gulfcoast Archives | The Aesthetic Clinique

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

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For Restylane Silk…Size Matters…Smaller is Better

Lip Enhancement with Restylane Silk.

Traumatic Lip before Restylane Silk Treatment

One Day after Restylane Silk Treatment

Dr. Weiner performing Lip Enhancement with Restylane Silk – Before

Immediately after Dr. Weiner injected Restylane Silk

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Restylane has become the number one trusted dermal filler in the world. With over 20 million treatments worldwide, and numerous publish studies, Restylane’s safety and efficacy is well established. It is composed of hyaluronic acid (HA), a naturally occurring substance that is found in skin and joints. It’s duration of action is about 6-12 months, depending on the location it is placed. (My other blog explains duration in more detail) Crosslinking, a process that joins adjacent strands of the HA, is essential, because the breakdown of the HA would occur in weeks without it.

Restylane is composed of similarly sized HA particles, with a concentration of 100,000 per ml. Perlane, a “cousin” of Restylane, is exactly the same as Restylane, except that it’s concentration is 10,000 particles per ml. Both of these products have been on the US market for years, Restylane since 2005, and Perlane since 2007. Restylane Silk, the newest US FDA approved filler, is composed of 500,000 HA particles per ml.

This means that the Restylane Silk HA particle is 1/5th the size of the regular Restylane HA particle, and that’s the reason behind it’s magic.

Although Restylane Silk was approved in the US in 2014, it has been used under the name Restylane Fine Lines for over 15 years in Canada. There has been a huge experience in Canada using this product to improve superficial fine lines and in LIP ENHANCEMENT. In the US, there are now only 2 FDA approved fillers for the lips, Restylane, and Restylane Silk. Silk is also approved for the perioral area (area around the mouth). It’s the author’s opinion that part of the problem lip enhancement has been disappointing to many patients is that US physicians didn’t have access to the proper filler. Fish lips, sausage lips, uneven lips, overfilled lips have dissuaded many potential patients from ever trying lip enhancement.

The small particle size of Restylane Silk allows the skilled and experienced physician to add product in the very superficial aspect of the lip, in the submucosa. This was impossible with other fillers without lumps being visible. The product spreads in this plane, so only a couple points of injection are needed in each quadrant of the lip. By being so superficial, and with only a couple injection points, the discomfort associated with the injection is markedly decreased. In addition, by staying superficial, and not deep, the risk of a bruise is significantly less. Very precise alloquots of Restylane Silk can be placed along the border of the lip (vermillion), cupids bow and peaks, in the tubercles, and corners of the mouth much easier than the larger particle HA fillers.

The addition of Restylane Silk to the aesthetic physician’s armamentarium fills a necessary niche that was missing in lip enhancement. Patients can now anticipate less bruising, less discomfort, less lumps, with better and more natural results, thanks to the smaller particle size of Restylane Silk.

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Fraxel Dual Questions Answered by Dr. Steven Weiner, Destin, Florida.

****Please note that these questions were answered before Infini was available. It might be a better treatment option for certain conditions than Fraxel Dual or re:pair.****

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Q: Fraxel – which type for rejuvenation for mature skin?? I had the Palomar 1540 with a 50-15 setting.

A: Don’t be confused with imitations, there is the Fraxel Dual restore and Fraxel repair

There are many physicians who buy less expensive lasers and sell them as being Fraxel. The only thing in common with the Fraxel and the others is that they are fractional, like the Palomar. In my opinion, Fraxel Dual restore is the gold standard for non ablative skin resurfacing. The Fraxel repair is ablative, with more downtime, more pain, and more risk.

Q: Fraxel and Resveratrol?

A: Resveratrol is an antioxidant and should not affect recovery from Fraxel

I’m a big fan of Resveratrol. We sell the supplement, MegaResveratrol in our office. It has many studies behind it showing multiple benefits. It should not affect your recovery and may in fact speed the recovery from Fraxel.

