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The Top 14 Trends in Cosmetic Procedures (Plastic Surgery) for 2014 as Predicted by Dr. Steven Weiner

This coming year is an exciting one with a couple new FDA approvals expected. It’s also going to see several procedures fade away and new approaches with the “gold standards”.

Kythera’s ATX-101 will be approved for reducing the double chin fat using only an injection. The procedure will need to be repeated 3-5 times in most people, but there will be no incisions and minimal risks. Side effects will be swelling and discomfort that will last maybe up to a week. Off label, it could be used for fat in the belly, love handles, or thighs.
Longer acting dermal fillers for total facial volumization will catch on. Fillers such as Voluma, Sculptra, and Artefill can be used to add volume to the temples, cheeks, midface, jawline, and preauricular area. Even earlobes can use a little volume in most people. Very little side effects other than swelling and bruising are noted with these “Liquid Facelifts”, particularly when blunt cannulas are used. Results are instant with Voluma and Artefill, and gradual with the Sculptra. Duration of improvement is about 2 years with Voluma, 2-3 years or longer with Sculptra, and over 5 years (some doctors may say permanent) with the Artefill.
Botox administration will be “lighter” to give a more natural look. No more frozen faces leaving people expressionless. Particularly in the forehead, less Botox using a “micro injection” technique, means more movement and less risk of dropping the brows. The downside to this lighter dosing is that its duration will be slightly less.
A new topical neuromodulator, Revance’s RT001, will be FDA approved in 2014. Unfortunately, this won’t eliminate all the injections. It will be great for the crows feet area and possible for reducing underarm sweat though. It still will be administered in the doctor’s office (not for in home use).
Tattoo removal will become easier with less trips to the doctors office. With new protocols like the R20 and R0, several treatments (up to 4) can be combined into one office visit. It looks like the side effects and risks are the same as doing only one treatment per visit. The Picosure laser seems to also lead to faster ink removal but it is still too expensive to be widely available.
RF (radiofrequency) skin tightening will become even more popular, spurred on by microneedling devices which are more effective than transcutaneous ones. Being able to drive the RF energy to deeper levels both safely and reliably, as with the Infini, will lead to better and more predictable results. The other RF devices such as Thermage, Exilis, Pelleve and Tripolar will become less and less relevant as consumers are disappointed by their results.
There will be even more interest in noninvasive fat removal. Lead by Coolsculpting, people will find that having no downtime, minimal risks, and getting real observable fat loss is better than getting liposuction. Certain areas such as outer thighs have been difficult to treat noninvasively but new attachments with Coolsculpting and/or new devices using high frequency ultrasound (HIFU) might be developed to treat all the areas that liposuction traditionally treats. RF fat reduction will also become more popular because they will be more effective than prior versions. Zerona will lose all relevance due to its lack of sustained results.
Lip enhancements will be smaller and done using blunt cannulas. It seems like the trend for having your lips enter the room before you do is waning. People want to look like they have naturally beautiful lips and not obviously overdone lips. Using blunt cannulas enables one to have minimal downtime, minimal discomfort, and a naturally enhanced look.
People will become more concerned with anti-aging procedures of the hands and chest. Volumization using Sculptra in the declotage and Radiesse in the hands will become popular. Skin tightening using the Infini RF device will help with the wrinkles. Spots can be improved with the Fraxel Dual or Q-switched laser.
Tear trough injection will be the most popular area treated with dermal fillers. Blunt cannulas make this procedure both comfortable, safe, and quick. Restylane is the filler of choice for this area. By treating the tear trough and upper cheek, the nasolabial folds (smile lines) actually improve as well due to the lifting from above. Patients will have some swelling in most cases for a couple days which can be reduced by sleeping elevated. Bruising is minimal or none with the cannulas when compared to the needles which almost always has bruising lasting up to a week or more.
Men will do more cosmetic procedures. The drivers for this will be the competitive jobs market and the “no downtime” procedures. Sometimes experience isn’t all that is needed to land a job. To compete with the younger job seekers, the more “experienced” men are seeking procedures that can improve their looks, yet not keep them out of the public for very long. Botox, fillers, Ulthera, and Coolsculpting will become even more popular for men.
The number of people getting facelifts will continue to drop. With the improvements in skin tightening by Ulthera and full face volumization with dermal fillers, particularly collagen stimulators (Artefill and Sculptra) the aging face can be more naturally improved. There will be a trend for younger patients to start anti-aging treatments earlier leading to “more graceful” aging. People are not as willing to undergo the knife given the associated risks, downtime, and potential for undesirable results.
Artefill, a permanent filler that stimulates collagen, will gradually replace fat grafting for the face. As an off the shelf solution, Artefill is much more attractive to the patient than undergoing 2 procedures for fat; fat harvesting and then grafting. Also, fat is not always predictable with its “take”, and there can be a need for more than one procedure. Fine tuning with fat is also somewhat difficult and is much easier with Artefill. The apprehension behind the permanent aspect of Artefill has not been borne out and more of the well known injectors are warming up to Artefill.
Hydroquinones will gradually be replaced by other products to help with pigmentary problems. This trend started in Europe and South America. They have banned hydroquinones because of concerns over their potential carcinogenicity (even though there have been no known documented cancers from hydroquinones), ochronosis (pigmentation side effect that is very difficult to treat), and possible rebound hyperpigmentation. SkinMedica’s Lytera and Neocutis Perle will become acceptable replacements.

