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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:

  1. Both are fractional treatments (only treat a portion of tissue) which is safer and leads to faster healing.
  2. 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.
  3. 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.
  4. All skin types can be treated with both technologies.
  5. 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.
  6. 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).
  7. 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.
  8. Both can be safely off the face – neck, chest, extremities, under arms (hyperhidrosis)
  9. Both are extremely safe technologies with very little side effects and don’t use lasers (so safer for the eyes).
  10. 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

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Why Juvederm is NOT a good choice for the Tear Trough or Eye Area

Juvederm is one of the most popular dermal fillers in the US.  As with most fillers, it is only FDA approved for the nasolabial folds, but is used “off label” in other areas of the face.  Although Juvederm is a very safe filler for use around the face, there are certain characteristics that make it the wrong choice for filling the “tear trough” and areas around the eye.

Like many of the popular FDA approved fillers, Juvederm is a hyaluronic acid (HA) filler.  The other commonly used HA fillers are Restylane, Perlane, Voluma, and Belotero.  One of the characteristics of HA fillers that extends their longevity is that they are hydrophilic.  Hydrophilic means “water loving” which translates into the HA fillers absorbing up to 10 times their volume with water from the surrounding tissues.  Although all the HA fillers have this characteristic, Juvederm is the MOST HYDROPHILIC of the dermal fillers mainly because it is has the highest concentration of HA. This is a disadvantage around the eye because it often results in PROLONGED EDEMA around the eye.  All the HA fillers have been known to do this but it is particularly common with Juvederm.  Dr. Weiner has seen this problem with people that have been injected with Juvederm in the tear trough even up to 3 years earlier.  RealSelf.com is replete with stories and pictures of very unhappy patients with this Juvederm problem.

Another disadvantage of Juvederm in the eye area is related to its cohesivity.  This is the ability of the product to bind to itself.  Juvederm has low cohesivity, which means it tends to spread to the surrounding areas, causing a correction to areas beyond the injected area.  This is fine for some areas, but in the tear trough, which is a very small area, doctors need precise control of the filler.  The physician wants to know that when he places the filler in the tear trough, it will stay exactly there, and it doesn’t with Juvederm.

Fortunately, hyaluronidase is an antidote for HA fillers, and can be used for dissolving fillers with poor cosmetic results. For Juvederm, dissolving with hyaluronidase is harder and requires more treatments than the other HA fillers.  Some believe this is related to the higher cross linking in Juvederm than other fillers.  Nonetheless,  Juvederm can be successfully reversed even in instances where the chronic edema has been present for several years.

Around the eye and tear trough area, the HA filler of choice should be Restylane.  There are some physicians that are happy with Belotero and Restylane Silk.  Another great option is Sculptra but only in very experienced hands.  Remember too, that cannulas are a much safer option for the injection in this area, with less risk, less bruising, and less downtime.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Facebook: http://www.facebook.com/TheAestheticClinique/

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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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!
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. What is better, Infini or Ulthera?  My new blog answers this in detail: Infini vs Ulthera

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Facebook: http://www.facebook.com/TheAestheticClinique/

Various Acne Treatments offered by Dr. Steven Weiner

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See Also:  State of the Art in Acne Scar Treatment

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Facebook: http://www.facebook.com/TheAestheticClinique/

How Long Do Dermal Fillers Last…..It Depends!

It happens everyday.  Patients ask how long they can count on their dermal filler lasting.  The problem is, is that there is no quick and easy answer.  There are a number of variables that factor into filler longevity, with the ultimate unknown being that there is no way that a physician can determine how one’s body is going to degrade a particular filler.