Q: The Hyperpigmentation Post Fraxel Laser Treatment for Stretch Marks on Arms? (photo)

A: Hyperpigmentation after Fraxel for stretch marks is treated with hydroquinones

Hyperpigmentation after laser is more common in darker skin types and people with a lot of sun exposure. I can be treated most often with hydroquinones 4%. If not improving, adding Retin A +/- a steroid cream. It almost always resolves. A better, newer treatment for stretch marks, particularly darker skin types, is the Infini RF device. I would try it, but not many docs have it presently. Steve Weiner, MD, Facial Plastics, Destin, Fl

Q: Will Fraxel Laser Help White/mature Stretch Marks on Ethnic Skin? Stretch Marks Are on the Buttocks.

A: Fraxel will help mature stretch marks but don’t expect more than 30-40% improvement

Mature stretch marks are difficult to treat, particularly on an ethnic person because of the risks with laser of hyperpigmentation. It will help, but to the degree you desire, I don’t know. You will also need at least 5 treatments, maybe 10. A new technology called the Infini by Lutronic might be promising for this and time will tell. Steve Weiner, MD, Destin, Florida.

Q: Can Fraxel Be Used on a Scalp Laceration? (photo)

A: Fraxel 1550 is great to improve scars but using topicals first is probably a good idea for early wounds

The problem is that for the laser to work effectively, you must shave the area. This might not be what you want. In my opinion, use the Scar Recovery Gel from SkinMedica as well as Retin A, 0.05%, and the scar should heal up fairly well. Save the Fraxel if it doesn’t heal to your satisfaction. Another laser for early scars is the VBeam, but you also have to shave the area to be treated.

Q: CoolTouch, Thermage or Fraxel for Crows Feet?

A: Crows feet are best treated with Botox not laser.

Crows feet are produced with the active muscle contraction of the obicularis oculii. By relaxing with Botox this muscle doesn’t contract and the crow feet are less. If you are opposed to Botox you might want to try Belotero for your crows feet.

Q: Fraxel to Restore Pigment to Skin Damaged by Cryotherapy?

A: Hypopigmentation from Cryotherapy can be improve with the Fraxel 1550 Laser

Hypopigmentation is a difficult problem to fix. Having said that, the Fraxel has been shown to repigment areas which have lost pigment. It won’t usually completely come back. If cryotherapy was used for precancerous lesions, I prefer the Fraxel 1927 or Levulan because there is very little risk of hypopigmentation with these methods. They will be more expensive but well worth it in my opinion. Steve Weiner, MD, Destin, Florida, Facial Plastic Surgery.

Q: Does Fraxel Actually Work on White Stretch Marks?

A: Fraxel Dual works for mature white stretch marks but won’t resolve them

I have treated several people for this problem. The best you can expect is about 40% improvement, and thats after about 4-5 treatments. There really is no other treatments available for this problem other than excision.

Q: Can I Have Full Face Fraxel Laser After Having Had Facial Silicone Injections Several Years Ago?

A: After having silicon injections, even years prior, there is a risk of activating an inflammatory response w Fraxel or injections

Even though you’ve been doing relatively fine from the silicon, any invasive procedure might activate an inflammatory response or granuloma. Having said that, I’ve haven’t encountered problems with people that have had silicon but it is a risk you need to be aware of and the physician should discuss with you.

Q: Will Fraxel Laser Make Active Acne Worse? Will It Cause a Flare Up if You Are in Remission?

A: Fraxel can temporarily make acne worse but in long run it makes it better

The Fraxel Dual can stimulate acne for the first couple weeks. Acne prone patients I put on minocin to help prevent having a flair. However, it reduces the sebaceous glands and thereby helps with acne in the long run.

Q: I Am Planning on Having 3-4 Fraxel Treatments Spaced One Month Apart. What is Your Recommendation Concerning Sun Exposure?

A: Sun exposure inbetween Fraxel treatments (as well as after) should be minimized.

You want to have as little direct sun exposure as possible when receiving any laser treatment. I usually say 3 weeks before and after treatment at the very least. Sun exposure will lead to rev’d up melanocytes which will lead to pigmentation issues. It doesn’t mean staying indoors, it means wearing sunscreen, a hat, and avoiding intense sun exposure. Heliocare can help reduce the tan and burn associated with sun exposure too as well as antioxidants such as those found in TNS Essential Serum from SkinMedica.

