Lutronic Archives | The Aesthetic Clinique

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

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

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

Action II Erbium Laser for Resurfacing and Bella V Vaginal Rejuvenation

Lutronic has added a new laser to it’s armamentarium and it is called the Action II. There are several different applications for this laser which include: fractional laser resurfacing, the “Shining” laser peel, skin lesion ablations, and the “Bella V” procedure for vaginal rejuvenation.

Erbium lasers are ablative lasers, they cause ablation of the tissue treated. This means that there will be vaporization of the treated skin. The Action II is a fractional laser, so only a “fraction” of the area treated will be ablated. Studies show that fractional lasers are safer and provide improved recovery times when compared to total (100%) ablative lasers. Comparing an erbium laser to a CO2 laser (which is also ablative), the erbium will have less coagulation of the tissue – less heat is transmitted to the surrounding tissues. The clinical result is that there is less crusting, less wound care, and faster healing with the erbium vs the CO2 laser.

Fractional Laser Resurfacing: The Action II uses a stamping handpiece that has approximately 15% coverage (15% of the skin is ablated) per pass. Depths are controlled by varying the energy as well as the pulse stacking. Typically patients will receive between 1-2 passes. The procedure takes about 30 minutes to complete. Only topical anesthetic is needed and patients are very comfortable throughout the procedure. Wound care which includes soaks and specialized creams is required for about 4 days. There is minimal to no crusting with this laser. More than one treatment might be needed to get optimal results.
- Indications: Treating deep wrinkles, sun damaged skin, pigmentation, and laxity
Shining Peel: This is a very superficial laser resurfacing with minimal depth and can be done without topical numbing creams. It takes about 15 minutes and is meant to have almost no downtime. It causes a rejuvenation of the skin
- Indications: Treat superficial wrinkles, minor pigmentation, enlarged pores
Surgical Handpiece: This is a microfocused beam to treat very small skin lesions. No anesthetic is needed.
- Indications: Treat sebaceous hyperplasia, seborrheic keratosis, actinic keratosis, benign nevus, skin tags, warts
Bella V: This handpiece/procedure is used for vaginal rejuvenation and stress incontinence. The handpiece is insert to the vagina. It has a unique 360 degree treatment zone as the laser is pulsed. There are 2 pulses, a shorter ablative or subablative pulse, followed by a longer nonablative (heating) pulse. The handpiece is gradually withdrawn about 0.5cm and another pulse is fired. The is done throughout the entire vagina and introitus and then repeated. If there is a component of stress incontinence, the area of the tissue around the urethra is treated more aggressively. The entire procedure takes about 10-15 minutes and no topical anesthetics are required. (At this time, external vaginal treatments are performed using the ThermiVa at the Aesthetic Clinique.)
- Indications: vaginal laxity, vaginal atrophy, decreased moisture, stress incontinence

3 Year Experience with Infini – High Intensity Focused Radiofrequency

[wpvideo hCA7PZR1]

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

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

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

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

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

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

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

Action II Erbium Laser for Resurfacing and Bella V Vaginal Rejuvenation

3 Year Experience with Infini – High Intensity Focused Radiofrequency

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.

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