In the US, the majority of patients are injected with Hyaluronic Acid (HA) fillers.  The commonly known HA fillers are:  Juvederm Ultra, Juvederm Ultra Plus, Restylane, Perlane, Voluma, and Belotero.  The differences between the HA fillers are their manufacturing process, and the concentration of the HA in the filler.  The harder the HA is for the body to break down, the longer it will last.  A larger particle of HA has less surface area then multiple smaller particles taking up the same space.  Less surface area means there is less area for the cells to “chew up” the HA.  In general, larger particles will last a little longer than smaller particles.  Another factor in HA fillers is how tightly the particles are bound together.  Cross-linking, adding bonds between molecules of HA, has been shown to significantly add longevity.  All HA fillers are a combination of cross-linked and non cross-linked HA.  Too much cross-linking leads to a filler that is very hard to inject, and has led to more complications (in a filler that is no longer on the market).  Non cross-linked fillers last only 3-4 months and are hardly used anymore.  One last variable in HA fillers is their ability to attract water, their hydrophylic properties.  The more they attract water, the longer the HA filler gives a correction.

The fillers that are collagen stimulators, tend to lead to longer longevity.  Fillers in this group are:  Radiesse, Sculptra, and Bellafill.  While studies have shown a very mild collagen response to the HA fillers, the visible volume correction with the HA fillers is the gel, not the collagen.  With the collagen stimulators, the body responds to what is injected by creating an inflammatory response and lays down collagen.  Until the particle is degraded by the body, collagen will continue to be produced.  Radiesse is made of calcium hydroxylapatite, and is the shortest duration in this group.  Artefill should be considered a permanent filler, because its component, Poly Methyl Methacrylate (PMMA), does not get broken down by the body.  Sculptra has consistently given about 2-3 years duration in studies and in the authors experience.

The location in the face a filler is injected is one of the most important factors to determine longevity. Areas where there is more movement, there is faster breakdown.  In order of increasing duration in the face, the order is (in the author’s experience):

  1. Lips
  2. Marionette
  3. Nasolabial Folds
  4. Tear Troughs
  5. Cheeks
  6. Temples

(Forehead, nose, earlobes are variable)

A couple more very important variables that should be mentioned.  The more filler that is injected, the longer it will last.  This applies to all the fillers.  Also, filler doesn’t stop working all of a sudden.  It takes months of gradual loss to notice a difference in volume.  In fact, even when the patient believes there is no longer results, biopsies have proven that there is still filler present.

After all the above explanation, the author’s experience with the commonly used fillers is:

  1. Lips:  HA fillers give about 4 months, longer with recurrently injected lips.
  2. Tear troughs:  HA’s – about 9-12 months, Sculptra and Bellafill – years.  Juvederm could last years and should never be injected in tear troughs.
  3. Nasolabial:  similar to tear troughs
  4. Temples:  HA’s – 12-18 months, Sculptra and Bellafill – years
  5. Cheeks:  HA’s – 18 months, perhaps 2 years with Voluma; Sculptra and Bellafill – years

Remember that individual results are unpredictable.  These are generalizations and offer no guarantee as to how long a patient’s results will last.  There are many variables that factor into longevity that are listed above, not to mention how each individual responds, degrades, a certain filler.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Facebook: http://www.facebook.com/TheAestheticClinique/

Amazing Things That Can Be Done (By the Experts) With Dermal Fillers

This is the golden age for minimally invasive cosmetic procedures.  Who would have ever thought 15 years ago, that procedures done in the office in a matter of 20-30 minutes could result in demonstrable improvements in one’s appearance with results lasting, in some cases, a year or more?  Without the need for downtime, anesthesia, or significant costs, cosmetic procedures have flourished, with many people who never would consider enhancements, “dipping their toe” in these procedures.  The concept of “preventative maintenance” has spurred the younger generation to start earlier, with smaller, less dramatic, but noticeable procedures as well.

At the forefront of the wave of cosmetic enhancements are dermal fillers.  When Restylane was FDA approved in 2003, a revolution in the field was born.  Although the main focus was to improve the nasolabial folds, the “smile” lines, in its inception, the broad “off label” use of it, along with subsequent FDA approval of other fillers, treatments have spread to just about every area of the face.  There are now about a dozen dermal fillers on the market, with the majority of them based on hyaluronic acid, a naturally occurring substance that is found in skin and joints.  Hyaluronic acid fillers (Restylane, Perlane, Voluma, Juvederm, Belotero) provide a soft, very well tolerated fill, with an extremely safe profile.  There is also a level of security knowing that these fillers are generally completely reversible, using the widely available enzyme, hyaluronidase, that can dissolve hyaluronic acid, in minutes to hours.