Q: Still Have Very Distinct Red Square Patches and Microdot Tracks on Cheeks 11 Days After Fraxel – Should I Be Worried? (photo)

A: You did not get the Fraxel Laser..There are docs using other lasers and saying it’s Fraxel

Fraxel uses a rolling tracking system and the laser comes out in lines, not squares. The Fraxel is an expensive laser and there is a fee you pay the company every time it is used. It is the state of the art for laser resurfacing in my opinion. Doctors buy less expensive lasers and say they are giving you Fraxel. It looks to me like you have been overtreated for your skin type. You should go back to your doctor and get evaluated and look at the machine which you were treated with.

Q: Fraxel Dual 1927 Vs 1550?

A: Difference between the Fraxel 1927 and 1550 wavelengths.

As you stated, the 1550 wavelength is a deeper penetrating laser and is more suited for scars, wrinkles, and some mild pigment improvement. It is non ablative so there is no open wounds. It will have more swelling than the 1927. There is some peeling, but more with the 1927. The 1927 is a “partially ablative” laser that is very superficial and used to help pigmentation and superficial fine lines. Both laser wavelengths are approved for removing precancerous lesions (actinic keratosis). In general, I use both lasers at the same sitting, unless someone is only concerned about pigmentation or AK’s (1927), or more concerned about scarring (1550). My video show the 1927 laser. Also, because the 1550 goes deeper, it is more painful during the procedure.

Q: Are These Setting of Fraxel Really High? 55 Energy, 6 Treatment Level, 8 Passes

A: The settings for the Fraxel 1550 you had are for moderate wrinkles, scars

The highest setting for the energy is 70 and you were at 55mj. This is needed to improved deep wrinkles and scars. The second number is related to how much of the skin is treated. You were at the medium level for that. So these are very safe parameters. The passes really doesn’t matter in the end, it is basically how fast the procedure goes, but should be at least 6. The more passes, the less treatment per pass, the more margin of error for the operator in unintended overlapping of the passes.

Q: Will Fraxel Dual Laser Treatment Damage Gore Tex Line Lift or Filler?

A: Fraxel Dual is safe for fillers and Goretex implant

The laser from the Fraxel Dual goes about 1.5-1.7mm deep at most. Studies have shown that is does not affect fillers. Goretex is placed much deeper than the depth the laser penetrates to as well.

Q: Not Peeling After Day 3.. is This Normal?

A: Not peeling yet after 3 days from Fraxel Dual is fine, it will!

You describe the correct sequence of events. Your skin gets darker and the pigmentation looks more prominent after getting the Dual. You should start peeling from 3-5 days after the procedure and it will usually start around the mouth and then work upward. The cheeks might take the longest to completely peel. When all is peeled, you skin will be smoother and less pigmented. You must make sure the skin is moisturized before and during the peeling.

Q: Will Fraxel Restore Damage Hair Follicles at Level 9 and 75 Mj Setting?

A: Fraxel Dual or re:store laser will not damage hair follicles

Hair follicles are damaged by a laser that is attracted to melanin, the pigment in skin and hair. The typical wavelengths of the hair removal lasers are lower (Diode – 800, Alexandrite 765) than the Fraxel Dual (1550 and 1927nm). The Fraxel might singe the hair but won’t permanently affect the growth of the hair.

Q: Do You Need to Wear Eye Protection for Fraxel?

A: Eye protection for the patient during Fraxel should be done

Having said that, the Fraxel laser is not very dangerous to the eyes. It has to do with it’s wavelength. It’s attracted to water, so the most it would do is cause an injury to the conjunctiva or cornea. It’s not attracted to the retina or iris where the lasers that are attracted to pigment (KTP, Pulsed Dye, Diode, Alexandrite) can cause visual lose or blindness. So, the Fraxel is relatively safe to the eye. If you would have been injured to the eye with the Fraxel, it would present as pain immediately, and you would have irritation, swelling, pink/redness of the eye. If this didn’t occur, you’re good, but would use eye protection next time.