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

Press Release regarding these predictions by Dr. Weiner.

What the Heck is Going on with Hydroquinones? Are they about to be banned in the US?

Hydroquinones have been the standard of care in the US for over 50 years for treating skin pigmentary problems such as: melasma, chloasma, post inflammatory hyperpigmentation (PIH) and sunspots (lentigos). It’s mechanism of action is proposed to be that it competes with tyrosine in its conversion to melanin thereby leading to less pigment production by the melanocyte but it may also have a toxic effect on the melanocyte. Despite its long safety record, there is a growing opinion amongst state legislative boards to ban the use of hydroquinones. Just recently, Obagi stopped shipping hydroquinone products to Montana, New York, Massachusetts, and New Hampshire. In 2011, Texas banned the use of hydroquinones and a reinstatement of its use was veto’d by the Governor in mid 2013. The European Union has placed a ban on its use since 2001. Japan and South Africa have similar laws and there are strict guidelines in several countries in Asia and Africa. In 2006, the FDA put a temporary restriction on hydroquinones but ruled them safe after a several month investigation. So what’s the problem with this highly prescribed topical skin treatment?

There seems to be 3 factors going against hydroquinones:

There is a question of whether hydroquinones are carcinogenic. In high concentrations (greater than the typical 4% found in medical offices) when used in mice, it has been shown to cause cancers. In a report from the American College of Toxicology and OSHA, hydroquinones are categorized as “mutogentic” with the potential to cause alterations in DNA and cancer. To my knowledge, there has not been a case of human cancer directly attributed to topical use of hydroquinones.
Abuse of the hydroquinones can cause ochronosis which is a dark blue/black pigmentation of the skin. This seems to be a problem mainly in foreign countries where people are using higher concentrations (up to 10%) and not under medical guidance. Ochronosis is a very difficult problem to treat. Having lighter skin in Asian countries is a sign of wealth because your skin hasn’t been exposed to the sun while working in the fields. Abuse of hydroquinones is common in these countries.
Many people seem to get a rebound hyperpigmentation that may be worse than the original problem. Because the product decreases the amount of melanin in the skin, it becomes more sensitive to the sun as well, leading to hyperpigmentation. Dr. Obagi has now recommended taking breaks from hydroquinone to allow the melanocytes to stabilize. He also never recommends using greater than 4% concentrations of hydroquinones. There are also a subset of people who are sensitive to hydroquinones, developing redness in the area its applied.

Last year, SkinMedica, the second largest skincare line in US physicians offices, discontinued production of hydroquinones after Lytera was introduced. Dr. Obagi (no longer associated with the Obagi skincare products) who has been a staunch supporter of hydroquinones, has a new skincare line promoting non hydroquinone pigment control.

Given the fact that there are now fairly good alternatives (ie LYTERA from SkinMedica) for treating hyperpigmentation conditions, it seems the use of hydroquinone will gradually be discontinued in the US. Negative sentiment seems to stacking up despite its long track record of safe usage.

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

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

Website: http://www.theclinique.net

Dr. Steve Weiner: “FINALLY…A Radiofrequency (RF) Skin Tightening Device that Makes Sense. Infini by Lutronic.” Includes an overview of the RF skin tightening industry.

Before and after one treatment with the Infini. After is 8 weeks after the treatment.

Infini treatment of forehead lines. After (right) is 8 weeks after one treatment.