Although less popular, it must be mentioned that there are other dermal fillers which are FDA approved, each with their own niche market.  Radiesse is composed of microspheres of calcium hydroxyapatite, and is known as a very robust filler, that has a very high G prime, a measure of it’s lifting ability.  Sculptra is composed of Poly L Lactic Acid (PLLA), also naturally occurring as a sugar in the body, and is known as a collagen stimulator.  Its use is for global, long lasting, volumization of the face.  The longest duration FDA approved filler is Artefill.  It is composed of microspheres of Poly Methyl Methacrylate (PMMA) which is a synthetic molecule.  Artefill is considered a permanent filler and works as a collagen stimulator, similar to Sculptra.

The understanding of the aging face has made great strides in the last decade.  It is now widely understood that loss of volume is the primary cause of the aging face.  Leading this volume loss is the shrinking of the multiple fat pads of face, primarily of the cheek and periorbital area.  This is why aging often begins to show around the eyes.  Gravity contributes to our aging problems and often manifests itself by the descending of these fat pads. Relegated to a less relevant problem than 15 years ago, is the aging related to excess skin.  Plastic Surgeons have tightened loose skin for decades during facelifts, often leaving people appearing skeletonized and hollow, but without wrinkles.  It is now understood that most of the redundant skin can be improve with proper volumization of the offending fat pads, and most facelifts incorporate this during surgery presently.  (In the author’s opinion, most of the patients undergoing the knife could have had their concerns addressed using a combination of fillers and skin tightening devices.)

The common manifestations of volume loss are:

  1. Temporal hollows
  2. Loss of cheek volume
  3. Tear trough deformity
  4. Excessive crows feet and forehead lines
  5. Low hanging eyebrows
  6. Hollowness of the eye (orbit)
  7. Jowls
  8. Poorly defined jawline
  9. Small lips
  10. Dropping of nasal tip
  11. Lip lines (smokers lines)
  12. Corners of mouth dropping causing sad look
  13. Saggy neck
  14. Elongation and narrowing of the face

All the above mentioned aging effects can be improved with dermal fillers.  Expertise is required to recognize exactly what areas need to be treated to replenished the lost volume, while still maintaining a natural appearance.  It’s been shown that the brain can recognize less than a 1mm change in brow position.  When corrections are not done properly, it is very easy for the brain to catch it.  Poor corrections of the lips probably stands out in most people’s memory, where they are either too full, out of proper proportion, or there was poor attention to landmarks.

Experienced dermal filler injectors are no longer “chasing lines”, the symptom of aging.  The goal is to lift and replenish lost volume by addressing the cause of the aging of the face.  Of note, even the neck’s problems can be improved by properly injecting the face.  Choosing a doctor that has experience in recognizing the areas affected by volume loss and has the knowledge and expertise to improve those areas is essential for optimal patient outcomes.

 

Fractional Coagulation is in, Bulk Heating is out for Radiofrequency (RF) Skin Tightening

Ever since Rox Anderson suggested that treating a portion (fraction) of skin while leaving untreated healthy tissue behind as the basis for the Fraxel Skin resurfacing laser over 10 years ago, patients have been having less downtime, less risk, and less discomfort with their laser procedures.  Healing is dramatically improved because the adjacent nontreated dermis is able to provide the needed blood supply, nutrients, and local immune response much faster than the traditional treatments and results have been shown to be very similar in efficacy.