Q: Telangiectasias Appearing Ater Fraxel?

A: Telangiectasias are easily treated with VBeam

Telangiectasias can occur after any procedure, including Fraxel, injections, or Radiofrequency devices. The good news is that they are easily treated with a no downtime almost painless laser called the VBeam Perfecta. You might require a couple sessions.

Q: Will Acne Scar Resurface if I Dont Do Fraxel Regularly?

A: The improvement from Fraxel Dual re:store for acne scars is permanent

After the edema settles down and you are about 3 months out from your Fraxel treatment for acne scars, the result you have should last a lifetime, IF you don’t create more scarring with further acne. The question always asked of me is how many do I need. That is difficult to answer, could be 5 or 10, depending on the degree of scarring, and how much you want it improved. Also you can only expect improvement and not resolution of your scars. Unfortunately, the skin will never look entirely normal, but better.

Q: Have Heard Different Answers About Fraxel Recovery Time During Consultations, Which is Correct?

A: Downtime after Fraxel Dual is variable

Downtime after a Fraxel Dual depends on the settings and the individual. Obviously if your have more aggressive settings, you will have more swelling and downtime. Also, different people have different degrees of swelling and redness. Typically, after about 4 days, the peeling is done and there still is mild swelling. The skin is intact. Some of my patients go in public throughout their recovery, it depends on your comfort with the recovery process. I would say it would be unusual for the downtime to be 2 weeks though. You will have pinkness of the skin for several weeks, but I don’t consider this downtime.

Q: More Fraxel to Fix Fraxel Damage?

A: Try another physician

This doesn’t sound like normal care. I haven’t heard of treating with Fraxel and needling at the same time. Perhaps it was subcision, but still I would not do this at the same time. Also, only 7 weeks out, I would not treat with such a permanent filler. At this point, more fraxel or a pulse dye laser (V Beam) would probably be helpful.

Q: Side Effects of Too Many Fraxel Restore Treatments?

A: No issue with multiple Fraxel dual or re:store treatments

This very question came up at a recent meeting with all the best laser surgeons in the world at Mass General (Harvard). Dr. Rox Anderson, the inventor of fractional laser resurfacing said he saw no issues with multiple treatments.

He even stated that your incidence of skin cancer will be lower (not higher as some bloggers have stated) with the resurfacing.

Q: Fraxel Restore or Repair for General Improvement of my Skin?

A: For general skin resurfacing, both the Fraxel re:pair and Fraxel re:store Dual work well

I think that you have some scarring/textural irregularities on your face. I think the better result will probably be from the re:pair, perhaps even more than one. However, you have to be able to have downtime, do dressing changes, and have general redness for up to 8 weeks. If your lifestyle does not allow you to do this, the new Fraxel Dual is having great results for this problem with less downtime, but more treatments.

Q: Preventing PIH After Fraxel Restore or Repair

A: Using Hydroquinone a month prior and Gentlewaves helps prevent PIH from Fraxel

Starting hydroquinones 4% 1 month prior and restarting soon after the procedure will help prevent PIH from Fraxel. There is also a recent paper that suggests pre and post procedure Gentlewaves will decrease the risk of PIH as well. Avoiding the sun for 6 weeks prior to the procedure and good sunscreen also is important.

Q: Fraxel Restore Test Area for Dark Circles?

A: Dark circles around eyes is hard to treat

Please keep us updated about your results. Up to this point, dark circles have been hard to treat. Please moderate your expectations. Dermal fillers have seemed to be the most helpful, but smoothing out the shadows around the eyes from volume loss. I have a Dual and would love to add this application to my services if this works. The Dual is a very safe laser and test spotting is not a bad idea, but usually not needed.

Q: What is Fraxel Dual?

