the blunt cannulas, the fillers should not be affected. Sculptra and Bellafill are not affected at any depth and are frequently done at the same time as the Infini by Dr. Weiner. If the filler is placed in the dermis, they are at risk of being degraded.
How long should I wait between treatments? Consecutive treatments can be done as close as 3 or 4 weeks. If this is not possible because of your schedule, don’t worry, the final results are not affected.
How painful is the Infini? Most patients will rate the majority of the procedure a 3 or 4/10. The areas which might be higher are over the bone, such as the forehead, cheeks, and jawline. We have recently implemented changes in technique to make all but the forehead more comfortable. The forehead can be excluded if desired. All patients report no discomfort when the procedure is complete.
Can the Infini be used on other parts of the body? We routinely treat the neck and chest in conjunction with the face treatment. Other areas we have treated are arm laxity, knee area, and scars from abdominal surgery. Stretch marks have been treated but results are variable. We have successfully treated hyperhidrosis with the Infini as well. Bottom line is that when appropriate depths and settings are used, the Infini can be used on all areas of the body.
How many passes are performed on each area? Each area is treated at least with 3 depths and 2 passes for each depth. Some areas area treated at 4 or 5 depths.
What patients would you exclude? Very few patients wouldn’t be candidates. Patients with pacemakers should not be treated. If there is metal in an area of the face, the skin overlying this area can not be treated. Patients on blood thinners can be treated but will get bruising. We try to hold all thinners if it is possible prior to treatment. Aspirin needs 12 days for it’s action to be completely reversed on the platelets. Patients with severely sun damaged skin will theoretically respond less than a person with healthy skin.
Why is Infini safe for darker skin patients? The Infini is protective of the epidermis, where the pigment cells are, because it’s needles are insulated. Also, the depth can be adjusted so the heat from the RF stays in the dermis, below the most superficial layer. Other devices are either not insulated, or try to push heat through the skin, potentially damaging the pigment cells.
How does the Infini compare to lasers for treating acne scars? The Infini is safer than a laser, with less downtime, and no risk to the eyes. As stated above, the darker skin patients can be treated more safely with the Infini when compared to a laser because a laser will heat the upper layer of skin, the epidermis. Lasers have the risk of pigment changes (darker or lighter). Results from Infini appear to be better than lasers for acne scars. It is postulated the the increased depths of the Infini (up to 3.5mm) vs lasers (maximum about 1.8mm) seems to the difference. Also, elastin is produced (elastinosis) in response to a RF treatment, and this is not the case in laser resurfacing.
How long do results last? This is a difficult question and will be different for each patient. The collagen created will last at least 7 years. However, the amount of collagen is variable, and depends on the overall skin health, patient’s health, smoking habits, age, tanning, sun exposure, and lifestyle. It is usually recommended to have a “touch up” performed every 12-18 months.
What is better, Infini or Ulthera? My new blog answers this in detail: Infini vs Ulthera