Until recently, all RF devices have applied heat to the skin/dermis in a nonfractionated approach, called “Bulk Heating”.  Whether the RF device is Bipolar or Monopolar, if the heating element does not penetrate the skin, the energy is pushed into the deeper layers using this method.  The implication of bulk heating is that all precision is lost.  Exact placement of the heat is impossible, with large opportunities for errors in depth of penetration and/or temperature control.  When treating skin, heat from the RF device using bulk heating can be placed too superficial, leading to burns or pigmentation changes, or too deep, leading to fat loss.  The dermis needs to be heated to 42 degrees C for 3 minutes to affect collagen stimulation. Only if skin temperature is measured can the operator be sure that the 42 degrees is reached with bulk heating, which is not the case for most bulk heating devices.  One last temperature issue is that bulk heating devices are unable to obtain coagulation of the tissue, which occurs at about 67 degrees C, which is needed for maximal tissue contraction and collagen stimulation.

The Infini uses microneedles to deliver the radiofrequency energy IN A FRACTIONAL manner.  Its unique array of needles allows the energy to flow between the needles, creating 49 coagulation points AT A SPECIFIED DEPTH in the dermis.  Surrounding tissue is sparred, which makes for very little downtime.  The superficial layer of skin is spared (because the needles are insulated), leading to no wound care, and markedly reduced risk of burns and pigmentation issues affecting the epidermis.  The temperature created in the areas between the needle is enough to create coagulation, for maximal tissue contraction and collagen stimulation.

(Not all microneedling RF devices are fractional.  Fractora uses microneedles, but because the energy is directed from the needles to the skin surface, the heating is in a fashion similar to bulk heating devices.  Also, because more tissue is affected using this heating method, discomfort is much higher and local anesthetic needs to be injected in most cases.)

It has taken a long time for RF devices to catch on to the fractional technology revolution.  The Infini has created much more precision in the delivery of RF energy to the dermis, allowing for higher degrees of skin tightening, while affording the safety and quick recovery time that fractional technology has created.

All Botox Providers are NOT the same. Choose carefully!

Botox injections are the most popular cosmetic procedure performed worldwide.  Millions of patients are injected each year with the wrinkle fighting drug.  Its popularity is attributed to:

  • There is minimal downtime – 15 minutes of bumps from the injection
  • The procedure is highly effective in improving wrinkles
  • Discomfort is usually minimal
  • Side effects are few and rare
  • Cost is fairly reasonably, but depends on how many areas are done
  • The time it takes to get a treatment is less than 10 minutes

So why is the “Was it Worth It” review on Realself.com for Botox only 69%?  This can be attributed to multiple reasons, which be further elaborated upon in this blog.  (A large volume practice should have a satisfaction rate in the >95%.)

Although the Botox procedure looks very routine to the observer/client, don’t equate this to being a simple procedure that all injectors can master easily.

All patients will age differently, so what areas need treating for optimal cosmetic results needs to be tailored specifically to each patient.  A cookie cutter approach to every patient will not work.  There are several areas of the face which can be considered advanced:  lips, corners of mouth, neck, gummy smile, under eye, bunny lines, inner eyebrows which require a highly trained and experienced injector, or you will live with a disfiguring facial appearance for 3 months.

The trend is moving away from the frozen, no movement, very obviously treated face to a more natural appearance.  Rather than blasting and overwhelming the forehead with Botox, a technique using very small, precisionly placed aliquots that  allows for movement but with diminished wrinkles.  This is a more difficult technique to master.

Shortcuts are often routine in regards to Botox.  A majority of practices will draw up syringes of Botox in the morning, or the day before, by a nurse, medical assistant, or office staff.  That means the patient will need to get injected in multiples of what is contained in a syringe, leading to limited customization.  Also, errors in dilution and sterile technique are possible when filling the syringes is not done by the same person that is injecting the Botox.  (Botox comes in a powder form and needs to have saline added to reconstitute it to become an injectable solution.)  Dr. Weiner mixes all his Botox personally, and will draw up the appropriate amounts for each patient in the room, just prior to injection.