A: Fraxel Dual is 2 lasers in one treatment

Fraxel introduced the Dual about 1-2 months ago. I combines a 1927nm laser with an upgraded version of the 1550nm (re:store) laser. The 1927 laser is a superficial laser that is brand new to the aesthetics market. It is somewhat a blend of non ablative and ablative technology — referred by the company as “disruptive” to the skin. It removes pigment better than any laser I’ve encountered, in usually 2 treatments. It is relatively quick (10-12 minutes for the face) and fairly comfortable to have done. It will cause the skin to darken over the first 3 days and then peel. There is no wound care. Social downtime for about 3 days.

It is often combined with the 1550nm laser to give both a deep and a superficial treatment. When done with the 1550, there is slightly more swelling and redness. The 1550 has more discomfort. The Dual’s 1550 has been modified to be faster, more effective, and more comfortable (has integrated cooling) than the prior Fraxel re:store laser. Usually you will require 3 instead of 4 treatments with this laser as compared to the previous version. My experience with this laser has been very good. The satisfaction of my clients is high.

Q: Thermage Free with Fraxel, is It Worth It?

A: Thermage is a great addition to Fraxel re:pair or re:store

There have been recent clinical studies showing the benefit of doing both Fraxel laser treatment and the Thermage together. What happens is that you have tightening at both a superficial and and deeper layer of tissue leading to better results. The safety profile of the current Thermage CPT is extremely good and for the hour or so it takes to get the face treated, I would highly recommend doing the Thermage as well.

UPDATE: We no longer do Thermage. Ulthera is more precise and more consistent results.

Q: Treatment Spacing of 4 Days for Fraxel and Thermage?

A: Timing of Fraxel and Thermage

Thereare no restrictions regarding the timing of Thermage and Fraxel. They affect different areas of the skin. However, after having as many treatments as you describe, you probably have fully appreciated any benefits that you get from these treatments. If you want more improvement, I’d suggest the Fraxel re:pair.

Q: Should I Have Fraxel Re:pair or Active FX?

A: Recent study suggests better results from Fraxel Re:pair over the Active FX

In a paper recently presented at the American Society for Laser Medicine and Surgery, it showed both were effective, but the Fraxel Re:pair side had better tightening. It was a split face study, one side got the Fraxel Re:pair, the other the Active FX. The study was done by a group out of NY and NJ. It was a blinded study to the patients (they didn’t know which side was which laser). There were 10 patients.

Hope this helps!

Q: Fraxel Repair or Fraxel Restore for Loose Skin?

A: Fraxel re:pair more aggressive and more results than the Re:store

The Fraxel re:pair is a fractional CO2 laser. CO2 lasers are aggressive/ablative lasers that will give you the best results for skin tightening. They have been around for over 20 years. The recent resurgence of these lasers is the fractional technology which leads to less downtime, and less side effects.

The re:store is an Erbium laser that is non ablative. It typically will have less downtime, less results, and requires multiple treatments. When you add up all the downtime with the re:store (about 2 days with each treatment) it equals the downtime that a re:pair would have (about 1 week). My suggestion is to get the re:pair by an experienced physician for your best skin tightening results.

Q: Fraxel Repair Vs. Fraxel Restore

A: Fraxel re:store and re:pair are different

The Fraxel re:pair is a fractional CO2 laser and the re:store is a fractional erbium laser. The re:pair requires usually only one treatment (except for acne scars), whereas the re:store is usually a series of 4-6 treatments.

The re:pair will tighten the skin, the re:store will minimally tighten, even after 6 treatments. Wrinkle control is also far superior with the re:pair over the restore. The reason that the re:pair causes more wrinkle control and tightening is because it actually removes tissue, whereas the re:store thermally heats the tissue.

Also, CO2 lasers cause more thermal injury to the surrounding tissue, which leads to more collagen and better wrinkle control. The cost of 4 or more treatments with the Fraxel re:store is more than the cost of 1 Fraxel re:pair treatment. The Fraxel re:pair was introduced at the American Academy of Dermatology on January 31, 2008. The Fraxel re:store received FDA clearance July, 2004.

Q: Can Fraxel CO2 Be Used for Upper Arm Skin Wrinkles?

A: Use Thermage for tightening crepey skin

Fraxel has recently had FDA approval of a few new handpieces for the Re:pair laser. One of them is made to do body treatments as you are desiring. It will take a few months for those to be manufactured and in the hands of the physicians. The crepey skin can be improved but not redundant skin – this would have to be excised.