Infini RF treatment of face and neck. After (right) is 6 weeks after 1 treatment. Show improvement in jowls, jawline, upper eyelids, and cheeks wrinkles.

Infini treatment for neck and lower face wrinkles.

15 hours after having the Infini Treatment, ready for work

3 hours after Infini Treatment, she had already gone to yoga

[youtube=http://youtu.be/yoNqal9Y54Y]

[youtube=http://youtu.be/8JGuWHG6n8I]

[youtube=http://youtu.be/pKKAZC4RqrQ]

Dr. Weiner’s White Paper on Infini (more medical terms and more detailed than blog)

Dr. Weiner explains why Coagulation is so important in tightening skin

Radiofrequency use in medical treatments has over a 70 year history. It has been used for multiple applications but the most exciting innovations recently have been in skin tightening. Thermage in 2002 was the first to market a device which was FDA approved to tighten skin and improve wrinkles. Since then, there have been a least a dozen devices come to market with similar technology including: Exilis, Venus Freeze, Pelleve, Viora Reaction, 3Deep RF, Accent XL, eMatrix, eTwo, TriPolar RF, ReFirme, Sublime, Fractora, Evolastin, and most recently Infini. The “knock” on most of these devices has been:

The results are variable – most patients get minimal or no results
Multiple treatments (6 or more) are often needed with touch ups with some of the devices

This blog will help the reader understand how RF devices tighten skin, the problem with most RF devices (why they mostly don’t work), and why the Infini by Lutronic is a game changer in this group. Research has shown that heating the dermis to a certain temperature will cause collagen stimulation and contraction. By heating to 40-45 degrees Celsius, enough heat is created to cause the body to try to repair the area by laying down new collagen. Higher temperatures, in the 65 degree range, will denature collagen and cause contraction. Obviously this requires more energy but this equates to more visible results. Here’s the problem with all cutaneous devices (Exilis, Venus Freeze, Pelleve, Viora Reaction, 3Deep RF, Accent XL, eMatrix, eTwo, TriPolar RF, ReFirme, Sublime): It is very difficult to heat the dermis to a temperature that is effective and still maintain safe temperatures for the skin surface. If the surface were to reach the 40-45 degree area, it would burn. So, these device’s solution has been to try to cool the surface while pumping in energy to the deeper layers. This becomes a very difficult and unpredictable task. The devices rely on the tissues to carry the energy to the right level. Differences in skin thickness, hydration and the composition of collagen and fat can lead to placement of the energy at unknown or variable depths. If the energy is placed too deep, you can get fat necrosis, as what was occurring with the early Thermage device, and if placed too superficial, the skin can burn or get hyperpigmentation. Also, if you don’t actually reach the critical temperatures, you will get no stimulation of collagen. Multiple treatments are the norm for several of these devices because getting collagen stimulation is very difficult with the one treatment. The bottom line is that

ALL CUTANEOUS RF DEVICES, NO MATTER WHAT THEY ARE CALLED, HAVE THE PROBLEM WITH UNPREDICTABLE HEATING OF THE DERMIS AND THEREFORE UNPREDICTABLE OR VERY LITTLE RESULTS.

Skin surface is cooled and RF energy is pumped through the skin surface to heat dermis is UNPREDICTABLE manner

During Thermage, the skin surface is cooled and then RF energy is pumped through the skin surface to heat the dermis in an UNPREDICTABLE manner

Infini vs Other RF Devices

Ever since Fraxel was approved in 2005, the concept of treating areas fractionally has been the desired treatment modality for most devices. By treating only a fraction of the tissue, you can have more safety, more comfort, yet still get fairly similar results than treating the entire area. This concept has been borne out mainly with lasers in the arena of fractional laser resurfacing. Now comes another “knock” for the majority of RF devices: Almost all of the devices use a bulk heating method and not a fractional heating, so the risk, downtime, and discomfort are high. By keeping surrounding tissues untreated (fractionally) as with the Infini, you get faster healing, less pain, and much less risk. So how can we get more predictability with RF? Penetrate the skin to the level you would like to heat with microneedles and bypass the superficial layer that must stay cool and untreated. You can heat the deeper tissues to a much higher level with this technique, leading to greater collagen remodeling, collagen contraction, and stimulation. As a secondary benefit, the actual penetration with microneedles has been shown to mechanically stimulate fibroblasts to produce collagen.