Discomfort related to the injection can be minimized using various techniques.  Using preserved saline has been shown to result in less pain than using regular saline.  Needle size, speed of injection, and using proper needle placement is also a key factor affecting comfort.  Dr. Weiner also uses several distraction techniques, capitalizing on the Gate Theory (the brain has difficulty processing more than one sensory input at the same time).

Varying the concentration of Botox is a technique Dr. Weiner has used for years.  Certain areas require different dilutions to lead to maximal cosmetic benefits.

Touch ups to correct minor imperfections require an advanced injectors experience.  They also need a responsive provider, easily available for a drop in or work in patient.

Getting injected by an unknown provider at someone’s Botox party, is never a good idea, and almost  always leads to problems that one has to live with for 3 months.  The “savings” never is worth it.

Although Botox is extremely popular, as the Realself.com stats show, there are many people that are not pleased with their experience.  This is not the norm for the high volume, experienced injector.  As explained above, there are many intricacies which can contribute to better results. Hopefully the public will understand that Botox should not be considered a routine cosmetic procedure, and they need to select their providers carefully.

Slimming Ones Facial Appearance with Botox/Dysport

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The ideal shape for an aesthetically pleasing face has been referred to as “an upside down egg” or heart-shaped.  It is desirous to have the upper face wider than the mid/lower face.  It brings more attention to the eyes, the center of beauty.  Widening of the lower face can give a female a more masculine appearance, and also is a sign of aging. The causes of enlargement of the mid/lower face are:

  1. Enlarged masseter muscles.  Often caused by bruxism (grinding one’s teeth)
  2. Obesity
  3. Genetics.  Asian females tend to have this issue
  4. Jowling associated with the aging face

By injecting the masseter muscles with Botox or Dysport, the muscles can diminish in size and atrophy over time.  If the procedure is repeated and regularly administered, a long-term slimming of the mid and lower face can be achieved.  Candidates for this procedure are people who fall into the #1 and #3 category. Risks are minimal, but this can affect your smile if not done by someone who has experience with the anatomy and performing this procedure.

Many people would also benefit from injecting the temples simultaneously with filler to help create the upside down egg-shape to the face (from a square-shaped face).

For the person that falls into the #2 and #4 category, there is some literature that suggests that Ulthera might be helpful.  Although a much newer technology, Infini might work for this as well, time will tell.  By going to depths that are much deeper than the skin, into the fat layer, it might be possible to decrease the amount of fat in these areas and thereby slim the face.

Coagulation is Necessary For Maximum Skin Tightening; Science and Experience Prove This – INFINI is the Best Solution

It is fundamental that my patients understand the science behind their treatments.  There is too much “quasi science” in the aesthetic industry that is fooling the general public.  As a result, many patients are dissatisfied with their outcomes and have buyer’s remorse.  Perhaps the most controversial area of the industry is with “skin tightening” procedures.  After reading this and my previous blog on the Infini, hopefully you will recognize the reasons why most of the devices/procedures for skin tightening don’t work well and why the Infini stands out from the crowd.

To achieve skin tightening, the deeper layer of the skin, the dermis, needs to create new collagen.  It has been found that heating this layer of skin can stimulate neocollagenesis (new collagen production).  The threshold is 42 degrees centigrade to impart a stimulus to the dermis, because at this temperature collagen denaturing occurs (the bonds holding collagen together break down).  The body senses the injury, and during the repair of this area, new, youthful collagen is produced.  The response is very mild at these temperatures.  At higher temperatures, 55-70 degrees centigrade, coagulation of the collagen and surrounding tissue occurs, with more coagulation seen in the higher range of those temperatures.

WHEN COAGULATION OCCURS, THE BODY’S RESPONSE TO THE INJURY IS MUCH MORE INTENSE.  TO ACHIEVE MAXIMUM SKIN TIGHTENING AND COLLAGEN FORMATION, COAGULATION IS NEEDED IN THE DERMIS.