Answer updated 4/23/09:

I now feel that the best non surgical approach is Thermage. The new Fraxel handpiece hasn’t really turned out to be a revolutionary change.

I have recently added Thermage to my office. I have seen several clients who have had surgery that have been left with very large and long scars. Thermage seems to offer an alternative that has no real downside.

Q: Fraxel Re:pair Vs. Fraxel Re:store for Reducing Large Pores?

A: Both will work, but re:pair is overkill

I have seen improvements with the Fraxel re:pair for pore size which are dramatic, but if you don’t need all the other improvements (pigment, scarring, tightening, texture), then stick with something that is less expensive and less downtime like the re:store, Lux 1540, or IPL.

Steve Weiner, MD Facial Plastic Surgeon, Destin, Florida

Q: What is Fraxel Recovery Like?

A: Painless after Fraxel, swelling lasts under 5 days

Universally, nobody complains of pain after the procedure. Swelling is the worst on the second day after the procedure and gets better by day 5 or so. Seeing streaking is common and will go away. Redness lasts up to 3 months, but usually about 3 or 4 weeks.

Q: Fraxel Restore Vs. Fraxel Repair

A: Fraxel repair is the best laser for skin tightening and wrinkles

The Fraxel re:pair has fractional laser technology that made the CO2 laser much safer than completely ablative CO2 lasers. The company has seen none of the risks that the older CO2 had – hypopigmentation, scarring, and lines of demarcation. The CO2 laser has been long regarded as the gold standard for wrinkles and tightening, but with the previously mentioned risks happening in about 15 percent of patients, it fell out of favor.

Another benefit of the Fraxel re:pair is the depth of penetration, up to 1.6mm, much deeper than the prior CO2 lasers which went 0.3mm as well as the 2 competitive lasers – Mixto – 0.7mm, and the Deep Fx, which is 1mm. Deeper treatments mean better results.

The other Fraxel (re:store) is an erbium laser, and is considered non-ablative (does not remove tissue) whereas the re:pair causes ablation. Removing tissue will result in more wrinkle correction and tightening. The CO2 also causes some peripheral heat damage which also leads to more tightening. The erbium causes very little peripheral heating.

There is more downtime with the re:pair but it’s only one treatment. All my patients are extremely pleased with the re:pair, and I can’t say that about the re:store.

Voluma is the latest filler to be FDA approved – What makes it different? Dr Steve Weiner explains

Front view before and after 12 syringes of Voluma: cheeks, temples, marionette lines, and preauricular area.

45 degree view after 12 syringes of Voluma injected.

45 degree view before and after 12 syringes of Voluma: cheeks, temples, marionette lines, and preauricular area.

Voluma, 12 syringes injected, 90 degree photo

After 12 syringes of Volume, 90 degree view. Injected cheeks, temples, marionette lines and preauricular area.

[youtube=http://www.youtube.com/watch?v=XERvczwIOOg]

[youtube=http://www.youtube.com/watch?v=wd9r3Tw43YU]

Juvederm Voluma was approved by the FDA today for treatment of age related volume loss in the cheek area. This is the first filler to be approved for this purpose. Its main component is Hyaluronic acid which is also found in Juvederm Ultra, Restylane, Perlane, and Belotero, all FDA approved fillers. Juvederm Voluma is a thicker, more viscous version of Juvederm Ultra which gives it more “substance”. The technical term for this property is called “G prime”. The higher the G prime, the better ability for the filler to lift and support skin and surround structures. Compared with Juvederm Ultra, Juvederm Voluma has about 10 times (10X) the G prime. A comparison graph is shown below (from Going With the Flow: An Overview of Soft Tissue Filler Rheology and Its Potential Clinical Applications, Part II by Hema Sundaram, MD, FAAD):

As seen in the chart, Radiesse, Perlane, and Restylane have higher G primes than Juvederm Voluma. Although these others are not approved for volume loss of the cheek, they are all used commonly “off label” for this application.