$Precise fractional controlled thermal injury of the Infini$

Precise fractional controlled thermal injury of the Infini, vs monopolar and bipolar RF, vs ablative laser

There currently are many popular treatments based solely on microneedling (Vampire Microneedling). By creating an opening in the skin with the needles, topical therapeutics can be applied at the conclusion of the treatment which will get to levels much deeper than when typically applied to the surface of the skin. These can include: growth factors (rejuvenation), Vitamin C (for collagen), hydroquinones (for pigment), Retin A (rejuvenation and acne). Going deeper into the skin allows for some treatment opportunities which haven’t been/or poorly been addressed in the past with RF devices: Acne treatment (attacking the sebaceous glands), acne or other scarring (particularly darker skin types), and sweating (attacking the sweat glands). There are 3 devices on the market which use this microneedling concept:

Evolastin
Fractora
Infini

Evolastin: Uses 32g needles in depths which are between 1-2mm. The needles enter the skin in a tangential manner, so the exact depth is hard to predict. The energy transmits between paired needles, so the heating in fractional and localized. The major problem is that the patient requires tumescent anesthesia (infiltrating lidocaine mixed with saline) into the area being treated. This adds additional time, discomfort, and risk. Another concern is that this solution actually changes the tissue characteristics, so the treatment becomes less predictable – maybe more or less effective in different areas or maybe safety concerns in certain areas.

Evolastin has tangential needle placement and large caliber needles

Fractora: Uses needles which have a fixed depth of 1mm. The energy is transmitted through the needles and circles back to the electrode sitting of the surface of the skin. The surface probe has a sensor to monitor the skin temperature so as to maintain it within safe parameters. This is truly NOT fractional because the energy is dispersed in the areas between the needle tips and the skin surface. Here we go again with unpredictable traveling of the energy through the tissues and bulk heating. Concerns for safety and discomfort come to mind.

$Fractora electrodes are not insulated and treatment is not fractional.$

Fractora electrodes are not insulated and treatment is not fractional.

Infini: Uses needles which are 200 microns (small). Has variable depth of penetration from 0.5mm to 3.5mm so in the same treatment, several different levels of the dermis can be treated PREDICTABLY. Also, some parts of the face have different thicknesses of dermis, so the variable depth allows for treatment of the entire face. A depth of 3.5mm is much deeper than the other 2 needle devices. The energy is transmitted between the needles which results in true fractional RF ablation in the dermal tissue. The energy only travels a very small distance so the discomfort is minimized. (The more distance the energy travels through tissue, the more pain is felt.) The surface tissue is safe because the needles are at a level that won’t transmit energy to the epidermis. The treatment time is fairly quick: full face treatments take about 30 minutes, as do the neck procedures. For optimal results, it can take 2-3 treatments and full results take the standard 4-6 months to fully achieve (when the collagen remodeling is complete.)

$Infini showing the microneedles causing a small precise fractional dermal injury at multiple levels$

Infini showing the microneedles causing a small precise fractional dermal injury at multiple levels

The wide spectrum of indications of the Infini are:

Improving superficial fine lines and wrinkles of the face, eyes, neck
Improving the elasticity of aged and solar damage “thin” skin
Treating scars of all types but particularly acne scars. It has a great advantage over laser for darker skin types. Infini might turn out to be the “go to” device for scars over the Fraxel Dual 1550 because of deeper treatment levels (3.5mm vs 1.8mm of the Fraxel) and without the pigmentation risks.
Tightening loose skin on all parts of the body including: arms, chest, knees, abdomen. There are no limitations as to where the skin can treated on the body.
Potentially a treatment for acne and hyperhidrosis
No exclusion of patients based on skin type with no risk of hyperpigmentation.
Downtime is limited to only about 2 days of sunburn like sensation and slight redness

When comparing to the Ulthera, the differences are:

Ulthera is more for lifting than for the superficial lines and wrinkles
Ulthera is only used on the face and neck at the present time
Ulthera is still being evaluated for acne scars
Ulthera can be used in conjunction with Infini for even greater tightening and lifting then just Infini or Ulthera alone
Ulthera results in 15,000 coagulation points with a treatment, Infini is over 50,000
Ulthera depths are below the dermis for the most part where tissue tightening is not very effective.