Digression:  The long standing “gold standard” for wrinkle control and skin tightening (without surgery) has been considered the fully ablative CO2 laser.  It has been determined that its efficacy is based primarily on its significant coagulation effect.  The risks associated with complete removal of the upper layer of the dermis – prolonged healing, redness, scarring, infection, and hypo and hyperpigmentation – have significantly curtailed its use.  Recent technology improvements that have made the CO2 laser fractional (treating only a fraction of the skin) has greatly reduced the risks, but they are still present.  Erbium laser resurfacing, which traditional has very little coagulation, has not been shown to have the same results as the CO2 laser.  Changes in the Erbium to give it more of a coagulation effect on the skin have lead to better results.

The ideal skin tightening device would cause tissue coagulation in the dermis, but have very little of the risks and downtime associated with the CO2 laser.  Radiofrequency devices have been trying for over 10 years to do this without success.  They try to heat the dermis, but not the epidermis (upper layer of the skin) to the 42 degrees needed to get a mild neocollagenesis.  THE PROBLEM IS THAT ALL THE NON PENETRATING RF DEVICES CAN DO, AT THEIR VERY BEST, IS HEAT, BUT NOT COAGULATE, TISSUE IN THE DERMIS.

So what devices can coagulate tissue is the dermis aside from the CO2 laser:  Microneedling RF devices (like Infini) and Ulthera (High Frequency Ultrasound).  In this category, Infini wins hands down.  All of the other microneedling devices currently on the market have one or more of the following downfalls:

  1. The needles are not insulated so the epidermis is at risk for injury (pigmentation or indentation risks)
  2. The needle depth is fixed and not variable.  The facial skin has a huge variation in depth, from 0.38mm to 3mm.  Ideally, the coagulation is placed at the deep dermal layer.  If it is too deep, there will be minimal collagen response.
  3. The themal injury is not fractional.  Treating fractionally is the way to treat in 2014.  This allows for accelerated healing, minimal risks, without compromising results.
  4. Their temperatures don’t reach the level high enough for coagulation.  Without coagulation, results won’t be as good.

THE INFINI USES INSULATED NEEDLES, HAS VARIABLE NEEDLE DEPTH (0.5mm-3.5mm), AND CAUSES A FRACTIONAL COAGULATION INJURY IN THE DERMIS.

Infini Skin Tightening

Infini Coagulates the Dermis

Ulthera has been a great tool in our office for the past 5 years.  When comparing the Infini to the Ulthera, the following deficiencies in skin tightening have come up:

  1. Ulthera currently only has 3 depths – 1.5mm, 3mm and 4.5mm.  For most of the face, only the 1.5 is at the level of the dermis.  Ulthera reportedly tightens at the deeper muscular layer, the SMAS, but this has yet to be a proven mechanism by histological samples (looking under the microscope at biopsies).  Much of the coagulation from Ulthera is in the subcutaneous fat or fat layer, an area that produces very little or no collagen.  It does explain the improvement in the jawline and upper neck though, the areas where there are fatty deposits.
  2. Ulthera lays down about 15,000 thermal coagulation points (TPC’s) during a treatment.  The Infini will create 50,000 or more of these TPC’s during a treatment.  More TPC’s probably mean more results because Ulthera has proven that going from 7500 TPC’s to 15,000 TPC’s gave them better results.
  3. Ulthera is more expensive for the physician to use, so the costs get passed on to the patients.

To summarize, skin tightening requires a coagulation injury in the deeper dermis.  The discussion above has tried to show that besides the Infini, all other RF devices fail to deliver a predictable, safe, thermal injury to the point of coagulation in the dermis.  Without the coagulation in the dermis, results will be unsatisfactory.   In essence, the Infini has made Thermage, Venus Freeze, Exilis, Pelleve, Tripolar, Titan – all OBSOLETE.  

To get a better grasp of the RF skin tightening Industry, please read the blog:  “FINALLY…A Radiofrequency (RF) Skin Tightening Device that Makes Sense.  Infini by Lutronic.” Includes an overview of the RF skin tightening industry.

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2050 West County Highway 30A Suite 114
Santa Rosa Beach, Fl 32459
Phone: 850-622-1214

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