Being very thick/viscous, Voluma will need to be injected with large bore needles or blunt cannulas. It is mixed with lidocaine (numbing medication) from the factory, so the procedure is very well tolerated. It’s longevity is longer than most fillers, lasting up to 2 years in their clinical trials. At 2 years, 76% of patients were still satisfied with their Voluma results. (It was 90% at 6 months). Also, at 2 years, the average patient’s perception was that they looked 3 years younger since the Voluma treatment. (It was perceived as 5 years after 6 months).

Obviously, the volume needed for correction varies from patient to patient, depending on their degree of volume loss. During the clinical trials, the average volume needed for correction was just over 6cc. Some patients needed up to 13 syringes.

An advantage of Voluma over Radiesse, Artefill, or Sculptra is that Voluma can be “erased” or dissolved with an easily obtained enzyme called hyaluronidase. Although it is seldom used, it can give patients the piece of mind that their results don’t have to last for a year if they aren’t happy with it.

Initially, Voluma is being released to a select number of physicians who are very experienced injectors. These physicians will then become trainers for the other physicians with less experience. Dr. Weiner has been chosen as one of these initial users of Voluma, and it should be available at his office in November.

Dr. Weiner is Facial Plastic Surgeon who laid down his scalpel in 2005 and now concentrates on minimally and noninvasive cosmetic procedures. His website is http://www.theclinique.net His YouTube is: http://www.youtube.com/user/StevenFWeinerFacial

What’s new in Botox Treatments, MicroBotox, and the Upcoming “Botox Cream” by Revance Theraputics

New Botox techniques: MicroBotox, Mesobotox. Revance RT001.

Dr. Weiner answers questions about Botox

Botox was originally FDA approved for treating stabismus (lazy eye) and blepharospasm (spasms of the eyelids) in 1989. When treating around the eye, patients and doctors were noting the wrinkles around the eyes were improving and brows were elevating. Studies were then initiated by Drs. Jean and Alastair Carruthers to test the cosmetic effects of Botox. It actually took 4 years to recruit enough patients to complete the study. In 2002, the first indication for Botox cosmetic use in the glabella (frown line) was approved. Botox has since become the most popular cosmetic procedure in the world. Its no downtime, consistent and effective results have made it a mainstay for people desiring a quick wrinkle improvement. Earlier this year, the FDA approved the second indication: for use in the lateral canthal rhytids (crows feet). Although the crows feet and other areas of the face and neck have been used (legally) off-label since the early 2000’s, this new approval will allow the company, Allergan, to market this new indication to the public. This will create more public awareness about what Botox can do, and make it even more popular.

The newest buzz about Botox is a technique that has been used by Dr. Weiner for several years is called “MicroBotox”. This is when the diluted Botox is injected in multiple very small doses in the area treated. The theory here is that the effects of the Botox are more evenly spread over the areas treated and the chances of having areas over treated is less. The most notable area for this technique is in the forehead. The result of MicroBotox is a more natural look which is not frozen and the dosage of Botox is less. This technique has also been described for use in the neck by a Korean physician at a recent meeting. It was shown to mildly improve the neck wrinkles and improve the texture of the skin. For some people who have recalcitrant acne problems, MicroBotox (sometimes called “mesoBotox” when used in this situation) can be injected very superficially into the facial skin. However, there is a risk of affecting facial muscles and Revance’s RT001, a topical “Botox”, should be a better alternative to this technique.

In the near future, a cream to apply a substance similar to Botox will be FDA approved. Revance Therapeutics is developing RT001 for use in the lateral canthal rhytids (crows feet) and has shown great promise. It will be a cream which is applied in the physicians office and stays in place for about 15-30 minutes. This will eliminate injections for this area and is completely painless. The results seem to be impressive, possibly better than injections. The reason the results are better is similar to why MicroBotox is better for the forehead- the dosing seems to be more evenly applied to the muscles around the eyes. Other areas being tested by Revance are: underarm hyperhidrosis (sweating), migraines, and rhinitis (runny nose). Off label potential uses are for acne and general overall skin improvement of the face and neck. Unfortunately, the other areas which Botox is injected in, frown lines and forehead line, have muscles which are too deep to allow the topical ingredient to get to those depths. Whether or not the upper lip lines (smoker lines) will be treatable with RT001 has yet to be tested.