To summarize, RF skin tightening has over a 10 year history which has been fraught with several different technical hurdles: unpredictable results, discomfort, and safety concerns. Using microneedling RF, we can get the energy down to the level needed with more accuracy and more safety. Infini seems to have the right combination of the transmission of energy through their needle tips as well as having variable depths to be the ideal RF Skin Tightener at the present time. It also has a broad list of indications including acne scars, skin tightening on the body, and improving the fine lines and wrinkles of facial skin.

Dr. Steve Weiner is a Facial Plastic Surgeon who “laid down his scalpel” in 2005 and concentrates solely on non invasive and minimally invasive cosmetic procedures at The Aesthetic Clinique. He is one of the first 15 adopters of the Infini in the United States. His website is http://www.theclinique.net . Call for a consultation: 850.622.1214

This link is from a European round table discussion about Lutronic Infini and Spectra (both at The Aesthetic Clinique). Infini discussion starts on page 7. http://digital.miinews.com/publication/?i=174629

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

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

How to improve your melasma

Melasma is skin pigment disorder (hyperpigmentation) which occurs in patches, which is often caused by fluctuations in hormones. It occurs mostly in females, most commonly affects the cheeks, forehead, nose, jawline, and upper lip. When associated with pregnancy it is called Chloasma, “mask of pregnancy”. It is exacerbated by oral contraceptives and exposure to sunlight and heat. Most people have fluctuations in their pigmentation, with the summer months being the worst.

There still is no consensus as to the exact etiology of the disorder. It seems that the melanocytes, the cells which produce pigment (melanin), are abnormally hyperactive. There are 3 forms of the disease: epidermal (superficial), dermal(deep), and mixed. It is often a frustrating disease for both patients and physicians because there is no easy cure. Recurrences are the rule. Often after taking months to improve, one or two sun exposures will reverse the disorder to it’s original state.

The first steps to improve melasma are:

Limit sun exposure. Use hats, suncreens, and sunglasses daily! Physical sunscreens are better because they also reduce the skin temperature.
Try to reduce the hormones in your BCP’s or use another form of birth control
Even if you are fully protected from the sun, heat can exacerbate the pigment, so try to limit outdoor exposure.
Even visible light has been shown to exacerbate melasma. We now recommend daily use of Heliocare to combat this.

If simple measures don’t improve melasma to your satisfaction, then try these measures from your Dermatologist or Plastic Surgeon:

Begin Retin A or Retinol. This suppresses the melanocyte and increases cellular turnover thereby decreasing pigmentation.
Hydroquinone 4%. This is a cream which suppresses the pigmentation production from the melanocyte. Although some physicians go to higher strengths, there are more risks of getting complications and rebound hyperpigmentation. (Please see the link, hydroquinones are on the way out.)
Lytera from SkinMedica. This is a new product that attacks pigmentation at 4 different levels.
Chemical Peels. Regular chemical peels seem to help control melasma and are the mainstay of therapy at The Aesthetic Clinique. It seems the consensus among Dermatologists as well.

After exhausting all the above measures and your melasma is still a concern, it’s time to consider using lasers. Only as a last resort are laser used because there are risks of making melasma worse. There are 2 lasers FDA approved for melasma and The Aesthetic Clinique has both of them. The Fraxel Dual is a resurfacing laser and treats the superficial epidermal form of melasma. Usually one to three treatments are needed and there are a few days of downtime. The other laser is the Lutronic Spectra Q switched laser. This is used for all types of melasma and there is no downtime. The Spectra can require 5 to 10 treatments with 1-2 touch ups per year. This laser might give a longer term solution to the problem because it actually causes permanent change to the melanocyte whereas the Fraxel Dual affects the pigmentation secreted from the melanocyte.

Although melasma can be a frustrating stubborn disease, there are many treatment options available. The Aesthetic Clinique has the 2 lasers which are FDA approved for treating melasma.

Please call our office to see what treatment options are available for you melasma. 850.622.1214. The Aesthetic Clinique, Steve Weiner, MD, Facial Plastic Surgeon, between Destin and Panama City Beach, Florida.

The Top 14 Trends in Cosmetic Procedures (Plastic Surgery) for 2014 as Predicted by Dr. Steven Weiner

What the Heck is Going on with Hydroquinones? Are they about to be banned in the US?

Dr. Steve Weiner: “FINALLY…A Radiofrequency (RF) Skin Tightening Device that Makes Sense. Infini by Lutronic.” Includes an overview of the RF skin tightening industry.

How to improve your melasma

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