Even though Botox has been FDA approved since 2002 for cosmetic uses, there are still new techniques, new uses (approvals), and a new delivery model (topical) for a competitor which will soon get approval. The aesthetic industry is constantly changing and Dr. Weiner works hard to stay at the forefront of all the latest techniques and technologies. To learn more about Dr. Weiner, visit his website: http://www.theclinique.net For a consultation call: 850.622.1214. Dr. Weiner is a Facial Plastic Surgeon who devotes 100% of his practice to noninvasive and minimally invasive cosmetic procedures. His practice is called the Aesthetic Clinique and is located in Santa Rosa Beach, which is between Destin and Panama City Beach, Florida.

Link to the app for Brilliant Distinctions, the reward program for Botox, Juvederm, SkinMedica Products and Peels, and Latisse

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

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

Don’t Forget The Hands and Decolletage When Thinking About Your Cosmetic Refinements!

Before and after hand volumization with Radiesse.

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[youtube=http://youtu.be/dFvVOtK4xCo]

Most of the procedures advertised and touted have to do with rejuvenating and beautifying the aging face and neck. This blog is to bring attention to the often ignored areas: The Decolletage (chest) and The Hands. There are some simple, quick, and little to no downtime procedures that can be performed to bring these areas up to speed with your face and neck cosmetic improvements.

Just as the other parts of the body, the hands and chest lose volume from fat loss, and thinning of the skin. In the hands, the vessels and tendons become more apparent, and in the decollete, wrinkles form the “cleavage” area. The easiest way to improve this problem is with filler. Using micro blunt cannulas, the procedure becomes nearly painless and without any downtime. Filler of choice for the hands would be Radiesse, and for the chest, Sculptra. For the Sculptra treatment, it will take 2-3 sessions, but this will give 2 or more years of improvement. It thickens the skin by stimulating the skin to produce collagen.

Most people these days protect their face from the sun, but the chest and hands are neglected. Sunscreen is important fo r these areas as well. Sun damage on these areas presents as:

Hyperpigmentation, “sun spots”, lentigos
Wrinkles
Thinning of the skin
Skin cancers and pre cancerous lesions

Hyperpigmentation is treated with skin care, peels, and lasers. Proper skin care can include: Sunscreen, Retin A or Retinol (for the chest), Growth factors like TNS Essential Serum (for the chest), and body skin care like Environ which exfoliates and hydrates. For more extensive damage chemical peels can be done, or laser procedures. If just wanting a few spots removed, the Spectra Q-Switched Laser is state of the art to remove individual spots. They will darken and then flake off over 2-3 weeks. If the skin is covered with pigmented lesions, the Fraxel Dual 1927 is required. This will require 2-3 treatments and is a nice laser peel that rejuvenates the underlying skin as well and thickens the dermis. Peeling from the 1927 takes about 2 weeks to resolve. Subsequent treatments can be done after 1 month. The Fraxel Dual is also a great tool to remove and prevent pre cancerous skin lesions called actinic keratosis. It is FDA approved for this purpose and is equal in efficacy to the topicals used for this like: Aldera, Efudex, and Carac.

There are 2 technologies which have yet to be used extensively in the chest and hands but offer promise. Ulthera (Ultherapy) and Infini. These devices create small injuries in the dermis which lead to the body tightening the overlying skin, laying down collagen, and thickening the skin. There are already FDA trials of the Ulthera on the chest. Infini is a very new technology and Dr. Weiner is one of the first in the country to have it. Soon hands will be done with the Infini at The Aesthetic Clinique and results will be posted.

Often people who look much younger than their stated age, the truth is seen in their hands. Don’t ignore this area, as well as the chest! There are several easy ways to get them to match your youthful facial appearance.

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

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

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

Website: http://www.theclinique.net

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Don’t Forget The Hands and Decolletage When Thinking About Your Cosmetic Refinements!

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